The pathology and evaluation of surgical treatment in a ruptured giant popliteal/crural cyst associated with rheumatoid arthritis

Popliteal cysts are often observed in patients with rheumatoid arthritis (RA), and giant cysts that extend from the popliteal to the crural region (popliteal/crural cysts) are occasionally encountered. We studied the background of popliteal/crural cysts and therapeutic results, and evaluated its etiologic factors and the effectiveness of surgical treatment. Nine knees of eight patients with popliteal/crural cyst secondary to RA, which was treated surgically because it resisted conservative treatment, and was followed up for 1 year or longer after surgery, were evaluated. The patients were five men and three women, with a mean age at surgery of 59.1 years and a mean duration of RA disease of 4.5 years. Only one male patient suffered pain in the bilateral joints. The mean level of erythrocyte sedimentation rate was 61.3 mm/h (range 3.9–100.2), the mean level of C-reactive protein was 3.6 (0.1–8.2) mg/dl, and the mean Lansbury index was 36.4 (12–61) at surgery. The cyst disappeared completely after surgery, and the postoperative course was uneventful in eight knees, but recurrence was observed in just one knee of the bilateral case. However, in this patient the cyst that recurred was not as large as the one before surgery, and it was eventually brought under control by subsequent outpatient medical management. Inflammatory reactions were suppressed, if temporarily, in all patients. The patients evaluated in this study showed the following characteristics: the male–female ratio of the patients was biased to males compared with that of RA patients in general; although knee joint damage was radiographically mild, marked symptoms of arthritis were observed in not only the knees but also other joints in all patients; and the disease could not be controlled effectively by medication. However, after surgical resection of the cysts, general as well as local signs of inflammation were mitigated, and surgery was considered to be very effective for the treatment of ruptured giant popliteal/crural cyst associated with RA.     

Haemorrhage into a popliteal cyst: an unusual complication of haemophilia A.

A 7(1/2)-year-old boy with severe haemophilia A had increasing discomfort and pain in his left knee after sledding on ice and landing on his knees. Left knee pain persisted for days despite recombinant factor VIII replacement. Imaging studies showed that by day 10 a popliteal cyst had ruptured, with diffusion of blood into the calf muscles. This case illustrates another possible bleeding complication in patients with a bleeding disorder and a popliteal cyst.     

Pseudothrombophlebitis in a Patient with Behçet’s Syndrome: Doppler Ultrasound and Magnetic Resonance Imaging Findings

A 33-year-old man with a known diagnosis of Beh?et's syndrome (BS), presented with pseudothrombophlebitis resulting from acute rupture of a popliteal cyst. Doppler ultrasound and magnetic resonance imaging findings are explained. Differentiation of rupture of a Baker's cyst from true thrombophlebitis, especially in patients with BS, who are potentially susceptible to thrombotic events, is extremely important.     

The pathology and evaluation of surgical treatment in a ruptured giant popliteal/crural cyst associated with rheumatoid arthritis

Abstract

Popliteal cysts are often observed in patients with rheumatoid arthritis (RA), and giant cysts that extend from the popliteal to the crural region (popliteal/crural cysts) are occasionally encountered. We studied the background of popliteal/crural cysts and therapeutic results, and evaluated its etiologic factors and the effectiveness of surgical treatment. Nine knees of eight patients with popliteal/crural cyst secondary to RA, which was treated surgically because it resisted conservative treatment, and was followed up for 1 year or longer after surgery, were evaluated. The patients were five men and three women, with a mean age at surgery of 59.1 years and a mean duration of RA disease of 4.5 years. Only one male patient suffered pain in the bilateral joints. The mean level of erythrocyte sedimentation rate was 61.3?mm/h (range 3.9–100.2), the mean level of C-reactive protein was 3.6 (0.1–8.2) mg/dl, and the mean Lansbury index was 36.4 (12–61) at surgery. The cyst disappeared completely after surgery, and the postoperative course was uneventful in eight knees, but recurrence was observed in just one knee of the bilateral case. However, in this patient the cyst that recurred was not as large as the one before surgery, and it was eventually brought under control by subsequent outpatient medical management. Inflammatory reactions were suppressed, if temporarily, in all patients. The patients evaluated in this study showed the following characteristics: the male–female ratio of the patients was biased to males compared with that of RA patients in general; although knee joint damage was radiographically mild, marked symptoms of arthritis were observed in not only the knees but also other joints in all patients; and the disease could not be controlled effectively by medication. However, after surgical resection of the cysts, general as well as local signs of inflammation were mitigated, and surgery was considered to be very effective for the treatment of ruptured giant popliteal/crural cyst associated with RA.     

