Compressive neuropathy of the tibial nerve and peroneal nerve by a Baker's cyst: case report

We report a case of Baker's cyst that induced compression of both the tibial and common peroneal nerves. The patient presented with calf atrophy and foot drop over a 6-month period. These signs and symptoms could have been mistaken for those of spinal origin. Based on an electrodiagnostic study and magnetic resonance imaging, compression of nerves by an asymptomatic Baker's cyst measuring 6x4 cm was confirmed. This cyst communicated with the articular joint which was also associated with a medial meniscal lesion. We treated the patient arthroscopically by performing partial medial meniscectomy, and through the posterolateral and the posteromedial portal, decompression of the Baker's cyst was performed. Approximately 6 weeks after the arthroscopic decompression, the cyst recurred. Therefore open resection was performed. At 1-year follow-up, the patient had considerable improvement in motor as well as sensory function and showed no evidence of recurrence. Although the electrodiagnostic studies showed an improvement in symptoms, the patient continued to complain of lower leg weakness owing to delayed diagnosis and cyst decompression. We believe that Baker's cysts should also be considered in the differential diagnoses of patients who present with neuromuscular dysfunction in the calf and leg.     

Evaluation of the knee pathology by ultrasonography

Fourteen patients undergoing total knee replacement for the arthritic conditions of the knee were evaluated by ultrasonography (USG) prior to surgery. USG findings (synovium, fluid, femoral cartilage, cyst and loose bodies) were compared with surgical findings. USG and surgical findings matched for synovial pathology in 57%, for presence fluid in 71% and for cartilage damage in 45%. Loose bodies and cyst present in one patient was not picked up by USG. Baker's cyst was detected in one patient.     

关节镜下半月板内快速缝合器治疗膝关节半月板损伤

目的探讨关节镜下运用半月板内快速缝合器经半月板内缝合损伤半月板的方法和常见问题。方法关节镜下对69例确诊为半月板体部或后角损伤膝关节实施半月板缝合，半月板内快速缝合器数目1～3个，缝合长度15．17mm。结果术中1例出现植入体2（T2）“卡壳”，3例植入他后回抽锚枪过程中他从种植部脱落。术后按Lysholm评分标准：优61例，良8例。结论关节镜下半月板缝合具有微创、显露清楚等优点，半月板内快速缝合器缝合半月板快速高效，经修整后的纤维软骨比较牢固，术后愈合率高。     

虚拟内窥镜图像增强膝关节镜手术导航系统

膝关节镜手术是利用内窥镜的膝关节微创手术,具有创口小、恢复快等优势,但同时整个手术仅凭术中二维膝关节镜图像引导,存在缺乏深度信息、容易出现遮挡、依赖手术经验等缺点。利用虚拟内窥镜技术,将术前与术中的信息结合,互为补充,为膝关节镜手术进行导航,增加其便利性和可靠性。提出基于虚拟内窥镜技术的膝关节镜手术导航系统:首先通过对内窥镜及整个坐标系统的标定,完成对整个系统的坐标描述;然后针对实时追踪的内窥镜视角,实现对应范围术前信息的渲染,最后将术前术中及融合信息通过二维、三维显示方式,全面地展示给医师。完成系统的搭建及完整的膝关节模型实验,将术前术中信息同时显示、精确融合,实现导航功能;实验的定位标定均方误差小于1 mm,术前术中图像融合匹配均方误差小于0.7 mm,分立及融合图像均可实时显示。综合定位信息与术前信息的膝关节镜手术导航系统,可以实时进行内窥镜图像增强,为膝关节镜术提供多源信息融合引导,为医生提供直观、便捷的手术导航效果。     

