The Knee 14 (2007) 333 – 335

Short communication
Patellar osteomyelitis presenting as prepatellar bursitis
Ho-Rim Choi ⁎
Dept of Orthopaedic Surgery, SoonChunHyang University Hospital, 23-20 BongMyung-dong, CheonAn, 330-721, Republic of Korea
Received 16 March 2007; received in revised form 23 April 2007; accepted 23 April 2007

Abstract

Peripatellar lesions causing knee pain include cellulitis, bursitis, synovitis, septic arthritis and patellar osteomyelitis. We present here two
cases of patellar osteomyelitis which were misdiagnosed as prepatellar bursitis. Operative treatment was required for these lesions. Patellar
osteomyelitis should always be considered when treating a peripatellar lesion, although it is very rare condition.
© 2007 Elsevier B.V. All rights reserved.

Keywords: Patellar osteomyelitis; Prepatellar bursitis

1. Introduction appearance of soft tissue swelling. Under the impression of

Osteomyelitis of the patella is an uncommon condition
that is considered to be a disease of childhood. Prompt,
early diagnosis of this condition is difficult because of its
rarity and variety of presentation. Recently, we experienced
two cases of patellar osteomyelitis that were misdiagnosed
as prepatellar bursitis. The literature is reviewed and dis-
cussed briefly.
2. Case 1
A 9-year-old boy was admitted to our department with a
10-day history of painful swelling and increased skin
temperature of his right knee. Approximately 1 month
prior to presenting in our department, the patient sustained
blunt trauma to his right knee, but sought no medical
treatment and appeared to heal well. A slightly tender
swelling, redness, and increased skin temperature were
observed. However, there was no floating or external wound.
His white blood cell (WBC) count was 8300 with 75%
neutrophils. His erythrocyte sedimentation rate (ESR) was
40 mm/h and his C-reactive protein (CRP) level was
33.9 mg/L. Radiographs were unremarkable except for the
cellulitis, he was placed on intravenous cefazedone. Three
days after admission, the pain and swelling improved, and
the tenderness was localized to the prepatellar bursa with
equivocal fluctuation. A Tc99 m bone scan showed increased
uptake around the patella (Fig. 1). Ten days after intravenous
antibiotic therapy, prepatellar swelling and fluctuation were
still present. A tentative diagnosis of septic prepatellar
bursitis was made, and the bursa was subsequently excised.
During surgery, the bursa was found to be filled with
necrotic, pus-like material, and a small stalk was connected
to the patella with a cortical opening. Through the bony
opening, the patella was debrided and curetted with purulent
necrotic material, resulting a cavitary defect with dimension
of approximately about 1 × 1 × 1 cm (Fig. 2). The patient was
subsequently treated with 3 weeks of intravenous cephaze-
done followed by 3 weeks of oral antibiotics. The
microscopic evaluation of curetted material was consistent
with osteomyelitis, although the culture result was negative
(Fig. 3). At 1 year follow-up, the patient had a full range of
knee motion and no pain with residual spur change of the
patella on simple X-ray.
3. Case 2

