Trochanteric pain after total hip replacement

What is the trochanteric region ?

The trochanteric region is the prominent area on the lateral side of the hip, slightly below the pelvis and toward the upper thigh. It corresponds to the greater trochanter, where the gluteal tendons insert – particularly the gluteus medius, one of the most important tendons of the hip. This muscle stabilizes the pelvis during single-leg stance and walking.

A bursa lies over the greater trochanter, normally painless.

Common causes of trochanteric pain after hip replacement

A frequent cause of post-replacement trochanteric pain is gluteus medius tendinopathy, sometimes associated with trochanteric bursitis. Gluteus medius tendinopathy commonly affects women over 60, especially in cases of excess weight. Tendon degeneration may already exist before the hip replacement and persist after surgery.

Diagnosis relies on ultrasound, which shows tendon insertion changes on the bone, sometimes associated with inflammation of the trochanteric bursa. Treatment includes structured physiotherapy and possibly ultrasound-guided corticosteroid injections. In some cases, surgical tendon repair may be considered.

The influence of the surgical approach

Some surgeons still use the transgluteal Hardinge approach to implant total hip prosthesis, which is detrimental because it requires detaching the anterior portion of the gluteal tendons from their bony insertion. These tendons sometimes fail to heal after hip replacement, resulting in chronic trochanteric pain and limping. Patients may also notice their foot turning outward due to the weakening of the internal rotator muscles cut during surgery.

Diagnosis relies on:

• Reviewing the operative report
• Clinical examination, locating tenderness near the incision area
• Ultrasound, confirming tendon rupture
• MRI with metal-artifact-reduction protocol, assessing tendon integrity and muscle degeneration

We frequently perform gluteal tendon repair in patients operated via the transgluteal Hardinge approach.

Pain related to incorrect muscle tension adjustment

In some situations, trochanteric pain may result from improper muscle tension adjustment during prosthesis implantation. If the medio-lateral femoral offset is not properly restored, excessive muscle tension may occur, leading to increased traction forces on the trochanteric region. Patients may notice that the lateral hip area appears wider and that their clothing feels tighter.

Diagnosis relies on:

• Clinical examination
• Comparison of pre- and postoperative radiographs
• Ideally, a 3D CT scan to precisely measure femoral offset

When the offset is increased by more than 30%, this can lead to significant painful complications and contribute to an unhappy hip replacement .

Trochanteric pain of spinal or neurological origin

Sometimes the pain does not originate from the hip but is referred from the lumbar spine, caused by nerve compression or radicular involvement.

In such cases, it is essential to :

• Perform a complete neurological examination
• Look for sensory-motor deficits
• Examine the lumbar spine
• Order appropriate imaging (lumbar radiographs, EOS scan, CT or MRI, electromyography)

These investigations help rule out neurological conditions that may coexist with hip pain.

The importance of accurate diagnosis and appropriate imaging

Trochanteric pain after total hip replacement must always be thoroughly evaluated with targeted imaging studies to precisely determine the cause and recommend the appropriate medical or surgical management.

How to prevent trochanteric pain ?

Prevention relies on several essential principles:

• Using a direct anterior approach, which preserves the gluteal tendons and surrounding musculature
• Performing preoperative 3D CT planning, crucial for accurately measuring the hip anatomy and medio-lateral offset
• Implanting a custom-made prosthesis, ensuring precise adjustment of muscle balance and avoiding painful tension

As part of the preoperative evaluation, it may also be necessary to examine the lumbar spine to avoid overlooking associated neuropathic pain.

In older women, the presence of gluteus medius tendinopathy combined with osteoarthritis must be identified and treated simultaneously to prevent residual pain after surgery.