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Rheumatoid synovial cyst of the hip.

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Synovial cysts of the hip are believed to occur
rarely (1-3). Cysts of the hip itself or the equivalent,
enlargement of the iliopsoas bursa, have been described in a variety of disorders. These diagnoses have
included degenerative joint disease (3-7), rheumatoid
arthritis (1,2,8), synovial chondromatosis (9, lo), and
pigmented villonodular synovitis (1 1). Swelling of the
lower extremity may occur, but its relationship to a
possible occlusive effect from the cyst is rarely
Case Report. The patient, a 74-year-old white
woman with chronic rheumatoid arthritis, was admitted to the Mount Sinai Hospital in October 1980
because of complaints referable to progressive swelling, of 6 months' duration, of the left lower extremity.
Significant history included the following surgical procedures: in 1969 a giant popliteal synovial cyst was
removed from the left calf; in 1976 a recurrent poplitea1 cyst was removed from the same area and a synovectomy of the left knee was performed; in 1977
bilateral total knee replacement arthroplasties were
From the Departments of Orthopaedics, Medicine (Rheumatology), Radiology, and Vascular Surgery, Mount Sinai Medical
Center, New York, New York.
Roger N. Levy, MD: Clinical Professor of Orthopaedics,
Mount Sinai School of Medicine; George Hermann, MD: Associate
Professor of Radiology, Mount Sinai School of Medicine; Moshe
Haimov, MD: Associate Professor of Vascular Surgery, Mount
Sinai School of Medicine; Herbert S. Sherry, MD: Assistant Clinical
Professor of Orthopaedics, Mount Sinai School of Medicine; John S .
Train, MD: Assistant Professor of Radiology, Mount Sinai School of
Medicine; Selvan Davison, MD: Clinical Professor of Medicine
(Rheumatology), Mount Sinai School of Medicine.
Address reprint requests to Roger N. Levy, MD, Department of Orthopaedics, Mount Sinai School of Medicine, Annenberg
17-90, One Gustave Levy Place, New York, N Y 10029.
Submitted for publication March 26, 1982; accepted April
16, 1982.
Arthritis and Rheumatism, Vol. 25, No. 11 (November 1982)
performed; and in 1978 an open reduction and internal
fixation for a right intertrochanteric hip fracture was
Physical examination revealed diffuse swelling
of the entire left lower extremity from the inguinal area
to the toes, with pitting edema present from the
midtibial area distally.
Full painless range of motion was present at
both hips. A painless range of motion from 0-10.5" was
present at both knees, and ligament stability was
noted. No physical signs suggesting infection were
present. No masses could be palpated in the inguinal
area, in the left lower abdominal quadrant, nor by
pelvic or rectal examination. Peripheral pulses were
Initial laboratory examination of blood and
urine only confirmed the previously established diagnosis of rheumatoid arthritis and did not suggest any
other underlying disease states. Initial radiologic examination demonstrated an intact joint space in the left
hip. No evidence of lucent lines was noted at the knee
prosthetic arthroplasties.
A pelvic sonogram revealed an echo-free mass
in the left pelvis, anterior and lateral to the bladder
wall. This was considered compatible with either a
cystic mass or a lymph node mass.
A left femoral venogram was performed. On
injection of dye, there was a massive reflux of contrast
medium to below the level of the knee, indicating
proximal compression, and an extrinsic impression
was seen on the lateral aspect of the left common
femoral vein and left external iliac vein (Figure 1).
These findings of an apparent cystic mass compressing the external iliac and common femoral veins
on the lateral aspect prompted us to perform a left hip
bursa, the enlarged stalk, and the communication to
the hip joint were excised. An anterior longitudinal
capsulotomy was performed and the joint inspected.
The articular surface appeared normal. Considerable
hypertrophic synovium was noted, and an anterior
synovectomy was performed. Microscopic examination was consistent with a bursa1 cyst and rheumatoid
Postoperatively, the patient’s previous limb
swelling resolved, and she regained her prior hip
Discussion. Synovitis in joints or other synovial
lined structures, such as bursae or tendon sheaths,
may lead to a fluid-filled enlargment of these anatomic
parts. Fifteen percent of normal cadavers have been
shown to have a communication between the iliopsoas
bursa and the hip joint. This frequency is believed to
increase in the presence of hip disease (1,3,5,12-15). A
triad of findings has been suggested by Melamed and
associates (5) to be present when arthritic hip disease
has extended into the iliopsoas bursa. These are: a
mass in the inguinal area, pressure on nearby struc-
Figure 1. The external iliac vein (curved arrows) is compressed by a
mass above the left acetabulum. Note the contrast-filled synovial
recess lateral to the femoral vein (short arrow).
arthrogram. Arthrography revealed an intact joint
space and an enlarged articular recess. The synovium
appeared thickened. At completion of the joint injection, an enlarged synovial cavity filled with contrast
material and measured approximately 4 x 5 cm was
located proximal and slightly medial to the hip joint
(Figure 2). This was considered compatible with a
synovial cyst originating from the hip joint.
