623274 research-article2015
TAB0010.1177/1759720X15623274Therapeutic Advances in Musculoskeletal DiseaseDJ Berkoff, ZW Sandbulte
Therapeutic Advances in Musculoskeletal Disease
Fibrin glue for olecranon bursitis: a case report David J. Berkoff, Zachary W. Sandbulte, Harry C. Stafford and Joshua N. Berkowitz
Introduction Olecranon bursitis is a common cause of elbow pain and swelling. Causes of aseptic inflammation of the olecranon bursa include trauma, gout, calcium pyrophosphate dihydrate crystal deposition disease, rheumatoid arthritis, and systemic lupus erythematosus. Most cases occur in men between the ages of 30 years and 60 years. The inflammatory response within a bursa can lead to permanent epithelial damage and recurrent symptoms. There is little literature to guide therapy for recurrent olecranon bursitis. Commonly used conservative modalities include ice, compression, and activity modification with use of elbow padding. Aspiration, corticosteroid injection, and surgery are often reserved for persistent cases. Weinstein and colleagues studied patients with both acute and chronic olecranon bursitis, finding aspiration alone was sufficient for resolution of effusion in 55% of patients at 2 weeks, 77% at 8 weeks, and 91% at 24 weeks. In contrast, patients who received intrabursal steroid injections improved more quickly, but with more subsequent complications. In the group treated with aspiration and triamcinolone hexacetonide injection, 3 out of 25 patients (12%) developed a septic bursitis compared with none with aspiration only [Weinstein et al. 1984]. A recent review by Baumbach and colleagues suggests that chronic, nonseptic olecranon or prepatellar bursitis that does not resolve after initial aspiration and corticosteroid injection should be treated with bursectomy [Baumbach et al. 2014]. For patients who do not desire to proceed with surgery, the literature offers little further guidance. This case report presents a novel treatment for recurrent olecranon bursitis using a fibrin glue sealant. After failure of conventional therapies, a patient with chronic, refractory nonseptic olecranon bursitis was treated with ultrasound-guided injection of fibrin glue, resulting in complete
resolution of his refractory bursitis. This therapy provided a safe and minimally invasive alternative to bursectomy. Fibrin sealants have been used for many years during various types of surgeries and procedures. Its unique properties and minimal risk make it an attractive treatment option for persistent nonseptic olecranon bursitis. Case report A 61-year-old man without significant past medical history presented with greater than 1 year of left posterior elbow discomfort and swelling (Figure 1). He denied history of elbow trauma, describing insidious onset and worsening of his symptoms. The pain was worsened by resting on the affected elbow. However, he remained able to play golf and perform activities of daily living with minimal discomfort. He denied numbness, tingling, or weakness in the affected arm. His primary care and orthopedic physicians had performed a total of four prior aspirations and one steroid injection into the left olecranon bursa, with compressive wrapping utilized after each procedure but no immobilization. This provided temporary relief, but fluid would re-accumulate in the olecranon bursa 2–3 weeks following drainage. Fluid cultures were negative. The patient was frustrated but repeatedly expressed reluctance to pursue operative management.
Letter to the Editor
Ther Adv Musculoskel Dis 2016, Vol. 8(1) 28–30 DOI: 10.1177/ 1759720X15623274 © The Author(s), 2015. Reprints and permissions: http://www.sagepub.co.uk/ journalsPermissions.nav
Correspondence to: Joshua N. Berkowitz, MD Department of Family Medicine, University of North Carolina, 590 Manning Drive, Campus Box 7595, Chapel Hill, NC 27599-7595, USA [email protected] David J. Berkoff, MD Department of Orthopaedics, University of North Carolina, Chapel Hill, NC, USA Zachary W. Sandbulte, MD Private Practice, WinstonSalem, NC, USA Harry C. Stafford, MD Departments of Family Medicine and Orthopaedics, University of North Carolina, Chapel Hill, NC, USA
Examination of the left elbow showed a 5 cm, nontender, fluctuant mass over the olecranon process without surrounding erythema or warmth. There was a full range of motion of 0–150 degrees with normal pronation and supination. He had normal strength with elbow flexion and extension. Neurovascular examination was normal. Radiographs of the left elbow showed soft tissue swelling over the olecranon process without radiographic signs of fracture, spurring, foreign body, or free air.
