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Three Part Question

In [adults with olecranon bursitis which has been drained by needle aspiration] is [injection with a steroid better than conservative management alone] at [preventing recurrence]?

Clinical Scenario

A 56 year-old male patient attends review clinic with recurrent olecranon bursitis. The bursitis was aspirated one week previously, and the resulting culture is negative. You wonder whether re-aspiration and bursal steroid injection will prevent recurrence.

Search Strategy

Medline 1950 - 2008
Embase 1980 -2007
Medline:(exp.bursitis OR bursitis.af.) AND (exp.steroids OR steroid$.af. OR exp.adrenal cortex hormones OR corticosteroid$.af. OR glucocorticoid$.af OR exp.dexamethasone OR dexamethasone.af. OR exp.hydrocortisone OR hydrocortisone.af. OR hydrocortistab.af. OR exp.methylprednisolone OR methylprednisolone.af. OR (depo adj5 medrone).af. OR depomedrone.af. OR exp.prednisolone OR prednisolone.af. OR deltastab.af. OR exp.triamcinolone OR triamcinolone.af. OR adcortyl.af. OR kenalog.af.) LIMIT to human AND English Language
Embase:(exp.bursitis OR bursitis.af.) AND (exp.steroid OR steroid$.af. OR exp.corticosteroid OR corticosteroid$.af. OR exp.glucorticoid OR glucocorticoid$.af OR exp.dexamethasone OR dexamethasone.af. OR exp.hydrocortisone OR hydrocortisone.af. OR hydrocortistab.af. OR exp.methylprednisolone OR methylprednisolone.af. OR (depo adj5 medrone).af. OR depomedrone.af. OR exp.prednisolone OR prednisolone.af. OR deltastab.af. OR exp.triamcinolone OR triamcinolone.af. OR adcortyl.af. OR kenalog.af.) LIMIT to human AND English Language

Search Outcome

Medline: 273 papers
Embase:307 papers
of which 2 were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Smith DL, McAfee JH, Lucas LM, Kumar KL, Romney DM 1989 USA	42 male patients with nonspetic olecranon bursitis.	Blinded Randomised Controlled Trial	Size of bursal swelling	Significant difference in size of bursal swelling between the group injected with steroid and the non-steroid group	Small numbers. No power calculation. Questionable as to whether true blinding of steroid group was achieved.
			Re-aspiration rates	Steroid group had a lower re-aspiration rate
			Unwanted effects	No significant unwanted effects in either group
Weinstein PS et al 1983 USA	60 male patients with culture negative traumatic olecranon bursitis	Retrospective Cohort Study	Percentage of patients with bursal effusion	Marked and abrupt reduction in patients with bursal effusion in steroid group	Retrospective study. 7 patients unaccounted for. No statistical analysis used.
			Unwanted effects	Within the steroid group, 3 patients developed septic olcranon bursitis and 5 developed skin atrophy (none in conservatively treated group)

Comment(s)

Both studies show decrease in size of bursal swelling following steroid injection. However, the retrospective cohort study suggests a significant risk of septic olecranon bursitis and skin atrophy following this intervention. This increased risk is not shown in the only randomised controlled trial performed in this area. This is a well conducted trial, but with small numbers and no power calculation.

Editor Comment

CF

Clinical Bottom Line

Insufficient evidence exists at present to prove that the benifits of steroid injection outway the risk of unwanted effects. A larger ransomised controlled trial would be welcome.

References

1. Smith DL, McAfee JH, Lucas LM, Kumar KL, Romney DM Treatment of Nonseptic Olecranon Bursitis. A Controlled, Blinded Prospective Trial Arch Intern Med 1989;149:2527-2530
2. Weinstein PS, Canoso JJ, Wohlgethan JR Long-term follow-up of corticosteroid injection for traumatic olecranon bursitis Annals of the Rheumatic Diseases 1984, 43, 44-46