Risk Factors for Lateral Trochanteric Pain Following Anterior Approach Total Hip Arthroplasty

Document Type : RESEARCH PAPER

Authors

1 Jefferson Health New Jersey, Stratford, NJ, USA

2 Rothman Orthopaedic Institute, Egg Harbor Township, NJ, USA

Abstract

Objectives: The principal aim of our study is to investigate risk factors for lateral trochanteric pain (LTP) 
after direct anterior approach (DAA) primary total hip arthroplasty (THA).
Methods: A retrospective case control study was developed from 542 patients who underwent primary THA over a 
9-year period to form two patient cohorts. Two hundred and seventy-one patients diagnosed with LTP were matched 
with 271 controls. Chart review revealed patient demographics, surgical approach, and femoral components utilized. 
Change in limb length and offset were assessed through preoperative and postoperative radiographic 
measurements.
Results: There was a higher proportion of current or former smokers in the LTP group (34.5% vs 21.74%, p=0.003). 
There was no significant difference in use of high offset stems vs. standard offset stems between groups (15.9% vs. 
18.5%, p=0.494). However, the LTP group had significantly higher increase in both femoral offset (+3.55mm vs 
+1.79mm, p<0.001) and total offset (+0.16mm vs -1.16mm, p=0.031) in comparison to controls.
Conclusion: An increase in total offset, femoral offset, and smoking history are factors associated with LTP after 
DAA primary THA.
 Level of evidence: I

