Treatment of Popliteal (Baker) Cysts With Ultrasound-Guided Aspiration, Fenestration, and Injection: Long-term Follow-up

Systematic review and meta-analysis of studies comparing cyst wall preservation against cyst wall resection during arthroscopic popliteal cyst decompression

INTRODUCTION

The optimal arthroscopic management for popliteal cyst decompression remains uncertain, with ongoing debate between preserving the cyst wall or completely removing it. The purpose of this study is to compare the outcomes and complications of arthroscopic popliteal cyst decompression with cyst wall preservation and cyst wall resection.

METHODS

A systematic review adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was conducted. It encompassed studies that focused on arthroscopic popliteal cyst decompression, considering both cyst wall preservation and cyst wall resection. The quality assessment of the included studies was carried out using the Methodology Index for Non-Randomized Research criteria. Following this, meta-analyses were conducted, employing odds ratios (ORs) for dichotomous outcomes and calculating mean differences (MDs) for continuous outcomes.

RESULTS

Four articles included a collective of 214 knees. Each of these studies presented level 3 evidence. The comparison between the cyst wall preservation group and the cyst wall resection group revealed similar clinical outcomes based on the Rauschning and Lindgren grade (grade 0 [OR = 0.66, 95% CI: 0.37-1.19, p = 0.17]; grade I [OR = 1.33, 95% CI: 0.66-2.67, p = 0.43]; grade II [OR = 1.39, 95% CI: 0.46-4.14, p = 0.56]; grade III [OR = 3.46, 95% CI: 0.13-89.95, p = 0.46]) and Lysholm score (MD = 0.83, 95% CI: -0.65-2.32, p = 0.27). However, MRI results indicated a significant improvement in the cyst wall resection group (cyst disappearance [OR = 0.50, 95% CI: 0.28-0.90, p = 0.02]; cyst shrinkage or decrease in size [OR = 1.41, 95% CI: 0.78-2.55, p = 0.26]; cyst persistence or recurrence [OR = 7.63, 95% CI: 1.29-45.08, p = 0.02]). Nevertheless, the operative time for cyst resection was significantly longer compared to cyst preservation (MD = -14.90, 95% CI: -21.96 - -7.84, p < 0.0001), and the cyst wall resection group experienced significantly higher complications than the cyst wall preservation group (OR = 0.24, 95% CI: 0.06 to 1.02, p = 0.05).

CONCLUSION

During arthroscopic popliteal cyst decompression, cyst wall resection led to longer operative times and higher complication rates but lower recurrence rates and better MRI outcomes. The functional outcomes after surgery were found to be similar.

Ultrasound-guided bursal injections

The native bursa is a structure lined by synovium located adjacent to a joint which may serve to decrease friction between the tendons and overlying bone or skin. This extra-articular structure can become inflamed resulting in bursitis. Steroid injections have proven to be an effective method of treating bursal pathology in various anatomic locations. Performing these procedures requires a thorough understanding of relevant anatomy, proper technique, and expected outcomes. Ultrasound is a useful tool for pre procedure diagnostic evaluation and optimizing needle position during these procedures while avoiding adjacent structures. The purpose of this article is to review core principles of ultrasound-guided musculoskeletal procedures involving bursae throughout the upper and lower extremities.

Management of symptomatic Baker's cysts with ultrasound and fluoroscopic-guided aspiration followed by therapeutic injection with Depomedrone and Bupivacaine leads to a durable reduction in pain symptoms in a majority of patients; A case series and literature review

Purpose

To evaluate the efficacy of ultrasound and fluoroscopic-guided aspiration and therapeutic injection of Baker's cysts in the relief of pain and pressure symptoms.

Methods

A retrospective, observational, single-arm study of consecutive patients referred from the Orthopaedic service for image-guided aspiration followed by therapeutic injection of symptomatic Baker's cysts was performed with institutional approval in the context of a Quality Improvement project. Patients' pain was graded using a 10-point Likert scale. Under standard sterile conditions, a 10 cm 5 Fr Yueh centesis needle was advanced into the cyst under direct ultrasound guidance, septae disrupted as necessary, the contents of the cyst aspirated, and a sample sent for microbiological analysis. Bursography was performed in an attempt to identify the expected communication with the knee joint, the contrast was aspirated and 40 mg of DepoMedrone and 5 ml of Bupivacaine were injected.

