Orthopaedics & Traumatology: Surgery & Research 109 (2023) 103595

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Original article

Risk factors for residual popliteal cyst after arthroscopic

decompression and cystectomy: Associated with degenerative
cartilage lesions
Myung-Seo Kim a , Joong-Won Lee a , Jin-Hwan Ahn b , Kyeong-Uk Min a , Sang-Hak Lee a,∗
a
Department of Orthopedic Surgery, Kyung-Hee University Hospital at Gangdong, 892, Dongnam-ro, Gangdong-gu, 05278 Seoul, Republic of Korea
b
Department of Orthopaedic Surgery, Saeum Hospital, 449, Siheung-daero, Geumcheon-gu, 08534 Seoul, South Korea

a r t i c l e i n f o a b s t r a c t

Article history: Background: In previous studies, good results have been reported after arthroscopic treatment of popliteal
Received 20 May 2022 cysts and concomitant intra-articular pathology. However, only a few studies have reported the associated
Accepted 6 March 2023 factors with residual popliteal cysts. The aim of this study was to examine the clinical and radiographic
outcomes and investigate the factors associated with the recurrence of popliteal cyst after arthroscopic
Keywords: cyst decompression and cyst wall resection.
Popliteal cyst Hypothesis: The authors hypothesized that residual popliteal cyst after arthroscopic decompression and
Baker’s cyst
cystectomy would be associated with degenerative cartilage lesions.
Residual popliteal cyst
Arthroscopic decompression and
Patients and methods: From December 2010 to December 2018, 54 patients with popliteal cysts were
cystectomy treated with arthroscopic decompression and cyst wall resection through an additional posteromedial
Additional posteromedial cystic portal cystic portal. Magnetic resonance imaging (MRI) or ultrasonography was used to observe whether the
popliteal cyst had disappeared or decreased. The maximum diameter of the popliteal cyst was mea-
sured after surgery. The patients were classified into the disappeared and reduced groups according to
the treatment outcome. Age, sex, symptom duration, preoperative degenerative changes based on the
Kellgren-Lawrence (K-L) grade, cartilage lesions according to the International Cartilage Repair Soci-
ety (ICRS) grades, synovitis, functional outcomes, and associated intra-articular lesions were compared
between the two groups. The functional outcome was evaluated on the basis of the Rauschning and Lind-
gren knee score. The study included 22 men and 32 women, with mean age of 49.6 years (range, 5–82
years). According to the ICRS grade system, 28 (51.8%) patients had grade 0 to II, 26 (48.2%) patients had
grade III to IV.
Results: Follow-up radiographic evaluation revealed that the cyst had completely disappeared in 20
patients (37%) and reduced in size in 34 (63%). The mean cyst size was decreased significantly from 5.7 cm
(range, 1.7–15 cm) to 1.7 cm (range, 0–6.4 cm), and the Rauschning and Lindgren knee score showed
improved clinical features in all the patients. Between the disappeared and reduced groups, the presence
of degenerative cartilage lesions (p = 0.022, odds ratio 8.702, 95% confidence interval: 1.368–55.362)
showed statistically significant differences.
Discussion: Through the posteromedial cystic portal, cysts were completely removed in approximately
40% of patients, and the size was reduced in 60% of patients. Presence of degenerative cartilage lesion
represents an associated risk factor for residual popliteal cyst. These findings could be helpful in ensuring
explaining poor prognostic factors.
Level of evidence: IIIb; retrospective cohort study.
© 2023 Elsevier Masson SAS. All rights reserved.