28 http://tab.sagepub.com
DJ Berkoff, ZW Sandbulte et al.
Figure 1. Elbow with olecranon bursitis.
Figure 2. Ultrasound image of fibrin glue injection into the olecranon bursa.
Based on benign characteristics of multiple previous aspirations, prior fluid analysis, and stable clinical status, the diagnosis of recurrent nonseptic olecranon bursitis was made. Several treatment options were discussed, including surgery, doxycycline sclerodesis, and the use of fibrin glue. The patient expressed reservations regarding surgical management, preferring to try additional nonoperative measures. The decision was made to proceed with drainage and injection of Tisseel fibrin glue (Baxter International Inc., Deerfield, IL, USA) into the olecranon bursa. The patient consented to the procedure. Under sterile conditions, and using ultrasound for needle guidance, 10 ml of serous fluid were drained from the bursa. The bursa was then sealed using 2 ml of fibrin glue, which was visualized under ultrasound to fill the bursal sac (Figure 2). After the injection, the elbow was immediately covered with a compressive wrap and the patient was instructed to minimize activity for 72 h, but the elbow was not immobilized. After 72 h he gradually resumed normal activity without any limitations.
to fluid accumulation within the bursa. Patients may also be concerned with the cosmetic appearance. Most of these patients have aseptic chronic bursitis that is a nuisance. Doxycycline sclerodesis has shown some positive outcomes in treatment for persistent seromas, but there are few other suggested treatment options before surgery is considered [Tejwani et al. 2007]. Having additional nonsurgical therapeutic options to use in chronic or recurrent cases is beneficial, as some patients may prefer not to proceed directly from a single corticosteroid injection to bursectomy as some treatment algorithms suggest [Baumbach et al. 2014].
Follow-up evaluations were performed at 3 weeks, 2 months, and 6 months postprocedure. He has continued to report normal use of the elbow without recurrence of swelling or discomfort in his elbow. Examinations have shown a nonerythematous left elbow with a full range of pain-free motion and no fluctuance. The patient is pleased with the results. Discussion Recurrent olecranon bursitis can be frustrating for patients and physicians. Many patients have significant pain and limitation of functioning due
Fibrin sealant (glue) has been used for various clinical applications, including osteochondral fractures, ganglion cysts, peripheral nerve suturing, and seromas [Radosevich et al. 1997; Shigeno et al. 1995; Berkoff et al. 2013]. There have not been prior case reports detailing its use for recalcitrant, nonseptic olecranon bursitis, nor are there reports regarding its use for nonseptic prepatellar bursitis. While it may be reasonable to consider the use of fibrin glue for treatment of prepatellar bursitis in a manner similar to its use for olecranon bursitis, there is as of yet no data to support this. Fibrin sealants (e.g. Tisseel) are derived from human pooled plasma and consist of fibrinogen, factor XIII, thrombin, and ionized calcium [Spotnitz, 2012]. Some commercially available products also contain an antifibrinolytic agent. Together, these elements mirror the final steps of the clotting cascade, forming a fibrin clot where they are infused. The clot functions as a hemostatic agent and adhesive. Typically, the clot is resorbed within 1 week, allowing for natural healing to take
http://tab.sagepub.com 29
Therapeutic Advances in Musculoskeletal Disease 8(1) place. Complications associated with the use of fibrin sealant are rare. As with all blood products, there exists a risk for transmission of infectious disease. With fibrin products this risk appears to be low, though there are reports of transmission of parvovirus B19 [Kawamura et al. 2002]. There has also been one case report of anaphylaxis from use of fibrin glue [Milde, 1989]. Additional case reports exist describing air emboli occurring as a result of using a fibrin sealant [Ebner et al. 2011]. However, these cases described patients undergoing abdominal surgery, and the fibrin sealants were administered in a pressurized, aerosolized form. We are not aware of any septic complications following the use of fibrin glue. Conclusion In this case report, we describe a novel treatment for olecranon bursitis. We were able to prevent recurrence of a previously refractory bursal effusion with the use of fibrin sealant, a noninvasive therapy that is generally welltolerated. Although nonseptic olecranon bursitis will frequently resolve with conservative management, treatment using fibrin glue may be an option for refractory, chronic nonseptic olecranon bursitis. The use of fibrin sealant may be beneficial for other patients with similar conditions. Funding This research received no specific grant from any funding agency in the public, commercial, or notfor-profit sectors. Visit SAGE journals online http://tab.sagepub.com
SAGE journals
Conflict of interest statement The authors declare that there is no conflict of interest.
