J Orthop Sci (2013) 18:340342
DOI 10.1007/s00776-011-0151-2
CASE REPORT
Intraarticular epidermal cyst of knee
Jung Ho Noh Young Hak Roh Hyo Jin Lee
Kyung Nam Ryu Woo Kim
Received: 24 February 2011 / Accepted: 11 August 2011 / Published online: 31 August 2011
! The Japanese Orthopaedic Association 2011
Introduction
An epidermal cyst is a common benign lesion that generally
exists in subcutaneous tissue. Prevalent sites of the lesion
are the trunk, neck, face, hand, and foot [1]. It generally
develops from a trauma leading to the implantation of an
epithelial element. It can also congenitally develop, probably
through the inclusion of epidermal elements during neural
tube closure in embryogenesis. It rarely develops after an
orthopedic procedure, and there have been only a few reports
of such a lesion around the knee [24]; the majority of
them developed in subcutaneous tissue. The authors know of
only one report on an epidermal cyst in a joint cavity [3]. In
this work, we report an epidermal cyst that developed in a
knee joint cavity after an arthroscopic procedure.
Case
A 50-year-old man visited the authors hospital due to right
knee pain after hiking. He had no previous history of
trauma. An arthroscopic partial meniscectomy of the
medial meniscus on the right knee through anteromedial
and anterolateral portals had been performed on him
J. H. Noh (&) ! Y. H. Roh ! W. Kim
Department of Orthopaedic Surgery,
National Police Hospital, 58 Garakbon-dong,
Songpa-gu, Seoul 138-708, Korea
e-mail: bestknee@hotmail.com
H. J. Lee
Department of Pathology, National Police Hospital,
Seoul, Korea
K. N. Ryu
Department of Radiology, Kyung Hee University Medical
Center, Seoul, Korea
123
10 years before at the same hospital, and the MRI at that
time showed no cystic lesion. He had no history of trauma
after the previous surgery. He had not had any intraartic-
ular injection, aspiration, or acupuncture of the joint. His
subjective symptom was medial joint pain while walking,
which was aggrevated by jogging. Tenderness on the
medial joint line and a positive McMurray test were found
during physical examination. He also had pain on the
posterior side with deep flexion of the knee.
Simple radiographs of the knee were normal. On MRI,
an oval-shaped lesion was noted in the prefemoral space of
the distal femur (Fig. 1). The lesion was 2.3 9 2 9 1 cm
in size, with mild contour bulging of the overlying syno-
vium in the suprapatellar pouch. On proton and fat-satu-
rated T2-weighted images, the lesion was bright, showing
high signal intensity with a sharp margin. There was no
penetration through adjacent structures, suggesting a
benign lesion. A tear on the posterior horn of the medial
meniscus was also shown. First of all, the lesion was
considered to be a cystic mass such as a ganglion cyst
rather than solid lesion, although gadolinium-enhanced MR
images were not obtained. Epidermal cyst was also inclu-
ded in the differential diagnosis because the lesion had a
slightly lower signal intensity than the adjacent synovial
fluid on fat-saturated T2-weighted images.
Arthroscopic evaluation was conducted, and a tear in the
medial meniscus at the posterior aspect was observed as
well as the cyst. Partial meniscectomy was performed. A
dome-shaped mass was found in the suprapatellar pouch
just above the chondral margin, which contained a pale
yellow-colored cheese-like substance (Fig. 2). It was
excised using a punch and shaver. Pathologic findings for
the cyst showed squamous epithelial cells, keratinized
debris, and a granulomatous reaction, which are typical
findings for an epidermal cyst (Fig. 3). After 1 year, he did
Epidermal cyst in knee joint
Fig. 1 MRIs showed a homogeneous high signal intensity cystic lesion with a thin wall in the suprapatellar pouch
Fig. 2 Arthroscopic view through the anterolateral portal. A mass
covered with synovium is seen in the suprapatellar pouch. After it had
been puctured with an arthroscopic punch, a yellow-colored, cheese-
like material spilled out
not have any symptoms, and a follow-up MRI did not show
any recurrence.
Discussion
There have been several theories regarding the origin of
epidermal cysts. First, the traumatic theory suggests that
341
trauma or surgical procedures applied to subcutaneous
tissue may result in epithelial migration [2, 5]. Second, the
congenital theory suggests pathogenesis resulting from
embryonic misplacement of epithelial cells during closure
of the neural tube [6, 7]. The third theory is penetration of
the existing mass into the adjacent tissue [8]. The epider-
mal cyst generally develops in dermis or subcutaneous
tissue and is usually diagnosed when the person notices a
bump or mass on their skin. It may be asymptomatic. MRI
may sometimes be necessary to differentiate it from other
lesions. Epidermal cysts are iso- or slightly hyperintense on
T1W images and hyperintense on T2W images [9].
