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.     

Clinical features of patients with osteoarthritic knees followed by development of rheumatoid arthritis]

We investigated clinical features of patients with osteoarthritic knees followed by development of rheumatoid arthritis (RA) after several year's interval. The subjects were 16 knees of 8 patients with osteoarthritis (OA) including one man and 7 women. The mean age at development of OA knee was 62.8 years (range; 45-73). The mean age at later development of RA was 66.0 years (range; 52-79). The mean follow-up period was 96.4 months (range; 28-191). We evaluated clinical features using the 1987 revised Criteria of the American College of Rheumatology (ACR), laboratory dates including RF, CRP, ESR, the number of joints with RA, and femorotibial angle (FTA). The mean number of features of patients which was fulfilled with the ACR criteria was 3.3 +/- 1.6 at the onset of RA. Only four patients were seropositive through the total follow-up period. The serum level of RF, CRP, and ESR were reduced at the follow-up period. The mean number of the joints involved in RA was 11.0 +/- 5.1 (range; 4-22) and wrist and shoulder joints were involved more frequently than other joints except knees. High tibial osteotomy (HTO) was performed on 5 knees of 3 patients and the mean degree of FTA was 168.8 +/- 1.9 degrees just after surgery. However, 36 months after development of RA, joint destruction and valgus deformity occurred on 3 knees and the mean degree of FTA of 5 knees was ended up to 159.6 +/- 11.3 degrees. Our experiences suggested that RF, CRP, ESR and lesions of other joints should be carefully evaluated in the OA patients with seropositivity or knee hydrarthrosis and that histological analysis for synovium should be assessed by the biopsy at time of HTO or arthroscopic surgery to improve accuracy of diagnosis.     

Ultrasonography is superior to clinical examination in the detection and localization of knee joint effusion in rheumatoid arthritis

OBJECTIVE: Musculoskeletal ultrasonography allows real-time imaging of joint structures and may be used to complement clinical examination in rheumatological practice. We compared ultrasonography (US) with clinical examination (CE) in the detection of effusion, suprapatellar bursitis, and Baker's cyst of the knee in rheumatoid arthritis (RA) in order to determine whether US provided additional clinical information. METHODS: A total of 22 patients with RA (ACR criteria) underwent independent clinical and US examination of both knees for suprapatellar bursitis, knee effusion, and presence of Baker's cyst. US was performed using an ATL HDI 3000 machine with L7-4 MHz and CL10-5 MHz probes. Clinical examination was performed using standard techniques by an experienced rheumatologist. Patients with previous knee surgery were excluded from the study. RESULTS: A total of 44 knees were examined at a total of 130 sites (one patient was unable to lie prone for US of popliteal fossae). US detected soft tissue abnormality (suprapatellar bursitis, knee effusion, or Baker's cyst) at 54/130 (42%) sites, while CE detected soft tissue abnormality at 36/130 (28%) sites. US detected 17 (39%) cases of suprapatellar bursitis in 44 knees, 7 (16%) of which were detected on CE. US detected 27 (61%) knee joint effusions in 44 knees, 16 (36.36%) of which were detected on CE. US detected 10 (23.81%) Baker's cysts in 42 knees, 2 (4.76%) of which were detected on CE. Taking US of the knee as the gold standard, CE was specific but not sensitive in the detection of soft tissue abnormality of the knee in RA. CONCLUSION: US is more sensitive than CE in the detection of suprapatellar bursitis, knee effusion, and Baker's cyst in RA. CE underestimates knee inflammation in RA. This has implications for the use of CE as a component of standardized disease activity scores and in guiding knee joint aspiration.     

Evaluation of popliteal cysts and painful calves with ultrasonography: comparison with arthrography.

Grey-scale ultrasonography will detect reliably the presence of clinically significant popliteal cysts, fluid collections which do not fill by arthrography, and will frequently demonstrate ruptured cysts and the soft tissue changes resulting from a recent leak. Forty-eight knees, in 25 patients with popliteal and/or calf pain were examined by ultrasonography followed by arthrography. Popliteal cysts were demonstrated in 40% (19/48) by ultrasound and in 46% (22/48) by arthrogram. For comparison between arthrography and ultrasonography chi2 = 8.58 and contingency coefficient, phi = 0.42 (p less than 0.01). Acute cyst rupture was shown in 2 patients (8%) by both arthrography and ultrasound. In a further study ultrasonography demonstrated popliteal cysts with a prevalence of 31% (22/72) in 36 patients with definite or classical rheumatoid arthritis compared with 4% (3/72) in controls closely matched for age and sex. This difference in prevalence between the rheumatoid patients and controls was highly significant chi2 = 17.48, p less than 0.001. Ultrasonography, therefore, will demonstrate noninvasively the presence of popliteal cysts, may assist in the diagnosis of rupture, and furthermore will assist in quantitative, sequential assessment of patients with painful knees and calves.     

