Clinical efficacy of endoscopic debridement combined with compression suture in the treatment of recalcitrant aseptic olecranon bursitis

Abstract

Purpose

To investigate the clinical efficacy of endoscopic debridement combined with compression suture in the treatment of aseptic olecranon bursitis.

Methods

A retrospective analysis was conducted on 28 patients, including 25 males and 3 females, who underwent endoscopic debridement combined with compression suture for the treatment of aseptic olecranon bursitis at Huzhou Central Hospital from February 2017 to January 2024. Visual analogue scale (VAS) scores, Mayo elbow function scores, complications, recurrence rates and wound scars were evaluated to assess the treatment efficacy.

Results

The average follow-up time was 12 ± 5 months (range: 5–22 months). The VAS score was slightly greater on postoperative day 1 than preoperatively, but this difference was not statistically significant. Compared with the preoperative level, the VAS score was significantly lower at 2 weeks post-surgery, and the patients were generally free of pain. The patients’ Mayo elbow function score was significantly improved at 2 weeks after the operation, and their elbow function was generally normal at 1 month after the operation. At the final follow-up, no recurrence or obvious scarring was found in any of the patients, and all of them exhibited normal elbow function without any reported pain.

Conclusion

Endoscopic debridement combined with compression suture for the treatment of aseptic olecranon bursitis has several advantages: simple operation, minimal invasiveness, minimal postoperative pain, rapid recovery, a low recurrence rate, and satisfactory overall efficacy.

Level of evidence Level IV

Introduction

Olecranon bursitis is a common benign disease of the elbow that is caused primarily by microtrauma [1]. A systematic review suggested that nonsurgical management is the optimal treatment for olecranon bursitis, because it has a significantly higher rate of clinical resolution and lower rates of overall complications [2]. Surgical treatment can be considered for patients who fail to respond to conservative treatment. Open bursectomy may result in substantial surgical trauma, since the bursa is situated in a subcutaneous and superficial position, which can easily cause skin damage during the operation. In addition, open bursectomy often requires postoperative drainage, and results in scarring on the posterior median of the elbow, which in turn can affect joint movement and cause discomfort during desk work. A study by Gokhan reported that compared with open bursectomy, endoscopic bursectomy is a time-saving and efficient surgical treatment option for olecranon bursitis [3]. Timothy noted that open bursectomy can potentially cause complications such as skin necrosis, wound dehiscence, and the development of cutaneous fistulas, which may necessitate repeat surgery[4].While endoscopic treatment of olecranon bursitis has shown good results, there is still a certain recurrence rate[5, 6]. The purpose of this study was to evaluate whether endoscopic debridement combined with compression suture can lead to improved outcomes and a reduced recurrence rate in patients with aseptic olecranon bursitis.

Patients and methods

Patients with olecranon bursitis who underwent endoscopic debridement combined with compression suture were retrospectively evaluated at Huzhou Central Hospital from February 2017 to January 2024.

Inclusion criteria

(1) Olecranon bursitis was confirmed by ultrasound; (2) strictly conservative treatments had been applied for more than three weeks; and (3) the follow-up time was more than three months.

Exclusion criteria

(1) Localized infectious symptoms, including redness, heat, and pain were present; (2) the maximum diameter of the bursa was less than 2 cm; and (3) the olecranon bursa was caused by gout, rheumatoid arthritis, or autoimmune diseases.

General information

In total, 28 patients were recruited consecutively; they comprised 25 males and 3 females, with an average age of 61.3 years (range: 45–76 years). All the cases were aseptic and caused by microtrauma. Treatments, including ice, rest, and anti-inflammatory and analgesic drugs, were used in acute cases during the first 3–5 days. Aspiration was performed in chronic cases with no improvement for more than two weeks, after which an elastic bandage was used to prevent swelling and effusion. Surgical treatment was recommended for patients who were unresponsive to conservative treatments. The average maximum diameter of the bursas was 3.8 ± 1.4 cm (range: 2–8 cm). The average time interval before surgery was 34.3 ± 7.6 days (range: 22–52 days).

Surgical methods

All the surgeries were performed by a single surgeon. Under general anaesthesia, the patient was placed in the lateral position with an axillary roll in place. All prominences were well padded using a beanbag, and the elbow was positioned without a tourniquet. The patient was then prepped and draped in the standard sterile fashion. The ulnar nerve and humeral epicondyles were marked before the operation, with vigilant protection of the ulnar nerve maintained throughout the operation. Two 0.5 cm incisions were made distally medial and distally lateral to the bursa along the dermatoglyph (Fig. 1).