Pseudothrombophlebitis in neuropathic arthropathy

The pseudothrombophlebitis syndrome is a complication of large, ruptured, or dissecting popliteal cysts. We report a patient with neuropathic arthropathy of the knee and the pseudothrombophlebitis syndrome secondary to a dissecting popliteal cyst. This represents another form of arthritis associated with this syndrome.     

Treatment of popliteal cysts via arthroscopic enlargement of unidirectional valvular slits

Abstract

Objective. The aim of the present study was to investigate the efficacy of arthroscopic enlargement of unidirectional valvular slits for the treatment of popliteal cysts and to evaluate potential factors affecting the outcomes of our arthroscopic procedure.

Methods. Twenty-nine patients aged 43–77 years with popliteal cysts were treated with arthroscopic cyst decompression. Surgery was performed via two posterior portals after creating a transseptal portal. Rauschning and Lindgren clinical score, magnetic resonance images, and osteoarthritic grade were evaluated pre- and postoperatively, and cartilage degeneration class was confirmed via arthroscopy. The mean follow-up period was 22.9 ± 14.6 months (range, 9–60 months).

Results. Twelve cysts disappeared completely (group D), while 16 reduced and one enlarged (group R) in size by the final follow-up. Twenty-two (75.9%) of 29 popliteal cysts diminished to a volume that was less than 10% of the preoperative volume. Clinical scores improved in 93.1% of the patients, and more patients (68.8%) in group R had positive joint effusion at the final follow-up compared with group D (17.7%; p < 0.01).

Conclusions. Arthroscopic cyst decompression was effective in the treatment of symptomatic popliteal cysts. Intra-articular pathologies associated with joint effusion should be corrected simultaneously.     

Epidermoid cyst originating from an intrapancreatic accessory spleen

We report a rare case of an epidermoid cyst originating from an intrapancreatic accessory spleen, in a 40-year-old Japanese man with no clinical symptoms. A cystic tumor in the pancreatic tail was detected incidentally by abdominal ultrasonography. The patient was referred to the KKR Tachikawa Hospital for further examination of the tumor. Preoperative imaging findings suggested that the tumor was an epidermoid cyst originating from an intrapancreatic accessory spleen. On both pre-and post-contrast computed tomography and magnetic resonance images, the solid compartment of the tumor had the same X-ray attenuation and intensity as the spleen. Upon surgical excision, the mass consisted of solid and cystic components that were macroscopically evident on the preoperative images. Microscopic analysis revealed that the solid component was an accessory spleen in the pancreatic tail, whereas the cystic component was lined with stratified epithelium representative of an epidermoid cyst. This is the thirteenth report (in English) of an epidermoid cyst originating from an intrapancreatic accessory spleen, and the first case to be diagnosed prior to surgery.     

Association of spondylarthropathies with lumbar synovial cysts

 Intraspinal synovial cysts presenting with lower back pain and radiculopathy are well known but rare. They are associated with facet joint arthopathy, generally degenerative in nature. Spinal synovial cysts have not been described in spondyloarthropathies (SpA). We report a case of a 66-year-old man with a chronic undifferentiated SpA who presented with severe weakness of both legs. A centrally located spinal cyst was encountered on MRI and led to excision of a highly inflammatory synovial cyst. This association may not be fortuitous and be related to inflammation of the facet joint in SpA. Received: 17 April 2002 / Accepted: 12 August 2002     