Diagnosis of knee prosthetic joint infection; aspiration and biopsy

BackgroundProsthetic joint infection (PJI) is a significant cause of morbidity and mortality following knee replacement surgery. The diagnosis can be challenging and is based on a combination of clinical suspicion, radiographic findings and also biochemical/ microbiological investigations. Our Aim was to review the role of aspiration and biopsy in the diagnosis of PJI in Total Knee Arthroplasty (TKA).Method/resultsAspirated synovial fluid should be analysed by direct culture, via blood culture bottles, EDTA bottles for cell count and ‘point of care’ testing such as leucocyte esterase or alpha defensin. Synovial WCC and PMN cell percentage are important steps in diagnosis of both acute and chronic PJI. A minimum of 5 deep samples using a 5 clean instrument technique should be obtained and sent for tissue culture done either blind or arthroscopic. Formal fluoroscopic guided interface biopsy has also been described with excellent results. In a recent series of 86 TKRs preoperative arthroscopic biopsy group had a sensitivity of 100%, specificity of 94.7%, positive predictive value of 87.4% and a negative predictive value of 100%.ConclusionIn the presence of clinical suspicion with raised biomarkers, it is recommended that aspiration +/- biopsy with synovial fluid testing is performed. Direct culture and cell count are recommended. ‘Point of care tests’ such as Leucocyte Esterase testing should be considered. Duration of culture, including pathogen and host factors, should be discussed with a local microbiology/ID department in the context of a formal multi-disciplinary team.     

Two-stage TKA for tuberculosis septic arthritis of the knee masquerading as pigmented villonodular synovitis: A case report

A 25-year-old female presented with left knee pain following arthroscopic synovectomy for presumed pigmented villonodular synovitis (PVNS). Radiographs and magnetic resonance imaging demonstrated tricompartmental arthritic changes. She underwent a two-stage procedure first involving antibiotic spacer implantation, followed 1 week later by spacer removal and definitive total knee arthroplasty (TKA) once initial intraoperative culture results were negative. Subsequent cultures confirmed tuberculosis septic arthritis. Repeat evaluation 1 year postoperatively showed no complications and patient satisfaction with left knee function. This is a unique case report in the United States describing 1-year outcomes following staged TKA for tuberculosis septic arthritis masquerading as PVNS.     

A modified surgical method for treating Baker's cyst in children

Surgery for Baker's cysts in children is plagued by high recurrent rate after the operation. In this study, a modified surgical method is developed to avoid the recurrence. Between 1995 and 2002, nine symptomatic Baker's cysts were excised in nine children, including six boys and three girls with a mean age of 5.7 years, were reviewed retrospectively. The diagnosis and follow-up were confirmed by clinical and ultrasound investigation. The modified surgical technique features a step in which the orifice of the posterior joint capsule is closed tightly by the application of one purse-string non-absorbable suture, and augmented by the suturing of the gastronomies tendon onto the closed orifice of the knee-joint capsule. Then the affected knee is immobilized with long leg cast for 2 weeks. After a mean follow-up of 8.3 years (ranged from 5.6 years to 12.1 years), none of the cysts recurred. All the patients were free of symptoms and none complained of any cosmetic problems. While comparing the affected and the unaffected knee, neither limitation of motion nor difference of muscle power was found. From the results, the modified surgical method is considered effective to treat the symptomatic Baker's cyst in children and to avoid its recurrence.     

Cyst fluid cytology and chemical features in a case of lymphoepithelial cyst of the pancreas: A rare and difficult preoperative diagnosis.

Most pancreatic cysts (90%) are inflammatory pseudocysts. Approximately 10% of pancreatic cysts are neoplasms, including serous cystadenomas, and mucinous tumors, some of which are malignant. Analysis of pancreatic cyst fluid obtained by percutaneous or endoscopic fine-needle aspiration is increasingly being used for the preoperative diagnosis of pancreatic or peripancreatic cysts. However, cyst fluid chemical and cytologic features in less common types of pancreatic cysts have not been reported. Lymphoepithelial cyst of the pancreas is exceedingly rare, and only occasional individual reports have described cyst fluid findings. We report on a case of lymphoepithelial cyst of the pancreas developing in a middle-aged man. Cyst fluid aspirated under radiological guidance showed elevated levels of carcinoembryonic antigen (CEA), CA19-9, CA 125, and amylase, and a viscosity greater than that of serum. A cell block preparation of a fine-needle aspiration showed tissue fragments with a keratinized squamous lining and a lymphocytic infiltrate in the wall, and abundant background keratinous debris. The cytologic and biochemical findings in this case exhibit similarities to the findings reported in other reports, and may represent a recognizable pattern on cyst fluid analysis.     