Because of this confirmation that the obstruction to venous drainage from the left lower extremity
was due to an intrapelvic extension of a synovial cyst
of the hip, surgical exploration was performed through
a combined transabdominal and anterolateral hip joint
exposure. The mass was thought much too large for
conservative treatment. A large ( 5 x 5 cm) round cystic
mass was noted to be compressing the external iliac
vessels. It was tracked below the inguinal ligament and
found to originate in an enlarged stalk of iliopsoas
bursa. The mass was contiguous under the anterior
gluteus medius muscle with the anterior capsule of the
hip joint. The enlarged synovial cyst and iliopsoas
Figure 2. Left hip arthrogram shows a contrast-filled enlarged
intrapelvic synovial cyst (arrow).
tures, and roentgenographic changes of arthritis in the
Our case report illustrates the lack of clinical
reliability of this diagnostic triad. Clearly, local pressure from the intrapelvic cyst upon the external iliac
vein was the cause of swelling in the lower extremity
due to interference with venous return. The cyst was
almost entirely proximal to the inguinal ligament with
a relatively long stalk extending from the iliopsoas
area, and hence, no palpable inguinal mass was noted
in the already swollen limb. Stage I of rheumatoid
arthritis is synovitis without articular damage (16).
This was noted by the normal appearance of the hip
joint on preoperative radiologic examination and confirmed at the time of surgery when capsulotomy revealed a normal articular surface but considerable
synovial hypertrophy.
For accessible or smaller cysts, it would seem
reasonable to attempt aspiration of cyst contents and
steroid instillation. Inaccessible, large, or persistent
cysts will require excision of the cyst and synovectomy of the joint to avoid recurrence.
Considering the frequency of rheumatoid hip
disease and the relative paucity of case reports, this
would appear to be a rare disorder. On the other hand,
it is possible that the occurrence of such cysts may be
more common, but the clinical diagnosis may be
missed in a patient with multiple problems. Certainly,
chronic swelling of the limb in patients with hip joint
disease is not rare. It is the purpose of this report to
call attention to this possible explanation.
2. Samuelson C , Ward JR, Albo D: Rheumatoid synovial
cyst of the hip: a case report. Arthritis Rheum 14:105108, 1971
3. Warren R, Kaye JJ, Salvati E: Arthrographic demonstration of an enlarged iliopsoas bursa complicating
osteoarthritis of the hip. J Bone Joint Surg 57A:413-415,
4. Hucherson DC, Denmam FR: Non-infectious iliopectineal bursitis. Am J Surg 72576, 1946
5. Melamed A, Bauer CA, Johnson JH: Iliopsoas bursa1
extension of arthritic disease of the hip. Radiology
89:54-58, 1967
6. O’Connor DS: Early recognition of iliopectineal bursitis.
Surg Gynecol Obstet 57:674, 1933
7. Staple TW: Arthrographic demonstration of iliopsoas
bursa extension of the hip joint. Radiology 102515-516,
8. Palmer DG: Synovial cysts in rheumatoid disease. Ann
Intern Med 70:61-68, 1969
9. Cullen TS: A large cystic tumor developing from the
iliopsoas bursa, containing large free cartilaginous masses. JAMA 54: 1184, 1910
10. Eisenberg KS, Johnston JO: Synovial chondromatosis
of the hip joint presenting as an intrapelvic mass: a case
report. J Bone Joint Surg 54A:17&178, 1972
11. Can- CR, Berley FV, Davis WC: Pigmented villo-nodular synovitis of the hip joint: a case report. J Bone Joint
Surg 36A:1007-1013, 1954
12. Chandler SB: The iliopsoas bursa in man. Anat Rec
58235, 1934
13. Finder JG:Iliopectineal bursitis. Arch Surg 36:519, 1938
14. Gatch WD, Green WT: Cysts of the ilio-psoas bursa.
Ann Surg 82:277, 1925
15. Stephens VR: Cystic tumor of the iliopectineal bursa:
report of two cases. Arch Surg 49:9, 1944
16. American Rheumatism Association: Primer on arthritis.
JAMA 119:1089-1104, 1958
1. Coventry MB, Polley HF, Weiner AD: Rheumatoid
synovial cysts of the hip: report of three cases. J Bone
Joint Surg 41A:721-730, 1959
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hip, synovial, rheumatoid, cysts
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