Ask Dr. Geier – Prepatellar Bursitis

I was on trauma call for orthopaedics at MUSC this weekend. I was preparing to start a hip fracture surgery when the rep for the nail we were using to fix the fracture asked me about my Post and Courier columns. He asked when I was planning on switching from my sports medicine surgeon role to a full-time journalist and blogger.

David

Cindy in Hollywood, SC asks:

I had my right kneecap drained three times. Now it has a ball about the size of a large marble on top. It’s very hard. It is painful only if I run or walk a distance. It’s ugly to look at. Should I see about having it removed and can it be removed under local anesthesia?

The symptoms Cindy describes sound like prepatellar bursitis. The patella, or kneecap, has a small fluid-filled sac just outside of it to serve as sort of a shock absorber when kneeling or to prevent friction during knee range of motion. It is normally very thin. When it is inflamed, it bursa can become large and swollen. Typically swelling is the most common complaint, although the amount of swelling in front of the patella can become uncomfortable. Typically it is not red or warm unless it is an infected bursa, which happens occasionally.

Most patients with prepatellar bursitis do not remember any specific inciting event. It is often seen in manual laborers, such as carpenters, who kneel frequently. Frequent kneeling puts pressure on the bursa causing it to become inflamed and swollen. (A very similar circumstance happens in olecranon bursitis. The bursa at the tip of the elbow gets inflamed in truck drivers or people who ride in cars frequently with their elbows against the window or center console.)

Most of the time the treatment for prepatellar bursitis is symptomatic. I usually recommend that patients try icing the knee to decrease the inflammation and possibly try anti-inflammatory medications. I try to avoid drawing fluid off, if possible. In my experience, very little fluid is actually withdrawn, and it often comes right back. Also multiple attempts at draining the fluid potentially increases the risk of infecting the bursa, leading to a septic bursitis that often requires urgent surgery. Sometimes draining the fluid off and injecting cortisone one time to try to keep the inflammation from returning is an option.

Drain fluid for prepatellar bursitis?

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Occasionally nonsurgical treatments including rest, ice, anti-inflammatory medications, avoiding direct pressure on the bursa, and even repeat attempts at drainage are unsuccessful. In this case surgery can be useful. Typically the surgery involves making a small incision over the bursa and removing the entire bursa. This is usually done in hospitals or surgery centers to minimize the chance of infection. It also does not usually require full general anesthesia but can often can be done with a combination of local anesthesia and sedation or a regional nerve block. Removing the bursa surgically usually successfully resolves the problem.

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