Fig. 1

The ulnar nerve and humeral epicondyles are marked prior to the operation. Two incisions are delineated—one distally medial and one distally lateral to the bursa—following the natural skin creases

The incisions were created for use as surgical portals. The surgeon then inserted the endoscope through one incision and the shaver through the other incision into the bursa. The endoscopic view revealed a red inflammatory reaction on the bursal wall, which was always accompanied by multiple sites of papillary hyperplasia and fibrous cords connected in the bursa. The fibrous adhesions in the capsule were removed by the shaver (Fig. 2), and the inferior bursal wall was appropriately scraped to avoid overzealous resection which could lead to postoperative haemorrhagic complications. The papillae on the superior bursal wall were then scraped, and the bursal wall was roughened with a spatula rather than with a shaver to protect the skin. A radiofrequency probe was recommended to thoroughly ablate the residual papillary hyperplasia and inferior inflammatory bursal wall, thereby reducing postoperative bleeding and roughening the bursal wall (Fig. 3).

Fig. 2 

The fibrous adhesions within the capsule are debrided via a shaver

Fig. 3

A radiofrequency probe is used to perform thoroughly ablation of the papillary hyperplasia and the inflamed inferior bursal wall

The probe was inserted through the other portal to ablate the residual synovium. The surgeon then inserted a 2–0 absorbable suture through the centre of the bursa to stitch the skin and inferior bursal wall together under endoscopic monitoring to reduce the bursal cavity. For large bursas, a cross stitch was employed. The endoscope was removed, and the remaining liquid was completely evacuated. The suture knots were subsequently secured, but not excessively tightened to avoid obvious postoperative scarring. The incisions were retained without stitching to facilitate postoperative drainage (Fig. 4).

Fig. 4

Compression suture and incisions used as postoperative drainage holes

Next, compressive wound dressings were applied. The patients were instructed to perform flexion and extension exercises of their fingers and wrists postoperatively but were advised to limit flexion of the elbow beyond 90° within the first 2 weeks.

Evaluation of the curative effect

The VAS scores (pre-operation, 1 day, 2 weeks), postoperative complications, and Mayo elbow function scores (pre-operation, 2 weeks, 1 month) were recorded and statistically analysed to evaluate the patients’ recovery of elbow joint function. At the final follow-up, the patients’ pain levels and functional status were evaluated and the status of recurrence and scarring was documented.

Statistical methods

All the statistical analyses were performed via SPSS Version 20.0. The normality of the data was tested. Descriptive statistics included the mean and standard deviation (SD) for continuous variables and percentages for categorical variables. Rank-sum tests were used to compare the preoperative and postoperative VAS and Mayo scores. A p-value less than 0.05 was considered statistically significant.

Results

All the operations were completed under endoscopy, and there was no instance of postoperative nerve injury or incisional infection. On the first day after the operation, the VAS score (Fig. 5) was slightly higher than that before the operation, but the difference was not statistically significant. There was no obvious pain reported by the patients in the immediate postoperative period. Two weeks after the operation, the VAS score was significantly lower than that before the operation (P < 0.01) and the patients were essentially free of pain. However, the range of motion of the elbow joint was slightly lower postoperatively than before the operation because of partial immobilization at that time. The Mayo score (Fig. 6), at 2 weeks after the operation was significantly greater than that before the operation (P < 0.05). One month after the operation, the Mayo elbow function score was further improved by rehabilitation exercise, significantly exceeding the preoperative score (P < 0.01) and essentially returning to normal levels. Only 2 patients experienced residual mild pain at the one-month follow-up, which fully resolved by the final follow-up. The average follow-up duration was 12.1 months (range: 5–22 months). At the final follow-up, no patient demonstrated any recurrence or conspicuous scar hyperplasia after the operation, and all patients exhibited normal elbow function without any reported pain.

