Working Diagnosis:
The patient was diagnosed with recurrent prepatellar bursitis. With no growth on the most recent fluid culture, but having started oral doxycycline prior to aspiration, it was unclear whether this was recurrent septic bursitis or recurrent traumatic bursitis.

Treatment:
Options for treatment for recurrent bursitis include aspiration, sclerotherapy, surgical incision and drainage, and bursectomy. Due to recurrence and desire to avoid surgery, this patient underwent aspiration and sclerotherapy. The skin and tract were anesthetized with 5 mL of 2% lidocaine. Under ultrasound guidance, the prepatellar bursa was aspirated and treated with 100 mg of doxycycline powder reconstituted in 10 mL of normal saline (doxycycline powder is dissolved in normal saline similar to how Botox is reconstituted). The bursa was then injected and aspirated repeatedly (5-10 times) to promote sclerosis. Follow up was recommended in 7-14 days for re-evaluation and potential for aspiration of any remaining sclerosing fluid. In the interim until follow up, relative rest was recommended, as well as avoidance of pressure on the bursa, which in this case meant no kneeling and no wrestling.

Outcome:
The procedure was uncomplicated and well tolerated. At the 2-week follow up, the patient had complete symptom resolution without recurrence or need for repeat aspiration. He returned to full activity within 2 weeks. He returned to play at an international level with no recurrent bursitis to date, now a year post treatment.

Author's Comments:
If prepatellar bursitis is recurrent and nonoperative options are unsuccessful, or the bursitis becomes chronic, patients may undergo operative bursal incision and drainage or more invasive prepatellar bursectomy. A newer treatment option for recurrent bursitis is emerging. Reconstituted doxycycline's sclerosant effect, mediated through endothelial irritation and fibrosis, has been utilized in pleurodesis and recurrent seroma management postoperatively. Emerging data suggests its utility in chronic bursitis refractory to conservative measures, providing a minimally invasive alternative to surgery. There are publications showing its utility in treating recurrent olecranon bursitis. In one case control study, outcomes of sclerotherapy compared to surgical bursectomy for olecranon bursitis had similar success rates as well as recurrence rates, but none of the patients who underwent sclerotherapy required a surgical bursectomy. There were reportedly high satisfaction rates following the sclerotherapy procedure, and this identifies that this may be a reasonable alternative to attempt prior to more invasive surgical procedures. <br> <br>This case highlights the potential of doxycycline sclerotherapy as a treatment option for prepatellar bursitis that is an accessible, low risk intervention that may shorten recovery, reduce recurrence in athletes, and expedite return to play.

Editor's Comments:
Recurrent prepatellar bursitis can be a challenging condition to manage, particularly in athletes whose sport requires repetitive kneeling and direct pressure over the anterior knee. While conservative management and aspiration are commonly utilized for prepatellar bursitis, recurrent cases may ultimately require procedural intervention. It is helpful for the clinician to recognize that there are multiple options for procedural intervention and that bursectomy is not the only possible interventional treatment available. This case highlights doxycycline sclerotherapy as a potential minimally invasive treatment option for recurrent prepatellar bursitis. Doxycycline was selected for its established sclerosant properties and prior use in the management of recurrent fluid collections in other settings. Its ability to induce local inflammation and fibrosis may promote obliteration of the bursal space and help to reduce or prevent recurrence. <br> <br>One important consideration in recurrent prepatellar bursitis is distinguishing septic from aseptic bursitis. This particular patient's prior episode was culture-positive for methicillin-sensitive Staphylococcus aureus, raising concern for a potential recurrent infection. However, the absence of systemic symptoms at presentation and a negative bacterial culture during the current reported episode supported management as recurrent bursitis without evidence of active infection at the time. <br> <br>In conclusion, sclerotherapy may provide a minimally invasive alternative treatment option for prepatellar bursitis that can be well tolerated by patients and lead to satisfactory outcomes that may be comparable to those seen with surgical bursectomy.

References:
1. Al Daoud, Fadi, et al. "Management of chronic abdominal wall seroma with doxycycline sclerotherapy using a negative pressure wound therapy system KCI-v.a.c.ultaTM-A Case report." International Journal of Surgery Case Reports, vol. 51, no. C, Jan. 2018, pp. 25-28, https://doi.org/10.1016/j.ijscr.2018.08.014. <br> <br>2. Caliendo, Mark V., et al. "Sclerotherapy with use of doxycycline after percutaneous drainage of postoperative lymphoceles." Journal of Vascular and Interventional Radiology, vol. 12, no. 1, Jan. 2001, pp. 73-77, https://doi.org/10.1016/s1051-0443(07)61407-9. <br> <br>3. Parker, Charles H, and Jeffrey C Leggit. "Novel treatment of prepatellar bursitis." Military Medicine, vol. 183, no. 11-12, 24 May 2018, https://doi.org/10.1093/milmed/usy098. <br> <br>4. Heffner JE, Standerfer RJ, Torstveit J, Unruh L. Clinical efficacy of doxycycline for pleurodesis. Chest. 1994 Jun;105(6):1743-7. doi: 10.1378/chest.105.6.1743. PMID: 8205870. <br> <br>5. McDermott D, Wakefield D, Kowalsky M, Sethi P, Vitale MA, Morrey BF. Intrabursal Doxycycline Sclerotherapy for Recurrent Olecranon Bursitis of the Elbow: A Case Control Study. J Hand Surg Glob Online. 2024 Apr 8;6(4):504-509. doi: 10.1016/j.jhsg.2024.03.006. PMID: 39166200; PMCID: PMC11331157. <br> <br>6. Orr, Jordan, and Mahmood Gharib. "Ultrasound-guided doxycycline injection for aseptic olecranon bursitis: Case report." Pain Medicine Case Reports, vol. 5, no. 6, 31 Aug. 2021, pp. 301-304, https://doi.org/10.36076/pmcr.2021.5.301. <br> <br>7. Pulsiripunya C, Youngchaiyud P, Pushpakom R, Maranetra N, Nana A, Charoenratanakul S. The efficacy of doxycycline as a pleural sclerosing agent in malignant pleural effusion: a prospective study. Respirology. 1996 Mar;1(1):69-72. doi: 10.1111/j.1440-1843.1996.tb00013.x. PMID: 9432409. <br> <br>8. Ramkumar A. Doxycycline Sclerotherapy to Manage Seroma Following Breast Cancer Surgery. Indian J Surg Oncol. 2020 Mar;11(1):23-24. doi: 10.1007/s13193-019-00982-x. <br> <br>9. Prepatellar bursitis longitudinal, Dr. Taco Geertsma, https://www.ultrasoundcases.info/proximal-prepatellar-bursa-1713/ <br> <br>10. Prepatellar bursitis transverse, Dr. Taco Geertsma, https://www.ultrasoundcases.info/proximal-prepatellar-bursa-1713/

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