猪囊尾蚴抗原的免疫化学研究

应用琼脂双扩散(DID)、免疫电泳(IEP)、聚丙烯酰胺凝胶电泳(PAGE)和十二烷基硫酸钠聚丙烯酰胺凝胶电泳(SDS-PAGE)对猪囊尾蚴的各部分抗原,即完整幼虫、囊液、头节和囊壁抗原进行分析。实验结果表明,4种抗原间存在相同的抗原成分。囊液中含有糖蛋白和脂蛋白。囊液、头节和囊壁蛋白质的主要分子量均在100KDa以下。囊液与头节有3条分子量相同的主带(60、46、38KDa),与囊壁只有1条分子量(46KDa)相同主带。从免疫学和生物化学角度初步探索了囊液、头节和囊壁蛋白质之间的相互关系及主要蛋白质组分。     

Arthroscopic loose body removal and cyst decompression using a posterior trans-septal portal in the blind spot during knee arthroscopy—Technical report

Some lesions such as cyst, loose body, and mass around the knee joint tend to localize at the posterior aspect of the proximal tibia. Although arthroscopic procedures of the knee joint's posterior compartment have been developed through posteromedial, posterolateral, and posterior trans-septal portals, the posterior aspect of the proximal tibia remains difficult to access and manipulate. We report an arthroscopic loose body removal and cyst decompression on the posterolateral aspect of the proximal tibia using a posterior trans-septal portal. This area represents a blind spot in knee arthroscopy.     

Arthroscopically-aided lateral meniscal repair and reduction of lateral tibial plateau fracture: long-term follow-up with MR imaging

Three patients sustained a Schatzker type II depressed lateral tibial plateau fracture and a tear of the lateral meniscus following a valgus injury to the knee. An arthroscopically-aided reduction of the articular surface was performed. This was followed by an autogenous iliac crest buttress graft with cancellous screw fixation. The meniscal tear was abrased with a rasp or a shaver. An arthroscopic repair of the lateral meniscus during the same session was performed. Clinical follow-up, including MR imaging of the knee at 68 months (range 60–74 months), showed an excellent clinical result and a completely healed meniscus in all patients. Arthroscopic meniscal repair in combination with arthroscopically-aided reduction of a depressed lateral tibial plateau fracture is technically possible. Restoration of the anatomy of both tibial plateau and lateral meniscus will optimize the outcome.     

Neuroendoscopic removal of large choroid plexus cyst: a case report

Choroid plexus cysts (CPCs) are the most common neuroepithelial cysts, occurring in more than 50% of some autopsy series. They are typically small and asymptomatic and are discovered incidentally in older patients, usually in the trigone of the lateral ventricle. Symptomatic CPCs (usually exceptionally large, 2-8 cm) are rare. The authors report a case of large symptomatic choroid plexus cyst, located in the trigone of the right lateral ventricle in a 26-yr-old man who presented with headache and vomiting. The patient underwent endoscopic removal through a burr hole placed 3 cm from the midline and just behind the hair line. The histological examination of the cyst wall was consistent with choroid epithelium. Despite of postoperative intraventricular hemorrhage and catheter infection, he discharged home without neurologic deficits. The endoscopic fenestration rather than excision should be considered as the first surgical procedure because the goal of treatment is shrinkage of the cyst until normal cerebrospinal fluid flow is restored.     