磁共振成像在类风湿关节炎患者膝关节病变研究中的意义

目的　初步探讨磁共振成像 (MRI)技术在类风湿关节炎 (RA)患者膝关节病变临床诊断中的应用价值。方法　对 2 0例RA患者的 34个膝关节进行多种序列成像并分析其MRI表现。结果　MRI可清晰显示RA膝关节的滑膜增生及血管翳形成、关节软骨破坏、骨质受侵、关节囊积液、半月板及韧带异常、窝囊肿形成以及皮下结节等改变 ,并能通过血管翳的信号和强化程度判断疾病是否处于活动期。结论　与X线相比 ,MRI对RA的骨质侵蚀破坏更为敏感 (P <0 0 1)。MRI能直接显示RA患者膝关节不同时期的各种改变 ,有助于疾病的早期诊断和临床分期     

Magnetic resonance imaging and ultrasonographic evaluation of the patients with knee osteoarthritis: a comparative study

The objectives of the present work were (1) to establish the prevalence of the abnormalities detected by magnetic resonance imaging (MRI) and ultrasonography (US); and (2) to compare these imaging techniques in detail. The study group consisted of 58 patients with symptomatic knee OA and 16 volunteer control subjects. Knee joint was evaluated for femoral condylar cartilage changes, effusion, synovial thickening and popliteal cysts using MRI and US. All knees with OA had cartilage abnormalities on US examinations and normal cartilage was detected in less than 3% of these knees by MRI. Majority of the knees with OA had effusion using US (70%) or MRI (85%). Synovial thickening observed on US (34%) and MRI (50%) were common in the knees with OA. Popliteal cysts were detected in 40% of the knees with OA using US and 35% using MRI. This study confirmed that there was a significant correlation between the MRI and US techniques for evaluating the cartilage and soft tissue changes in the patients with knee OA. There were more significant differences between the controls and the symptomatic knees which had Kellgren-Lawrence (K-L) grade 2 or more OA for the cartilage and soft tissue abnormalities on MRI and US. The prevalence of cartilage changes, effusion, synovial thickening and popliteal cyst using MRI and US were increased as the radiographic grade of OA increased. US examinations could be an alternative to initial evaluation tool to MRI in patients with knee OA.     

Popliteal aneurysm simulating a Baker's cyst in a patient with rheumatoid arthritis: a case presentation

Baker's cyst is the most common mass located in the back side of the knee, the popliteal fossa, in patients with degenerative and inflamatory disease of the knee. Popliteal mass may also be due to proliferation of adipose tissue, popliteal artery aneurysm, thrombotic vein, or tumor. These lesions are rarer and may easily be misinterpreted as cysts. We show a man with rheumatoid arthritis who is presenting a palpable mass in the popliteal fossa. Ultrasonography examination demostrated a popliteal artery aneurysms.     

Intra-articular injection of high molecular weight hyaluronan after arthrocentesis as treatment for rheumatoid knees with joint effusion

OBJECTIVE: The aim of this study was to find if a complete synovial fluid aspiration before injection of intra-articular high molecular weight hyaluronan influences the treatment result for knees with rheumatoid arthritis (RA), including joint effusion and the prognostic factors related to clinical effect. METHODS: The arthritic knees including effusion were randomized to arthrocentesis or no arthrocentesis before the hyaluronan (1.9-2.5 x 10(6)) was injected into knee joints five times every week. All patients were followed up for 6 months. RESULTS: One hundred eighteen RA patients (80 knees in the arthrocentesis group, 81 knees in the no-arthrocentesis group) were included. The proportion of no relapses in the arthrocentesis group was higher than that in the no-arthrocentesis group. In the arthrocentesis group, regression analysis showed that duration of knee arthritis (<5 months), CRP (<4 mg/dl), and Larsen grade (相似文献   

Nuclear magnetic resonance (NMR) tomographic imaging for popliteal cysts in rheumatoid arthritis.

