What is the gold standard treatment for olecranon bursitis with significant fluid collection, septa, and local hypervascularity after failed conservative management?

Management of Refractory Olecranon Bursitis with Significant Fluid Collection

For olecranon bursitis with significant fluid collection (4.8 × 1.9 cm with septa and hypervascularity) that has failed conservative management, surgical intervention through endoscopic bursectomy is the gold standard treatment due to superior outcomes and fewer complications compared to open bursectomy. 1, 2

Diagnostic Confirmation

Before proceeding with surgical intervention, confirm the diagnosis with:

• Ultrasound: Useful for confirming bursal fluid collection, evaluating bursal wall thickening, and guiding aspiration if needed 1
• Aspiration with fluid analysis: To rule out septic bursitis by sending fluid for:
  • Cell count and differential
  • Gram stain and culture
  • Crystal analysis to exclude gout or pseudogout

Treatment Algorithm

1. Final Conservative Management Trial (if not exhausted)

• NSAIDs: Naproxen 500 mg twice daily (not exceeding 1250 mg initially, then 1000 mg thereafter) 1
• Rest, ice application (10-minute periods through a wet towel), compression, and elevation
• Activity modification to reduce pressure on the affected elbow
• Consider one-time aspiration without corticosteroid injection

2. Surgical Management (Gold Standard for Refractory Cases)

Endoscopic Bursectomy (Preferred)

• Advantages 2:
  • Higher patient satisfaction scores (8.5 vs 5.29 for open procedure)
  • Shorter hospitalization time (0.56 days vs 1 day)
  • Better cosmetic results
  • Fewer wound healing complications
  • Comparable operative time to open procedure

Open Bursectomy (Alternative)

• Consider when endoscopic expertise is unavailable or in cases with:
  • Significant septation that may complicate endoscopic removal
  • Suspected infection requiring more extensive debridement
• Be aware of higher complication rates:
  • Wound healing problems (reported in up to 27% of cases) 3
  • Recurrence rates (reported in up to 22% of cases) 3

Post-Surgical Management

1. Immediate post-operative care:

   • Compression dressing for 48-72 hours
   • Elevation of the extremity
   • Early range of motion exercises to prevent stiffness

2. Follow-up care:

   • Remove sutures at 10-14 days
   • Progressive return to activities over 2-4 weeks
   • Full return to normal activities typically by 6 weeks

Important Considerations and Pitfalls

• Avoid corticosteroid injections: Associated with increased complications including skin atrophy, infection, and chronic local pain 1, 4

• Rule out septic bursitis: If suspected, surgical intervention should be expedited, and appropriate antibiotics started

• Patient education: Counsel on prevention of recurrence through:

  • Avoiding direct pressure on the elbow
  • Using elbow pads during activities that might cause pressure
  • Ergonomic modifications at work/home

• Surgical complications to monitor:

  • Wound dehiscence
  • Infection
  • Recurrence
  • Nerve injury (particularly the ulnar nerve)

The evidence strongly supports endoscopic bursectomy as the gold standard for refractory olecranon bursitis, offering better outcomes with fewer complications compared to open surgical techniques 2, 5. The presence of septa and hypervascularity in this case further supports the need for definitive surgical intervention rather than continued conservative measures.