Enhanced MRI would be necessary if it is hard to rule a
solid mass out. The definitive diagnosis is made based on
pathologic findings of a cystic lesion lined by stratified
squamous epithelium containing lamellated keratin. Epi-
dermal cysts can be treated with simple excision. Only a
few cases of intraarticular epidermal cyst have been
reported. Strauchen and Strefling [3] reported a case of
epidermal cyst in a meniscus that was considered to be an
iatrogenic complication of a procedure including aspira-
tion, an arthrogram, or arthroscopy. Muellner et al. [2]
reported an epidermal cyst that developed at an outflow
portal after arthroscopic operation, but the lesion was in
subcutaneous tissue not in the knee joint. The clinical
significance of the present lesion is unclear. The subject
had no symptoms of the cystic lesion. The radiographic
123
342
Fig. 3 Photomicrographs of the lesion. a Epithelial lining (arrow)
and synovial lining (arrow head) are seen, and fibrous connective
tissue is present between the two linings (H&E, original magnification
940). b Stratified squamous epithelial lining with abundant keratin-
ized debris (H&E, original magnification 9100)
discovery of this lesion was coincidental, and an operation
to excise such a cyst may not be necessary (unless meniscal
symptoms are present). However, it would be helpful to
reconsider the pathogenesis of this epidermal cyst. Based
on a review of the patients previous operations and con-
sultation with the surgeon who performed the previous
surgery, neither a superomedial nor a superolateral portal
was made during the arthroscopic procedure that the
patient had previously undergone, so the chance that an
epithelial fragment was directly implanted due to the
penetration of prefemoral soft tissue with a surgical
instrument was very low. Most iatrogenic or traumatic
123
J. H. Noh et al.
epidermal cysts that have been reported were adjacent to
the scar or puncture site, which suggests that direct
implantation of the cutaneous squamous cells caused the
lesions. The lesion in the present case was away from the
portal and was not in subcutaneous tissue. The authors
therefore suggest that the cyst arose due to indirect
implantation: an epithelial fragment from the portal (i.e.,
generated during the insertion of the trocar or instruments)
drifted into the joint and into the suprapatellar pouch.
However, there are no previous reports that have proposed
such a theory for the origin of an epidermal cyst. Thus, the
pathogenesis of the present case is not yet very clear. The
possibility of a congenital origin is, however, also low,
considering that the cystic lesion was not seen on the MRI
taken 10 years before. Therefore, this is an extremely rare
case in which an epidermal cyst was found in a joint cavity
after an arthroscopic procedure.
Acknowledgments Written informed consent was obtained from
the patient to publish this case report, including the images. The
authors did not receive any grants, payments, other benefits, or out-
side funding in support of the research or for the preparation of this
case report. The authors did not receive a commitment or agreement
to provide such benefits. The authors are thankful to Wonjoo Jung for
editorial assistance.
References
1. Handa U, Kumar S, Mohan H. Aspiration cytology of epidermoid
cyst of terminal phalanx. Diagn Cytopathol. 2002;26:2667.
2. Muellner T, Nicolic A, Lang S, Schabus R, Kwasny O. Epider-
moid cyst after arthroscopic knee surgery. Arthroscopy. 1998;14:
3314.
3. Strauchen JA, Strefling AM. Epidermal inclusion cyst of the
meniscus. Case report. J Bone Joint Surg Am. 1982;64:290.
4. Karacal N, Topal U, Kutlu N. Popliteal epidermoid cyst: an
unusual location. Plast Reconstr Surg. 2004;114:8301.
5. Ettinger RL, Manderson RD. Implantation keratinizing epidermoid
cysts. A review and case history. Oral Surg Oral Med Oral Pathol.
1973;36:22530.
6. Musharrafieh RS, Tawil AN, Saghieh SS, Macari G, Atiyeh BS.
Epidermoid cyst of the thumb. Orthopedics. 2002;25:8623.
7. Adachi H, Yoshida H, Yumoto T, Naniwa S, Okuno M, Morimoto
K, et al. Intraosseous epidermal cyst of the sacrum. A case report.
Acta Pathol Jpn. 1988;38:15614.
8. Zadek I, Cohen HG. Epidermoid cyst of the terminal phalanx of a
finger; with a review of the literature. Am J Surg. 1953;85:7714.
9. Shibata T, Hatori M, Satoh T, Ehara S, Kokubun S. Magnetic
resonance imaging features of epidermoid cyst in the extremities.
Arch Orthop Trauma Surg. 2003;123:23941.
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