Solitary true cyst of the pancreas in an adult: report of a case

Background: Solitary true cyst of the pancreas is rare in adults, and the differential diagnosis of cystic lesions of the pancreas is challenging. Aim of the Study: To describe a solitary true cyst of the pancreas in an adult and discuss the differential diagnosis. Methods: A 50 yr old woman presented with a mass lesion in the right upper quadrant of the abdomen. Abdominal computed tomography showed a cystic lesion, with a maximum diameter of 12 cm, between the inferior surface of the liver and the ascending colon. The cyst was homogenous and had smooth edges. On magnetic resonance imaging, a unilocular cyst was seen that was low intensity on T1-weighted images and very high intensity on T2-weighted images. No connection between the cyst and the pancreatic ductal system was demonstrated on endoscopic retrograde cholangiopancreatography. Laparotmy was performed with a presumptive diagnosis of cystic tumor of the pancreas. Results: On pathologic examination, the cyst was serous and was lined with a single layer of normal cuboidal epithelium that was periodic acid Schiff stain negative. Meticulous examination failed to identify honeycomb-like microcysts characteristic of serous cystadenoma. The final diagnosis was a solitary true cyst of the pancreas. Conclusion: The differential diagnosis of solitary true cyst from other cystic lesion of the pancreas usually is based on histology. Particular care must be taken to distinguish this lesion from macrocystic serous cystadenoma.     

Infected cardiac hydatid cyst

A 24 year old woman presented with chest pain and palpitation. The presence of a semisolid mass—an echinococcal cyst or tumour—in the left ventricular apex was diagnosed by echocardiography, computed tomography, and magnetic resonance imaging. The infected cyst was seen at surgery. The cyst was removed successfully by using cardiopulmonary bypass with cross clamp.


Keywords: cardiac hydatid cyst; infected cardiac hydatid cyst     

Rupture of Baker's cyst producing pseudothrombophlebitis in a patient with Reiter's syndrome

This is an unusual case of pseudothrombophlebitis resulting from rupture of Baker's cyst in a patient with Reiter's syndrome. The patient presented with a swollen, painful left calf and persistent itching on the skin of the calf. Ultrasonography showed a ruptured popliteal cyst with minimal hemorrhage and fluid collection within the fascial compartments and gastrocnemius muscle. Color Doppler ultrasound showed a patent popliteal vein and artery and duplex Doppler scans revealed a normal flow pattern. In conclusion, the clinical picture of deep vein thrombosis and that of pseudothrombophlebitis are difficult to distinguish by clinical examination and necessitate detailed examination by imaging techniques. Persistent pruritus on calf skin resulting from irritation of inflammatory synovial fluid may be an important clinical feature.     

Popliteal cyst rupture and the pseudothrombophlebitis syndrome

Fifteen patients presented during a four-year period with a pseudothrombophlebitis syndrome, subsequently confirmed arthrographically as being due to popliteal cyst rupture. Initially the majority of patients (73%) were erroneously diagnosed as having calf vein thrombosis, and were anticoagulated for periods of three to ten days. Clinical differentiation from venous thrombosis was usually impossible. Contrast arthrography was the definitive diagnostic investigation, revealing popliteal cysts in all patients, and an active synovial leak into the calf in 13 cases (87%). The mean delay in performing arthrography was 5.3 days, the procedure usually being performed after normal contrast venography. Doppler and isotope venography yielded misleading or equivocal results (42%) delaying diagnosis, and prolonging periods of potentially dangerous anticoagulation. We suggest that the marked overlap in the emergency presentation of popliteal cyst rupture and calf vein thrombosis mandates the aggressive use of arthrography combined with venography in all patients presenting with a painful swollen leg.     

