Abstract A 31-yr-old soldier presented with an 8-mo history of right prepatellar bursitis with 1-mo history of pain and loss of range of motion. His symptoms did not respond to activity modification, compression, nonsteroidal anti-inflammatory agents, or repeated aspirations with fenestration. After thorough discussion, the soldier and his provider reviewed the literature and found a single case report of intrabursal sclerotherapy in two patients with recalcitrant prepatellar bursitis. After informed consent, the patient wished to proceed with the scelerotherapy. Utilizing ultrasound guidance, the bursal sac was aspirated then injected with the scerlosing agent polidocanol. The patient had a much slower reaccumulation of swelling and at the two week follow-up the procedure was repeated. The patient has had no reaccumulation of the fluid as of 10 mo post-procedure and has resumed all his normal activities with no symptom limitation. This case demonstrates that sclerotherapy has utility in the management of recurrent non-septic prepatellar bursitis. CASE REPORT Persistent or recurrent non-septic activity limiting prepatellar bursitis can be a vexing problem. The following illustrative case describes a novel non-surgical option. A healthy, 31-yr-old soldier presented with an 8-mo history of right prepatellar bursitis (Fig. 1). Although there was no acute trauma, the soldier had been engaging in powerlifting 4–5 d a week and trail running. He had steadily increased his trail running over the last 5 mo to a peak of 7 h a week. He reported that the swelling occurred overnight following a typical lower body strength training session. He subsequently eased his volume to 1 h of running per week and reduced intensity and volume of exercises involving knee flexion for approximately a month, but there was an increase in the amount of swelling. Since the swelling did not impede his performance nor was there a change after a decreased load, he resumed his regular conditioning program. At the 7-mo mark the bursal swelling began to affect his range of motion (ROM), and he began to have anterior knee pain with running and squats. He initiated self-treatment with 800 mg ibuprofen three times a day, compression wraps and a neoprene knee sleeve. No change in the swelling was noticed, and he continued to have decreasing ROM along with the continued anterior knee pain thus the reason he sought care. At no time did the patient have any erythema, warmth or other signs of infection and was systemically well with an otherwise negative review of systems. FIGURE 1. View largeDownload slide Prepatellar bursal swelling after two previous aspirations. Note that the appearance was exactly the same as the initial presentation. FIGURE 1. View largeDownload slide Prepatellar bursal swelling after two previous aspirations. Note that the appearance was exactly the same as the initial presentation. On physical examination, the right anterior knee had a large non-erythematous swelling in the prepatellar region that was neither indurated nor painful to palpation. The remainder of his knee exam was normal to include ligamentous and meniscal testing. Point of care ultrasound confirmed a large non-loculated anechoic swelling confined to the prepatellar space and specifically no evidence of an intra-articular effusion. Treatment options were discussed and the patient elected to proceed with a therapeutic ultrasound-guided aspiration. Under ultrasound guidance an 18 gauge needle was used to aspirate the bursa sac until it was completely collapsed. This was followed by multiple passes with the needle into the bursa sac by removing the needle from the sac but not withdrawing from the skin and the passing the needle again into the sac in order to fenestrate the bursa sac as to minimize any reaccumulation. A total of 38 mL of straw-colored, non-turbid fluid was aspirated. As the patient had no symptoms and physical exam was not concerning for an infection and ultrasound evaluation did not reveal any of the signs consistent with a crystal-induced bursopathy, no fluid analysis or cultures were sent. A compression wrap was left in place for 24 h, and the patient abstained from lower extremity exercises. The fluid re-accumulated within 5 d to pre-aspiration size. Another aspiration was performed utilizing ultrasound guidance until bursal collapse resulting in 40 mL of a similar aspirate as before followed by multiple bursal sac fenestrations as before. Within 7 d the fluid re-accumulated to pre-treatment dimensions. (Fig. 1) Following each aspiration patient adhered to lower extremity rest with the use of compression and naproxen 500 mg twice a day. Further treatment options were discussed which included serial aspirations, repeat aspiration with intrabursal corticosteroid injection, or referral for bursectomy. After thorough discussion, the soldier and his provider reviewed the literature and found a single case report of intrabursal sclerotherapy in two patients with recalcitrant prepatellar bursitis.1 After informed consent, the patient wished to proceed with the sclerotherapy. Under ultrasound guidance, the bursal sac was again aspirated till collapse with 32 mL of fluid being obtained. Then 6 mL of polidocanol was injected into the sac. The patient had a much slower reaccumulation of swelling and at the 2 wk follow-up the procedure was repeated. Ultrasound revealed new loculation of the bursal space (Fig. 2), which was believed to be the result of the initial sclerosant injection. This time only 20 mL of fluid was obtained and another 4 mL of polidocanol was injected (Fig. 3). The patient has had no reaccumulation of the fluid as of 10 mo post-procedure and has resumed all his normal activities with no symptom limitation. FIGURE 2. View largeDownload slide Ultrasound image after three aspirations and one sclerosing agent injection. FIGURE 2. View largeDownload slide Ultrasound image after three aspirations and one sclerosing agent injection. FIGURE 3. View largeDownload slide Ultrasound image immediately