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A giant ganglion cyst of the semimembranosus tendon: a case report.
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MedLine Citation:
PMID:  19918417     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
We report a rare case of a 'giant ganglion' with 24 x 10 x 12 cm dimensions originating from the semimembranosus tendon. The patient presented with chronic pain and a palpable mass in his left calf located between the superior aspect of the popliteal fossa and the distal third of the calf. MRI revealed the mass to be a ganglion in close relation to the semimembranosus muscle at its attachment to the tibia. The patient was operated on and had complete resolution of symptoms postoperatively. To the best of our knowledge there are no other case reports in the literature of ganglion cysts of similar size arising from the tendon of semimembranosus. A brief review of the literature is included.
Authors:
Sunil Garg; Talal Al-Jabri; Sanjay Mutnal; Farid Moftah
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Publication Detail:
Type:  Journal Article     Date:  2009-08-05
Journal Detail:
Title:  Cases journal     Volume:  2     ISSN:  1757-1626     ISO Abbreviation:  Cases J     Publication Date:  2009  
Date Detail:
Created Date:  2009-11-17     Completed Date:  2011-01-07     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  101474272     Medline TA:  Cases J     Country:  England    
Other Details:
Languages:  eng     Pagination:  8305     Citation Subset:  -    
Affiliation:
Trauma and Orthopaedics, Queen Mary’s Hospital, South London Healthcare NHS Trust, Frognal Avenue, Sidcup, DA146LT, UK. sunil_garg9@hotmail.com
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From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Cases J
ISSN: 1757-1626
Publisher: Cases Network Ltd
Article Information
? 2009 Garg et al.; licensee Cases Network Ltd.
open-access:
Received Day: 23 Month: 6 Year: 2009
Accepted Day: 10 Month: 7 Year: 2009
Electronic publication date: Day: 05 Month: 8 Year: 2009
collection publication date: Year: 2009
Volume: 2E-location ID: 8305
PubMed Id: 19918417
DOI: 10.4076/1757-1626-2-8305
Publisher Id: 8305

A giant ganglion cyst of the semimembranosus tendon: a case report
Sunil Garg1 Email: sunil_garg9@hotmail.com
Talal Al-Jabri1 Email: talaljabri@doctors.org.uk
Sanjay Mutnal2 Email: sanjay.mutnal@dvh.nhs.uk
Farid Moftah2 Email: farid.moftah@dvh.nhs.uk
1Trauma and Orthopaedics, Queen Mary?s Hospital, South London Healthcare NHS TrustFrognal Avenue, Sidcup, DA146LTUK
2Trauma and Orthopaedics, Darrent Valley HospitalDartford, DA28DAUK

Introduction

A ganglion is best described as a cyst filled with colloid material met within the vicinity of a joint or tendon sheath. They most commonly occur on the dorsal aspect of the wrist [1]. Popliteal (Baker?s) cysts are commonly reported in patients with underlying osteoarthritis or rheumatoid arthritis and are usually diagnosed clinically but may require the aid of ultrasonagraphy or magnetic resonance imaging (MRI) for further structural detail. The popliteal fossa and calf is an unusual location for a ganglion [2]. Ganglia in the region of the knee are usually situated over the interval between the femur and tibia, most often on the lateral aspect of the joint and may attain the size of a walnut [3]. We report an interesting case where a ?giant ganglion? was identified in the popliteal and calf region mimicking an unruptured Baker?s cyst.


Case precentation

A 50-year-old Caucasian male presented to clinic with a mass in his left popliteal fossa and calf which had been increasing in size over the past six months. This had been associated with intermittent pain in the popliteal fossa. The patient also, felt the mass to be aesthetically displeasing.

Physical examination revealed a non-tender swelling extending from the superior aspect of the popliteal fossa to the junction of the middle and distal third of the calf. The mass was cystic in consistency and transilluminated with a well defined margin. Flexion at the knee was restricted due to the size of the swelling. The ankle had an uncompromised range of movement (Figures 1 and 2).

Full blood count and inflammatory markers were normal. X-rays of the knee and tibia were normal. An ultrasound scan of the mass revealed the cystic nature of the swelling. A provisional diagnosis of a Baker?s cyst was made. An MRI of the knee and leg was obtained which revealed a large cystic lesion measuring 24 ? 10 ? 12 ;cm in the posteromedial aspect of the knee and calf. The lesion was reported to have multiple septae and was closely related to the semimembranosus muscle (Figures 3a and 3b). Following the MRI an excision was planned.

