Cystic Lesions About the Knee Treatment & Management

  • Author: David M Gonzalez, MD, FACS; Chief Editor: Carlos J Lavernia, MD, FAAOS   more...
 
Updated: Jan 24, 2010
 

Medical Therapy

Medical treatment of some cysts may be effective. Bursal cysts due to acute trauma sometimes respond to nonsteroidal anti-inflammatory medication, rest, immobilization, and compression. Cysts that form secondary to gouty arthritis respond to an antigout treatment program. Cysts caused by rheumatoid arthritis and osteoarthritis can respond to medical treatment regimens. Infected cysts respond to antibiotics after being surgically drained.

Next

Surgical Therapy

Surgical therapy by excision of the mass is the mainstay of treatment for most symptomatic cysts that are not bursal in nature and that have not responded to nonsurgical treatment. (Note: Treatment should be directed at the cause of the enlarged cyst, such as adventitial bursal cysts caused by an osteochondroma or an enlarged Baker cyst that requires addressing intra-articular causes through arthroscopic surgical procedures.) Other cysts, such as meniscal cysts, extraneural cysts, and ganglion cysts, can respond to surgical excision.

Previous
Next

Preoperative Details

Perform a thorough preoperative workup as described above (see Workup) to confirm that the mass is cystic in nature and is not a solid tumor that may be benign or even malignant.

Previous
Next

Intraoperative Details

Intraoperative details are dependent on the location of the cyst being treated. A prepatellar-infected bursitis is approached through a midline incision. Then, the contents of the bursa are evacuated, and all loculations are lysed. After thorough irrigation and debridement, the wound is packed open and allowed to drain. Appropriate antibiotics are begun, and the wound is readdressed in 2 to 3 days.

A popliteal or Baker cyst can be approached in a number of different ways. One way is to place the patient supine with the knee slightly flexed on the operating table. A lazy-S skin incision is made in the popliteal fossa. The cyst can usually be seen beneath the deep fascia and presents itself between the medial head of the gastrocnemius and the semimembranosus. The cyst is dissected by means of sharp and blunt dissection until its communication with a capsule is seen. The base is excised, and the defect is usually closed.

Other cysts related to bursitis, such as medial gastrocnemius bursitis and semimembranosus bursitis, are treated in a similar fashion. Depending on the exact location, other approaches can be used, such as the medial hockey-stick incision with the knee flexed at 90°. Basic knowledge of the surgical approaches to the anterior, medial, lateral, and posterior aspects of the knee can serve the surgeon well in approaching any cyst about the knee.

Previous
Next

Postoperative Details

Postoperative rehabilitation is similar after excisions of all knee cysts. After surgery, the patient is placed in a knee immobilizer for comfort. Isometric exercises are begun on day 1, as are straight-leg raises. Weight bearing in the knee immobilizer as tolerated is allowed. Knee range-of-motion exercises are begun in the first few days after surgery as soon as the wound is stable and postoperative inflammation begins to subside.

Previous
Next

Complications

Postoperative complications from knee-cyst excision include infection, nerve or blood vessel damage from the operative dissection, hematoma formation, and recurrence of the cyst. If the inciting cause of the cyst is not addressed, the pain may remain after excision despite removal of the cyst. Meniscal cysts may recur after simple excision of the cyst because the meniscal tear was not addressed.

Previous
Next

Outcome and Prognosis

The treatment objective is to relieve pain and to improve functionality of the extremity by addressing the knee cyst. The best results are obtained if the cyst is properly evaluated, diagnosed, and treated. However, even in the best of hands, recurrence is possible. Baker cysts are notorious for developing synovial fistulae and for becoming infected.

Treating the underlying cause of the knee cyst is key, and appropriate arthroscopic treatment of meniscal tears, articular cartilage injuries, and cruciate ligament tears can also favorably affect results.

Previous
Next

Future and Controversies

The etiology of some knee cysts (eg, meniscal cysts, cruciate ganglion cysts) remains controversial. As further reports and histologic studies continue, the origins of such cysts will become clearer.

Previous
 
Contributor Information and Disclosures
Author

David M Gonzalez, MD, FACS  Partner, Sports Medicine Surgery and General Orthopaedic Surgery, San Antonio Orthopaedic Group

David M Gonzalez, MD, FACS is a member of the following medical societies: American Medical Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Society of Military Orthopaedic Surgeons, Texas Medical Association, Texas Orthopaedic Association, and Western Orthopaedic Association

Disclosure: Contributor Honoraria Other

Specialty Editor Board

Robert D Bronstein, MD  Associate Professor, Department of Orthopedics, Division of Athletic Medicine, University of Rochester School of Medicine

Robert D Bronstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Thomas M DeBerardino, MD  Associate Professor, Department of Orthopedic Surgery, Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician, Orthopedic Consultant to UConn Department of Athletics, University of Connecticut Health Center

