Orthopedics

Feature Article 

Surgical Outcomes in Endoscopic Versus Open Bursectomy of the Septic Prepatellar or Olecranon Bursa

Timothy C. Meade; Marcus S. Briones, MD; Adam W. Fosnaugh, MD; Jeffrey M. Daily, MD

Abstract

In this study, the authors investigated the viability of endoscopic bursectomy as a treatment for septic prepatellar and olecranon bursitis. Conventional treatment of septic bursitis consists of aspiration, antibiotics, and rest. When conservative treatment fails, however, surgical intervention is sometimes required to resolve the infection. Typical surgical intervention consists of open bursectomy, in which the infected bursa is excised via an incision in the region of the skin directly above the bursa. The tenuous nature of the blood supply to this region of the skin results in a rather high rate of wound healing issues such as necrosis and wound dehiscence. Recently, endoscopy has been proposed as a less invasive means of bursectomy, although initially it was only recommended for cases of aseptic bursitis. A degree of uncertainty has persisted in the literature as to whether endoscopic bursectomy allows for sufficient debridement of the infected tissue to avoid recurrence of bursitis. The authors report on 27 cases in which endoscopic bursectomy was performed for recalcitrant septic bursitis. Fourteen of these cases were septic olecranon bursitis and 13 were septic prepatellar bursitis. The authors reported good results, with no wound healing complications and only 1 minor recurrence. They also reported much shorter hospital stays than have been reported both for more conservative treatments of septic bursitis and in other case series on endoscopic bursectomy. The authors conclude that endoscopic bursectomy is a superior alternative to open bursectomy for the treatment of recalcitrant septic prepatellar and olecranon bursitis. [Orthopedics. 2019; 42(4):e381–e384.]

Abstract

In this study, the authors investigated the viability of endoscopic bursectomy as a treatment for septic prepatellar and olecranon bursitis. Conventional treatment of septic bursitis consists of aspiration, antibiotics, and rest. When conservative treatment fails, however, surgical intervention is sometimes required to resolve the infection. Typical surgical intervention consists of open bursectomy, in which the infected bursa is excised via an incision in the region of the skin directly above the bursa. The tenuous nature of the blood supply to this region of the skin results in a rather high rate of wound healing issues such as necrosis and wound dehiscence. Recently, endoscopy has been proposed as a less invasive means of bursectomy, although initially it was only recommended for cases of aseptic bursitis. A degree of uncertainty has persisted in the literature as to whether endoscopic bursectomy allows for sufficient debridement of the infected tissue to avoid recurrence of bursitis. The authors report on 27 cases in which endoscopic bursectomy was performed for recalcitrant septic bursitis. Fourteen of these cases were septic olecranon bursitis and 13 were septic prepatellar bursitis. The authors reported good results, with no wound healing complications and only 1 minor recurrence. They also reported much shorter hospital stays than have been reported both for more conservative treatments of septic bursitis and in other case series on endoscopic bursectomy. The authors conclude that endoscopic bursectomy is a superior alternative to open bursectomy for the treatment of recalcitrant septic prepatellar and olecranon bursitis. [Orthopedics. 2019; 42(4):e381–e384.]

Prepatellar and olecranon bursitis are relatively common conditions, occurring in at least 12 of 100,000 individuals annually.1 The rate of occurrence is particularly high among those in professions such as roofing and plumbing, which subject individuals to repetitive trauma to the knee or elbow.2 Approximately one-third of all cases of olecranon and prepatellar bursitis are septic.3 These cases, characterized by pain, tenderness, warmth, and erythema of the overlying skin, are far less likely to self-resolve than cases of the more innocuous mechanical bursitis. Eventually, if left unaddressed, they can lead to severe complications such as necrosis of the skin and infection of the surrounding tissue.4

Typically, conservative treatments such as aspiration, immobilization, and antibiotics are considered to be preferred for septic bursitis.4 However, if not applied promptly, these methods yield a rather high rate of recurrence. More recalcitrant cases of septic bursitis often merit surgical intervention to avoid complications from unchecked infection.5,6 The conventional method of surgical treatment of septic bursitis is an open bursectomy, in which the septic bursa is excised via an incision in the skin directly above the bursa. However, these regions of the skin are cellulitic and have a tenuous blood supply, particularly after being subjected to pressure from the engorged bursa. This creates the potential for complications such as skin necrosis, wound dehiscence, and the development of cutaneous fistulas, which can require reoperation.7,8 Additionally, long-term tenderness of the surgical scar is rather common, which can prove deeply problematic for those with physically demanding occupations.9