Fig. 5

Visual analogue scale. n = 28; ns indicates not significant; ** indicates P < 0.01

Fig. 6

Mayo function score. n = 28; * indicates P < 0.05; ** indicates P < 0.01

Discussion

Although endoscopic bursectomy for olecranon bursitis has demonstrated favourable outcomes, postoperative complications and a notable recurrence rate persist [5,6,7]. Our study demonstrated that applying endoscopic debridement combined with compression suture to treat olecranon bursitis results in reduced surgical trauma, minimal postoperative pain, rapid functional recovery, the absence of recurrence and complications, and overall satisfactory outcomes. In our patients, the VAS scores were assessed on postoperative day 1, and there was no additional pain due to the procedure. These findings indicated that our surgical protocol effectively reduced surgical trauma and postoperative pain. The Mayo functional scores for the elbow joint significantly improved two weeks after surgery, and were almost normal one month after surgery, which met the requirements of patients for rapid recovery and further confirmed the effectiveness of our surgical protocol.

Aseptic olecranon bursitis is a prevalent disease that typically arises from microtrauma. The condition is often self-limiting and resolves with conservative management such as rest, ice, compression, orthotic devices, and nonsteroidal anti-inflammatory medications [1, 8]. Corticosteroid injection carries substantial risks, and is therefore not routinely recommended for the treatment of aseptic bursitis [2, 9]. Surgical management is considered for patients who are refractory to nonoperative treatment. Bursectomy can be performed if symptoms persist despite conservative measures [1, 10]. Traditional open bursectomy is frequently complicated by skin injury, necrosis, hypoesthesia, scar hyperplasia and pain with elbow flexion [3, 4]. A retrospective analysis of 37 cases involving resection of the olecranon bursa revealed wound healing problems in 10 (27%) patients and recurrence in 8 (22%) patients [11]. A retrospective study by Jeffrey examined 28 patients who underwent endoscopic olecranon bursectomy for the treatment of recalcitrant olecranon bursitis [12, 13]. The patients in that study reported no recurrences or wound-healing complications and exhibited high levels of function and satisfaction following the procedure. However, during the surgery, the incisions were marked 2 fingerbreadths to the bursa and blunt dissection and tunneling deep to the adipose tissue were performed to create endoscopic portals to the bursa which may cause additional surgical trauma. The authors assessed single-question SANE scores in 20 patients at the last follow-up, and although most patients were satisfied with their function, the lowest reported score was 80% of the normal score. Chen described an extrabursal endoscopic technique in which the bursa was not entered but rather excised in its entirety under endoscopic vision [14]. However, in our assessment, this type of technique poses challenges in avoiding additional damage and may extend the operative duration. A retrospective study encompassing 150 patients analysed risk factors for revision surgery in the operative treatment of traumatic injuries of the olecranon and prepatellar bursa [5]. The main primary cause of reoperation was wound infection, which we believe may be closely associated with postoperative drainage. Rhyou et al. retrospectively reviewed 30 patients who underwent endoscopic olecranon bursal resection, and achieved excellent outcomes without recurrence [15]. A drainage tube was inserted into the portal to mitigate incision-related complications in those cases. However, the VAS score was not assessed in the early stage after surgery and, thus may not have reflected discomfort caused by the drainage tube.

In contrast to previous studies, we further assessed the VAS and Mayo scores in the early stage after the operation in our cases and the patients had positive experiences, which were attributed to the surgical techniques we applied. We operated within the bursa to minimize surgical trauma and simplify the procedure. Different manipulations of the superior and inferior bursal walls helped to decrease postoperative pain, prevent postoperative synovial fluid secretion, and reduce postoperative bleeding. The incisions were used as postoperative drainage portals, thereby avoiding postoperative discomfort associated with a dedicated drainage tube. Moreover, the compression suture effectively reduced the bursal cavity. During postoperative follow-up, there was no apparent scar hypertrophy caused by compression suture or surgical incisions. Overall, endoscopic debridement combined with compression suture for the treatment of recalcitrant aseptic olecranon bursitis effectively reduced surgical trauma, accelerated recovery, and decreased recurrence rates.

Our research, however, has several limitations. There was an insufficient number of cases for meaningful comparisons, and all procedures were performed by a single surgeon. Thus, further long-term follow-up studies with large sample sizes and multiple centres are needed to conclusively establish the advantages of endoscopic debridement combined with compression suture in the treatment of aseptic olecranon bursitis.

Conclusion

Endoscopic debridement combined with compression suture for the treatment of aseptic olecranon bursitis is a safe, effective, and straightforward approach, with no apparent recurrence or other complications observed postoperatively.