Journal of Orthopaedic Science 29 (2024) 390e393

Contents lists available at ScienceDirect

Journal of Orthopaedic Science

journal homepage: http://www.elsevier.com/locate/jos

Case Report

Double-layered reconstruction of the posterior capsule in a

recalcitrant Baker's cyst: A case report
Chin-Kai Huang a, Chih-Kai Hong a, b, Fa-Chuan Kuan a, b, c, d, Wei-Ren Su a, b, e,
Kai-Lan Hsu a, b, d, f, *
a
Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
b
Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine,
National Cheng Kung University, Tainan, Taiwan
c
Division of Orthopedics, Department of Surgery, National Cheng Kung University Hospital Dou Liou Branch, National Cheng Kung University, Yunlin,
Taiwan
d
Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
e
Musculoskeletal Research Center, Innovation Headquarter, National Cheng Kung University, Tainan, Taiwan
f
Division of Traumatology, National Cheng Kung University Medical Center, Tainan, Taiwan

a r t i c l e i n f o

Article history: 2. Report of the case

Received 29 December 2021
Received in revised form A 57 year-old woman with no underlying diseases came to our
7 March 2022 hospital due to a left popliteal mass. A plain film of the left knee
Accepted 9 April 2022
Available online 27 April 2022
showed osteoarthritis with medial compartment joint space nar-
rowing, Kellgren and Lawrence grade II. Magnetic resonance im-
Keywords: aging (MRI) showed a cystic lesion between the gastrocnemius and
Posterior capsule reconstruction semimembranosus tendon (Fig. 1A) and a degenerative tear of the
Baker cyst medial meniscus posterior horn. The synovial fluid and blood an-
Fascia lata graft
alyses showed no elevation in uric acid or any associated rheu-
matoid factors. Previously, she had received an open cystectomy
with a posterior approach, and the pathology showed a Baker's cyst
with a fibrous wall and a synovial lining. However, a recurrent
popliteal cyst in her left knee was still observed post-operatively
despite multiple arthrocenteses. Within three years, she under-
went a total of six operations, including an open cyst excision and a
posterior capsule repair, arthroscopic intra-articular debridement,
1. Introduction and an arthroscopic cystectomy, with limited effects (Table 1).
There was also an infection episode during her 3rd operation in
A popliteal cyst, also known as a Baker's cyst, is a cystic mass which the synovial culture showed Klebsiella pneumonia, which
with large effusion at the popliteal region, mostly due to distention she recovered from post-operatively after use of an antibiotic.
of the gastrocnemio-semimembranosus bursa [1]. For operative
management, open cystectomy and arthroscopic intervention have 2.1. Surgical technique
traditionally been adopted, with a recurrence rate reported to range
from 0 to over 50% [2]. Here, we report a case sustained from a Finally, for her 7th surgery, we adopted posterior capsule
recalcitrant Baker's cyst, which recurred after an open cystectomy reconstruction with tensor fascia lata. The patient was placed in a
and arthroscopic intervention and was successfully managed prone position, and a lazy-S shape skin incision was performed,
through posterior capsule reconstruction with a double-layered following her previous surgical scar. After opening the fibrotic tis-
tensor fascia lata graft. sue between the gastrocnemius muscle and the semimembranosus
muscle, a clear, yellowish fluid appeared, and posterior capsule
tissue loss was observed. In order to cover the defect in the pos-
* Corresponding author. Department of Orthopedics, National Cheng Kung Uni-
versity Hospital, College of Medicine, National Cheng Kung University No.138,
terior capsule, we harvested a 2 cm*5 cm graft from her tensor
Sheng-Li Road, Tainan City 70428., Taiwan. Fax: þ886 6 2353535 fascia lata on her left side (Fig. 1B) as an autograft for posterior
E-mail address: [email protected] (K.-L. Hsu). capsule reconstruction. The graft was cut in half, with each piece

https://doi.org/10.1016/j.jos.2022.04.005
0949-2658/© 2022 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.

Downloaded for Sofía Vargas ([email protected]) at Autonomous University of Guadalajara from ClinicalKey.com by Elsevier on
January 24, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
C.-K. Huang, C.-K. Hong, F.-C. Kuan et al. Journal of Orthopaedic Science 29 (2024) 390e393

Fig. 1. (A) Proton density weighted images with fat stranding of the left knee axial view before the 7th operation showed fluid accumulation over the gastrocnemio-
semimembranosus bursa (arrow). (B) The 2 cm*5 cm tensor fascia lata graft. (C) Proton density weighted images with fat stranding of the left knee axial view after the 7th
operation showed a prominent reduction in intra-cystic fluid. A thin intermediate signal structure between the gastrocnemius and semimembranosus tendon (arrow).