One recent chart review of open olecranon bursectomies, in cases of both septic and aseptic bursitis, placed the rate of wound healing complications at 27% and the rate of recurrence at 22%.10 The high rate of complication in patients who undergo this procedure has spurred the development of alternative approaches to bursectomy. In 1990, Kerr and Carpenter11 proposed, for the first time, the use of endoscopic bursectomy to treat recurrent bursitis. Early literature on the technique cautioned against its use in cases of septic bursitis for fear of insufficient excision and subsequent recurrence of infection.8,11 More recently, however, some evidence, in the form of case reviews with relatively small subject pools, has been reported suggesting that endoscopic excision is, in fact, a safe and effective procedure for the debridement of septic bursae.12,13 However, the prevailing uncertainty in the literature on the subject indicates that this is far from an accepted fact.8,14,15 The current authors sought, through this case series, to determine the efficacy of endoscopic excision as an alternative to open bursectomy in the treatment of recalcitrant septic bursitis.

Materials and Methods

This study received institutional review board approval prior to collection of any data. The authors' administrative database was queried to identify patients with a diagnosis of septic olecranon and septic prepatellar bursitis (International Classification of Diseases, Ninth Revision/International Classification of Diseases, Tenth Revision codes 726.33, 726.65, M70.42, M70.41, M70.40, M70.20, M70.21, M70.22, and M71.169) who were treated by 1 of 4 surgeons practicing at the primary study site between 2007 and 2017. Charts were then reviewed to identify those who had undergone endoscopic excision of their septic bursitis. All patients who had undergone endoscopic resection of a septic prepatellar or olecranon bursa were considered for inclusion in the study. Patients who had previously undergone open bursectomy and patients who had not yet completed their course of care were excluded. Medical records of eligible patients were reviewed to determine any postoperative complications that occurred as well as length of hospitalization, infective organism, and demographic data such as age, sex, and Charlson Comorbidity Index score.

Surgical Technique

Prepatellar. Patients are positioned supine on the operating table (Figure 1). They are prepped and draped in the usual fashion, and the portals are established at the superolateral and inferomedial peripheral aspect of the enlarged bursa. Stab incisions are made in the normal, unaffected skin. The arthroscopic cannula is placed in the bursa through the superolateral portal and the effusion is evacuated (Figure 2). The bursa is inflated with arthroscopic fluid under 40 to 50 mm Hg and the aggressive 4.5-mm shaver is placed in the inferomedial portal. Debridement is performed in the same fashion as olecranon bursectomy. Arthroscopic fluid, 9 to 12 L, is used for irrigation during the procedure. A large suction drain is placed in the bursa, exiting through the superolateral portal (Figure 3). The other portal is closed with nylon sutures. The drain is removed on postoperative day 2. If skin breakdown with development of cutaneous fistula has already occurred, this technique is no longer applicable.

Septic prepatellar bursitis with a large amount of fluid collection.

Figure 1:

Septic prepatellar bursitis with a large amount of fluid collection.

Position of the arthroscope and the shaver during the operation.

Figure 2:

Position of the arthroscope and the shaver during the operation.

The knee immediately after excision. Suction was placed to avoid creating a cavity or recollecting fluid.

Figure 3:

The knee immediately after excision. Suction was placed to avoid creating a cavity or recollecting fluid.

Olecranon. The patient is positioned supine with a bump under the shoulder of the affected upper extremity. After standard preparation and draping, the cubital fossae and the position of the ulnar nerve are carefully determined. Small stab wounds are made at the periphery of the bursa. One wound is proximal-lateral and the other distal-medial to the bursa, penetrating uncompromised, uninfected, skin. A standard arthroscope is placed in the proximal portal and the effusion is drained. Pump pressure is maintained at approximately 40 mm Hg while a 4.5-mm aggressive shaver is used to resect the inflamed, hypertrophic bursal tissue. Care is taken not to violate the dermis or underlying tendon. A total of 9 L of arthroscopic fluid is used to irrigate the bursa during the procedure. A TLS (tiny little suction) drain (Stryker, Kalamazoo, Michigan) is placed, exiting through the lateral portal. The other portal is closed with nylon sutures. A bulky dressing is applied. Splinting is optional. The drain is removed on postoperative day 2.

