CHAPTER 5 Arthroscopic Resection of the Olecranon Bursa
A prominent and painful olecranon bursa occurs as a result of inflammation. The cause is often repetitive trauma with thickening of the bursal wall, and there may be fibrinous loose bodies within the bursa. Other rheumatologic conditions, such as rheumatoid arthritis or gout, are often associated with olecranon bursitis.
PATIENT EVALUATION
History and Physical Examination
The bursa lies over the point of the olecranon. A general medical history and physical examination are carried out and followed by specific assessments. When the bursa wall is markedly thickened and especially when there are fibrinous loose bodies, it usually does not respond to conservative management. Resection of the bursa should be considered. Infection and other rheumatologic conditions should be excluded.
TREATMENT
Indications and Contraindications
The main indication for surgery is a bursa that has failed to respond to conservative management. A previously infected bursa with a thickened wall should be removed to prevent further episodes. When the bursa wall is markedly thickened and especially when there are fibrinous loose bodies, it usually does not respond to conservative management, and resection of the bursa should be considered.
Arthroscopic resection should not be carried out in the presence of infection. Infection in the bursa should first be eradicated with débridement and antibiotics. An acutely infected bursa should be drained. Initial drainage can be achieved with open or arthroscopic approaches (with limited débridement). After the infection has been eradicated, a formal arthroscopic bursal excision can be perfumed safely.
Before performing arthroscopic resection, significant rheumatologic conditions such as rheumatoid arthritis or gouty arthritis should be excluded. In this situation, the bursa pathology is likely to recur, and this represents a relative contraindication to resection.
Conservative Management
The initial management for olecranon bursitis is conservative. The patient should be given a trial of nonsteroidal anti-inflammatory drugs (NSAIDs). The bursa may be aspirated under sterile conditions, and cortisone can be injected into the bursa. In many cases, bursitis will resolve. Use of a compression wrap or sleeve helps to decrease the swelling. The use of topical NSAIDs has not been clearly defined.
Open Excision
The alternative to arthroscopic resection is open resection of the bursa. There have been no comparisons of open and arthroscopic treatment. However, open treatment does involve a relatively large incision, with the attendant risk of wound complications such as poor healing.1 Patients may be left with residual hypersensitivity over the scar. However, it usually is considered a satisfactory alternative treatment in the absence of the necessary arthroscopic skills.
Control of Septic Bursitis
In a patient with septic bursitis, the sepsis should be controlled before carrying out an arthroscopic resection. The study from Stell2 indicated that acute olecranon septic bursitis could be managed on a conservative basis in many cases. The principle is to determine the infective agent. An aspirate of the bursa should be carried out with cultures and sensitivity tests performed.
Appropriate intravenous antibiotics may be given in the emergency department, followed by oral antibiotics. The patient needs careful observation. If the infection fails to resolve, the area may require surgical drainage.
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