Results

Thirteen patients were referred, nine of whom satisfied the inclusion criteria (all female, average age 63.8 years). Over a 35-month period, 11 procedures were performed (bilateral in 1, repeated in another) yielding an average volume of 20.1 ml (range 10 - 50 mls). In 2/11 procedures the communication with the knee joint was outlined. The average follow up post-procedure was 8.3 months. The average patient's pain score reduced to zero from 5.7 for an average period of 5.96 months. After this period patients reported a gradual return of an ache, but none returned to the pre-procedure severity which, in some cases, had prevented them from sleeping.

Conclusion

Aspiration of symptomatic Baker's cysts under Ultrasound and fluoroscopic guidance followed by therapeutic injection of DepoMedrone and Bupivacaine leads to a durable reduction in pain symptoms in a majority of patients.

Evaluation of the effects of dexamethasone iontophoresis, galvanic current, and conservative treatment on pain and disability in patients with knee osteoarthritis and Baker's cyst

Objectives

This study aims to evaluate the effectiveness of galvanic current and dexamethasone iontophoresis in the treatment of knee osteoarthritis and Baker's cyst (BC).

Patients and methods

This prospective, randomized, controlled, single-blind study included 37 patients (9 males, 28 females; mean age: 57.8+10.3 years; range 40 to 75 years) with knee osteoarthritis and BC, between January and August 2020. The patients were randomized into three groups: the iontophoresis group (n=13), the galvanic current group (n=11), and the control group (n=13). The numerical rating scale (NRS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and ultrasonographic measurements of BC were recorded at baseline, two weeks, and six weeks. All groups received the same physiotherapy program. Dexamethasone iontophoresis and galvanic current therapy were administered to the patients in the iontophoresis and galvanic current groups, respectively, with a galvanic current at an intensity of 0.1-0.2 mA/cm2 for 10 days.

Results

There was no significant dissimilarity in demographic and clinical characteristics, basal NRS (resting and exercise) and WOMAC scores, and basal cyst volumes between groups. A significant temporal change was found in three groups for resting NRS, exercise NRS, and WOMAC scores and cyst volumes, except for the cyst volume in the control group. There was a notable difference in terms of improvement in cyst volumes between baseline and the second week in the iontophoresis group compared to the galvanic current group (p=0.046). There was a significant improvement in resting NRS and exercise NRS scores between baseline and the second week in the galvanic current group compared to the control group (p=0.015 and p=0.002, respectively). Additionally, a significant improvement was observed in resting NRS and exercise NRS scores between baseline and the second week in the iontophoresis group compared to the control group (p=0.009 and p=0.001, respectively).

Conclusion

A significant clinical and functional improvement was detected with dexamethasone iontophoresis in the treatment of patients with knee osteoarthritis and BC.

Using a Double Syringe Sterile System for MSK Aspiration/Injection Procedures Eliminates Risk of Iatrogenic Infection

Introduction

Diverse musculo-skeletal pathology can be treated conservatively by different types of injections and in most cases, results are significantly better if the existing inflammatory fluid is aspirated prior to injection of medication solutions. The present study analyses an original technique which uses infusion therapy accessories to create two types of closed sterile double syringe systems, and compares the benefits of using such a system in aspiration/injection procedures to classic aspiration injection technique that implies changing and connecting multiple syringes to the same needle, thus increasing the risk for septic complications. The aim of the present study is to minimize therapeutic risk of iatrogenic septic complications during aspiration/injection procedures.

Methods

1024 patients underwent aspiration/injection procedures in our clinic using the double syringe system between 2015 and 2020. During the early stages of the study, the second type of assembly was rendered impractical so the study continued with analyzing a single type of double syringe system using a three way infusion therapy device which is readily available, and allows the assembly of a closed sterile system with a single, two-step procedure technique. Iatrogenic local septic complications were followed by means of a six week clinical follow-up evaluation with additional investigations only if necessary.

Results

In 1024 procedures we report 0% incidence of iatrogenic septic complications, or other types of complications and recommend this technique in a vast array of rheumatic, orthopedic or traumatic conditions that require aspiration/injection procedures.