The ability of nuclear magnetic resonance (NMR) tomographic imaging to show a change in proton spin-lattice relaxation time (T1 value) in the joints of patients with rheumatoid arthritis before and after treatment with intra-articular steroid has been assessed. Six patients with seropositive rheumatoid arthritis and clinical evidence of a popliteal cyst were examined by both NMR tomography and arthrography. In all cases the presence of active rheumatoid arthritis was shown by an increase in the T1 values of the synovium of the joints. After arthrography a consistent but small rise in T1 value was noted which fell to below the initial reading after treatment by intra-articular injection of an anti-inflammatory agent. In all cases the presence of the popliteal cyst was clearly shown by both NMR tomography and arthrography. The findings indicate that NMR tomography provides a sensitive method for the demonstration of inflammatory joint disease, popliteal cysts, and possibly for monitoring response to therapy.     

Popliteal masses masquerading as popliteal cysts.

Two popliteal swellings, thought initially to be synovial cysts associated with arthritic knees, were found to be unrelated tumours of serious significance. In the presence of neurological signs or a large cyst in association with a noninflammed knee joint a disease other than a simple synovial cyst should be considered.     

Detritus synovitis in chronic polyarthritis: a clinical and operation histologic evaluation

In rheumatoid arthritis (RA) joint inflammation is due to two processes: 1) the underlying inflammatory process (UIP) characterized by a lymphoplasmacellular infiltration of the synovial tissue, as well as pannus formation, and 2) the detritogenic synovitis (DS), a synovial response to articular wear products from cartilage and bone (detritus) that induces a preferentially fibrinous inflammation. In order to estimate the role of DS in the clinical presentation of such joints, 40 patients with RA undergoing knee-joint surgery on 48 occasions were evaluated for clinical parameters, radiological stage (Larsen), and histopathological characteristics of UIP and DS. The clinical parameters were comparable in knee joints with predominantly UIP or DS. However, DS was regularly seen in knees with advanced destruction according to Larsen's stages 4 to 5, while UIP occurres in joints even without radiological damage. In conclusion, it is assumed that the poor response of patients with advanced RA to so-called long-term drug therapy may be in part explained by the modifying influence of joint detritus on the underlying "rheumatoid" inflammatory process.     

SIX-YEAR FOLLOW-UP OF MULTIPLE JOINT REPLACEMENT SURGERY TO THE LOWER LIMBS

We report a 6-yr follow-up study of an original population of50 patients who had three or more major joints (hips and knees)replaced. Thirty-one of 32 surviving patients were still ambulantin the community, and all patients described significant painrelief. No RA patient was requiring permanent inpatient or residentialcare and the family remained the main social support. They remaineda very disabled group with a median Health Assessment Questionnairescore of 2.75. Ten required revision surgery: three hips andseven knees; four patients required their fourth lower limbjoint (hip/knee) replaced and seven patients required surgeryto the upper limbs and nine feet during the follow-up period.The median 10-yr survival of hip and knee arthroplasties inmultiple joint replacement (MJR) patients with RA was 90.5 and78.6% respectively. There was an increased incidence of cervicalmyelopathy in MJR patients 16.9%. The mortality rate was higherthan expected (standardized mortality ratio = 590) but the actualsurgery was not implicated. MJR therefore appears to be a worthwhilepolicy, even at long-term follow-up. KEY WORDS: Multiple joint replacement, Rheumatic arthritis, Cervical myelopathy     

KNEE LAXITY IN PATIENTS WITH OSTEOARTHRTTIS AND RHEUMATOID ARTHRITIS

Thirty-four patients with osteoarthritis (OA) and 32 patientswith rheumatoid arthritis (RA) were studied to determine theeffects of OA and RA on the laxity of the knee joints. Laxitywas measured with the Genucom Knee Analysis System. The antero-posteriorlaxity of the OA and RA knees was greater than the control,normal knees in the early stage, and decreased with the severityof disease in OA, but not in RA. Severe OA and RA were associatedwith a restricted internal-external rotation at the knee jointcompared with the control. Internal-external rotation decreasedwith worsening of both diseases. Varus-valgus laxity tendedto increase slightly with the severity of disease. While themorphological changes of the cruciate ligaments in advancedOA and RA were not statistically different, the laxity of OA-afflictedknees was affected slightly by the severity of the damage tothe cruciate ligaments. KEY WORDS: Osteoarthritis, Rheumatoid arthritis, Knee joint, Laxity, Cruciate ligament     

