What is the treatment for recurrent prepatellar bursitis?

Treatment of Recurrent Prepatellar Bursitis

Conservative management should be the first-line treatment for recurrent prepatellar bursitis, with surgery reserved for patients who have failed conservative therapy. 1

Initial Conservative Management

Activity Modification and Protection

• Relative rest to prevent further damage and promote healing 1
• Avoid kneeling or direct pressure on the affected area
• Consider protective padding or knee pads when kneeling is unavoidable, especially for those whose occupation requires kneeling 2

Physical Interventions

• Cryotherapy (ice) for acute pain relief
  • Apply melting ice water through a wet towel for 10-minute periods 1
• Elevation of the affected area to reduce swelling 1
• Compression with elastic bandage to control effusion

Medications

• NSAIDs for short-term pain relief
  • Effective for reducing inflammation and pain
  • Note: While effective for acute symptoms, NSAIDs have no effect on long-term outcomes 1
• Acetaminophen as an alternative for those who cannot tolerate NSAIDs

Aspiration

• Aspiration may be considered for significant effusion
• Important caveat: Bursal aspiration of non-infectious prepatellar bursitis carries risk of iatrogenic septic bursitis and is generally not recommended unless necessary 3

Management of Specific Types of Recurrent Bursitis

Non-infectious Recurrent Bursitis

1. Continue conservative measures for 6-8 weeks
2. If inadequate improvement after conservative therapy:
   • Consider corticosteroid injection
   • Note: While locally injected corticosteroids may be more effective than oral NSAIDs for acute pain relief, they do not alter long-term outcomes 1

Septic Prepatellar Bursitis

1. Bursal aspiration with fluid analysis (Gram stain, culture, cell count, crystal analysis) 3
2. Antibiotics effective against Staphylococcus aureus (most common pathogen) 3
3. Splinting and intravenous antibiotics with or without aspiration are usually successful 4
4. For patients who are not acutely ill, outpatient oral antibiotics may be considered 3
5. For acutely ill patients, hospitalization with intravenous antibiotics is recommended 3

Surgical Management

Surgical intervention should be reserved for cases that have failed conservative therapy for 3-6 months 1. Options include:

1. Bursectomy - Complete removal of the bursa

   • Caution: Open bursectomy has been associated with skin necrosis and other wound complications 5

2. Endoscopic bursectomy

   • Less invasive alternative with potentially better cosmetic and functional results
   • Studies show good outcomes with endoscopic treatment under local anesthesia 6
   • Advantages include shorter recovery time and lower risk of skin complications

Follow-up and Prevention

• Address underlying factors that may contribute to recurrence:

  • Occupational modifications for those who kneel frequently
  • Proper protective equipment when kneeling is unavoidable
  • Treatment of any predisposing skin conditions or fissures 1

• Monitor for recurrence, especially in patients with occupational risk factors

  • Patients who kneel at work may continue to have symptoms even after successful treatment 4

Treatment Algorithm for Recurrent Prepatellar Bursitis

1. Start with conservative measures (rest, ice, elevation, NSAIDs) for 6-8 weeks
2. If no improvement, consider corticosteroid injection (for non-septic bursitis)
3. For septic bursitis, use appropriate antibiotics and consider aspiration
4. If symptoms persist after 3-6 months of conservative management, consider surgical referral for possible bursectomy
5. For recalcitrant cases, endoscopic bursectomy may offer better outcomes than open bursectomy

Remember that patients with occupational risk factors may require ongoing preventive measures even after successful treatment to prevent future recurrences.