References Baumbach, S., Lobo, C., Badyine, I., Mutschler, W. and Kanz, K. (2014) Prepatellar and olecranon bursitis: literature review and development of a treatment algorithm. Arch Orthop Trauma Surg 134: 359–370 . Berkoff, D., Kamath, G. and Kanaan, M. (2013) Fibrin glue as a non-invasive outpatient treatment for post-arthroscopic knee seromas. Knee Surg Sports Traumatol Arthrosc 21: 1922–1924. Ebner, F., Paul, A., Peters, J. and Hartmann, M. (2011) Venous embolism and intracardiac thrombus after pressurized fibrin glue during liver surgery. Br J Anaesth 106: 180–182. Kawamura, M., Sawafuji, M., Watanabe, M., Horinouchi, H. and Kobayashi, K. (2002) Frequency of transmission of human parvovirus B19 infection by fibrin sealant used in thoracic surgery. Ann Thorac Surg 73: 1098–1100. Milde, L. (1989) An anaphylactic reaction to fibrin glue. Anesth Analg 69: 684–686. Radosevich, M., Goubran, H. and Burnouf, T. (1997) Fibrin sealant: scientific rationale, production methods, procedures and current clinical uses. Vox Sang 72: 133–143. Shigeno, Y., Harada, I. and Katayama, S. (1995) Treatment of cystic lesions of soft tissues with fibrin sealant. Clin Orthop Relat Res 321: 239–244. Spotnitz, W. (2012) Hemostats, sealants and adhesives: a practical guide for the surgeon. Am Surg 78: 1305–1321. Tejwani, S., Cohen, S. and Bradley, J. (2007) Management of Morel-Lavallee lesion of the knee: twenty-seven cases in the national football league. Am J Sports Med 35: 1162–1167. Weinstein, P., Canoso, J. and Wohlgethan, J. (1984) Long-term follow-up of corticosteroid injection for traumatic olecranon bursitis. Ann Rheum Dis 43: 44–46.
30 http://tab.sagepub.com
TAB0010.1177/1759720X15623274Therapeutic Advances in Musculoskeletal DiseaseDJ Berkoff, ZW Sandbulte
Therapeutic Advances in Musculoskeletal Disease
Fibrin glue for olecranon bursitis: a case report David J. Berkoff, Zachary W. Sandbulte, Harry C. Stafford and Joshua N. Berkowitz
Introduction Olecranon bursitis is a common cause of elbow pain and swelling. Causes of aseptic inflammation of the olecranon bursa include trauma, gout, calcium pyrophosphate dihydrate crystal deposition disease, rheumatoid arthritis, and systemic lupus erythematosus. Most cases occur in men between the ages of 30 years and 60 years. The inflammatory response within a bursa can lead to permanent epithelial damage and recurrent symptoms. There is little literature to guide therapy for recurrent olecranon bursitis. Commonly used conservative modalities include ice, compression, and activity modification with use of elbow padding. Aspiration, corticosteroid injection, and surgery are often reserved for persistent cases. Weinstein and colleagues studied patients with both acute and chronic olecranon bursitis, finding aspiration alone was sufficient for resolution of effusion in 55% of patients at 2 weeks, 77% at 8 weeks, and 91% at 24 weeks. In contrast, patients who received intrabursal steroid injections improved more quickly, but with more subsequent complications. In the group treated with aspiration and triamcinolone hexacetonide injection, 3 out of 25 patients (12%) developed a septic bursitis compared with none with aspiration only [Weinstein et al. 1984]. A recent review by Baumbach and colleagues suggests that chronic, nonseptic olecranon or prepatellar bursitis that does not resolve after initial aspiration and corticosteroid injection should be treated with bursectomy [Baumbach et al. 2014]. For patients who do not desire to proceed with surgery, the literature offers little further guidance. This case report presents a novel treatment for recurrent olecranon bursitis using a fibrin glue sealant. After failure of conventional therapies, a patient with chronic, refractory nonseptic olecranon bursitis was treated with ultrasound-guided injection of fibrin glue, resulting in complete
resolution of his refractory bursitis. This therapy provided a safe and minimally invasive alternative to bursectomy. Fibrin sealants have been used for many years during various types of surgeries and procedures. Its unique properties and minimal risk make it an attractive treatment option for persistent nonseptic olecranon bursitis. Case report A 61-year-old man without significant past medical history presented with greater than 1 year of left posterior elbow discomfort and swelling (Figure 1). He denied history of elbow trauma, describing insidious onset and worsening of his symptoms. The pain was worsened by resting on the affected elbow. However, he remained able to play golf and perform activities of daily living with minimal discomfort. He denied numbness, tingling, or weakness in the affected arm. His primary care and orthopedic physicians had performed a total of four prior aspirations and one steroid injection into the left olecranon bursa, with compressive wrapping utilized after each procedure but no immobilization. This provided temporary relief, but fluid would re-accumulate in the olecranon bursa 2–3 weeks following drainage. Fluid cultures were negative. The patient was frustrated but repeatedly expressed reluctance to pursue operative management.