Discussion

The double syringe system is practical, easy to use, it completely eliminates the risk of iatrogenic infection due to manipulation errors, and significantly simplifies the technique for sonography guided aspiration/injection procedures for musculo-skeletal pathology.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part V, knee

Objectives

Interventional procedures around the knee are widely adopted for treating different musculoskeletal conditions. A panel of experts from the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the existing literature to assess the evidence on image-guided musculoskeletal interventional procedures around the knee, with the goal of highlighting some controversies associated with these procedures, specifically the role of imaging guidance, as well as the efficacy of the medications routinely injected.

Methods

We report the results of a Delphi-based consensus of 53 experts in musculoskeletal radiology, who reviewed the published literature for evidence on image-guided interventional procedures around the knee to derive a list of pertinent clinical indications.

Results

A list of 10 statements about clinical indications of image-guided procedures around the knee was created by a Delphi-based consensus. Only two of them had the highest level of evidence; all of them received 100% consensus.

Conclusions

Ultrasonography guidance is strongly recommended for intra-articular and patellar tendinopathy procedures to ensure the precision and efficacy of these treatments. Prospective randomized studies remain warranted to better understand the role of imaging guidance and assess some of the medications used for interventional procedures around the knee.

Key Points

• A list of 10 evidence-based statements on clinical indications of image-guided interventional procedures around the knee was produced by an expert panel of the ESSR.

• Strong consensus with 100% agreement was obtained for all statements.

• Two statements reached the highest level of evidence, allowing us to strongly recommend the use of ultrasonography to guide intra-articular and patellar tendon procedures to ensure higher accuracy and efficacy of these treatments.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08258-1.

Bedside ultrasound-guided aspiration and corticosteroid injection of a baker's cyst in a patient with osteoarthritis and recurrent knee pain

Baker's cyst accompanying knee osteoarthritis represents a common cause of knee pain presenting to the emergency department. In this case report, a 56-year-old male presented with atraumatic left knee pain and swelling. Radiographically, he had tricompartmental osteoarthritis and was found to have a baker's cyst on duplex ultrasound. Using point-of-care ultrasound, the cyst was aspirated and corticosteroids were injected. The patient tolerated the procedure well and was discharged with a compression wrap and orthopedic follow-up. Baker's cyst aspiration with corticosteroid injection represents a safe alternative treatment option for patients. In some cases, this treatment may be definitive. Orthopedists currently use this procedure to reduce pain and improve function for patients with chronic knee ailments related to baker's cysts. As demonstrated in this case report, implementing this bedside procedure in the emergency department with orthopedic follow-up expands non-surgical, non-narcotic treatment options for patients with chronic knee pain secondary to Baker's cysts with osteoarthritis.

Popliteal Cysts: A Systematic Review of Nonoperative and Operative Treatment

BACKGROUND

Treatment methods for popliteal cysts have varied over the past several decades and have posed challenges to providers as recurrences were frequent. With greater understanding of relevant anatomy, both operative and nonoperative treatment methods have evolved to appropriately target relevant pathology and improve outcomes. The purposes of this review were to outline the evolution of treatment methods and to qualitatively summarize clinical outcomes.

METHODS

We performed a systematic review on treatments for popliteal cysts to include publications from 1970 to 2019. Other inclusion criteria consisted of studies with ≥10 patients enrolled, studies with a patient age of ≥16 years, studies with an adequate description of the treatment technique, and studies with a Level of Evidence of IV or higher. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and literature quality was assessed using a modified Coleman methodology score.

RESULTS

Thirty studies met inclusion criteria in this review. Nine studies discussed nonoperative treatment, and 21 studies discussed operative treatment. Eight of the 9 nonoperative treatment studies utilized corticosteroid injections. The most recent studies have advocated for ultrasound-guided intracystic injection with possible cyst fenestration. Most operative studies utilized an arthroscopic approach to enlarge the communication with the joint space. However, alternative treatment techniques are still utilized.

CONCLUSIONS

The current literature on the treatment of popliteal cysts indicates that intracystic corticosteroid injection with cyst fenestration is an effective nonoperative treatment method. Arthroscopic surgical procedures with enlargement of the communication have been most widely studied, with positive results; however, further studies are needed to confirm superiority over other treatment methods.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Ultrasound-guided arthroscopic communication enlargement surgery may be an ideal treatment option for popliteal cysts - indications and technique

PURPOSE

Several studies have shown an excellent success rate of communication enlargement surgery for popliteal cysts (Baker's cysts). Ultrasound-guided surgery can improve the accuracy of this procedure and may lead to better outcomes. This study describes a simple ultrasound-guided arthroscopic technique to manage popliteal cysts and reduce postoperative pain.

