Meniscal Cysts

Evan Watts

Overview
 A condition characterized by a local collection of synovial fluid within or adjacent to the meniscus
 Epidemiology
o incidence
 no studies of the general population
 found in 1-4% of MRI studies of the knee
o demographics
 most commonly associated with a meniscal tear
 no trend to increased age
o location
 perimeniscal cysts
 small lesions of fluid within the meniscus
 medial cysts are slightly more common than lateral, 2:1 ratio (although literature data are conflicting)
 medial cysts = posterior horn
 lateral cysts = anterior horn or mid-portion
 parameniscal cysts (e.g., baker cysts)
 extruded fluid outside the meniscus (most common)
 usually located between semimembranosus and medial head of gastrocnemius
 Pathophysiology
o mechanism of injury
 meniscal tear functions as a one-way valve
 synovial fluid extrudes and then concentrates to form gel-like material
o pathoanatomy
 horizontal and complex tears, usually = parameniscal cysts
 radial or vertical tears, usually = perimeniscal cysts
 Associated conditions
o articular cartilage injury
o anterior cruciate ligament tear
Anatomy
 Meniscus
o composition
 fibroelastic cartilage
 interlacing network of collagen, proteoglycan, glycoproteins, and cellular elements
 composed of 65-75% water
 Collagen
 90 % Type I collagen
o shape
 medial meniscus
 stretched-out, C-shape with triangular cross section
 lateral meniscus
 more circular in shape
 covers larger area of articular surface
o Blood supply
 medial inferior genicular artery
 supplies peripheral 20-30% of medial meniscus
 lateral inferior genicular artery
 supplies peripheral 10-25% of lateral meniscus
 synovial fluid
 central 75% of meniscus' receive nutrition through diffusion
Presentation
 History
o may have recent trauma
 Symptoms
o asymptomatic
o pain
 localized to medial/lateral joint line or back of knee
o mechanical symptoms
 locking and clicking
o delayed or intermittent knee swelling
o weakness or claudication (neaurovascular impingement)
 Examination
o inspection
 popliteal mass
 best visualized with the knee in extension
o palpation
 joint line tenderness
 palpable mass
o motion
 crepitus
Imaging
 Radiographs
o should be normal in young patients with an acute meniscal injury or cyst
 MRI
o indications
 MRI is most sensitive diagnostic test for meniscal cyst and meniscal tear
o findings
 cyst with bright T2 signal
 necrotic tissue, nerve sheath tissue, and pus can all resemble cysts on T2-weighted MRIs
 IV contrast enhancement may be needed
Treatment
 Non-operative
o rest, NSAIDS, rehabilitation
 indications
 indicated as first line of treatment for small perimeniscal cysts and parameniscal cysts
 outcomes
 trial of medical therapy to observe patients pain response
 may be effective in population with degenerative tears
o aspiration and steroid injection
 indication
 isolated baker's cysts in young patient
 technique
 cyst drainage
 ultrasound guided injection into the cyst
 outcomes
 poor outcomes in older degenerative mensical tears with associated cysts
 Operative
o arthroscopic debridement, cyst decompression and meniscal resection
 indications
 perimeniscal cysts with an associated tear that is not amenable to repair (e.g., complex,
 degenerative, radial tear patterns)
 technique
 decompress cyst completely
 perform partial meniscectomy
 outcomes
 incomplete meniscal resection may lead to recurrence
o cyst excision using open posterior approach
 indications
 symptomatic parameniscal cysts
 outcomes
 incomplete resection may lead to recurrence
Technique
 Cyst excision using open posterior approach
o patient prone
o curved incision over popliteal fossa
o interval between medial head of gastrocnemius and semimembranosus
o sharp dissection of cyst margins to joint capsule
 Popliteal Cyst in Children
David Abbasi

Introduction

 Common soft tissue mass in children

o most often not associated with meniscal tears
 unlike in the adult population
 Pathoanatomy
o popliteal cysts usually are located
 between muscles of
 semimembranosus
 medial head of gastrocnemius
 from herniated posterior knee joint capsule synovium
 Anatomy

 Muscles posterior to medial knee capsule

o semimembranosus
o medial head of gastrocnemius
Presentation

 Symptoms
o usually asymptomatic
 Physical exam
o located in popliteal fossa
 usually located medially and distal to knee crease
 most pronounced with knee extended
o mass will transilluminate
Imaging

 Radiographs
o are normal
 Ultrasound
o consistent with cystic lesion
 MRI
o show fluid filled cyst
Treatment

 Nonoperative
o observation
 indications
 mainstay of treatment
 with majority of cases resolving spontaneously
 Operative
o excision
 indications
 only if cyst causes significant discomfort
 failure of spontaneous resolution