Compartment Syndrome of the Lower Leg After Surgery in the Modified Lithotomy Position: Report of Seven Cases

Purpose Acute compartment syndrome is known to develop after trauma or after postischemic revascularization. It also can occur when a patient has been lying in the lithotomy position during prolonged surgery. Methods were searched for the prevention of this iatrogenic complication after a series of seven patients who developed compartment syndrome after surgery at our hospital. Methods A series of seven consecutive patients who developed compartment syndrome of the lower leg(s) after abdominoperineal surgical procedures from 1997 to 2002 is presented and so are the lessons learned to prevent this problem. Results When comparing our experiences with data from literature, the seven patients had the usual risk factors for development of a compartment syndrome: lengthy procedure (>5 hours); decreased perfusion of the lower leg because of Trendelenburg positioning combined with the lithotomy position; and external compression of the lower legs (because of positioning, stirrups, or antiembolism stockings). Measures have been taken to prevent compartment syndrome from developing after prolonged surgery in the lithotomy position. This complication has not occurred again after the introduction of these measures two years ago. Conclusions Acute compartment syndrome can be prevented if adequate measures are taken, but after lengthy surgery, maximum alertness for emerging acute compartment syndrome remains indicated. Early diagnosis and treatment by four-compartment fasciotomy is still the only way to prevent irreversible damage.     

Popliteal cysts: Variations on a theme of Baker

Adams¹ in 1840 was the first to describe popliteal cysts, “the enlarged bursa is normally situated beneath the inner head of the gastrocnemius and communicates with the joint by a species of valvular opening.” Baker² whose name has been given to the cysts suggested in 1877 that the cyst may be a distended bursa related to the semimembranosus tendon. He also suggested that the cyst was connected with the knee synovium and pointed out that the fluid could not return to the joint. He considered that rupture could occur with the formation of calf cysts and that the leak could come from the popliteus bursa. He also commented (Case 1) on difficulty in distinguishing this syndrome from venous thrombosis. He quotes Foucher (1856)³ who described a typical history of a recurrent cyst with rupture. “An officer first noticed a small swelling in the inner side of the popliteal space, three days after a forced march on a rough road. The tumour only very gradually increased. About eighteen months after its first appearance a sudden effort at extending the leg caused a rupture of the wall of the cyst, the tumur disappearing at the same time that the calf of the leg began to swell. A bandage was applied, but the patient was not laid up. Two years afterwards the cyst was larger than ever; and for a short time the patient was obliged to lie up, as part of the fluid contents of the cyst, after a tight bandaging, had extended on both sides of the knee. Ultimately the disease disappeared.” Foucher described 6 cases, but did not observe the communication of the cyst with the knee.Thus, though much of what we know today^{4 ? 8} has been known for over a century, medical text books give scant attention to the subject. The varied clinical patterns derived from popliteal cysts still lead to misdiagnosis with undesirable if not disastrous consequences. ⁹ Current knowledge of this subject is brought together in this review.     

A giant biliary cyst of Todani IA in a young woman: A case report

Rationale:Biliary cysts (BC) are rare dilatations of various parts of a biliary tract. They account for approximately 1% of all benign biliary diseases. Total cyst excision and Roux-Y hepaticojejunostomy is the treatment method of choice in most patients. In this paper, a novel surgical treatment with the use of internal biliary and pancreatic catheters was presented.Patient concerns:A 21-years-old woman with a giant choledochal cyst of Todani IA type presenting with abdominal pain, nausea, fever and palpable abdominal mass. It had been previously drained as a misdiagnosed pancreatic cyst in another hospital.Diagnosis:A very high amylase level (107140,0 U/l) in drain fluid was noted in laboratory tests. Endoscopic retrograde cholangiopancreatography revealed a biliary cyst located in the distal common bile duct and a pancreaticobiliary anomaly was suggested. A cholangiography per catheter inserted to the biliary cyst showed a large round contrast-filled cyst. A cholangiography following cyst decompression revealed a very long, tortuous bile duct entering the duodenum.Interventions:Cholecystectomy, cyst resection, Roux-Y hepaticojejunostomy, and implantation of catheters into pancreatic and bile duct were performed. The postoperative course was uneventful and she was discharged on 12th day without any complications. Histopathology revealed a cyst wall partially lined with biliary-type and mucinous epithelium, with dysplasia ranging from low to high grade (biliary intraepithelial neoplasia, high grade), without invasion.Outcomes:The biliary and pancreatic catheters were removed during endoscopic retrograde cholangiopancreatography 8 weeks following surgery without any complications. Fourteen months later, the patient reported good health.Lessons:Diagnosis of the abdominal cyst should be very precise in order to avoid misdiagnosis and inadequate management. The early diagnosis and proper treatment of BC are needed in order to avoid serious complications. The cholangiocarcinoma is the most dangerous potential complication of BC due to dysplasia within the cyst wall as in our young female patient.     