Keywords

Main Subjects


1. Learmonth ID, Young C, Rorabeck C. The operation of the 
century: total hip replacement. Lancet. 2007; 370:1508–19. 
doi:10.1016/S0140-6736(07)60457-7.
2. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of 
primary and revision hip and knee arthroplasty in the United 
States from 2005 to 2030. J Bone Joint Surg Am. 2007; 
89:780–5. doi: 10.2106/JBJS.F.00222. 
3. Kelmer G, Stone AH, Turcotte J, King PJ. Reasons for Revision: 
Primary Total Hip Arthroplasty Mechanisms of Failure. J Am 
Acad Orthop Surg. 2021; 29:78–87. doi: 10.5435/JAAOS-D19-00860.
4. Sayed-Noor AS, Sjoden GO. Greater trochanteric pain after total 
hip arthroplasty: the incidence, clinical outcome and 
associated factors. Hip Int. 2006; 16:202–6. doi: 
10.1177/112070000601600304.
5. Moerenhout K, Benoit B, Gaspard HS, Rouleau DM, Laflamme 
GY. Greater trochanteric pain after primary total hip 
replacement, comparing the anterior and posterior approach: 
A secondary analysis of a randomized trial. Orthop Traumatol 
Surg Res. 2021; 107:102709. doi: 10.1016/j.otsr.2020.08.011.
6. Skibicki HE, Brustein JA, Orozco FR, Ponzio DY, Post ZD, Ong 
AC. Lateral Trochanteric Pain Following Primary Total Hip 
Arthroplasty: Incidence and Success of Nonoperative 
Treatment. J Arthroplasty. 2021; 36:193–9. doi: 
10.1016/j.arth.2020.07.043.
7. Abdulkarim A, Keegan C, Bajwa R, Sheehan E. Lateral 
trochanteric pain following total hip arthroplasty: 
radiographic assessment of altered biomechanics as a 
potential aetiology. Ir J Med Sci. 2018; 187:663–8. doi: 
10.1007/s11845-017-1701-1. 
8. Iorio R, Healy WL, Warren PD, Appleby D. Lateral trochanteric 
pain following primary total hip arthroplasty. J Arthroplasty. 
2006; 21:233–6. doi: 10.1016/j.arth.2005.03.041.
9. Worlicek M, Messmer B, Grifka J, Renkawitz T, Weber M. 
Restoration of leg length and offset correlates with 
trochanteric pain syndrome in total hip arthroplasty. Sci Rep. 
2020; 10:7107. doi: 10.1038/s41598-020-62531-9.
10. Fearon AM, Cook JL, Scarvell JM, Neeman T, Cormick W, Smith 
PN. Greater trochanteric pain syndrome negatively affects 
work, physical activity and quality of life: a case control study. 
J Arthroplasty. 2014; 29:383–6. doi: 
10.1016/j.arth.2012.10.016.
11. Kagan A. Rotator cuff tears of the hip. Clin Orthop Relat Res. 
1999:135–40. 
12. Pfirrmann CWA, Notzli HP, Dora C, Hodler J, Zanetti M. 
Abductor Tendons and Muscles Assessed at MR Imaging after 
Total Hip Arthroplasty in Asymptomatic and Symptomatic 
Patients. Radiology. 2005; 235:969–76. doi: 
10.1148/radiol.2353040403.
13. Farmer KW, Jones LC, Brownson KE, Khanuja HS, Hungerford 
MW. Trochanteric Bursitis after Total Hip Arthroplasty: 
Incidence and Evaluation of Response to Treatment. J 
Arthroplasty. 2010; 25:208–12. doi: 
10.1016/j.arth.2009.02.008. 
14. Shemesh SS, Moucha CS, Keswani A, Maher NA, Chen D, 
Bronson MJ. Trochanteric Bursitis Following Primary Total 
Hip Arthroplasty: Incidence, Predictors, and Treatment. J 
Arthroplasty .2018; 33:1205–9. doi: 
10.1016/j.arth.2017.11.016.
15. Schwartsmann CR, Loss F, de Freitas Spinelli L, et al. 
Association between trochanteric bursitis, osteoarthrosis and 
total hip arthroplasty. Rev Bras Ortop. 2014; 49:267–70. doi: 
10.1016/j.rboe.2014.04.009. 
16. Charnley J. Total hip replacement by low-friction arthroplasty. 
Clin Orthop Relat Res. 1970; 72:7–21. 
17. Charles MN, Bourne RB, Davey JR, Greenwald AS, Morrey BF, 
Rorabeck CH. Soft-tissue balancing of the hip: the role of 
femoral offset restoration. Instr Course Lect. 2005; 54:131–
41. 
18. Sakalkale DP, Sharkey PF, Eng K, Hozack WJ, Rothman RH. 
Effect of femoral component offset on polyethylene wear in 
total hip arthroplasty. Clin Orthop Relat Res. 2001:125–34. 
doi: 10.1097/00003086-200107000-00019.
19. Incavo SJ, Havener T, Benson E, McGrory BJ, Coughlin KM, 
Beynnon BD. Efforts to improve cementless femoral stems in 
THR: 2- to 5-year follow-up of a high-offset femoral stem with 
