Greater femoral trochanteric bursa injections under ultrasound guidance ensure the injectate is accurately given into the bursa. The greater trochanteric bursa is the largest of the bursae surrounding the proximal femur, with the others including the subgluteus minimus and subgluteus medius bursae, which can also be targeted.
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Indications
pain i.e greater trochanteric pain syndrome
diagnostic injection
Contraindications
Absolute
anaphylaxis to contrast/ injectates
active local/ systemic infection
Relative
recent injection with steroid in same or other body parts
gluteus minimus and/or gluteus medius tendon tear
ipsilateral hip arthroplasty
unable to remain still for the procedure
young age
Procedure
The general principles of guided injections are to:
cannulate the bursae under image guidance
administer injectate, usually a corticosteroid and a small amount of longer-acting local anesthetic, and avoid intratendinous injection
Pre-procedural evaluation
Relevant imaging should be reviewed, and details of the patient confirmed. The patient should have an opportunity to discuss the risks and benefits and consent obtained. A focussed pre-procedure ultrasound is usually performed to assess bursae, and the gluteus minimus and medius tendons which are also referred to the ‘rotator cuff of the hip’ 1.
Risks include
infection
bleeding
allergy
focal fat necrosis/ skin discolouration at injection site
complete tendon tear
Equipment
ultrasound machine, sterile probe cover and a skin marker
skin cleaning product
sterile drape
sterile field and tray for sharps
syringe selection i.e. 5mL and 3mL
larger bore drawing up needle
needle to administer local anesthetic i.e. 25-gauge needle
needle to cannulate the bursae i.e. 25 or 22-gauge 90mm Quincke needle
injectants i.e. local anesthetics, iodinated contrast, corticosteroid preparation
sterile gauze
adhesive dressing
Syringe selection
A suggested syringe and injectate selection for an ultrasound-guided greater trochanteric bursa injection -
5 mL syringe: 5 mL of local anesthetic i.e. 1% lidocaine
3 mL syringe: 40mg triamcinolone acetonide (40 mg/1 mL) and 2 mL 0.5% ropivacaine
Needle selection
Smaller gauge needles can be less painful but are less stiff and can bend when trying to pass through the iliotibial band to reach the bursa. Pre procedure planning should calculate length required to reach the bursa, as larger patients will require longer needles 2.
Greater trochanteric bursa: 25 or 22-gauge 90mm Quincke needle
Technique
Ultrasound
check for allergies and if on blood thinners
consent
optimize patient positioning by lying them on the side and facing away, with the ipsilateral hip facing upwards and exposing the lateral targeted proximal femur, aiming for posterior access
identify the greater trochanteric bursa in a transverse plane; perpendicular to the long axis, with dynamic maneuvers helping to identify a non-distended bursa 3
optimize imaging and mark a posterior skin entry point
clean skin and draw up appropriate medications
give local anesthesia along the proposed needle path
under ultrasound guidance using posterior to anterior approach, insert the needle in-plane with the transverse probe into the posterior aspect of the bursa
the needle tip position can be checked with a small amount of local anesthetic which should freely flow and distend the bursa
administer steroid containing injectate under direct visualization
removed needle and apply dressing/ band-aid as required
pain diary given if required
Complications
The most serious complication is infection. Steroid containing injections should be postponed if there are signs and/or symptoms of local and/ or systemic infection. Possible fat necrosis causing skin dimpling and skin discolouration can occur due to steroid leaking into the surrounding soft tissues 4.