Gas-like radiolucencies in a popliteal cyst

A 71-year-old man with rheumatoid arthritis complained of pain and swelling in the left calf. X-ray examination of the calf disclosed radiolucencies suggestive of soft tissue gas; however, subsequent investigation revealed no evidence of infection and an arthrogram showed a dissected popliteal cyst in the area of the gas. Gas-like radiolucencies in a popliteal cyst are an unusual finding which has not been previously reported.     

Arteriographic evidence of pseudoocclusion of the popliteal artery: don't be fooled.

Individuals with chronic lower extremity pain or lifestyle limiting claudication often undergo angiography prior to intervention. Occasionally initial angiographic findings are not indicative of a true pathologic process. Described below are two such cases. Both of the patients described had iliofemoral atherosclerotic disease with arteriographic suggestion of popliteal artery occlusion. However, their medical histories, noninvasive vascular studies, and arteriograms were not consistent with chronic popliteal artery occlusion. On subsequent arteriogram with knee flexion, the occlusions were found to be positional or pseudooccluded. Pseudoocclusion of the popliteal artery (POPA) does not require intervention, and therefore it is necessary to differentiate it from other pathologic processes. Discrimination of POPA from atherosclerotic occlusion, popliteal artery entrapment syndrome, cystic adventitial disease, and vasculitis is possible through history and exam. Arteriography is helpful because a lack of contralateral disease or collateral circulation may indicate a positional occlusion.     

Infected bronchogenic cyst causing dysphagia and retrosternal pain

Bronchogenic cysts are congenital. They are typically discovered in infancy or early childhood. Secondary infection of the cyst is uncommon. We present the case of a 17‐year‐old female who presented to the emergency department with intermediate onset of upper abdominal, and retrosternal chest pain and fever. Subsequent X‐ray and computerised tomography scan showed a bronchogenic cyst. The patient underwent subacute thoracotomy where a bronchogenic cyst filled with pus was located and excised. Bronchogenic cysts can be a rare cause of retrosternal pain. Please cite this paper as: Søndergaard EB, Pedersen JH and Kleive D. Infected bronchogenic cyst causing dysphagia and retrosternal pain. Clin Respir J 2013; 7: e1–e2.     

Non-invasive quantification of popliteal cyst volumes by three-dimensional ultrasonography

SIR, Popliteal cyst (Baker's cyst) arises in the medial aspectof the popliteal fossa and results from fluid distension ofthe gastrocnemius-semimebranosus (GS) bursa, which is locatedbetween the muscles bearing the corresponding names [1]. Thecommunication between the knee joint and the bursa, and thefluid dynamics of the cyst fluid contribute to the genesis ofthe popliteal cyst. Flexion of the knee causes the joint pressureto exceed bursal pressure and the valve-like connection betweenthe joint and the     

Giant Hepatic Cyst: A Possible Cause of Inferior Vena Cava Syndrome

An 80-year-old man was transferred to our institution with lower limb edema and worsening dyspnea following the administration of diuretic medication. Transthoracic echocardiography and computed tomography revealed a giant hepatic cyst (176×190 mm) compressing his right atrium and inferior vena cava (IVC). Laparoscopic cyst deroofing combined with omental packing and subsequent tube drainage immediately alleviated all his symptoms. The procedure was uneventful, and he was discharged without any complications on postoperative day 9; he had no recurrent symptoms or hepatic cysts at the postoperative 2-month follow-up. Therefore, a giant hepatic cyst can cause IVC syndrome, and laparoscopic deroofing is a beneficial approach for the treatment of accessible cysts.