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, and American Orthopaedic Society for Sports Medicine

Disclosure: Arthrex, Inc. Grant/research funds Other; Arthrex, Inc. Consulting fee Speaking and teaching; Genzyme Biosurgery. Inc. Grant/research funds Other; Musculoskeletal Transplant Foundation Grant/research funds Other; Histogenics Grant/research funds None

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Carlos J Lavernia, MD, FAAOS  Adjunct Clinical Professor, Department of Orthopedic Surgery, University of Miami School of Medicine; Medical Director, Orthopedic Institute at Mercy Hospital

Carlos J Lavernia, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, Arthritis Foundation, Biomedical Engineering Society, Florida Orthopaedic Society, and Orthopaedic Research Society

Disclosure: Zimmer Stock Implant Designer

References

  1. Goss CM, ed. Gray's Anatomy of the Human Body. 29th ed. Philadelphia, Pa: Lea and Febiger;1974: 353-4.

  2. Crema MD, Roemer FW, Marra MD, Niu J, Lynch JA, Felson DT, et al. Contrast-enhanced MRI of subchondral cysts in patients with or at risk for knee osteoarthritis: The MOST study. Eur J Radiol. Sep 18 2009;[Medline].

  3. Chatzopoulos D, Moralidis E, Markou P, Makris V, Arsos G. Baker's cysts in knees with chronic osteoarthritic pain: a clinical, ultrasonographic, radiographic and scintigraphic evaluation. Rheumatol Int. Dec 2008;29(2):141-6. [Medline].

  4. Shetty GM, Wang JH, Ahn JH, Lee YS, Kim BH, Kim JG. Giant synovial cyst of knee treated arthroscopically through a cystic portal. Knee Surg Sports Traumatol Arthrosc. Feb 2008;16(2):175-8. [Medline].

  5. Newsham KR. Recurrent popliteal cyst in an adult: a case report and review. Orthop Nurs. Jan-Feb 2009;28(1):11-4; quiz 15-6. [Medline].

  6. Sansone V, de Ponti A, Paluello GM, del Maschio A. Popliteal cysts and associated disorders of the knee. Critical review with MR imaging. Int Orthop. 1995;19(5):275-9. [Medline].

  7. Campbell SE, Sanders TG, Morrison WB. MR imaging of meniscal cysts: incidence, location, and clinical significance. AJR Am J Roentgenol. Aug 2001;177(2):409-13. [Medline]. [Full Text].

  8. Ryu RK, Ting AJ. Arthroscopic treatment of meniscal cysts. Arthroscopy. 1993;9(5):591-5. [Medline].

  9. Shetty GM, Nha KW, Patil SP, Chae DJ, Kang KH, Yoon JR, et al. Ganglion cysts of the posterior cruciate ligament. Knee. Aug 2008;15(4):325-9. [Medline].

  10. Weiner SR, Fan P. Popliteal cyst involvement with gonococcal arthritis-dermatitis syndrome. Sex Transm Dis. Jul-Sep 1983;10(3):141-3. [Medline].

  11. Marra MD, Crema MD, Chung M, Roemer FW, Hunter DJ, Zaim S, et al. MRI features of cystic lesions around the knee. Knee. Dec 2008;15(6):423-38. [Medline].

  12. Kosty JW, Moore JG. Juxta-articular myxoma within the suprapatellar pouch masquerading as a ganglion cyst. Orthopedics. Jul 2009;32(7):527. [Medline].

  13. Cone RO III. Imaging sports-related injuries of the knee. In: DeLee JC, Drez D, eds. Orthopaedic Sports Medicine: Principles and Practice. Philadelphia, Pa: WB Saunders;1994: 1568, 1593-8.

  14. Coral A, van Holsbeeck M, Adler RS. Imaging of meniscal cyst of the knee in three cases. Skeletal Radiol. 1989;18(6):451-5. [Medline].

  15. Crenshaw AH. Nontraumatic disorders. In: Canale ST, ed. Campbell's Operative Orthopaedics. 9th ed. St Louis, Mo: Mosby-Year Book;1998: 776-82.

  16. Damron TA, Rock MG. Unusual manifestations of proximal tibiofibular joint synovial cysts. Orthopedics. Mar 1997;20(3):225-30. [Medline].

  17. De Filippo M, Rovani C, Sudberry JJ, et al. Magnetic resonance imaging comparison of intra-articular cavernous synovial hemangioma and cystic synovial hyperplasia of the knee. Acta Radiol. Jul 2006;47(6):581-4. [Medline].

  18. Devereux D, Forrest H, McLeod T, Ahweng A. The nonarterial origin of cystic adventitial disease of the popliteal artery in two patients. Surgery. Nov 1980;88(5):723-7. [Medline].

