What is the management of prepatellar bursitis?

Management of Prepatellar Bursitis

The management of prepatellar bursitis should focus on conservative treatment initially, with surgical intervention reserved for cases that fail to respond to conservative measures. 1

Understanding Prepatellar Bursitis

Prepatellar bursitis is inflammation of the bursa located anterior to the patella, between the patella and the skin. It commonly presents with:

• Anterior knee pain and swelling over the patella 1
• History of direct trauma, repetitive kneeling, or occupational activities requiring kneeling 1, 2
• Possible skin erythema and warmth, particularly in cases of septic bursitis 1

Diagnostic Approach

• Evaluate for potential causes:

  • Chronic microtrauma (most common) - especially in occupations requiring kneeling 1, 2
  • Acute trauma/hemorrhage 1
  • Infection (septic bursitis) 1, 2
  • Inflammatory conditions (gout, rheumatoid arthritis) 1

• Key diagnostic tests when infection is suspected:

  • Bursal aspiration with fluid analysis (Gram stain, crystal analysis, glucose, cell count, culture) 1
  • Blood tests (white blood cell count, inflammatory markers) 1
  • Ultrasonography to distinguish bursitis from cellulitis 1

Treatment Algorithm

1. Non-Infectious Prepatellar Bursitis

For acute traumatic/hemorrhagic bursitis:

• Rest, ice, elevation, and analgesics 1
• Aspiration may shorten symptom duration 1, 3
• Activity modification to avoid kneeling 1, 2

For chronic microtraumatic bursitis:

• Conservative management with:

  • Rest and activity modification 1
  • NSAIDs for pain relief 4, 1
  • Padding to protect the knee during activities 4, 3
  • Avoidance of bursal aspiration due to risk of iatrogenic infection 1

• Corticosteroid injections:

  • May be considered for persistent cases, though high-quality evidence for benefit is lacking 1, 3
  • Should be performed with strict aseptic technique 3

2. Septic Prepatellar Bursitis

• Initial treatment:

  • Antibiotics effective against Staphylococcus aureus (most common pathogen) 1, 2
  • Splinting and intravenous antibiotics with or without aspiration 2
  • Outpatient oral antibiotics for mild cases; intravenous antibiotics for acutely ill patients 1

• For non-responsive cases:

  • Surgical drainage may be required 1, 2
  • Consider repeated aspirations before proceeding to surgery 2

3. Refractory Cases

For bursitis that fails to respond to conservative treatment:

• Surgical bursectomy may be considered 5, 6
• Endoscopic bursectomy has shown good results with minimal scarring and complications 6
• Open surgical excision is an option for severe or recurrent cases 5

Special Considerations

• Patients with occupations requiring kneeling have higher recurrence rates and may need occupational modifications 2
• Pre-existing chronic bursitis may lead to prolonged symptoms even after appropriate treatment 2
• Careful differentiation from other knee pathologies (arthritis, tendinitis, fracture) is essential 5

Treatment Pitfalls to Avoid

• Avoid corticosteroid injections in suspected septic bursitis 1
• Do not aspirate chronic microtraumatic bursitis unnecessarily due to infection risk 1
• Inadequate antibiotic treatment of septic bursitis may lead to treatment failure 2
• Failure to address underlying causes (especially occupational factors) may result in recurrence 1, 2