At surgery the swelling was found to be originating within the superficial posterior compartment of the leg without any communication with the knee joint or proximal tibio-fibular joint. The fluid inside the cyst was found to be mucinous. A definitive capsule was identified and the cyst was excised with its capsule.

Histology revealed the mass to be a ganglion (Figure 4). The ganglion consists of a meshwork of fibrous tissue; the meshes of which are occupied by colloid material. There was no endothelial lining and the fibrous tissue appeared to have been derived by a process of degeneration from the surrounding tissue.

The patient had an uneventful recovery with complete resolution of all symptoms (Figures 5a and 5b).


Discussion

A ganglion is a term applied to a cyst filled with colloid material which is met within the vicinity of a joint or tendon sheath. The commonest variety-the carpal ganglion-is met with a smooth, rounded, or oval swelling on the dorsal aspect of the carpus, usually towards its radial side. Ganglia are thought to arise from cystic degeneration in a tendon sheath or joint capsule usually in middle aged males [3]. Previously it has been postulated that popliteal cysts occur more commonly with increasing age and in males as there tends to be an increasing prevalence of intra-articular pathology in these groups of people [4].

Other theories for the development of popliteal cysts suggest that these cysts may be the result of a lack of support from surrounding structures which leads to a gradual disturbance in the mechanics of movement and the production of excess fluid in a synovial membrane [3]. A hernial protrusion of a synovial membrane of a joint or tendon sheath often occurs with the resultant formation of a ganglion. We have not been able to demonstrate any communication between the cavity of the cyst and that of an adjacent tendon sheath or joint. It is possible that this cyst may originate from a minute portion of synovial membrane being protruded and strangulated so that it becomes disconnected from that to which it originally belonged. It may then degenerate and give rise to colloid material, which accumulates and forms a cyst.

Large synovial cysts have been reported in patients with rheumatoid arthritis and a Baker?s cyst is a common finding in patients over 50 years old. However, it is very rare for a ganglion to reach a size of 24 ? 10 ? 12 ;cm and we have not found any case reports similar to this.

The differential diagnosis of ganglia in the calf and popliteal fossa can be demanding. Differentials such as a Baker?s cyst, haematomas, lipomas and a deep vein thrombosis must be excluded. Ultrasound can be used however is not adequate to visualise associated structures. MRI is the most accurate imaging modality and is best used for planning the surgical excision [5]. Although rare, ganglion cysts should be kept in mind while evaluating masses in the popliteal fossa and calf region. This case also highlights the importance of conducting accurate diagnostic tests in planning the surgical excision.


Notes
Consent

Written informed consent was obtained from the patient for the publication of this case report and the accompanying images. A copy of the written consent is available for review by the Editor-in-chief of this journal.

Competing interests

The authors declare that they have no competing interests.

Authors? contributions

SG, TAJ, SM and FM made substantial contributions to the acquisition of data and its analysis. SG and TAJ wrote and edited the manuscript. SG performed the literature search. SG was involved in the surgical management of the patient. All authors have approved the publication of this case report.


References
Garcia-Alvarez F,Garcia-Pequerul JM,Avila JL,Sainz JM,Castiella T. Ganglion cysts associated with cruciate ligaments of the knee: a possible cause of recurrent knee painActa Orthop BelgYear: 20006649049411196374
Adams R. Arthritis, chronic rheumatic, of the knee jointDublin J Med SciYear: 184017520523
Labropoulos N,Shifrin DA. New insights into the development of popliteal cystsBr J SurgYear: 2004911313131815376180
Handy JR. Popliteal cysts in adults: a reviewSemin Arthritis RheumYear: 20013110811811590580
Torregiani WC,Al-Ismail L,Munk PK. The imaging spectrum of Baker?s cystsClin RadiolYear: 20025768169112169279

Abbreviation
MRI Magnetic Resonance Imaging

Figures

[Figure ID: fig-001]
Figure 1. 

Posterior aspect of the left leg showing the location of the mass.



[Figure ID: fig-002]
Figure 2. 

Medial view of the mass in the left leg.



[Figure ID: fig-003]
Figure 3A and B. 

MRI showing a cystic lesion in the posteromedial aspect of the knee and calf.



[Figure ID: fig-004]
Figure 4. 

Histology of ganglion showing meshwork of fibrous tissue.



[Figure ID: fig-005]
Figures 5A and B. 

Postoperative images of patients leg after excision of the ganglion.



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