Genesis of the Structural and Functional Abnormalities and a Hydrostatic Model of Baker’s Cyst
Introduction. The knee joint is surrounded by a variety of cystic formations (CF) — bursa, which normally are not clinically manifested. All synovial cavities, particularly knee joints and bursa, which surround the knee joint, contain synovial fluid. Synovial fluid is an ultrafiltrate of the blood plasma and consists of proteins and interstitial fluid. The literature describes the bursa surrounding the knee joint, the ultrasound classification of Baker’s cysts depending on the stage of the course, which is offered by I.M. Danilova , and classification of cystic meniscal degeneration, but provides no information about the pathophysiological and histochemical changes that occur in CF of the knee joint, as well as no data on the pathophysiological model of the knee CF, which would reflect the nature of this disease in terms of physical and biochemical processes. Materials and methods. In the trauma department of the clinic of injuries of the Military Medical Center of the Northern Region from the beginning of 2016, we have observed 15 patients with a clinical picture of the knee cyst, verified by instrumental methods of examination: ultrasound investigation (UI), magnetic resonance imaging (MRI) and spiral computed tomographic arthrography (SCТA) of the knee joint. Of these, calf-semimembranosus bursitis was observed in 9 patients, meniscal cysts — in 5 patients, bursitis of the anterior knee — in 1 patient. Among patients, the men prevailed — there were 11 men and 4 women, respectively. The average age of patients was 43.5 years. The objects of the study were cystic formations of the knee joint. All patients with CF underwent a comprehensive survey that included UI, SCTA, MRI, measurement of intraarticular and intracystic pressure using contact manometer manufactured by the Stryker company and, subsequently, diagnostic and therapeutic arthroscopy. According to the US data, the patients were divided into 4 groups based on the percentage ratio of intraluminal layers (inclusions) to the total lumen of CF, making it possible to form a new classification of the knee CF to select a particular treatment. Results and discussion. The formation and progression of CF are influenced by a high blood pressure, which is an average of 29 mmHg in the flexion position and 58.4 mmHg in the extension position. Based on preliminary data, in our opinion, critical rates, at which rupture of a Baker’s cyst may occur, is pressure more than 60 mmHg. Usually, this complication occurs in chronic cyst when long-term adsorption of protein molecules on the cystic wall leads to the adsorption weakening of the strength and reduction of surface tension — Rehbinder effect. Conclusions. Taking into account the data of biochemical processes, ultrasound pictures and endoscopy data of the Baker’s cysts in various stages, we have found that the cyst wall itself doesn’t thickens, but there is parietal layers of protein molecules with the formation of globules, which form the so-called pseudowall. Subsequently, these layers are beginning to form the membranes between opposite walls, to thicken, leading to intimacy of a CF. In the later stages, these layers dominated over the lumen of a CF. This classification, which is offered by us, is based on the determination of percentage of intraluminal layers and the total lumen of a CF in two sections and reflects the main morphological changes that makes it possible to determine the optimal treatment for cystic formation and wide practical use in traumatology and orthopedics.
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