Conservative Management
Conservative management consists of protection, rest, ice, compression, and elevation (PRICE); nonsteroidal anti-inflammatory drugs (NSAIDs); and bursal aspiration. Intrabursal steroid injection may be indicated for the treatment of chronic NSB. For acute SB, antibiotic therapy is the key treatment and should be started as soon as infection is suspected after the bursal fluid aspiration.
A literature review by Brown et al found that at 1-year follow-up, patients with prepatellar SB who had undergone antibiotic therapy for less than 8 days did not experience a higher recurrence rate than did those who received a longer course of antibiotic treatment. [26]
Transient immobilization of the knee in the neutral position with a posterior splint may be needed in cases of acute prepatellar SB. [9]
Physical Therapy
After the initial period of rest, the goal of physical therapy is to regain any loss of ROM while increasing the flexibility of the quadriceps and hamstrings. Use of therapeutic modalities can be helpful to assist stretching in this period.
Occupational Therapy
The role of the occupational therapist in this scenario is to address modifications of activities in patients diagnosed with prepatellar bursitis secondary to overuse. Emphasize patient education, avoidance of kneeling, and use of kneepads if kneeling is necessary.
Surgical Intervention
Incision and drainage of the prepatellar bursa usually is performed when symptoms of septic bursitis have not improved significantly within 36-48 hours. Surgical removal of the bursa (ie, bursectomy) may be necessary for chronic or recurrent prepatellar bursitis. [10] Arthroscopic or endoscopic excision of the bursa has more recently been reported to have satisfactory results, with less trauma than open excision. [11, 12]
Using a systematic literature review, Baumbach et al developed a treatment algorithm for olecranon and prepatellar bursitis in which they advised that septic forms of these conditions initially be treated conservatively. They recommended that incision, drainage, or bursectomy be reserved for patients with severe, refractory, or chronic/recurrent disease. [27]
A study by von Dach et al suggested that even in cases of moderate to severe septic prepatellar or olecranon bursitis, it is safe to substitute a one-stage bursectomy with primary closure for a two-stage procedure. The study, which included 168 patients, also found that the median hospital stay was 2 days shorter with the one-stage approach than with the two-stage operation. [28] A study by Uçkay et al concluded that for adults with moderate to severe septic bursitis who require inpatient treatment, bursectomy with primary closure in combination with 7 days of antibiotic drug therapy is a safe and effective approach that saves resources. [29]
A study by Meade et al of 27 cases of recalcitrant septic prepatellar or olecranon bursitis indicated that endoscopic bursectomy can effectively treat these conditions. It has been questioned whether, when performed endoscopically, the procedure allows infected tissue to be adequately debrided in bursitis, thus preventing the disease’s recurrence. However, wound healing complications in the study were absent, and there was just one minor recurrence. In addition, hospital stays were reported to be much shorter than have been found in association with more conservative therapy for septic bursitis and in previous case series on endoscopic bursectomy. [30]
Similarly, the aforementioned literature review by Brown and colleagues indicated that in patients with either septic or nonseptic prepatellar bursitis, endoscopic and open bursectomy are equally effective. At 1-year follow-up, the rate of recurrence did not differ between the two techniques. The investigators also reported that at 1-year post surgery, 80% of patients who underwent endoscopic bursectomy were pain free. [26]
Consultations
Initiate early orthopedic surgery consultation for severe septic prepatellar bursitis that fails to improve within 36-48 hours and requires incision and drainage. Orthopedic surgery consultation should also be requested in recurrent and/or chronic prepatellar bursitis that does not respond to conservative treatment.
Initiate infectious disease consultation within 36-48 hours in septic prepatellar bursitis that is unresponsive to treatment.
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Prepatellar bursa in normal (left) and inflamed (right) state; trilaminar form.
Tables
Characteristic |
Septic bursitis (SB) |
Nonseptic bursitis (NSB) |
Appearance |
Purulent |
Serosanguineous, straw colored, or bloody |
White blood cell count per µL |
1500-300,000; mean 75,000 |
50-10,000; usually < 3000 |
Differential count |
Polymorphonuclear (PMN) cells |
Predominantly mononuclear cells |
Bursal fluid–to–serum glucose ratio |
< 50% |
>50% |
Gram stain |
Positive in 70% |
Negative |
Culture |
Positive |
Negative |