Table 1
Surgical history and intraoperative findings for the presented patient.

Date Surgical procedure Intraoperative finding Post Operative

Recurrence (months)

2018.07.13 Posterior approach, open cystectomy Coin-sized cyst with yellowish fluid 3
2018.11.03 Posterior approach, open cystectomy and capsule repair Posterior capsule rupture status post-repair with 1
defects
2019.03.08 Posterior approach, open cystectomy and capsule repair Posterior capsule rupture status post-repair with 1.5
with subcutaneous adipose tissue defects
2019.06.27 Arthroscopic intra-articular debridement Acute synovitis 2
Synovial fluid culture: Klebsiella pneumoniae
2019.10.07 Posterior approach, open cystectomy and capsule direct Posterior capsule rupture status post repair with defect 1
repair
2019.11.22 Arthroscopic valve debridement and cystectomy Medical meniscus posterior horn degenerative tear 0.5
Anterior cruciate ligament partial tear with a fibrotic
stump with debridement
2020.04.10 Posterior approach, open cystectomy, and posterior capsule Complete rupture of the posterior capsule Not for at least 18
reconstruction with a fascia lata graft

measuring 2 cm  2.5 cm. Two non-absorbable No. 1 silk stitches reconstruction was established. A suction drainage tube was placed
were passed through the paratenon of the gastrocnemius tendon, to temporarily reduce the intra-articular pressure for one week. A
which then penetrated out and into the fascia lata graft and sub- compressive dressing and avoidance of intense exercise were
sequently passed through the paratenon of the semimembranosus advised for one month. There was no splinting, and there were no
tendon (Fig. 2B). The silk was then pulled out, and the graft was limitations placed on weight bearing post-operatively. No further
pushed into the inner layer of the defect (Fig. 2C). Both ends of the articular debridement was performed. There was no evidence of
silk were then passed through the other graft, and the graft was cyst recurrence under a sonographic examination at the post-
pushed onto the outer layer of the defect. Finally, both ends of the operative 2-, 4-, and 6-week follow-ups. An MRI (Fig. 1C) post-
suture were tied, and a double-layered posterior capsule operatively 6 months showed a thin intermediate signal structure

Fig. 2. Illustration of an axial view of the knee. (A) A Baker's cyst between the gastrocnemius (GN) and the semimembranosus (SM) tendon. (B) A fascia lata graft was tightened up
to the posterior capsule defect with No. 1 silk (black line). (C) The graft was pushed into the inner side of the posterior capsule. (D) Another fascia lata graft was further tightened up
to the posterior capsule defect overlapping the first graft, forming a double-layered barrier.

391

Downloaded for Sofía Vargas ([email protected]) at Autonomous University of Guadalajara from ClinicalKey.com by Elsevier on
January 24, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
C.-K. Huang, C.-K. Hong, F.-C. Kuan et al. Journal of Orthopaedic Science 29 (2024) 390e393

