Reachout Orthopedics - Issue 2

however, posterior knee pain, knee stiffness, swelling, palpable mass, and discomfort can occur with the cyst alone. RA is a type of autoimmune disease that causes chronic inflammation in the whole body, in which the synovium is the primary target particularly. As the synovitis becomes more severe, the tissues become friable and may be easily torn in cases of popliteal cyst. If the extra-articular leakage is small and chronic, the patient may only present symptoms of swelling and/or edema of the lower extremity. However, if the leakage is acute and large in amount, this may result in serious complications such as compartment syndrome [8–11]. In cases of popliteal cyst rupture, extravasation of degraded blood products and inflammatory synovial fluid may cause irritation and inflammation of the surrounding fascia, muscles, and subcutaneous tissues. Liao et al . [4] have reported that RA was the second most common disease that were associated with popliteal cyst (20.6%) following OA (50.6%), which was investigated by ultrasonography. However, they have also emphasized that cases of ruptured popliteal cyst were more frequent in the inflammatory diseases (66.7%) such as RA than the degenerative one (33.3%). Although various conservative treat- ments for popliteal cysts with RA could be successfully, surgical interventions may be required for refractory or/and complicated cysts as presented in this report. Optimal RA disease activity control is crucial to prevent recurrence. One of the important implications of this report is that prompt evaluation should be conducted when lower leg swelling or edema develops in RA patients, as shown in case 1. All four cases in the present report were postmenopausal females and all six knees were combined with OA changes such as K–L grade 2 or 3, and meniscal/ ligament damage on MRI. Therefore, underlying pathophysiology of popliteal cysts in the cases might result from that of OA. However, unlike the cystic wall of popliteal cyst in patients with only OA pathology, the popliteal cyst wall in RA patients tends to be hypervascular and inflammatory, which can possibly make the walls friable, leading to leakage and rupture. With extension of pain and swelling to the lower leg especially with acute development, popliteal cystic wall leakage and subsequent rupture should be considered in this subgroup of RA patients. Since popliteal cyst is most frequently associatedwithOA,many reports regarding to treatment options have been focused on OA, with relatively few reports related to RA. In our literature review (Table 2) [15–23], which included nine reports, surgical interventions such as open synovectomy/cystectomy, arthroscopic synovectomy/cystectomy and biomechanical valve excision have been reported with overall successful outcomes. However, Ushiyama et al . [20] reported a case who had neurologic complication even after emergency fasciotomy, emphasizing the importance of early detection and intervention of such complicated popliteal cyst rupture for preventions of life-long neurologic impairments. In conclusion, arthroscopic intervention which allows the surgeons to perform radical debridement, synovectomy, biomechanical valve excision, and/or cystectomy in a delicate nature should be considered in patients with refractory and complicated popliteal cysts associated with RA or RA in combination with OA. Author contributions: JHY performed the surgery. JHY and HSL devised the project and the main conceptual ideas. HHK, JKL, and SYB aided in the interpreting the results and worked on the manuscript. JHY and HHK wrote the paper with input from all authors. JHY and HSL critically revised the manuscript at all stages of its production, final approval of manuscript, and review of literature. All authors discussed the outline and commented on the manuscript. Compliance with ethical standards Conflict of interest: Authors; Jae-Hyuk Yang, Hyuk-Hee Kwon, Jin Kyu Lee, So Young Bang, and Hye-Soon Lee declare that they have no conflict of interest. Publisher’s Note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References available on request Healthcare.India@springer.com Source: Yang, JH., Kwon, HH., Lee, J.K. et al . Rheumatol Int (2019). https://doi.org/10.1007/s00296-019-04278- 9. © Springer-Verlag GmbH Germany, part of Springer Nature 2019. concomitant chronic disease such as diabetes mellitus is needed. Finally, there are no adequately powered and controlled clinical trials of any intervention for midfoot OA, despite the region being the most commonly affected foot site [7], with a prevalence higher than hip OA [1]. Thus, research on management strategies for midfoot OA are also urgently needed. Conclusion Foot and ankle OA is highly prevalent, especially in older populations. Surprisingly, however, there has been very little clinical research in to the impact and treatment of foot and ankle OA, and much of the existing literature is based on small samples and has a number of methodological limitations such as a lack of blinding and/or controls. Knowledge of how to manage foot and ankle OA is extrapolated largely from OA studies at other lower-limb sites. Generally, OA guidelines advise advice and education, exercise and weight loss, where appropriate, as first-line strategies [44]. Low-dose acetaminophen, topical NSAIDs or topical capsaicin may also be considered as an adjunct to first-line treatments or in the case of inadequate pain relief. If these approaches remain insufficient, then either an oral NSAIDor COX-2 inhibitor may be substituted or added. Patients should be carefully monitored for symptomatic response and for any AEs, particularly the elderly and those with co-morbidities. There is limited evidence to suggest that HA injections may be useful for up to 6 months in people with ankle OA; however, evidence for other IA injections and in other foot joints is limited. Overall, further well-designed large RCTs are needed to provide evidence-based management options for this common and painful problem. Compliance with Ethical Standards Funding: No sources of funding were used in the preparation of this article. Conflict of Interest: Kade Paterson and Lucy Gates declare they have no conflicts of interest relating to the content of this article. References available on request Healthcare.India@springer.com Source: Paterson, K.L. & Gates, L. Drugs Aging (2019) 36: 203. https://doi.org/10.1007/s40266-019-00639-y. © Springer Nature Switzerland AG 2019. ...Cont'd from page 22 28 reachOut Orthopedics