Arthroscopic management of rare case of Baker’s cysts with lower calf hematoma

A 52-year-old man with pain and swelling in the popliteal fossa was initially misdiagnosed with deep vein thrombosis but later diagnosed with a ruptured Baker's cyst causing a hematoma. Successful treatment included arthroscopy drainage and open calf fasciotomy, emphasizing the importance of accurate diagnosis and effective management in such cases.

The man arrived with oedema and pain in the popliteal fossa. Initial symptoms that were reported occurred in the right knee joint 8 weeks before visiting the hospital, along with mild swelling that worsened with flexion-extension motion. He felt increasing discomfort as soreness and swelling developed behind the joint, especially when straightening the knee.

This man had a history of smoking about 20 cigarettes per day and occasional moderate alcohol consumption but has refrained from alcohol for the past eight weeks due to his current illness. He was on inconsistent anticoagulation therapy with a dosage of 15 mg of Rivaroxaban two times a day for about four weeks. Despite no history of trauma, he struggled with poorly controlled hypertension for the past five years, marked by significant fluctuations.

Two days after initial knee pain, a man developed calf swelling diagnosed as muscle vein thrombosis. Initially, doctors treated with anticoagulants and painkillers without a thorough history. As the symptoms worsened, a second ultrasound showed recanalization and fluid-filled dark patches between the calf muscles. Severe calf pain led to his transfer to our hospital for accurate diagnosis and comprehensive care.

Patient Characteristics: Age-gender: 52 years male; Height: 173 cms; Weight: 90 kg and; BMI: 30 kg/m².

The physical examination revealed significant swelling in the lower calf and knee joint. A noticeable cystic mass measuring 12 cm × 4 cm was seen behind the knee joint on the inner side of the calf. There was limited knee joint range of motion due to swelling and pain (VAS pain score: 5/10). The right calf had erythema, engorged superficial veins; severe pain on palpation (VAS pain score: 8/10). A weaker pulsation in the right dorsalis pedis artery compared to the other side was also observed. There were no neurological symptoms. Vital signs revealed blood pressure of 170/100 mmHg. The hemodynamic parameters showed normal WBC count, but elevated CRP (53 mg/L), ESR (38 mm), D-dimer (3.09 mg/L), and fibrinogen (5.84 g/L).

Imaging findings included a fluid-filled hypoechoic zone from knee to calf on ultrasound, with MRI indicating oedema around the right knee joint and infrapatellar fat pad, and fluid collections in the joint space, suprapatellar bursa, and a 44 mm popliteal fossa cyst extending into the calf. A 129 mm oval-shaped calf cyst with internal communication to the popliteal cyst was also noted.

The diagnosis was a popliteal fossa cyst extending into the calf, with potential compartment syndrome. Treatment planned included arthroscopic treatment for the popliteal cyst and open excision for the calf cyst.

Operative Procedure: Utilized three arthroscopic portals with a standard 30° arthroscope. Identified and resected the cyst opening via the posteromedial portal using basket forceps and a shaver. Enlarged the valvular opening of the posterior capsule for thorough removal. Removed the hypervascular cyst wall meticulously and performed a radical synovectomy. Inserted suction drainage and maintained operation time under 10 minutes.

Open Excision: Executed an 8 cm longitudinal skin incision meticulously through the layers of skin along the medial calf. Removed substantial dark brown blood clots indicative of a hematoma. Ensured thorough cyst evacuation and repaired communication with the knee joint.

Postoperative Care: Conducted tests to rule out infections. Achieved hemostasis and placed drainage tubes. Closed incision meticulously, prescribed pain relief and preventive antibiotics, and initiated rehabilitation exercises for recovery.

Notable alleviation of pain and swelling was observed post-surgery, with VAS pain scores declining to 2 out of 10 by day 2 and 1 out of 10 by day 7 post-discharge. There were no notable symptoms at the time of patient discharge, indicative of favourable post-operative recovery.

Subsequent postoperative follow-up conducted at 3 months revealed no signs of cyst recurrence, confirming the efficacy of the surgical intervention and supporting favourable long-term outcomes for the patient.

Post-Surgery Follow-up: After conducting a histopathological examination on day 7 after the surgery, the presence of fibro-hyalinized tissues and plasma cells indicative of active chronic inflammation within the cyst wall was uncovered.

Findings were consistent with established histological descriptions of cyst wall pathology documented in relevant literature.

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