between the gastrocnemius and semimembranosus tendon harvested tensor fascia lata tissue for the purpose of posterior
without cyst formation. She has been symptom-free for 18 months capsule reconstruction.
to date, and no donor site complications have been observed. To achieve complete waterproofing in the posterior capsule, we
used a double layered graft to reconstruct it. This type of recon-
struction has been described in repair of defects in human struc-
3. Discussion
tures, including complex incisional hernias [12], ventricular septal
defects [13], and pectus carinatum [14]. This technique apparently
The communication between the joint capsule and the
offers very secure anchorage plus double coverage. As in incisional
gastrocnemio-semimembranosus bursa allows joint fluid to move
hernias, ventricular septal defects, and pectus carinatum, a Baker's
into the bursa, and a valve-like structure causes fluid accumulation.
cyst is a soft tissue defect with pressure from the inner side. Thus,
There are many explanations for the cause of a one-way valve. In a
we attempted to apply a double-layered graft for reconstructing the
ball valve mechanism, the fibrin stops the fluid from going backward
posterior capsule of the knee. We hypothesized that with increases
to the knee joint even in the presence of high intra-cystic pressure.
in intra-articular pressure, the inner graft would be compressed
The Bunsen valve mechanism, however, is attributed to the mass
closely to the inner surface of the peritendon, in turn making the
effect of the cyst on the opening of the capsule, which traps the fluid
gap smaller. If there were to be some synovial fluid leakage from
[3]. A functional valve mechanism emphasizes the interaction of
the inner layer, the outer graft would also provide another barrier.
tendons pulling and compressing the opening when the knee is in
By using the temporary suction drainage and a double-layer pos-
flexion or extension. Some scholars believe that the destruction of
terior capsule reconstruction technique, full waterproofing was
this valve mechanism leads to successful treatment [4].
successfully achieved, and no further recurrence was noted during
Spontaneous resolution has sometimes been observed.
the follow-up period.
Ultrasound-guided aspiration with a corticosteroid injection is also
Although there are numerous surgical techniques used to treat
an option for minimally-invasive treatment of knee osteoarthritis
popliteal cysts, few studies have discussed recalcitrant cysts
complicated with a Baker's cyst. If persistent symptoms occur that
following failed surgical treatment. The large defect in the posterior
are refractory to the above treatment options, a surgical interven-
capsule and the bidirectional flow of fluid invalidate the use of
tion should be considered.
arthroscopic internal drainage and an open primary repair. Cap-
Popliteal cysts are traditionally treated through open excision
suloplasty with a partial gastrocnemius tendon flap has been suc-
from a posterior incision. However, this surgical procedure requires
cessfully used in treating recurrent popliteal cysts following
extensive exposure and carries a risk of neural or vascular injury.
arthroscopic cystectomy [15]. There was also a successful case of a
Patients also may suffer from postoperative scar formation,
chronic capsular defect repaired arthroscopically with a No. 2
resulting in an unsatisfying cosmetic appearance. More impor-
Polydiaxone suture [16]. However, in our case, the capsule defect
tantly, open excision does not address the associated intra-articular
was so large that neither a tendon flap nor a direct suture could
pathology and leads to a high recurrence rate. Thus, arthroscopic
create watertight sealing. Thus, we chose the tensor facia lata for a
intervention is currently adopted due to higher recurrence and
free graft to cover the defect.
complication rates with open excision [1]. An arthroscopic pro-
To the best of our knowledge, the concept of posterior capsule
cedure can additionally be used for meniscal or articular lesions
reconstruction presented in this work for a recurrent Baker cyst has
when removing valve-like structures, in turn re-establishing the
not been described before. Although the procedure is safe and is not
normal bidirectional communication between the cyst and the
a difficult surgical technique, it is not recommended as the first line
knee joint [5]. However, the reported recurrence rate after arthro-
of treatment for surgical treatment of a Baker's cyst because of the
scopic intervention ranges from 0% to 13.6% [6]. To further decrease
additional incision over the lateral thigh and additional harvesting
the recurrence rate after only arthroscopic valve debridement, an
of fascia lata tissue. However, we suggest that the procedure is
arthroscopic cystectomy, which removes the fibrous membrane,
effective in treating patients with recalcitrant Baker's cysts, espe-
nodules, and septa within the cysts, has been suggested when
cially in the case of patients where treatment has failed after either
performing the procedure [7].
an open or arthroscopic intervention.
Unfortunately, the presenting patient failed to respond to open
excision, arthroscopic debridement plus open excision, and an
arthroscopic cystectomy. Although the true reason was unknown, it Inform and consent
may have been attributed to persistent high intraarticular pressure
and loceking of the barrier between the gastrocnemius tendon and The patient was informed that data from the case would be
the semimembranosus tendon. To decrease the high intraarticular submitted for publication, and written consent was obtained.
pressure, we applied a suction drainage tube postoperatively for Approval was given by National Cheng Kung University Hospital
one week. In spite of this, it was difficult to re-establish a water- Institutional Review Board (NCKUH IRB No. B-EC-110-040).
proof barrier on the posterior capsule.
The tensor fascia lata, composed of mostly collagen fibers with a Approval of the requisite authority
few elastic fibers and fibroblasts, has great tensile strength in the
longitudinal direction. It has been demonstrated histologically to Approval was given by National Cheng Kung University Hospital
remain viable and retain its tissue characteristics after autogenous Institutional Review Board (NCKUH IRB No. B-EC-110-040).
transplantation, with donor site regeneration after harvesting [8]. It
is widely used in repairing or reconstruction of tissue defects such Funding source
as hernias [9] and superior capsule reconstruction in patients with
massive rotator cuff tears [10]. There are also cases of acetabular None.
labral reconstruction using fascia lata autografts with good short-
term results [11]. In our case, multiple debridement of the Baker's Declaration of competing interest
cyst had led to an enlarged gap in the posterior capsule, and pri-
mary closure with sutures had failed many times. Therefore, we There is no conflict of interest in this case report.