⁎ Tel.: +82 41 570 3641; fax: +82 41 572 7234. A 7-year-old boy was referred to our hospital for
E-mail address: choinagoya@yahoo.co.kr. persistent, painful swelling of his left knee, which had
0968-0160/$ - see front matter © 2007 Elsevier B.V. All rights reserved.
doi:10.1016/j.knee.2007.04.010
334 H.-R. Choi / The Knee 14 (2007) 333–335
Fig. 1. Tc99 m
bone scan shows increased uptake around the patella of the
right knee.
developed 3 weeks prior. Two weeks later, the symptom was
aggravated, and the subject visited a private clinic. Under the
impression of septic arthritis, clinicians performed needle
aspiration and saline irrigation of the joint with intravenous
antibiotic administration at the local clinic. However, the
symptom was not improved. On admission to our hospital,
the patient was afebrile and had a mild floating and swelling
of his knee with maximum tenderness over his patella. Simple
X-ray showed no significant abnormality. Laboratory find-
ings included a WBC count of 10,200 with 78% neutrophils
and an ESR of 42 mm/h. The CRP level was 8.5 mg/L. A
Tc99 m bone scan was interpreted to be negative. However, the
MRI showed prepatellar soft tissue swelling with inflamma-
tory change and suspicious anterior cortical breakage of the
patella (Fig. 4). With the impression that the patient had
prepatellar septic bursitis, we performed bursa removal on the
second day of admission. At surgery, through a bursal stalk, a
0.5 × 0.5 cm size cortical defect of the patella was found after
Fig. 2. After removal of the bursa and curettage of the bony lesion of the
patella, a cavitary defect remained.
Fig. 3. The curetted materials show necrotic bone and acute inflammatory
cells (H&E, ×400).
excision of inflamed prepatellar bursa. Through the orifice,
the patella was curetted and the cancellous bone was noted to
be soft and vascular. Cultures from the bursa and patella both
grew S. aureus. Microscopic evaluation of the curetted bone
was consistent with osteomyelitis, showing acute inflamma-
tory change and granulation tissue. The patient received
3 weeks of intravenous cefazedone and 6 weeks of oral
antibiotics. Although the patient showed no restriction of
joint motion or activity at 1 year follow-up, radiographs
showed fragmentation and elongation of the patella (Fig. 5).
4. Discussion
Osteomyelitis of the patella is a very rare condition
because the patella is largely cartilaginous prior to ossifica-
tion, and it has a rich blood supply with contributions from
the extraosseous and intraosseous anatomic networks
following ossification. The absence of a physeal plate may
also account for the rare occurrence of hematogenous
osteomyelitis in the patella [2,6,8]. Trauma can play a role
Fig. 4. The axial and sagittal views of the MRI demonstrate inflammatory
thickening of the prepatellar bursa. There is a mild defect on the anterior
cortex of the patella (arrows).
 H.-R. Choi / The Knee 14 (2007) 333–335
Fig. 5. Radiograph at 12 months' follow-up depicts fragmentation and
elongation of the patella (arrow).
in the etiology of osteomyelitis in adults. However, most
cases of osteomyelitis seen in children have no clear cause.
An important feature of this disease is that diagnosis is
frequently delayed because of its rarity and variable
presentation. Roy et al. [7] reported four cases of patellar
osteomyelitis. Among the four cases, only one case was
diagnosed as osteomyelitis 6 months after trauma due to a
radiographic finding of bony change. Another two cases
were diagnosed as pyogenic arthritis, while the other was
thought to be prepatellar bursitis. Vaninbroukx et al. [8] also
indicated delayed diagnosis of patellar osteomyelitis in all of
their three cases. Cahill [1] and Evans [2] said that patellar
osteomyelitis can be misdiagnosed as recurrent arthritis
because of its reactive joint effusion. The time needed to
arrive at a correct diagnosis ranged from 10 days to 1 year in
these reports. In our cases, the first case was initially
diagnosed as cellulitis, and was then diagnosed as prepatellar
bursitis. The second case was misdiagnosed as septic arthritis
in a private clinic and as prepatellar bursitis in our hospital.
The correct diagnosis of osteomyelitis could not be made
until the bursa was removed from the operation field.
We should have had considered the possibility of
osteomyelitis or tuberculosis upon the presentation of the
two subjects in our hospital. Mittal et al. [4] reported five
patients with patellar tuberculosis. All five cases showed
osteolytic lesions in the patella on plain film. These
investigators described the importance of CT or MRI scans,
335
which were helpful in confirming radiographic character-
istics of osteolytic lesions with sequestrum, and in delineating
any associated soft tissue lesions. In our cases, we could not
find any bony abnormalities on simple radiographs.
It is debatable whether prepatellar bursitis occurred as a
result of patellar osteomyelitis, or whether the prepatellar
bursitis extended to the patella to cause osteomyelitis [2,5].
However, the point is that we need to use caution to prevent
further progression of bony destruction through early, correct
diagnosis of osteomyelitis, and must prevent bursitis from
progressing to osteomyelitis if prepatellar bursitis is the
preceding lesion.
For early recognition and correct diagnosis, a high index
of suspicion should be addressed with high quality radio-
graphs. Haine et al. [3] reported patellar osteomyelitis in an
adult and emphasized the usefulness of MRI. In the first case,
we did not check the MRI because we thought the lesion to
be simple cellulitis or prepatellar bursitis. With the MRI, we
were able to obtain more information of peripatellar soft
tissue in the second case. However, the possibility that the
patient had osteomyelitis could not be predicted, even with
the MRI.
Patellar osteomyelitis is an uncommon condition. Its
diagnosis is not easy because of its non-specific clinical
features. We report these cases to emphasize that one must
retain an index of suspicion for patellar osteomyelitis when
treating a patient with persistent peripatellar pain and
swelling, inflammatory arthropathy, cellulites, or prepatellar
bursitis that do not respond to conventional management.
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