Total knee arthroplasty on the disease activity of rheumatoid arthritis

Abstract

The effects of total knee arthroplasty (TKA) on the disease activity of rheumatoid arthritis (RA) was investigated in the present study. The disease activity of RA in 58 patients who had undergone simultaneous bilateral TKA (116 knee joints) was examined before, and 1, 6 and 12 months and 3 and 5 years after the operation. The disease activity was assessed using the simplified Lansbury index according to the duration of morning stiffness, grip strength, joint count and erythrocyte sedimentation rate. In addition, C-reactive protein (CRP) and rheumatoid factor were also measured. The mean simplified Lansbury index and CRP significantly improved 1, 6 and 12 months after TKA surgery compared to preoperative levels. However, 3 and 5 years after TKA, the mean simplified Lansbury index indicated that the disease activity remained lower than the preoperative level in only 21 (36%) patients. The results of the present study demonstrate that TKA lowers RA activity for at least 1 year after surgery, and thus synovectomy and surgical resection of articular cartilage in the knee joint appear to have an anti-rheumatoid effect.     

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.     

99m Technetium scintiphotography in arthritis. II. its nonspecificity and clinical and roentgenographic correlations in rheumatoid arthritis

Technetium-99m scintiphotography of the hands, wrists and knee joints of 24 patients with rheumatoid arthritis (RA) showed abnormal localization of isotope in one or more synovial structures in 96% of hands, in 94% of wrists and in 74% of knees. The results of scintiphotography correlated well with clinical assessment of synovial thickening and tenderness in the proximal interphalangeal and metacarpophalangeal joints of 9 consecutive RA patients. Scintiphotography proved more sensitive than clinical examination only in knee joints; in 2 patients clinical involvement was antedated by positive scintiphotos. Joint visualization after intravenous pertechnetate was nonspecific, and positive scintigrams were obtained in other diseases associated with increased articular or periarticular vascularity. The technic is definitely useful in the serial evaluation of the results of local medical and surgical treatment of arthritis and as an aid in the diagnosis of psychogenic rheumatism.     

Ultrasonographic demonstration of popliteal cysts in rheumatoid arthritis

Ultrasound scanning techniques detected popliteal cysts in 14 of 24 knees affected with rheumatoid arthritis and associated with an anterior effusion. Serial scans demonstrated the persistence of cysts when effusion was not controlled by intraarticular steroid and lidocaine, and regression of cyst following control of effusion with anterior synovectomy. As the technique is noninvasive, painless, and reproducible, ultrasound scanning should be the technique of choice for the detection and assessment of popliteal cysts.     

Total knee arthroplasty on the disease activity of rheumatoid arthritis

The effects of total knee arthroplasty (TKA) on the disease activity of rheumatoid arthritis (RA) was investigated in the present study. The disease activity of RA in 58 patients who had undergone simultaneous bilateral TKA (116 knee joints) was examined before, and 1, 6 and 12 months and 3 and 5 years after the operation. The disease activity was assessed using the simplified Lansbury index according to the duration of morning stiffness, grip strength, joint count and erythrocyte sedimentation rate. In addition, C-reactive protein (CRP) and rheumatoid factor were also measured. The mean simplified Lansbury index and CRP significantly improved 1, 6 and 12 months after TKA surgery compared to preoperative levels. However, 3 and 5 years after TKA, the mean simplified Lansbury index indicated that the disease activity remained lower than the preoperative level in only 21 (36%) patients. The results of the present study demonstrate that TKA lowers RA activity for at least 1 year after surgery, and thus synovectomy and surgical resection of articular cartilage in the knee joint appear to have an anti-rheumatoid effect.     

Ultrasonographic demonstration of popliteal cysts in rheumatoid arthritis. A noninvasive technique.

Ultrasound scanning techniques detected popliteal cysts in 14 of 24 knees affected with rheumatoid arthritis and associated with an anterior effusion. Serial scans demonstrated the persistence of cysts when effusion was not controlled by intraarticular steroid and lidocaine, and regression of cyst following control of effusion with anterior synovectomy. As the technique is noninvasive, painless, and reproducible, ultrasound scanning should be the technique of choice for the detection and assessment of popliteal cysts.