engleski

UNUSUAL PRESENTATION OF GIANT POPLITEAL CYST IN PATIENTS WITH RHEUMATOID ARTHRITIS AND ITS TREATMENT

Background Popliteal or Baker's cyst represents fluid distension of the bursa in the popliteal fossa which communicates with the knee joint by valvular mechanisms. Most frequently, the bursa between the gastrocnemius and semimembranosus tendons is involved. Popliteal cyst can also develop due to herniation of the synovial layer through the posterior capsule. Baker's cyst is often associated with the knee intraarticular pathology, such as menisceal or chondral lesion, trauma, or rheumatoid arthritis. In spite the popliteal cyst is often easily recognized, sometimes is challenging for treating because a conservative therapy often failed and after surgical excision high recurrence was reported. Objective To report an unusual clinical and radiological features of popliteal cyst and to highlight the specific problems in treating the popliteal cysts in patients with rheumatoid arthritis. Methods The rheumatoid arthritis patient with popliteal cyst underwent all physical and laboratory test examinations, diagnostic procedures using ultrasound, MRI and arthrography. Arthroscopy was performed, as well as capsuloplasty and open synoviectomy. Results A 58 years old patient with well established rheumatoid arthritis (RA) of 10 years duration with occasional acute episodes was reported. No typical deformations of the joints were present. Under therapy (Methotrexate15 mg weekly, Methylprednisolon 4 mg daily) RA was satisfactorily controlled, but suddenly he developed swelling in the middle and distal part of the calf, with sensation of a pressure and a pain. He underwent the ultrasound examination which indicated large cyst filled with a liquid, ending at the level of Achilles tendon formation. The punction of the distal part of the cyst was performed, and synovial like liquid was obtained. As a result of the punction the relief of the symptoms was observed. However, a leakage from the cyst continued so we occluded the fistula with two sutures and performed MRI and arthrography. Both methods revealed a giant popliteal cyst with the distension in the calf. Arthroscopy was performed and findings on synovial membrane were typical for RA accompanied with the lesion of medial meniscus and well preserved cartilage. The partial meniscectomy was done and the cyst was removed using the open excision method followed by posterior capsuloplasty with the pedicle of gastrocnemius tendon. Recovery was fast and good, but the cyst recurrence was observed after 3 months. We surgically removed the cyst using posterior capsuloplasty again and open synoviectomy was done with no recurrence in the following postoperative period. Conclusion Backer's cyst could have atypical presentation and wide spectrum of symptoms which can make the differential diagnosis more difficult. In adult popliteal cyst primarily arthroscopy is indicated aiming to treat intraarticular pathology. Afterwards, removing of the cyst has to be done either arthroscopicaly or by open excision. Aiming to reduce the recurrence of the cysts in RA patients, we strongly suggest to perform posterior capsuloplasty in combination with synoviectomy.

rheumatoid arthritis; popliteal cyst; treatment

nije evidentirano