Reachout Orthopedics - Issue 2

15 mg weekly, prednisolone 5 mg daily, and subcutaneous golimumab. She showed mod- erate disease activity (DAS28-ESR 4.71) and had no joint symptoms other than left knee. Simple knee X-ray showed OA change with K–L grade 3. MRI revealed popliteal cyst leakage with meniscal and ligament damage of left knee and laboratory investigation of aspirated fluid from cyst revealed white cell count 16,000 (PMN 73%). She underwent intra-articular glucocorticoid injection into the knee joint, but the symptoms recurred. Arthroscopic cystectomy and synovectomy was performed. During the follow-up period of 12 months after surgery, there was no re- currence of popliteal cyst. Case 4 A 66-year-old woman with 7 years of history of seropositive RA presented with both knee pain. The disease activity of RA was well con- trolled and patient was taking methotrexate 15 mg weekly, hydroxychloroquine 200 mg daily. Simple knee X-ray revealed bilateral OA with K–L grade 3. MRI revealed septated pop- liteal cysts with meniscal tear in both knees and joint fluid analysis of left knee showed white cell count 90 (PMN 28%). Despite intra- articular glucocorticoid injection into both knee joints, symptoms persisted. Arthroscopic cyst excision and partial medial meniscecto- my were performed on both knees. After the operation, the patient is under observation for 12 months without recurrence. Discussion In the present study, four RA patients (six knees) in combination with OA having refractory popliteal cysts have successfully been treated with arthroscopic operation including cystectomy, synovectomy, and/ or correction of valvular communication of cysts. All cases have been actively treated with DMARDs and/or biologics such as golimumab for RA, by which disease activity of RA except knees was relatively well controlled. Popliteal cysts are generated by the communication of the bursas around the knee joint. During knee flexion and extension, a pressure difference occurs between the intra- articular and intracyst regions, leading to fluid collection as a check-valve mechanism [14]. Popliteal cyst is usually asymptomatic; Table 2: Review of all nine articles from literature search. References, country Number of case RA activity Symptoms Diagnostic image Rupture of cyst Treatment Outcome Jayson et al . UK [15] 7 NA Painful swelling Arthrogram No Anterior synovectomy Resolution Kirkham et al . UK [16] 2 Active Painful swollen left shin US, arthrogram Yes Open surgical drainage  +  steroid injection Resolution Kanekasu et al . Japan [17] a 5 NA Pain and swelling in the popliteal region MRI No Arthroscopic synovectomy (4 cases), open cyst excision (1 case) No recurrence in arthroscopic treatment, recurred in open cystectomy patient Tanaka et al . Japan [18] 31 NA Swelling, pain, and discomfort NA No Arthroscopic synovectomy plus pedicle graft capsuloplasty 74% resolution, 23% mild symptoms, 3% swelling and tenderness after normal activities Lee et al . Korea [19] 1 NA Knee pain, posterior tibial neuropathy US, MRI No Open surgical cystectomy Pain resolution, numbness remained Ushiyama et al . Japan [20] 1 NA Leg pain, drop foot, ant compartment syndrome CT, arthrogram Yes Emergency fasciotomy Palsy remained Mikashima et al . Japan [21] 8 Active Painful swelling MRI No Direct view cyst resection and/ or arthroscopic synovectomy 1 recurrence in cystectomy, only Ravlic-Gulan et al . Croatia [22] 1 Inactive Swelling in popliteal fossa US, MRI No Arthroscopic synovectomy, open cyst excision Re-cystectomy Anterior synovectomy Adiyeke et al . India [23] 1 Maybe inactive Swelling in popliteal fossa MRI No Arthroscopic cystectomy Resolution RA rheumatic arthritis, NA not applicable, US ultrasound, MRI magnetic resonance imaging, CT computed tomography a Article in Japanese with only abstract available Fig. 4: Histopathological images showing fibro-hyalinized tissue and plasma cells resulting from active chronic inflammation (hematoxylin and eosin staining, original magnifica- tion × 200). 27 reachOut Orthopedics