For the therapeutic treatment of a bursitis (bursitis), surgical and conservative procedures can be distinguished. The selection of an appropriate procedure here depends on various factors. In principle, an inflammatory process can occur at any bursa (bursa sac) found in the human body. For the therapy, it is of decisive importance to consider the location and structure of the respective bursa. The bursa is a cleft-shaped cavity that is filled with fluid and can thus cause a reduction of an existing pressure load in the tissue. Because of this, a bursa is localized in the musculoskeletal system at sites of increased pressure load. The reduction of the pressure load is based on the structure of the bursa consisting of an outer connective tissue layer and an inner synovial layer. One of the functions of the synovial layer is to secrete synovium (“synovial fluid“) so that fluid-based pressure load reduction can occur. Bursitis can occur as a result of various pathogenesis (disease development). Although bursae (plural bursa) differ in their anatomic location, they still generally have a similar function, so surgical procedures for therapeutic treatment are very similar.
Indications (areas of application)
- Bursitis – surgical measure should be used in case of sonographically (in ultrasound) confirmed diagnosis when conservative therapy failed. If a very acute pathological event is present, surgery should be performed immediately.
Contraindications
- Infectious bursitis – a bacterially infected bursa is a contraindication for performing surgery due to the risk of sepsis.
- Rheumatoid bursitis with simultaneous inflammation of the synovium of the hip joint – in the presence of this pathological finding, the operation is not feasible, because very often there is communication with the hip joint and a more radical synovialectomy (removal of the synovial membrane of the joint) is required.
Before surgery
- Discontinuation of anticoagulants (anticoagulants) – discontinuation of medications that help to inhibit clotting (“thin the blood“) is usually necessary before surgery is performed. After surgery, medication can usually be resumed relatively quickly.
- Antibiosis – administration of antibiotics (antibacterial agents) is indicated before performing surgery. Application is by intravenous single-shot (single application of the antibiotic).
The procedures
Invasive therapy for bursitis is not usually the first line of treatment. Usually, the patient is first advised to cool and immobilize the affected joint to reduce the swelling associated with the inflammatory process. Furthermore, anti-inflammatory (anti-inflammatory) drugs should be used in parallel to alleviate the inflammatory process. This group of drugs includes the non-steroidal anti-inflammatory drugs (NSAIDs), of which ibuprofen and diclofenac are the most important representatives. Only when these measures fail does a surgical procedure represent the necessary measure of therapy. However, peracute (very acute dangerous disease) inflammation of a bursa leaves no room for maneuver in the form of conservative therapy because of the risk of sepsis (blood poisoning), since delaying surgical intervention significantly increases the risk of sepsis.
Surgical procedures
For the selection of the surgical treatment procedure, the localization of the bursa represents the decisive factor. Bursoscopy (endoscopic reflection of a bursa).
- This surgical method is an endoscopic procedure, which is an adequate therapeutic option, especially in the presence of chronic inflammatory processes. The basic principle of the procedure is based on the removal of the inner synovial layer. For this purpose, a standard arthroscope is used.
- In contrast to the classic bursectomy (removal of the bursa), optimal wound healing can be achieved with bursoscopy. The significance of this difference could be demonstrated in clinical studies.
- Of decisive importance for the selection of the endoscopic procedure is the advantage that the affected patient can benefit on the one hand from the smaller scars and on the other hand from the reduced discomfort as a result of the sliding layer left in place while preserving the outer connective tissue layer of the bursa in the endoscopic approach.
Bursectomy (surgical removal of a bursa).
- Complete removal of the bursa is usually the standard procedure when nonoperative treatment options fail.
- However, with complete open surgical removal of the bursa, there is often the problem that scars remain as a result of the procedure, which are not only a cosmetic problem, but in addition can negatively affect the mechanics of the affected joint. Furthermore, the complete removal leads to loss of function in the form of the lack of reduction of pressure load, so that the joint structures can be damaged by the absence of the bursa.
- The operation is often performed in tourniquet and supine position, where the localization of the bursa to be removed is crucial for the surgical position.
- Before the bursa is removed, the subcutis (lower skin) is cut before the bursa can be removed from the tissue.
- The goal of bursa removal is to remove the bursa without risking opening the bursa. Due to this, the removal of the bursa is largely performed by blunt transection.
- In operations, for example, in the elbow area, the area is splinted after the procedure.
After surgery
- Thrombosis prophylaxis – especially when removing a lower extremity bursa, drug thrombosis prophylaxis is usually performed. The drugs used for this purpose are usually substances such as heparin. Attention should be paid to possible complications of prophylaxis.
- Anti-inflammatory (anti-inflammatory) drugs – for additional reduction of the inflammatory process are usually still applied non-steroidal anti-inflammatory drugs.
- Follow-up – after surgery has been performed, the wound must be checked regularly.
Possible complications
Depending on the procedure used, the frequency of occurrence of the various complications varies.
- Hematoma – a hematoma (bruise) occurs relatively frequently after both the endoscopic and conventional procedures. It is a harmless complication.
- Nerve lesion – due to the proximity to nerve cords, there is a risk of at least temporary (lasting only a certain time) nerve dysfunction, which may be accompanied by paresthesias (insensations).
- Bleeding – damage to blood vessels cannot be prevented during surgery. Bleeding may occur if hemostasis is not optimal.
- Infection – postoperative infection is a possible complication, but it is very rare, especially in endoscopic procedures.
- Compartment syndrome (condition in which increased tissue pressure leads to a reduction in tissue perfusion when the skin and soft tissue mantle is closed, resulting in neuromuscular disorders or tissue and organ damage) – this pathological event, in which there is a pressure load due to bleeding into a box, requires rapid pressure relief to prevent damage to tissue structures.