Letter to the Editor
Ther Adv Musculoskel Dis 2016, Vol. 8(1) 28–30 DOI: 10.1177/ 1759720X15623274 © The Author(s), 2015. Reprints and permissions: http://www.sagepub.co.uk/ journalsPermissions.nav
Correspondence to: Joshua N. Berkowitz, MD Department of Family Medicine, University of North Carolina, 590 Manning Drive, Campus Box 7595, Chapel Hill, NC 27599-7595, USA [email protected] David J. Berkoff, MD Department of Orthopaedics, University of North Carolina, Chapel Hill, NC, USA Zachary W. Sandbulte, MD Private Practice, WinstonSalem, NC, USA Harry C. Stafford, MD Departments of Family Medicine and Orthopaedics, University of North Carolina, Chapel Hill, NC, USA
Examination of the left elbow showed a 5 cm, nontender, fluctuant mass over the olecranon process without surrounding erythema or warmth. There was a full range of motion of 0–150 degrees with normal pronation and supination. He had normal strength with elbow flexion and extension. Neurovascular examination was normal. Radiographs of the left elbow showed soft tissue swelling over the olecranon process without radiographic signs of fracture, spurring, foreign body, or free air.
28 http://tab.sagepub.com
DJ Berkoff, ZW Sandbulte et al.
Figure 1. Elbow with olecranon bursitis.
Figure 2. Ultrasound image of fibrin glue injection into the olecranon bursa.
Based on benign characteristics of multiple previous aspirations, prior fluid analysis, and stable clinical status, the diagnosis of recurrent nonseptic olecranon bursitis was made. Several treatment options were discussed, including surgery, doxycycline sclerodesis, and the use of fibrin glue. The patient expressed reservations regarding surgical management, preferring to try additional nonoperative measures. The decision was made to proceed with drainage and injection of Tisseel fibrin glue (Baxter International Inc., Deerfield, IL, USA) into the olecranon bursa. The patient consented to the procedure. Under sterile conditions, and using ultrasound for needle guidance, 10 ml of serous fluid were drained from the bursa. The bursa was then sealed using 2 ml of fibrin glue, which was visualized under ultrasound to fill the bursal sac (Figure 2). After the injection, the elbow was immediately covered with a compressive wrap and the patient was instructed to minimize activity for 72 h, but the elbow was not immobilized. After 72 h he gradually resumed normal activity without any limitations.
to fluid accumulation within the bursa. Patients may also be concerned with the cosmetic appearance. Most of these patients have aseptic chronic bursitis that is a nuisance. Doxycycline sclerodesis has shown some positive outcomes in treatment for persistent seromas, but there are few other suggested treatment options before surgery is considered [Tejwani et al. 2007]. Having additional nonsurgical therapeutic options to use in chronic or recurrent cases is beneficial, as some patients may prefer not to proceed directly from a single corticosteroid injection to bursectomy as some treatment algorithms suggest [Baumbach et al. 2014].