Results

There were 27 eligible patients—13 who had undergone excision of a septic prepatellar bursa and 14 who had undergone excision of a septic olecranon bursa. Twenty-five of the 27 patients were male. The mean age of the prepatellar patients was 46.23 years (range, 8–77 years), and the mean age of the olecranon patients was 56.11 years (range, 39–80 years). Many practiced professions such as roofing, farming, and construction, which subjected them to frequent trauma to the knee and elbow. Twenty-one cases were confirmed via positive results of cultures. The remaining 6 patients had already begun a course of antibiotics, likely explaining their negative culture results. Consistent with the existing literature on septic bursitis, most cases were caused by Staphylococcus aureus—12 by methicillin resistant and 6 by methicillin sensitive.1,3,16Mycobacterium immunogenum, Streptococcus pneumoniae, and an unspecified gram-positive cocci were each the infective agent in a single case. Two patients, 1 with septic olecranon and 1 with septic prepatellar bursitis, were diabetic.

In the olecranon group, no issues with the surgical wound were reported. All 14 patients were successfully treated with endoscopic bursectomy and a course of antibiotics. There were no instances of recurrence. The mean postoperative hospital stay was 1.46 days (range, 0–4 days). In the prepatellar group, there were no complications directly associated with the surgical wound. Twelve of the 13 patients were successfully treated without recurrence with endoscopic bursectomy and a course of antibiotics. One patient experienced a recurrence, which was successfully resolved with 1 additional aspiration and 10 additional days of oral antibiotics. Additionally, 2 prepatellar patients had postoperative deep venous thrombosis, which, in both cases, was quickly and successfully resolved. The mean postoperative stay for prepatellar patients was 2.23 days (range, 0–8 days). Both diabetic patients had uneventful and successful recoveries.

Discussion

The shortcomings of open bursectomy have been well documented in the literature for decades. Necrosis, subcutaneous fistulas, recurrence, and practical issues arising from having a large, often tender scar on a part of the body that is subject to frequent minor trauma all occur rather frequently in patients who undergo open bursectomy. These difficulties have made surgeons eager to avoid open bursectomy when possible and to find alternative techniques that produce fewer undesirable outcomes.2,7–9 In 1976, Quayle and Robinson9 proposed techniques for the excision of both the prepatellar and the olecranon bursa that involved a lateral rather than an anterior incision. Although this technique does place the incision in a less vulnerable region of the skin, it still requires a rather large incision, and the surgical wound proved problematic for a fairly large contingent of their patients.2,9

In 1990, Kerr and Carpenter11 introduced endoscopic bursectomy and reported positive results. However, they urged surgeons only to employ the technique on aseptic bursitis, for fear that the infected tissue could not be sufficiently excised endoscopically and thus the technique would be ineffective.11,13 This perception has led to the exclusion of septic patients from the bulk of the literature on endoscopic bursectomy and its merits.8,12–15 Recently, a few case studies have arisen that challenge that notion, suggesting that endoscopic excision is a viable and effective technique to treat recalcitrant septic bursitis while avoiding the complications that often arise from traditional open bursectomy.12,13 The results of the current study further support this. The fact that the rate of recurrence that the authors observed (3%) was significantly lower than what has been reported in the literature for open bursectomy (22%) defies conventional wisdom on the subject, suggesting that carefully performed endoscopic bursectomy is, far more often than not, a permanent solution to septic bursitis. Additionally, the fact that the authors saw no issues in the healing of the surgical wounds themselves suggests a major advantage of endoscopic over open bursectomy, which yields wound healing issues in a reported 27% of patients.10