METHODS

After routine arthroscopic observation with a standard 2-portal approach, the arthroscope is redirected toward the posteromedial compartment from the anterolateral portal through the intercondylar notch. A posteromedial portal is then placed at this view. Subsequently, a contrast dye (indigo carmine) is injected into the popliteal cyst percutaneously using ultrasonography. This procedure makes it easier to find a capsular fold or valvular opening. The valvular opening between the semimembranosus and medial gastrocnemius is enlarged with a shaver and radiofrequency ablation. Cystectomy is not performed in any case. Finally, the irrigation fluid is suctioned, and the reduced cyst is visualized by ultrasound. Additionally, a periarticular multimodal drug injection is administered into the septum and inner wall of the cyst under ultrasound guidance.

CONCLUSIONS

Ultrasound-guided arthroscopic surgery for popliteal cysts can ensure reproducibility and be effective for postoperative pain relief. Thus, this combined procedure may be an optimal treatment option.

Efficacy and Safety of Musculoskeletal Ultrasound Guided Aspiration and Intra-Lesional Corticosteroids Injection of Ruptured Baker's Cyst: A Retrospective Observational Study

Objective:

The aim of the work was to demonstrate the effectiveness and safety of ultrasonographic guided aspiration performed with corticosteroid injection intra-lesional for ruptured Baker cysts (BCs).

Methods:

Single-center retrospective study that included 42 patients with knee joint disorder associated with ruptured BCs were treated by ultrasonographic guided aspiration of fluid from the cyst and different points from the calf then intra-lesional injection of corticosteroids once or twice, 1 week apart. Follow up were done weekly until complete resolution of symptoms. Visual analog scale (VAS) and Rauschning-Lindgren and Lysholm Knee Scoring Scales (RLC) were used for assessment.

Results:

Clinical parameters (VAS and RLC) improved significantly in all patients at both post injection evaluation visits (1 week and 12 weeks). Ultrasonographic features improved significantly with complete disappearance of free fluid in the calf in 35 (83.3%) cases 1 week after the injection, and in 41 (97.6%) after 12 weeks. As regards BCs only 4 (9.5%) cases showed complete disappearance after 1 week and there was recurrent BCs in 38 (90.5%) cases which required reaspiration. While after 12 weeks, BCs were completely disappeared in 23 (54.8%) cases, most of the relapsed BCs were complex BCs. No side effects were reported in all cases.

Conclusion:

Ultrasonographic guided aspiration followed by injection of corticosteroids intra-lesional is an efficient and safe method for managing ruptured BCs.

Infected Baker's Cyst: A New Classification, Diagnosis and Treatment Recommendations

Introduction:

Baker’s cyst has a high prevalence in adult population. Despite being usually asymptomatic, cyst complications may develop, such as an infection, rupture and content dissemination into the calf. This clinical presentation has a low incidence with few reports in the literature. We have not found any publication describing a systematic approach for its treatment. The purpose of this study is to propose a new classification, diagnosis, and treatment recommendations based on a case report and a literature review to guide physicians on the best course of treatment.

Case Report:

A 53-year-old man presented with sudden left popliteal pain associated with progressive knee and calf swelling and limited knee flexion. After the initial evaluation, a Baker’s cyst rupture and dissemination into the calf, associated with a septic arthritis, were diagnosed. An arthroscopic surgical irrigation of the knee and open debridement of the calf collection were performed.

Conclusion:

Our classification may allow an accurate and structured description of the different stages of Baker’s cyst presentations, with simplification of the clinical description, diagnosis, and treatment approaches.

Ultrasound Intervention of the Lower Extremity/Pelvis

Musculoskeletal (MSK) conditions are growing in prevalence. Ultrasound (US) is increasingly used for managing MSK conditions due to its low cost and ability to provide real-time image guidance during therapeutic interventions. As MSK US becomes more widespread, familiarity and comfort with US-guided interventions will become increasingly important. This article focuses on general concepts regarding therapeutic US-guided injections of corticosteroids and platelet-rich plasma and highlights several of the US-guided procedures commonly performed, involving the pelvis and lower extremity.