392

Downloaded for Sofía Vargas ([email protected]) at Autonomous University of Guadalajara from ClinicalKey.com by Elsevier on
January 24, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
C.-K. Huang, C.-K. Hong, F.-C. Kuan et al. Journal of Orthopaedic Science 29 (2024) 390e393

Acknowledgements [7] Kongmalai P, Chernchujit B. Arthroscopic treatment of popliteal cyst: a direct

posterior portal by inside-out technique for intracystic debridement. Arthrosc
Tech 2015 Apr;4(2):e143e8.
We thank Medical Device R & D Core Laboratory, National Cheng [8] Nahai F. The tensor fascia lata flap. Clin Plast Surg 1980 Jan;7(1):51e6.
Kung University Hospital, Tainan, Taiwan, and Ms. Shing-Yun Chang [9] Puia IC, Necula A, Puia A. Autologous fascia lata repair of hiatal hernia.
BS, MSc (Department of Orthopedic Surgery, National Cheng Kung J Gastrointest Liver Dis : JGLD 2014 Jun;23(2):224e5.
[10] Mihata T, Lee TQ, Watanabe C, Fukunishi K, Ohue M, Tsujimura T, et al. Clinical
University Hospital, College of Medicine, National Cheng Kung results of arthroscopic superior capsule reconstruction for irreparable rotator
University, Tainan, Taiwan) for assistance with this project. cuff tears. Arthroscopy 2013 Mar;29(3):459e70.
[11] Carreira DS, Kruchten MC, Emmons BR, Martin RL. Arthroscopic labral
reconstruction using fascia lata allograft: shuttle technique and minimum
References two-year results. J Hip Preserv Surg 2018 Aug;5(3):247e58.
[12] Matapurkar BG, Gupta AK, Agarwal AK. A new technique of "Marlex-perito-
[1] Herman AM, Marzo JM. Popliteal cysts: a current review. Orthopedics 2014 neal sandwich" in the repair of large incisional hernias. World J Surg 1991
Aug;37(8):e678e84. Nov-Dec;15(6):768e70.
[2] Van Nest DS, Tjoumakaris FP, Smith BJ, Beatty TM, Freedman KB. Popliteal [13] Asai T, Hosoba S, Suzuki T, Kinoshita T. Postinfarction ventricular septal
cysts: a systematic review of nonoperative and operative treatment. JBJS re- defect: right ventricular approach-the extended "sandwich" patch. Semin
views 2020 Mar;8(3):e0139. Thorac Cardiovasc Surg 2012 Spring;24(1):59e62.
[3] Jayson MI, Dixon AS. Valvular mechanisms in juxta-articular cysts. Ann Rheum [14] Park HJ, Kim KS. The sandwich technique for repair of pectus carinatum and
Dis 1970 Jul;29(4):415e20. excavatum/carinatum complex. Ann Cardiothorac Surg 2016 Sep;5(5):
[4] Rauschning W. Anatomy and function of the communication between knee 434e9.
joint and popliteal bursae. Ann Rheum Dis 1980 Aug;39(4):354e8. [15] Ravlic-Gulan J, Gulan G, Novak S, Sestan B. Rapid recurrence of a giant
[5] Newsham KR. Recurrent popliteal cyst in an adult: a case report and review. popliteal cyst in a patient with rheumatoid arthritis. J Clin Rheumatol :
Orthop Nurs 2009 Jan-Feb;28(1):11e4. ; quiz 5-6. practical reports on rheumatic & musculoskeletal diseases 2009 Sep;15(6):
[6] Han JH, Bae JH, Nha KW, Shin YS, Lee DH, Sung HJ, et al. Arthroscopic treat- 300e2.
ment of popliteal cysts with and without cystectomy: a systematic review and [16] Kim SJ, Kim JH. Arthroscopic repair of chronic capsular defect after popliteal
meta-analysis. Knee Surg Relat Res 2019 Jun 1;31(2):103e12. cystectomy. Knee 2004 Aug;11(4):331e4.

393

Downloaded for Sofía Vargas ([email protected]) at Autonomous University of Guadalajara from ClinicalKey.com by Elsevier on
January 24, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.