1. Introduction As the pathogenesis of popliteal cysts, it has been reported that

Popliteal synovial cysts, also known as Baker’s cysts, can cause
disabling symptoms, such as knee pain and locking sensation [1].
∗ Corresponding author.
E-mail address: sangdory@hanmail.net (S.-H. Lee).
not only the connection with the knee joint through the valve-like
effect [2], but also the intra-articular pathology can increase knee
effusion [3]. Several studies have reported that in up to 9% of cases,
popliteal cyst formation in adults is often associated with intra-
articular pathologies, such as inflammatory arthritis, osteoarthritis,
cartilage lesions, and meniscal tears [3–5].

https://doi.org/10.1016/j.otsr.2023.103595
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M.-S. Kim, J.-W. Lee, J.-H. Ahn et al.
This has led to the concept that underlying intra-articular lesions
should also be treated including valvular opening. Recent advances
in arthroscopic techniques have been made to better address
not only the cyst orifice but also the intra-articular pathology.
Arthroscopic treatment of popliteal cysts by enlarging the valvu-
lar opening to discontinue the one-way flow and a concomitant
treatment of intra-articular pathology has shown good results in
several studies [6–9]. So far, these studies have reported that all
the popliteal cysts had completely disappeared or decreased in size
without recurrence after arthroscopic cyst decompression. How-
ever, they did not consider the remnant fluid in the popliteal cyst.
Furthermore, the associated factors with such residual popliteal
cysts have not been thoroughly investigated.
There are only a few previous studies reporting risk factors for
residual popliteal cysts [10,11]. In a study that performed arthro-
scopic treatment for various intraarticular lesions, it was reported
that chondral lesions were associated with persistence of cysts.
However, cyst removal was not performed in this study [10].
Therefore, this study aimed to evaluate the factors associated
with residual popliteal cysts after arthroscopic cyst decompression
and cyst wall resection. The authors hypothesized that residual
popliteal cyst after arthroscopic decompression and cystectomy
would be associated with degenerative cartilage lesions.
2. Materials and methods
2.1. Clinical data of the patients
From December 2010 to December 2018, 89 patients with
popliteal cysts were treated with arthroscopic decompression and
cyst wall resection through an additional posteromedial cystic
portal. To evaluate intra-articular lesions, preoperative magnetic
resonance imaging (MRI) was performed for all the patients.
The indication for arthroscopic surgery included an MRI-detected
popliteal cystic lesion accompanied by symptoms associated with
combined intra-articular lesion, pain and limitation of motion, pal-
pable mass in the popliteal fossa, or recurrent popliteal cysts after
aspiration. The exclusion criteria included any prior operation on
the cyst using either an open or arthroscopic procedure, or the
patient’s refusal to undergo follow-up MRI or ultrasonography. As
a result, this study enrolled 54 patients who were followed up for a
mean period of 13.5 months (range, 2–106 months) after surgery.
The patients included 22 men and 32 women with mean age of
49.6 years (range, 5–82 years). The popliteal cysts were located
in the right knee in 30 cases and the left knee in 24 cases. MRI
or ultrasonography was used to observe whether the popliteal
cyst had disappeared or decreased, and the maximum diameter
of the popliteal cyst after arthroscopic surgery was measured. On
the basis of the treatment outcomes, the patients were classi-
fied into disappeared and reduced cyst groups. Age, sex, symptom
duration, follow-up period, preoperative Rauschning and Lindgren
grade, preoperative degenerative changes based on the Kellgren-
Lawrence (K-L) grade, degenerative cartilage lesions according to
the International Cartilage Repair Society (ICRS) grade, preopera-
tive large cyst size more than 6 cm in maximum diameter, synovitis,
functional outcomes, and associated intra-articular lesions were
compared between the two groups.
2.2. Surgical procedure
All the procedures were performed by two surgeons, and all
the popliteal cysts were treated using the same arthroscopic tech-
