Arthroscopic Treatment of Popliteal Cyst: A Direct Posterior Portal by Inside-Out Technique for Intracystic Debridement

Abstract

Popliteal cysts are characterized by enlargement of the gastrocnemius-semimembranosus bursa. The pathogenesis includes a valvular opening between the knee joint and the bursa, and associated intra-articular pathology may give rise to knee effusion. The mainstay of treatment is conservative. If popliteal cysts are symptomatic, analgesia, aspiration, and steroid injection therapy may be considered, but most recur rapidly. In the past, open excision was an option if they remained symptomatic, but the associated recurrence rate was high. One important reason was that the intra-articular pathology causing the knee effusion was not treated. We present an alternative minimally invasive arthroscopic treatment using dye (methylene blue) directly injected into the cyst, which will leak from the cyst into the joint, to identify the valvular opening. The thickened valve is opened using a basket forceps and then enlarged using a motorized shaver to disrupt the 1-way mechanism between the joint and bursa, as well as to establish an unobstructed freeway connection between them. We also present a safe technique to create a direct posterior portal. Intracystic debridement of the fibrous membrane, nodules, and septa through this portal will decrease the recurrence rate of the popliteal cyst.