What is the treatment for pre-patellar swelling?

Treatment of Pre-patellar Swelling

Begin with aspiration and Gram stain/culture to rule out septic bursitis, then proceed with conservative management including compression, NSAIDs, and activity modification; reserve surgical excision for chronic cases failing 3-6 months of conservative treatment.

Initial Assessment and Diagnostic Approach

• Aspirate all cases of prepatellar bursitis and perform Gram stain and culture, as 50% of septic cases show no clinical signs of infection 1
• The most common infecting organism is Staphylococcus aureus, typically penicillin-resistant 1
• Distinguish between acute traumatic, chronic, and septic bursitis through aspiration findings and clinical presentation 2, 3

First-Line Conservative Management (Non-Septic Cases)

• Apply compression to the affected knee to reduce fluid accumulation 4
• Prescribe oral or topical NSAIDs for pain relief and anti-inflammatory effects 5
• Implement activity modification by avoiding direct pressure and kneeling activities that aggravate the condition 4
• Consider repeated aspiration with fenestration for symptomatic relief in cases with significant fluid accumulation 4

Management of Septic Prepatellar Bursitis

• Initiate intravenous antibiotics with splintage as oral antibiotics prove inadequate in many cases 3
• Aspiration of the bursa combined with IV antibiotics is usually successful 3
• Perform surgical drainage if the infection fails to respond to IV antibiotics and aspiration (required in approximately 19% of cases) 3

Advanced Treatment for Recalcitrant Cases

• Consider ultrasound-guided intrabursal sclerotherapy with polidocanol for non-septic bursitis failing conservative management, with repeat injection at 2 weeks if needed 4
• This approach has demonstrated sustained resolution at 10 months post-procedure with no fluid reaccumulation 4

Surgical Management

• Reserve surgical excision for chronic massive prepatellar bursitis that has been present for extended periods (months to years) and interferes with daily activities 2
• Surgical excision involves removal of a thick-walled, well-demarcated cyst that can be dissected from surrounding tissues with relative ease 2
• Perform surgery only after 3-6 months of failed conservative treatment 5

Expected Outcomes and Prognosis

• Patients with preexisting chronic bursitis or those who kneel at work have worse long-term outcomes, with continued symptoms months or years after infection 3
• Surgical excision for chronic cases shows no recurrence at 2+ years follow-up 2
• Median time lost for initial injury is only 4 days, but recurrences significantly increase total time lost 1

Critical Pitfalls to Avoid

• Never assume prepatellar bursitis is non-septic based on clinical appearance alone—always aspirate and culture 1
• Avoid relying solely on oral antibiotics for septic bursitis, as they frequently fail 3
• Do not proceed directly to surgery without an adequate trial of conservative management 5
• Recognize that patients with previous bursitis episodes have impaired bursal defense mechanisms and worse prognosis 1