Arthroscopic internal marsupialization of meniscal cysts

Meniscal cysts begin with extrusion of synovial fluid through a tear of the meniscus, enlarging probably as a result of a one-way valve effect of the tear flap. We describe a technique of arthroscopic internal marsupialization of meniscal cysts with or without meniscectomy. A 5 mm channel was created in the capsule adjacent to the cyst arthroscopically for decompression of the cyst into the joint, thus equalising pressures between the cystic and intra-articular compartments. Only unstable meniscal tears were debrided down to a stable rim while intact meniscii or stable tears were left alone. Eight patients with MRI confirmed atraumatic medial or lateral meniscal cysts underwent surgery. At a mean follow-up of 39.1 months (12-94 months, S.D. 26.4), Tegner scores averaged 5.1 (3-8, S.D. 2.1) and Lysholm scores averaged 94.4 (85-100, S.D. 5.4). No cyst recurred. Arthroscopic internal marsupialization effectively decompresses meniscal cysts and prevents their recurrence, while preserving meniscal tissue and minimising arthrosis of the knee joint.     

开放手术与关节镜手术治疗成人腘窝囊肿疗效对比

目的：对关节镜和传统开放手术的疗效进行对比,探讨成人腘窝囊肿的有效治疗方法。方法：自2007年6月至2012年12月,我科接受手术治疗并获随访的腘窝囊肿成人患者30例,将其中行关节镜囊肿内引流术14例作为治疗组,后路开放手术囊肿切除术16例为对照组。记录并比较两组术前及随访Rauschning和Lindgren分级,并行B超检查以明确囊肿复发情况。结果：术后30例均随访3～6个月,平均5．6个月。术前两组Rauschning和Lindgren分级比较差异无统计学意义（P=0．779）,术后两组Rauschning和Lindgren分级比较差异有统计学意义（P=0．029）,治疗组疗效优于对照组。治疗组无一例囊肿复发,对照组复发率31％（5／16）,两组复发率比较差异有统计学意义（P=0．041）。结论：关节镜手术治疗成人腘窝囊肿,疗效更好,术后复发率更低,优于传统开放手术。     

关节镜下辅助小切口腘窝囊肿切除术的临床应用

目的:探讨关节镜下辅助小切口手术治疗腘窝囊肿的临床疗效.方法:回顾性分析2008年11月份至2010年8月我院收治的21例腘窝囊肿患者的临床资料.按Rauschning和Lingdgren分级法,其中Ⅰ级1例、Ⅱ级8例、Ⅲ级12例,均采取关节镜下辅助小切口囊肿切除术治疗.结果:21例术后均获随访,随访时间1～23个月,按Rauschning和Lingdgren分级法,0级18例,Ⅰ级2例,Ⅱ级1例.20例治愈,1例腘窝囊肿复发,总有效率95%.结论:关节镜下辅助小切口切除腘窝囊肿,可缩短手术时间,并具有创伤小、切除彻底、手术安全的特点.     

Heterotopic ossification within an arthroscopic portal after uneventful partial meniscectomy

We report the case of a 44-year-old man who underwent a partial medial meniscectomy for a meniscal tear whose postoperative course was complicated by the development of heterotopic ossification (HO) within the medial arthroscopic portal. Following a routine initial procedure, the patient presented with ongoing pain and a palpable, painful lump around the previous medial arthroscopy portal. Plain radiographs and MRI were suggestive of a bony structure within the soft tissues. Histopathological examination at repeat arthropscopy confirmed osseous tissue consistent with HO. Recovery after the second procedure was rapid and resulted in normal knee function and complete pain relief. HO within an arthroscopy portal is a rare complication following arthroscopic partial meniscectomy in the knee and has not previously been described in the literature.     

CA9 level in renal cyst fluid: a possible molecular diagnosis of malignant tumours

Aims:  The preoperative differentiation of malignant renal cystic tumours from benign lesions is critical, and it remains a common diagnostic problem. The aim was to examine if the Carbonic anhydrase 9 (CA9) level in cyst fluid can provide a molecular diagnosis of malignant cyst.
Methods and results:  Twenty-eight patients with a cystic renal mass were included. Fine-needle aspiration was performed to obtain the fluid. Postoperative pathology confirmed that there were 16 cystic renal cell carcinomas. Twelve benign cystic tumours were used as controls. One hundred microlitres of supernatant of cyst fluid was used to measure the CA9 protein level, which was measured by an enzyme-linked immunosorbent assay technique. CA9 was strongly detected and considered as positive in the cyst fluid of all 16 cystic malignant tumours (>1000 pg/ml), whereas its expression was negative in 11/12 benign cystic tumours (<300 pg/ml). The difference in percentages of positive CA9 between malignant and benign renal cystic tumours was significant ( P  < 0.001).
Conclusion:  The fluid of malignant cystic renal tumours contains a high level of CA9 protein. The measurement of CA9 level in cyst fluid may be used as a molecular diagnosis for differentiation between malignant and benign renal cystic masses.     