  19. Insall JN, ed. Surgery of the Knee. 3rd ed. New York, NY: Churchill Livingstone;1984: 739-40.

  20. Jobe CM, Wright M. Anatomy of the knee. In: Fu FH, Harner CD, Vince KG, eds. Knee Surgery. Baltimore, Md: Lippincott Williams and Wilkins;1994: 48-9.

  21. Kuhns JG. Adventitious bursas. Arch Surg. 1943;46:687-96.

  22. Liu YC, Lue KH, Lu KH. Conservative treatment for a symptomatic solitary ganglion cyst of the anterior meniscus invading into the infrapatellar fat pad. Knee Surg Sports Traumatol Arthrosc. Aug 18 [Epub ahead of print] 2006;[Medline].

  23. Masciocchi C, Innacoli M, Cisternino S, et al. Myxoid intraneural cysts of external popliteal ischiadic nerve. Report of 2 cases studied with ultrasound, computed tomography and magnetic resonance imaging. Eur J Radiol. Jan-Feb 1992;14(1):52-5. [Medline].

  24. Miller RH III. Knee injuries. In: Canale ST, ed. Campbell's Operative Orthopaedics. 9th ed. St Louis, Mo: Mosby-Year Book;1998: 1150-4.

  25. Morrison JL, Kaplan PA. Water on the knee: cysts, bursae, and recesses. Magn Reson Imaging Clin N Am. May 2000;8(2):349-70. [Medline].

  26. Niceforo A, Di Giunta AC, Caminiti S, Tirro S. A rare case of a large lateral meniscal cyst of the knee. Arthroscopy. Oct 1998;14(7):759-61. [Medline].

  27. Peetrons P, Allaer D, Jeanmart L. Cysts of the semilunar cartilages of the knee: a new approach by ultrasound imaging. A study of six cases and review of the literature. J Ultrasound Med. Jun 1990;9(6):333-7. [Medline].

  28. Recht MP, Applegate G, Kaplan P, et al. The MR appearance of cruciate ganglion cysts: a report of 16 cases. Skeletal Radiol. Nov 1994;23(8):597-600. [Medline].

  29. Roidis N, Zachos V, Basdekis G, et al. Tumor-like meniscal cyst. Arthroscopy. Jan 2007;23(1):111.e1-6. [Medline].

  30. Surendran S, Park SE, Lee HK, et al. Haemorrhagic synovial cyst of the posterior cruciate ligament: a case report. Knee. Jan 2007;14(1):55-8. [Medline].

  31. Thompson TL, Simpson BM, Burgess D, Wilson RH. Massive prepatellar bursa. J Natl Med Assoc. Jan 2006;98(1):90-2. [Medline].

  32. Turek SL. Orthopaedics: Principles and Their Application. 4th ed. Philadelphia, Pa: JB Lippincott;1984: 1400-1.

  33. Tyson LL, Daughters TC, Ryu RK, Crues JV 3rd. MRI appearance of meniscal cysts. Skeletal Radiol. Aug 1995;24(6):421-4. [Medline].

 
Previous
Next
 
Popliteal cyst. Courtesy of James K. DeOrio, MD, Laura W. Bancroft, MD, and Jeffrey J. Peterson, MD.
Ganglion in the Hoffa fat pad. Courtesy of James K. DeOrio, MD, Laura W. Bancroft, MD, and Jeffrey J. Peterson, MD.
Ganglion of the anterior cruciate ligament. Courtesy of James K. DeOrio, MD, Laura W. Bancroft, MD, and Jeffrey J. Peterson, MD.
Meniscal cyst. Courtesy of James K. DeOrio, MD, Laura W. Bancroft, MD, and Jeffrey J. Peterson, MD.
Tibial subchondral cyst. Courtesy of James K. DeOrio, MD, Laura W. Bancroft, MD, and Jeffrey J. Peterson, MD.
Baker cyst. Sagittal T2-weighted magnetic resonance image shows a large Baker cyst (arrow) posteromedial to the joint capsule and adjacent to the medial gastrocnemius muscle. Note the joint effusion and underlying complex tear of the medial meniscus (arrowhead). Courtesy of William B. Morrison, MD.
Meniscal cyst. Coronal T2-weighted magnetic resonance image shows a cyst (arrow) adjacent to the lateral meniscus (arrowhead) and also demonstrates a tear communicating with the cyst. Courtesy of William B. Morrison, MD.
Prepatellar bursitis. Sagittal T2-weighted magnetic resonance image shows a fluid collection (arrow) anterior to the patella. Courtesy of William B. Morrison, MD.
Cruciate ganglion. Sagittal T2-weighted magnetic resonance image shows a cyst (arrow) that slightly displaces the otherwise normal-appearing anterior cruciate ligament. Courtesy of William B. Morrison, MD.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.