In 2012, Dillon et al13 reported positive results in the treatment of septic prepatellar bursitis in a cohort of 8 patients with endoscopic bursectomy. They reported a mean hospital stay of 6 days postoperatively, which is significantly shorter than what has been reported in the literature for treatment with intravenous antibiotics alone, which yields a mean stay of 11 days.13,17 The current authors' observed mean hospital stay of 2.43 days in prepatellar patients and 1.46 days in olecranon patients is a notable improvement over both of those values. This difference is likely attributable to greater confidence in the effectiveness of endoscopic bursectomy and thus a greater reliance on oral rather than intravenous antibiotics near the end of the recovery period. By allowing compliant patients at a lower risk of recurrence to return home with oral antibiotics before the complete resolution of their infection, the authors were able to dramatically reduce the length of hospital stay compared with existing case series. In fact, 4 prepatellar and 3 olecranon bursectomies in the current series were conducted outpatient, with no intravenous antibiotics administered. These patients were prescribed a course of oral antibiotics with a mean duration of 10 days for those with olecranon bursitis and 17.25 days for those with prepatellar. Patients with more severe cases were typically administered intravenous antibiotics for 2 to 3 days before being sent home with a course of oral antibiotics for 10 to 21 days. The authors' low rate of recurrence would suggest that using oral antibiotics either exclusively or after a brief stint of intravenous antibiotics does not place most patients at inordinate risk. Exceptions to this principle may have to be made for high-risk patients, such as those who are immunocompromised, at the discretion of the surgeon. However, given that rising medical costs are of increasing concern, the ability to reduce hospital stays by nearly 60% on average through this treatment plan is of potential financial benefit to patients.

Either for fear of the risks of including immunocompromised patients or simply as a consequence of small subject pools, previous case reports on the use of endoscopic bursectomy to treat septic bursitis have largely excluded diabetic patients.12,13 In the current study, 2 patients, 1 with septic prepatellar and 1 with septic olecranon bursitis, were diabetic. Both of these patients had successful and uneventful recoveries with no recurrent infection. The patient with olecranon bursitis was administered intravenous antibiotics for 7 days and then sent home with a course of oral antibiotics for 10 days. The patient with prepatellar bursitis was administered intravenous antibiotics for 17 days and then prescribed a course of oral antibiotics for 18 days. Although diabetic and other similarly immunocompromised patients certainly merit close observation, these positive outcomes further suggest that concerns over the efficacy of endoscopic bursectomy may be unfounded and that it can be employed successfully even for patients who pose a high risk for recurrence. This is especially significant because immunocompromised patients are at a disproportionately high risk for septic bursitis and thus stand to benefit a great deal from an improved surgical technique.4

Conclusion

The use of endoscopic bursectomy to treat recurrent cases of septic bursitis has, in the authors' experience, yielded positive results for the treatment of septic prepatellar and olecranon bursitis. In a subject pool that included patients who have previously been considered prohibitively high risk, the authors saw short hospital stays, a low rate of recurrence, and no issues in the healing of the surgical wound. The body of literature on the subject would certainly benefit from a more extensive, prospective study with random assignment of open or endoscopic bursectomy. Even a retrospective study with a larger pool of patients would greatly reinforce the existing evidence of the efficacy of this treatment. Further, a study that included a larger pool of diabetic and other immunocompromised patients would allow for stronger conclusions to be drawn about the usefulness of the procedure for patients at a high risk of recurrence. Ultimately, however, the authors' experience suggests that endoscopic bursectomy is not only a viable but also a superior alternative to open bursectomy as a permanent, low-risk, and cost-effective treatment for recurrent septic prepatellar or olecranon bursitis.

References

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Authors

The authors are from the University of Notre Dame (TCM), Notre Dame, Indiana; and OrthoCarolina–Monroe (MSB, AWF, JMD), Monroe, North Carolina.

The authors have no relevant financial relationships to disclose.

The authors thank John Meade, MD, of OrthoCarolina and Caryn Thompson and Bryce Van Doren of OrthoCarolina Research Institute for their logistical support and guidance of this project.

Correspondence should be addressed to: Marcus S. Briones, MD, OrthoCarolina–Monroe, 703 Comfort Ln, Monroe, NC 28112 ( Marcus.Briones@orthocarolina.com).

Received: June 07, 2018
Accepted: October 16, 2018
Posted Online: March 27, 2019

10.3928/01477447-20190321-04

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