Olecranon Bursectomy with De-epithelialized Advancement Flap Reconstruction: A Novel Surgical Approach

Chronic olecranon bursitis is a common condition that occurs when an excessive amount of fluid accumulates within the bursal cavity.[1] [2] Common causes of olecranon bursitis include trauma, infection, and inflammatory diseases such as rheumatoid arthritis and gout.[3] Although this condition occurs frequently, there is no standardized method of treatment, and management is often based on anecdotal experience.[1] Chronic olecranon bursitis is most commonly managed using conservative measures, such as ice, rest, compressions, aspiration, and corticosteroid injections, due to the high-complication and recurrence rates associated with surgery.[1] [3] Various surgical techniques have been described with poor outcomes. The most commonly described techniques in literature include a simple open bursectomy and endoscopic bursectomy.[3] [4] [5] Surgeons often avoid an open bursectomy due to its high-rates of complication. There are frequent occurrences of necrosis, subcutaneous fistulas, wound dehiscence, and issues involving the large, painful incision scar on an area vulnerable to trauma.[5] In 1990, Kerr developed an endoscopic method of removing the bursa.[4] This method reduces complications involved with wound healing, but it is hesitantly used for septic bursitis because of limited visibility to fully debride the infection.[5]

To overcome these problems, the authors present a novel surgical technique that involves an olecranon bursectomy with de-epithelialized advancement flap reconstruction. The excisional portion of the surgery resembles a classic open bursectomy. The patients are placed in a supine position and prepped in a typical sterile fashion. Local anesthesia is administered (1% Xylocaine, 1:100,000 epinephrine), and a tourniquet is placed to minimize blood loss. A longitudinal incision is made across the bursa, protecting the ulnar nerve. The olecranon bursa is then excised under direct vision and irrigated with saline ([Fig. 1A]). After excision, the tourniquet is released, and hemostasis is obtained. The novel element of this procedure is the complex wound closure. First, remaining portions of the capsule are closed in using horizontal mattress sutures to reduce the dead space; a Penrose drain is placed deep to this layer ([Fig. 1B]). Then, rather than merely cutting out excess skin, the most ulnar portion of the skin flap is de-epithelized ([Fig. 1C]) to be used for further dead space obliteration. A vest-over-pants advancement was done by first burying the de-epithelialized skin to the most radial part of the wound in using horizontal mattress sutures ([Fig. 1D]). This creates a double layer of tissue over the elbow defect. The overlying skin is trimmed as needed and closed using running sutures ([Fig. 1E]). The idea is to prevent wound dehiscence and bursitis recurrence by eliminating the dead space and creating a tight seal around the wound. Postoperatively, the elbow is splinted with 20 degrees flexion for 7 days, followed by ACE wrapping out to length for 14 days.

Fig. 1 Open bursectomy with a de-epithelialized advancement flap reconstruction: (A) Bursa excised under direct vision. (B) Remaining capsule closed in horizontal mattress and Pentose drain placed. (C) 2 × 7 cm de-epithelialized skin flap. (D) Vest-over-pants advancement. (d) Closed wound.

This technique was successfully performed on two patients with chronic olecranon bursitis. Patient 1, an 80-year-old male with a history of gout and alcoholism, presented with chronic right olecranon bursitis refractory to aspiration, antibiotic therapy and compression ([Fig. 2A]). Aspiration showed no organisms or crystals. Due to the recalcitrant nature of the bursa, he underwent olecranon bursa excision (measuring 6 × 4 cm) in October 2010, using the technique described above. The patient did very well and had no postoperative complications or recurrence for the rest of his life (6 year follow-up, [Fig. 2B]). Patient 2, a 66-year-old male, presented with chronic left olecranon bursitis of traumatic etiology. The patient sustained a stabbing injury to the upper extremity, resulting in an extremely painful olecranon bursa that continued to increase in size refractory to aspiration and compression ([Fig. 2C]). In March 2019, a 5 cm bursa was excised, using our previously described technique. Like patient 1, the patient did very well and had no postoperative complications or recurrence (5 months follow-up, [Fig. 2D]). For both patients, the wound healed beautifully, no pain or tenderness was experienced, and full range-of-motion and strength was recovered.

Fig. 2 Pre- and postoperative status. Patient 1: (A) Preoperative bursa measuring 6 × 4 cm. (B) 3-month follow-up anteroposterior (AP) view. Patient 2: (C) preoperative olecranon bursa measuring 5 cm. (D) 4-month follow-up.

This letter describes a novel surgical technique for management of chronic olecranon bursitis using de-epithelialized advancement flap reconstruction. This technique offers various advantages. First, the elimination the dead space around the olecranon using a de-epithelialized advancement flap and multilayer closure minimizes the risk of bursitis recurrence. Evidence is limited because of a cohort of two patients, but both had no recurrence, with one having a very long follow-up of 6 years. Second, the multilayer closure and underlying additional dermal layer secures skin closure and prevents typical wound-healing complications. Finally, because of the open technique, it can be advantageous in septic bursitis cases, because the surgeon can see if the infection is removed in its entirety.

The authors present a surgical technique and solution to a very challenging problem, and we hope it will be helpful to the wider community in order to treat future olecranon bursitis cases.

Publication History

Article published online:
17 September 2020

• References

• 1 Sayegh ET, Strauch RJ. Treatment of olecranon bursitis: a systematic review. Arch Orthop Trauma Surg 2014; 134 (11) 1517-1536
• 2 Blackwell JR, Hay BA, Bolt AM, Hay SM. Olecranon bursitis: a systematic overview. Shoulder Elbow 2014; 6 (03) 182-190
• 3 Meric G, Sargin S, Atik A, Budeyri A, Ulusal AE. Endoscopic versus Open Bursectomy for Prepatellar and Olecranon Bursitis. Cureus 2018; 10 (03) e2374
• 4 Kerr DR, Carpenter CW. Arthroscopic resection of olecranon and prepatellar bursae. Arthroscopy 1990; 6 (02) 86-88
• 5 Meade T, Briones M, AW F, Daily JM. Surgical outcomes in endoscopic versus open bursectomy of the septic prepatellar or olecranon bursa. Orthopedics 2019; 42 (04) e381-e384