nique without an open procedure. Arthroscopic popliteal cyst
decompression was performed as previously described [6,12]. The
patients were positioned in the standard arthroscopy position,
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Orthopaedics & Traumatology: Surgery & Research 109 (2023) 103595
with lateral support at the level of a padded tourniquet and a
foot post to allow the knee to be maintained at 90 ◦ flexion when
required. Initially, a routine arthroscopic examination of the knee
joint was performed through standard anteromedial and antero-
lateral portals. Then, the arthroscope was inserted through the
anterolateral portal into the posteromedial compartment through
the intercondylar notch between the medial femoral condyle and
the posterior cruciate ligament with the knee at 90 ◦ flexion. The
posteromedial portal was established under light with 16 G spinal
needle guidance. Under visualization, meticulous probing was per-
formed through the standard posteromedial portal to find the
valvular opening to the cyst. In general, the opening was found
at the posteromedial side of the medial head of the gastrocnemius
after inferiorly displacing the capsular fold (Fig. 1). The most impor-
tant step in this procedure was to locate the opening connection
between the joint cavity and the popliteal cyst in the posterome-
dial compartment. The anatomy of the posteromedial joint capsule
was divided into three types according to the presence of a capsu-
lar fold and an opening according to the Johnson classification as
follows: type 1, which has no capsular fold and opening; and type
2, capsular fold without opening; and type 3, which has a capsular
fold with an opening [13,14]. If the opening connection of the cyst
had been identified, the capsular fold was resected using basket
forceps or a motorized shaver via the posteromedial portal. If the
opening was covered by a thin membrane over the capsular fold,
both were resected using basket forceps to verify the connection
into the cyst. When the capsular fold is removed, the cyst cavity can
be observed by advancing the arthroscope into the cyst via the pos-
teromedial portal (Fig. 2). If fibrous membranes or septa were found
within the cystic hole, an additional posteromedial cystic portal
was created. This portal is usually located in the posterior or inferior
direction from the posteromedial portal (Fig. 3). A complete arthro-
scopic cystectomy was performed by shaving the inner wall of the
popliteal cyst. Intra-articular lesions, such as meniscal tears, chon-
dral lesions, and synovitis, were then treated with corresponding
arthroscopic procedures, such as meniscectomy, meniscus repair,
chondral lesion debridement or microfracture technique, and syn-
ovectomy. Once a drain was inserted in the knee cavity through
the posteromedial portal, a compressive dressing was applied in
the popliteal fossa.
2.3. Postoperative rehabilitation
The patients were encouraged to perform active-passive flexion
exercises and quadriceps muscle strength exercises after surgery.
One week after the surgery, the patients were allowed full weight-
bearing ambulation. However, the patients who were treated
using the microfracture technique were recommended only partial
weight bearing for 6 weeks.
2.4. Clinical evaluation
In all the patients, preoperative MRI was performed to detect
intra-articular lesions and the communication between the knee
cavity and the popliteal cyst. Six months after the operation, MRI
or ultrasonography was used to observe whether the popliteal cyst
had disappeared or decreased, and the maximum diameter of the
popliteal cyst was measured. The functional outcome was assessed
on the basis of the Rauschning and Lindgren [15] knee scores preop-
eratively and at the final follow-up. The parameters considered for
the assessment were the subjective symptoms related to the pres-
ence of a popliteal cyst, such as sense of tension in the popliteal
fossa, pain, posterior swelling, and limitations in range of motion
(ROM). The criteria for the Rauschning and Lindgren grades were as
follows: grade 0, no limitation in ROM and no pain or swelling at the
popliteal fossa; grade 1, minimal ROM limitation, some swelling, or
M.-S. Kim, J.-W. Lee, J.-H. Ahn et al. Orthopaedics & Traumatology: Surgery & Research 109 (2023) 103595