Ultrasound guided fine-needle aspiration cytology: Diagnosis of hydatid disease of the abdomen and thorax

Eight cases of hydatid disease of the abdomen and thorax were diagnosed by fine-needle aspiration (FNA) cytology under ultrasound guidance. the age of the patients ranged from 28 to 60 yr with a median of 34.5 yr; the male to female ratio was 2:6. None of the cases were diagnosed clinically as hydatid diseases but following ultrasonography suspicion of hydatid cyst was raised in two cases. the locations of cysts were the liver in six cases, the lung in one case, and the mediastinum in one case. FNA yielded clear fluid in five cases and turbid fluid in three cases. Laminated cyst wall, scolices, and hooklets were observed in one case, scolices and hooklets were present in two cases, and laminated cyst wall along with hooklets were seen in two cases. the remaining three cases showed only laminated cyst walls which yielded positive reaction with periodic acid-Schiff reaction. Inflammatory cell reaction in the form of neutrophils was observed in four cases, including the three cases where turbid fluid was aspirated. Epithelioid cell reaction was present in one case. None of our eight cases showed any untoward allergic reaction following FNA. © 1995 Wiley- Liss, Inc.     

Subparaneurial ganglion cysts of the fibular and tibial nerves: A new variant of intraneural ganglion cysts

Over the last decade, the mechanism of formation of intraneural ganglion cysts has been established through a meticulous review of clinical findings and correlation with patterns produced on magnetic resonance imaging (MRI). Pathognomonic imaging patterns distinguish these rare lesions from the more common extraneural variants in almost all cases. In this report, we present a new pattern of cyst occurrence in the subparaneurial compartment of the nerve and provide potential anatomic explanations for its pathogenesis. Using an anatomic framework of connective tissue compartments of the nerve, we reviewed 63 (56 fibular and seven tibial) intraneural ganglion cysts in the knee region evaluated at our institution and all reports with MRI in the world's literature for evidence of cyst occurrence in the subparaneurial compartment. We identified six cases (five in the common fibular nerve and one in the tibial nerve) at our institution that had MR evidence of cyst in the subparaneurial compartment with a new complex lobulated pattern. All cases had articular branch connections to the superior tibiofibular joint, which at operation were resected along with the joints. Follow‐up revealed complete recovery in all instances and no clinical or radiological signs of recurrence. Three cases out of 80 in the literature exhibited the new complex lobulated MRI pattern. We present a new pattern of intraneural ganglion cyst occurrence in a potential space that surrounds peripheral nerves‐ the subparaneurial compartment. We believe that the unifying articular theory applies to the pathogenesis and management of these rare variants. Clin. Anat. 29:530–537, 2016. © 2015 Wiley Periodicals, Inc.     

Aggressive proximal tibio-fibular joint ganglion cyst after a total knee arthroplasty--a case report

Although the knee is a common location, a ganglion cyst arising from the proximal tibio-fibular joint (PTFJ) is relatively rarer. Unique diagnostic and management difficulties are encountered as these can extend into subcutaneous tissue, or spread along peroneal muscles and nerve, or erode adjacent bone. We report here a PTFJ ganglion cyst which was indolent for at least 12 years and then caused destructive and expansile changes in the fibula over a period of 6 years after a total knee arthroplasty (TKA), simulating a malignancy. Although no wear or foreign body reaction could be shown, this alarming progression of a PTFJ ganglion cyst in the fibula after the TKA is a noteworthy association, and has not been recognized and reported before. Awareness of such a lesion can aid in the diagnosis and prevent unnecessary aggressive management.