Follow-up evaluations were performed at 3 weeks, 2 months, and 6 months postprocedure. He has continued to report normal use of the elbow without recurrence of swelling or discomfort in his elbow. Examinations have shown a nonerythematous left elbow with a full range of pain-free motion and no fluctuance. The patient is pleased with the results. Discussion Recurrent olecranon bursitis can be frustrating for patients and physicians. Many patients have significant pain and limitation of functioning due
Fibrin sealant (glue) has been used for various clinical applications, including osteochondral fractures, ganglion cysts, peripheral nerve suturing, and seromas [Radosevich et al. 1997; Shigeno et al. 1995; Berkoff et al. 2013]. There have not been prior case reports detailing its use for recalcitrant, nonseptic olecranon bursitis, nor are there reports regarding its use for nonseptic prepatellar bursitis. While it may be reasonable to consider the use of fibrin glue for treatment of prepatellar bursitis in a manner similar to its use for olecranon bursitis, there is as of yet no data to support this. Fibrin sealants (e.g. Tisseel) are derived from human pooled plasma and consist of fibrinogen, factor XIII, thrombin, and ionized calcium [Spotnitz, 2012]. Some commercially available products also contain an antifibrinolytic agent. Together, these elements mirror the final steps of the clotting cascade, forming a fibrin clot where they are infused. The clot functions as a hemostatic agent and adhesive. Typically, the clot is resorbed within 1 week, allowing for natural healing to take
http://tab.sagepub.com 29
Therapeutic Advances in Musculoskeletal Disease 8(1) place. Complications associated with the use of fibrin sealant are rare. As with all blood products, there exists a risk for transmission of infectious disease. With fibrin products this risk appears to be low, though there are reports of transmission of parvovirus B19 [Kawamura et al. 2002]. There has also been one case report of anaphylaxis from use of fibrin glue [Milde, 1989]. Additional case reports exist describing air emboli occurring as a result of using a fibrin sealant [Ebner et al. 2011]. However, these cases described patients undergoing abdominal surgery, and the fibrin sealants were administered in a pressurized, aerosolized form. We are not aware of any septic complications following the use of fibrin glue. Conclusion In this case report, we describe a novel treatment for olecranon bursitis. We were able to prevent recurrence of a previously refractory bursal effusion with the use of fibrin sealant, a noninvasive therapy that is generally welltolerated. Although nonseptic olecranon bursitis will frequently resolve with conservative management, treatment using fibrin glue may be an option for refractory, chronic nonseptic olecranon bursitis. The use of fibrin sealant may be beneficial for other patients with similar conditions. Funding This research received no specific grant from any funding agency in the public, commercial, or notfor-profit sectors. Visit SAGE journals online http://tab.sagepub.com
SAGE journals
Conflict of interest statement The authors declare that there is no conflict of interest.
References Baumbach, S., Lobo, C., Badyine, I., Mutschler, W. and Kanz, K. (2014) Prepatellar and olecranon bursitis: literature review and development of a treatment algorithm. Arch Orthop Trauma Surg 134: 359–370 . Berkoff, D., Kamath, G. and Kanaan, M. (2013) Fibrin glue as a non-invasive outpatient treatment for post-arthroscopic knee seromas. Knee Surg Sports Traumatol Arthrosc 21: 1922–1924. Ebner, F., Paul, A., Peters, J. and Hartmann, M. (2011) Venous embolism and intracardiac thrombus after pressurized fibrin glue during liver surgery. Br J Anaesth 106: 180–182. Kawamura, M., Sawafuji, M., Watanabe, M., Horinouchi, H. and Kobayashi, K. (2002) Frequency of transmission of human parvovirus B19 infection by fibrin sealant used in thoracic surgery. Ann Thorac Surg 73: 1098–1100. Milde, L. (1989) An anaphylactic reaction to fibrin glue. Anesth Analg 69: 684–686. Radosevich, M., Goubran, H. and Burnouf, T. (1997) Fibrin sealant: scientific rationale, production methods, procedures and current clinical uses. Vox Sang 72: 133–143. Shigeno, Y., Harada, I. and Katayama, S. (1995) Treatment of cystic lesions of soft tissues with fibrin sealant. Clin Orthop Relat Res 321: 239–244. Spotnitz, W. (2012) Hemostats, sealants and adhesives: a practical guide for the surgeon. Am Surg 78: 1305–1321. Tejwani, S., Cohen, S. and Bradley, J. (2007) Management of Morel-Lavallee lesion of the knee: twenty-seven cases in the national football league. Am J Sports Med 35: 1162–1167. Weinstein, P., Canoso, J. and Wohlgethan, J. (1984) Long-term follow-up of corticosteroid injection for traumatic olecranon bursitis. Ann Rheum Dis 43: 44–46.
30 http://tab.sagepub.com