distal stem modification (Secur-Fit Plus). J Arthroplasty. 
2004; 19:61–7. doi: 10.1016/j.arth.2003.09.006.
20. Liebs TR, Nasser L, Herzberg W, Rüther W, Hassenpflug J. The 
influence of femoral offset on health-related quality of life 
after total hip replacement. Bone Joint J. 2014; 96-B: 36–42. 
doi: 10.1302/0301-620X.96B1.31530. 
21. Sayed-Noor AS, Pedersen E, Wretenberg P, Sjödén GO. Distal 
lengthening of ilio-tibial band by Z-plasty for treating 
refractory greater trochanteric pain after total hip 
arthroplasty (Pedersen-Noor operation). Arch Orthop 
Trauma Surg. 2009; 129:597–602. doi: 10.1007/s00402-008-
0693-8. 
22. Cassidy KA, Noticewala MS, Macaulay W, Lee JH, Geller JA. 
Effect of femoral offset on pain and function after total hip 
arthroplasty. J Arthroplasty. 2012; 27:1863–9. doi: 
10.1016/j.arth.2012.05.001. 23. Austin MS, Hozack WJ, Sharkey PF, Rothman RH. Stability and 
leg length equality in total hip arthroplasty. J Arthroplasty. 
2003; 18:88–90. doi: 10.1054/arth.2003.50073.
24. Williamson JA, Reckling FW. Limb Length Discrepancy and 
Related Problems Following Total Hip Joint Replacement. Clin 
Orthop Relat Res. 1978 ;( 134):135-8. 
25. Al-Amiry B, Mahmood S, Krupic F, Sayed-Noor A. Leg 
lengthening and femoral-offset reduction after total hip 
arthroplasty: where is the problem - stem or cup positioning? 
Acta Radiol. 2017; 58:1125–31. doi: 
10.1177/0284185116684676. 
26. Husby VS, Bjørgen S, Hoff J, Helgerud J, Benum P, Husby OS. 
Unilateral vs. bilateral total hip arthroplasty - the influence of 
medial femoral head offset and effects on strength and 
aerobic endurance capacity. Hip Int. 2010; 20:204–14. doi: 
10.1177/112070001002000211.
27. Yamaguchi T, Naito M, Asayama I, Ishiko T. Total hip 
arthroplasty: the relationship between posterolateral 
reconstruction, abductor muscle strength, and femoral offset. 
J Orthop Surg. 2004; 12:164–7. doi: 
10.1177/230949900401200205. 
28. Asayama I, Chamnongkich S, Simpson KJ, Kinsey TL, Mahoney 
OM. Reconstructed hip joint position and abductor muscle 
strength after total hip arthroplasty. J Arthroplasty. 2005; 
20:414–20. doi: 10.1016/j.arth.2004.01.016.
29. Kiyama T, Naito M, Shinoda T, Maeyama A. Hip Abductor 
Strengths After Total Hip Arthroplasty Via the Lateral and 
Posterolateral Approaches. J Arthroplasty. 2010; 25:76–80. 
doi: 10.1016/j.arth.2008.11.001.
30. McGrory BJ, Morrey BF, Cahalan TD, An KN, Cabanela ME. 
Effect of femoral offset on range of motion and abductor 
muscle strength after total hip arthroplasty. J Bone Joint Surg 
Br. 1995; 77:865–9. 
31. Malik A, Maheshwari A, Dorr LD. Impingement with total hip
replacement. J Bone Joint Surg Am. 2007; 89:1832–42. doi: 
10.1016/j.cuor.2008.10.009.
32. Matsushita A, Nakashima Y, Jingushi S, Yamamoto T, Kuraoka 
A, Iwamoto Y. Effects of the femoral offset and the head size 
on the safe range of motion in total hip arthroplasty. J 
Arthroplasty .2009; 24:646–51. doi: 
10.1016/j.arth.2008.02.008. 
33. Patel AB, Wagle RR, Usrey MM, Thompson MT, Incavo SJ, 
Noble PC. Guidelines for implant placement to minimize 
impingement during activities of daily living after total hip 
arthroplasty. J Arthroplasty. 2010; 25:1275-81.e1. doi: 
10.1016/j.arth.2009.10.007.
34. Kurtz WB, Ecker TM, Reichmann WM, Murphy SB. Factors 
affecting bony impingement in hip arthroplasty. J 
Arthroplasty. 2010; 25:624-34.e1-2. doi: 
10.1016/j.arth.2009.03.024.
35. Liebs TR, Nasser L, Herzberg W, Ruther W, Hassenpflug J. The 
influence of femoral offset on health-related quality of life 
after total hip replacement. Bone Joint J. 2014; 96-B (1):36-
42. doi: 10.1302/0301-620X.96B1.31530.
36. Lee JJ, Patel R, Biermann JS, Dougherty PJ. The 
musculoskeletal effects of cigarette smoking. J Bone Joint Surg 
Am. 2013; 95:850–9. doi: 10.2106/JBJS.L.00375.
37. Weber M, Woerner ML, Springorum H-R, Hapfelmeier A, 
Grifka J, Renkawitz TF. Plain radiographs fail to reflect 
femoral offset in total hip arthroplasty. J Arthroplasty. 2014; 
29:1661–5. doi: 10.1016/j.arth.2014.03.023.