Giant Baker's Cyst Associated with Rheumatoid Arthritis

We report a rare case of a "giant Baker's cyst-related rheumatoid arthritis (RA)" with 95 × 26 mm dimensions originating from the semimembranosus tendon. The patient presented with chronic pain and a palpable mass behind his left calf located between the posteriosuperior aspect of the popliteal fossa and the distal third of the calf. In MRI cystic lesion which was located in soft tissue at the posterior of gastrocnemius, extensive synovial pannus inside and degeneration of medial meniscus posterior horn were observed. Arthroscopic joint debridement and partial excision of the cyst via biomechanical valve excision were performed. The patient continued his follow-up visits at Rheumatology Department and there was no recurrence of cyst-related symptoms in 1-year follow-up. Similar cases were reported in the literature previously. However, as far as we know, a giant Baker's cyst-related RA, which was treated as described, has not yet been presented.

Popliteal (Baker's) Cysts in the Setting of Primary Knee Arthroplasty

BACKGROUND

Popliteal (Baker's) Cysts are rare complications of knee arthroplasty. Enlargement, irritation, or rupture of the cyst can lead to significant pain, tightness, and tenderness. The literature regarding popliteal cysts occurring following knee arthroplasty is limited and does not report prevalence, natural history, and treatment of popliteal cyst in the setting of knee arthroplasty.

METHODS

Following Institutional Review Board approval, 2,025 primary total and partial knee arthroplasties by four surgeons at one institution from 2011-2016 were reviewed for occurrence of popliteal cysts. Twelve cases occurring after arthroplasty were identified, including four unicompartmental knee arthroplasties and eight total knee arthroplasties. Demographic data were evaluated and symptoms, time of onset following arthroplasty, attempted treatment strategies, and success or failure of attempted treatments or interventions were recorded.

RESULTS

The mean age of patients that presented with a popliteal cyst was 63.6 years old (range = 45 - 78 years). There were 5 males and 7 females. The mean BMI was 26.32 (range = 19.0 - 35.0). In 2,205 primary knee arthroplasties performed from 2011-2016 (including 175 partial and 1850 total), the prevalence of popliteal cysts following surgery was 0.6% (n=12). All popliteal cysts were discovered between six weeks and two years following surgery, with the majority occurring during the first year. Twenty-five percent (3/12) of patients presented with minimal symptoms. These were managed expectantly. Seventy-five percent (9/12) were symptomatic. One patient had only a diagnostic ultrasound, two patients underwent ultrasound-guided aspiration and steroid injection, three underwent simple aspiration. Two underwent surgical excision. One cyst ruptured. All cases went on to symptomatic resolution. There was no association with diabetes, smoking, or body mass index. A disproportionately high number (25% or 4/12) occurred in partial knee arthroplasty.

CONCLUSION

While popliteal cysts following primary total knee arthroplasty are rare, they can become a persistent and even disabling problem for arthroplasty patients. Given the lack of formalized recommendations in the existing literature, we propose a treatment algorithm that has been successful in our clinic, including observation initially, ultrasound-guided injection/aspiration if symptomatic, and surgical excision as a last resort.

LEVEL OF EVIDENCE

Level IV.

Arthroscopic patterns of the poster-medial aspect of the knee joint: classification of the gastrocnemius-semimembranosus gateway and its relationship with Baker's cyst

BACKGROUND

The gastrocnemius-semimembranosus bursa may communicate with the knee joint. The arthroscopic anatomy of the posteromedial aspect varies depending on the angle of the oblique popliteal ligament, the level at which it crosses the medial gastrocnemius tendon, and its relationship with the capsular joint and synovia. The aim of this paper is to identify possible patterns, and to evaluate their characteristics and their relationship with Baker's cyst.

METHODS

data archived from 185 consecutive arthroscopies were evaluated; an anatomic description and classification was carried out; the percentages of association with BC and the associated pathologies were reported.

RESULTS

The different anatomies were classified into six groups based on the relationship above the medial gastrocnemius tendon, the capsular joint and synovia. The prevalence of Baker's cyst was 28.3%. The main associated intra-articular pathological condition was the contemporary presence of a meniscal tear and chondropathy.

CONCLUSION

Exploration of the posterior aspect of the knee must be performed routinely. Knowing the possible anatomy patterns of the posteromedial arthroscopic aspect of the knee joint could help to identify the cyst and its gateway, thus facilitating its treatment.

LEVEL OF THE EVIDENCE

III.