following the fourth aspiration and just prior to the second sclerosing agent injection. FIGURE 3. View largeDownload slide Ultrasound image immediately following the fourth aspiration and just prior to the second sclerosing agent injection. DISCUSSION Bursae are closed fluid filled sacs with an inner synovial membrane that provide a near frictionless glide between two tissue layers. Bursitis is a common complaint of accumulation of fluid in the bursa with or without inflammation that can be either septic or aseptic.2 Though prepatellar bursitis is a relatively common complaint, it is underreported in the literature, and there is a paucity of studies available.2,3 Many of these studies extrapolate findings in olecranon bursitis to the prepatellar bursa given the commonalities between the two conditions.2 The clinician must ensure that the bursa is not infected and if any doubt exists, aspiration with laboratory analysis must be performed. Septic bursa requires incision and drainage along with antibiotics. Non-septic prepatellar bursitis is a sterile inflammation with serous fluid accumulation within the bursa. This is commonly a result of acute or chronic trauma, crystal deposition, or systemic inflammatory diseases.1,2,4–7 Prepatellar bursitis is most commonly caused by friction between the dermal layers and the patella, or compressive forces from direct trauma. Athletes and professions that expose the individual to repetitive knee trauma are most at risk for developing prepatellar bursitis. The condition usually resolves with rest and protection of affected joint from subsequent trauma.2,4,6,8,9 Common initial treatments typically consist of compression and nonsteroidal anti-inflammatory drugs. Aspiration is controversial due to a high rate of reaccumulation and risk for causing a septic bursa. When aspiration is done, many experts recommend intraburasl steroids in addition.2,3 Surgery is typically reserved for recalcitrant cases of non-septic bursitis. Possible complications associated with surgery are reduced ROM, scar pain, chronic sinus tract formation, and prolonged immobilization with delay in return to sport.2,7 Additional treatment modalities have been described in the literature to include drain placement, autologous blood patch, and sclerotherapy.1,2,5,10 A 2009 case report describes two cases of chronic prepatellar bursitis refractory to aspiration and intrabursal corticosteroids, that was successfully treated by intrabursal injection of the sclerosing agent sodium morrhuate.1 In our illustrated case, the sclerosing agent polidocanol was successfully used. The selection was based more on the local hospital formulary than any difference between agents as systematic reviews of randomized trials have found no evidence to support one sclerosant over another.11,12 Our case required two sclerotherapy treatments. The authors are also aware of the successful use of doxycycline as a sclerotherapy agent in Morel-Lavallee lesions and extensive use in post-surgical lymphoceles.13 Risks of sclerotherapy include tissue necrosis if the injectant is not contained within the bursal sac. It is unclear at this time when consideration for sclerotherapy should be performed, whether at initial presentation, or after a single reaccumulation following therapeutic aspiration. We suggest that if significant fluid reaccumulation ensues after a successful aspiration, that the next step should be sclerotherapy. We based that on the increased risk of infection or injury with multiple aspirations. We further suggest that this an area ripe for study to make evidence based recommendations. REFERENCES 1 Ike RW: Chemical ablation as an alternative to surgery for treatment of persistent prepatellar bursitis. J Rheumatol 2009; 36( 7): 1560. Google Scholar CrossRef Search ADS PubMed 2 Baumbach SF, Lobo CM, Badyine I, Mutschler W, Kanz KG: Prepatellar and olecranon bursitis: literature review and development of a treatment algorithm. Arch Orthop Trauma Surg 2014; 134( 3): 359– 70. Google Scholar CrossRef Search ADS PubMed 3 Kim JY, Chung SW, Kim JH, et al. : A randomized trial among compression plus nonsteroidal antiinflammatory drugs, aspiration, and aspiration with steroid injection for nonseptic olecranon bursitis. Clin Orthop Relat Res 2016; 474( 3): 776– 83. Google Scholar CrossRef Search ADS PubMed 4 Mysnyk MC, Wroble RR, Foster DT, et al. : Prepatellar bursitis in wrestlers. Am J Sports Med 1986; 14( 1): 46– 54. Google Scholar CrossRef Search ADS PubMed 5 Bricker D: Closed bursotomy for chronic prepatellar bursitis: a self-described case. J Clin Rheumatol 2010; 16( 4): 193– 4. Google Scholar CrossRef Search ADS PubMed 6 McAfee JH, Smith DL: Olecranon and prepatellar bursitis. Diagnosis and treatment. West J Med 1988; 149( 5): 607– 10. Google Scholar PubMed 7 Quayle JB, Robinson MP: An operation for chronic prepatellar bursitis. J Bone Joint Surg Am 1976; 58-B( 4): 504. Google Scholar CrossRef Search ADS 8 Kasper DL: Harrison’s Principles of Internal Medicine , Vol 19th. New York, McGraw Hill Education, 2015. 9 Moore LK, Dalley AF, Agur AM: Clinically Oriented Anatomy , Vol 7th. Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014. 10 Nardella FA: Blood patch treatment for prepatellar bursitis (housemaid’s knee). N Engl J Med 1982; 306( 25): 1553. Google Scholar PubMed 11 Schwartz L, Maxwell H: Sclerotherapy for lower limb telangiectasias. Cochrane Database Syst Rev 2011; ( 12): CD008826. 12 Tisi PV, Beverley C, Rees A: Injection sclerotherapy for varicose veins. Cochrane Database Syst Rev 2006; ( 4): CD001732. 13 Tejwani SG, Cohen SB, Bradley JP: Management of Morel-Lavallee lesion of the knee: twenty-seven cases in the National Football League. Am J Sports Med 2007; 35( 7): 1162– 7. Google Scholar CrossRef Search ADS PubMed Published by Oxford University Press on behalf of Association of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US.
Military Medicine – Oxford University Press
Published: May 24, 2018
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