What is the recommended treatment for prepatellar bursitis?

Treatment of Prepatellar Bursitis

The recommended treatment for prepatellar bursitis should follow a stepwise approach, beginning with conservative measures including rest, NSAIDs, and compression, progressing to aspiration and antibiotics for septic cases, with surgery reserved only for refractory cases. 1

Initial Assessment and Classification

When evaluating prepatellar bursitis, it's crucial to determine whether the condition is:

1. Non-septic (aseptic) - approximately 2/3 of cases
2. Septic (infectious) - approximately 1/3 of cases

Differentiating Features

• Suggestive of septic bursitis:
  • Fever >37.8°C
  • Skin lesions or breaks over the bursa
  • Recent trauma with skin break
  • Prebursal temperature difference >2.2°C
  • Purulent aspirate
  • White cell count >3,000 cells/μl in aspirate
  • Positive Gram stain or culture

Treatment Algorithm

1. Conservative Treatment (First-Line for Non-Septic Bursitis)

• PRICE protocol:
  • Protection
  • Rest
  • Ice (cryotherapy)
  • Compression
  • Elevation
• NSAIDs for pain and inflammation
• Activity modification - avoid kneeling

2. Aspiration

• Indicated for:
  • Diagnostic purposes to rule out infection
  • Therapeutic relief of significant effusion
  • Collection of fluid for analysis in suspected septic cases

3. Treatment Based on Classification

For Non-Septic Bursitis:

• Continue conservative measures for 2-3 weeks
• For persistent cases or those with high athletic/occupational demands, consider:
  • Bursal aspiration with corticosteroid injection
  • Continued activity modification

For Septic Bursitis:

• Antibiotics - initially empiric coverage for Staphylococcus aureus (most common pathogen)
• Splinting of the knee
• Serial aspirations as needed
• Intravenous antibiotics for severe cases or those not responding to oral therapy 2

4. Surgical Management (Reserved for Refractory Cases)

Surgery should be considered only after failure of conservative treatment, particularly in:

• Chronic/recurrent cases
• Severe septic bursitis not responding to antibiotics and aspiration
• Cases with occupational requirements necessitating return to kneeling activities

Surgical options include:

• Endoscopic bursectomy - less invasive, allows faster recovery (average return to work in 18 days) 3, 4
• Open bursectomy - for severe or complicated cases

Special Considerations

• Occupational factors: Patients who kneel at work (e.g., concrete workers, carpet layers) have higher recurrence rates and may require more aggressive management 2
• Athletes: Professional athletes with prepatellar bursitis may benefit from endoscopic bursectomy, allowing return to sport in approximately 24 days 3
• Chronic cases: Patients with preexisting chronic bursitis have poorer outcomes and may require surgical intervention more frequently 2

Common Pitfalls to Avoid

1. Misdiagnosing septic vs. non-septic bursitis - Always consider aspiration for diagnosis in unclear cases
2. Premature surgical intervention - Evidence does not support immediate bursectomy for septic bursitis 1
3. Inadequate antibiotic treatment - Oral antibiotics alone may be insufficient for septic bursitis; consider IV antibiotics when indicated 2
4. Neglecting occupational factors - Patients who kneel at work need special consideration for prevention of recurrence

By following this stepwise approach to treatment, most cases of prepatellar bursitis can be successfully managed with conservative measures, reserving more invasive interventions for refractory cases.