Hip replacement surgery is a common orthopedic procedure to address a damaged hip joint. Patients often have detailed questions about the structures surrounding the joint, particularly the bursa, and whether it is affected by the operation. The decision regarding the bursa is not a simple yes or no, but a nuanced choice made by the surgeon based on the individual patient and the procedure’s requirements.
Understanding the Trochanteric Bursa
A bursa is a small, fluid-filled sac that acts as a natural cushion between bones, tendons, and muscles. These sacs are lined with a synovial membrane that secretes a lubricating fluid to reduce friction during movement. The trochanteric bursa is the specific bursa most relevant to hip replacement surgery, located over the prominent bony point on the outside of the upper thigh, known as the greater trochanter. This bursa functions to allow the large muscles and tendons that cross the hip joint to glide smoothly over the greater trochanter with minimal resistance. When this bursa becomes inflamed, a condition known as trochanteric bursitis occurs, causing pain on the side of the hip. This inflammation is a common cause of lateral hip pain, sometimes occurring independently of the joint disease that necessitates a hip replacement.
The Primary Goal of Total Hip Arthroplasty
Total hip arthroplasty (THA), or hip replacement, is a procedure focused on replacing the damaged joint surfaces. The main objective is to remove the diseased femoral head, which is the “ball” of the joint, and the damaged cartilage lining the acetabulum, the hip socket. The surgeon then implants prosthetic components to create a new, smooth-gliding joint. This reconstruction typically involves a metal stem inserted into the thigh bone (femur) with a ceramic or metal ball on top, and a metal shell lined with plastic or ceramic inserted into the hip socket. The ultimate goal is to eliminate the grinding pain caused by arthritis and restore the patient’s mobility and quality of life. Achieving this joint replacement is the central focus of the operation, with any actions taken on surrounding structures being secondary to this objective.
Factors Influencing Bursa Removal During Surgery
The removal of the trochanteric bursa during a total hip replacement is not a universal step and depends on two primary considerations: pre-existing pathology and the specific surgical approach utilized.
Pre-Existing Pathology
If a patient has a history of chronic, severe trochanteric bursitis that has been resistant to non-surgical treatments like injections and physical therapy, the surgeon may elect to remove the bursa. Removing the inflamed bursa eliminates a potential source of long-term post-operative pain. Studies suggest this simultaneous removal is effective for patients with this pre-existing condition.
Surgical Approach
The surgical approach also dictates whether the bursa is affected or removed. Some older or specific approaches, such as the direct lateral approach, may require the surgeon to cut through or manipulate the tissues over the greater trochanter to access the deeper hip joint. This process can involve the partial or complete excision of the bursa simply to create the necessary surgical window for the procedure.
The decision-making process is different with approaches like the direct anterior approach, which accesses the hip joint from the front by working between muscle planes. This technique often allows the surgeon to perform the hip replacement without directly disturbing the trochanteric bursa. Consequently, in these less-invasive procedures, the bursa is generally left intact unless it is clearly diseased.
Surgeon preference and individual technique also play a role in the decision to perform a prophylactic bursectomy. Some surgeons may routinely remove the bursa with the rationale that the surgical trauma will cause it to become scarred and lose its function as a friction buffer anyway. However, recent data suggests that routine, prophylactic bursa removal does not significantly reduce the overall incidence of post-operative trochanteric bursitis.
Recovery and Long-Term Outcomes in the Hip Area
Following total hip arthroplasty, the surrounding soft tissues, including muscles and tendons, require time to heal and adapt to the new joint mechanics. Biomechanical changes introduced by the prosthetic components can sometimes place new stresses on the area, which may lead to post-operative trochanteric pain. This pain can occur regardless of whether the original bursa was removed during the procedure.
If the bursa was removed during surgery, the body typically regenerates a new structure that serves a similar cushioning function over the greater trochanter. This new structure, which may be a regenerated bursa or a layer of fibrous scar tissue, helps to reduce friction between the bone and the overlying soft tissues. The long-term function of the hip is not compromised by the removal of the original bursa.
The incidence of post-operative trochanteric bursitis is relatively low, estimated to affect between 4% and 10% of patients. When this pain does occur, it is usually managed effectively with conservative treatments such as physical therapy, rest, and targeted steroid injections into the affected area. The primary focus of rehabilitation is the strengthening and balancing of the hip muscles to ensure smooth, pain-free movement over the area where the bursa is located or has reformed.