Arthroscopic Resection of the Olecranon Bursa

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CHAPTER 5 Arthroscopic Resection of the Olecranon Bursa

Darrell J. Ogilvie-Harris, Wayne S.O. Palmer

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.

Diagnostic Imaging

Plain radiographs can rule out significant bony pathology underneath the bursa. They are useful in detecting arthritis in the joint. Other imaging modalities are probably not useful unless specifically indicated.

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.

Stell2 showed that most patients with acute septic bursitis could be managed conservatively without the need for surgical intervention. If intervention is required, we recommend drainage of the bursa and allowing it to heal.

After the infection has been eradicated, an arthroscopic bursectomy or open bursectomy can be carried out under intravenous antibiotic coverage. We do not favor bursal resection in the presence of acute infection.

Arthroscopic Technique

The arthroscopic procedure is carried out under general anesthesia. A tourniquet is used. Although we have favored using a general anesthesia, there is no contraindication to using a regional technique. The procedure is done in the following steps:

1. Bursal distention. A needle is introduced into the bursa, and saline is injected to distend it. This may not be necessary if there is marked fluid in the bursa already. Distention of the bursa helps significantly in entering with the arthroscope.
2. Portals. The arthroscopic portals are proximal to the bursa (Fig. 5-1). Direct entry into the bursa lets the bursa collapse around the arthroscope and makes resection difficult. The portals therefore are started approximately 2 cm proximal to the margin of the bursa. The arthroscope is then introduced subcutaneously with a sharp obturator into the bursal sac (Fig. 5-2). Low pressure is used to prevent overdistention of the bursa (Fig. 5-3). A second portal is used to introduce a 4.5-mm, full-radius resector (Fig. 5-4). We favor using a curved resector to get around all areas of the bursal sac.
3. Removal of the bursal sac. We progressively remove the thickened bursal sac (Figs. 5-5 and 5-6). We start off on the olecranon surface and remove the sac until we can see the fibers of the triceps tendon (Fig. 5-7). We then progressively remove the bursal sac from the peripheral rim and then remove the bursal sac from the subcutaneous area. Care is taken not to perforate the skin in this area (Fig. 5-8).
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FIGURE 5-1 The positions of the portals are marked. They are 2 cm proximal to the bursal sac medially and laterally. The elbow is flexed slightly to gain access. The patient is supine with the arm across the chest. Notice that the surgeon’s initials are used to identify the side to be scoped in keeping with the World Health Organization’s recommendations.

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FIGURE 5-2 Bursal fluid drains as the scope enters a distended bursa.

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FIGURE 5-3 The arthroscope is introduced into the bursa with transillumination. Low pressure is used to prevent overdistention of the bursa.

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FIGURE 5-4 A second portal is used to introduce the arthroscope and shaver into the bursal sac.

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FIGURE 5-5 The view inside the olecranon bursa shows a thickened bursal sac with villous hyperplasia.

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FIGURE 5-6 A 4.5-mm resector used for removing villous tissue can be seen at the 1-o’clock position.

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FIGURE 5-7 The arthroscopic view shows the triceps after bursal tissue has been removed. Notice the shiny fibers of the triceps tendon after stripping the bursal sac.

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FIGURE 5-8 The bursal tissue has been resected, and the thin skin overlying the bursa is intact. Surgeons must take care not to penetrate the skin.

After completely removing the bursa, we remove the arthroscope but leave the shaver in situ. The tourniquet is then released. We ensure there is minimal or no residual blood in the resected area by sucking through the shaver tip.

The portals are then closed with nylon. Marcaine is injected locally into the portals, and a compressive soft tissue dressing is applied over the olecranon.

PEARLS& PITFALLS

• The major problem is achieving insufflation of the bursa, and the key is to inject saline into the bursa before inserting the arthroscope, which is introduced sharply to get it into the bursa.
• After the bursa has been penetrated by the arthroscope, low-pressure irrigation can keep the bursa patent for resection without overdistending the surrounding tissue.
• No one knows how much of the bursa must be resected to prevent disease recurrence. Avoid perforating the thin olecranon skin, because this can delay healing.
• Check the transillumination of the bursa and the arthroscopic view as you proceed.
• Resect the bursa until the shiny fivers of the triceps tendon are seen.
• Ensure patients do not have a rheumatologic disease, such as gout or rheumatoid arthritis, because they have a high recurrence rate.
• Avoid arthroscopic resection in the face of an infection. Treat the septic process first, and resect the bursa later.
• Avoid damage to the ulnar nerve. Carefully identify and mark the nerve preoperatively.

Postoperative Management

During the first 7 to 10 days, the patient wears an elastic compressive bandage. The bandage is taken off only for hygiene. It is important to keep some compression locally over the bursal area to prevent re-accumulation of blood and fluid.

At the end of 7 to 10 days, the sutures are removed. The patient is then allowed to mobilize the elbow. However, he or she should avoid direct contact on the point of the elbow for about 6 weeks to allow healing.

OUTCOMES AND CONCLUSIONS

There are only three reported arthroscopic series in the literature. In the report by Nussbaumer and colleagues,3 nine patients had resection of the olecranon bursa. There were no complications. In the report by Kerr and Carpenter,4 six patients had resection of the olecranon bursa, with complications occurring in two patients; one had gouty arthritis, and the other had CREST syndrome (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia), a limited form of scleroderma. In the report by Ogilvie-Harris,5 there were 31 cases of olecranon bursitis. Eight-six percent of the patients had no residual pain. There was residual pain over the olecranon in the remaining patients. In an unpublished review, another 14 cases were done with no complications or recurrences. These results indicate that the arthroscopic resection of the olecranon bursa can be a highly successful procedure.

REFERENCES

1. Degreef I, De Smet L. Complications following resection of the olecranon bursa. Acta Orthop Belg. 2006;72:400-403.

2. Stell IM. Management of acute bursitis: outcome study of a structured approach. J R Soc Med. 1999;92:516-521.

3. Nussbaumer P, Candrian C, Hollinger A. Endoscopic bursa shaving in acute bursitis. Swiss Surg. 2001;7:121-125.

4. Kerr DR, Carpenter CW. Arthroscopic resection of olecranon and prepatellar bursae. Arthroscopy. 1990;6:86-88.

5. Ogilvie-Harris DJ, Gilbart M. Endoscopic bursal resection: the olecranon bursa and prepatellar bursa. Arthroscopy. 2000;16:249-253.

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