Fig. 1. A. Arthroscopic finding obtained through an anterolateral portal of the left knee, showing the inferiorly displaced capsular fold by the probe covering the valvular
opening. B. Schematic drawing showing the anterolateral viewing portal and location of the posteromedial portal.

Fig. 2. A. Arthroscopic finding obtained through an anterolateral portal of the left knee, showing a capsular fold completely removed using basket forceps and motorized
shaver inserted from the posteromedial portal. B. After capsular fold removal, the opening is visible between the medial head of the gastrocnemius and the semimembranosus.
An arthroscope could be used to observe the cyst cavity by advancing it into the cyst via the posteromedial portal. C. Schematic drawing showing the completely resected
capsular fold and location of the posteromedial viewing portal.

a sense of posterior tension after intense activity; grade 2, limitation
of ROM < 20 ◦ , considerable swelling, and pain after normal activity;
grade 3, limitation of ROM > 20 ◦ , constant swelling, and pain even
when resting.
cysts were analyzed using a multiple regression method. All dif-
ferences were considered statistically significant at p < 0.05.
3. Results

2.5. Statistical analysis
The results were analyzed using statistical software (SPSS 21.0;
Chicago, IL, USA). The statistical significance of the differences in
continuous variables, such as age and cyst size was compared
using an independent t-test or Mann–Whitney U-test. Categori-
cal variables such as sex or combined intra-articular pathologies
were compared using the Chi2 test or Fisher exact test. Compar-
isons between the preoperative and follow-up stages, including
functional scores and MRI scans for the measurements of the cyst
dimensions, were made by using a paired t-test and Wilcoxon
signed-rank test. The associated factors with residual popliteal
In all the patients, a one-way valve-like opening in the pos-
teromedial compartment was found. The patients were treated by
enlarging the opening, and concomitantly correcting the combined
intra-articular lesions. Degenerative cartilage lesions of at least
ICRS grade I were the most common (46 cases, 85.2%), followed
by medial meniscal tears in 39 cases (71.8%), lateral meniscal tears
in 21 cases (38.9%), and synovitis and synovial hypertrophy in 17
cases (31.5%) (Table 1). The combined intra-articular pathologies
were treated using an arthroscopic procedure. Meniscal tears were
treated with partial meniscectomy in 28 cases or repair in 11 cases.
In addition, 11 patients with grade II cartilage lesions were treated
with chondroplasty, and 26 patients with grade III or IV cartilage

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Fig. 3. A. Operative photograph showing an arthroscope introduced from the posteromedial portal and a shaver inserted from the posteromedial cystic portal. B. Arthroscopic
finding obtained through the posteromedial portal of the left knee, showing the popliteal cyst cavity and a motorized shaver introduced through the posteromedial cystic
portal. C. Schematic drawing showing the location of the posteromedial cystic and the viewing portals.

Table 1 Table 3
Intra-articular pathologies associated with popliteal cyst (n = 54). Pre- and postoperative Rauschning and Lindgren grade.

Pathology No. of cases (%) Grade Before surgery Final follow-up

(No. of cases) (No. of cases)
Degenerative cartilage lesions of at least ICRS grade 1 46 (85.2%)
Medial meniscal tear 39 (71.8%) Grade 0 0 22
Lateral meniscal tear 21 (38.9%) Grade 1 17 31
Synovitis and synovial hypertrophy 17 (31.5%) Grade 2 31 1
Loose body 5 (9.3%) Grade 3 6 0
Plica syndrome 5 (9.3%)

Table 2
All the patients underwent follow-up radiographic evaluation
Accompanying treatments other than popliteal cyst decompression and cystectomy.
using MRI or ultrasonography, and the size of the remaining cysts
Accompanying treatment Disappeared Reduced group was measured. The mean time from surgery to imaging exam-
group (n = 34) ination was 8.6 months (range, 2–47 months). The follow-up
(n = 20) No. of cases (%)
No. of cases (%)
radiographic evaluation revealed that the cyst had completely dis-
appeared or decreased in size in all the cases. The mean cyst size
Meniscal resection 10 (50%) 18 (52.9%)
decreased significantly from 5.7 cm (range, 1.7–15 cm) to 1.7 cm
Meniscal repair 6 (30%) 5 (14.7%)
Chondroplasty 5 (25%) 20 (58.8%) (range, 0–6.4 cm; p < 0.001). The cyst had completely disappeared
Bone marrow stimulation 9 (45%) 3 (8.8%) in 20 patients (37%) and had decreased in size in 34 patients (63%).
Synovectomy 3 (15%) 3 (8.8%) The demographic and clinical characteristics of the two groups are
Plica resection 2 (10%) 3 (8.8%) shown in Table 4.
High tibial osteotomy 2 (10%) 0
Three risk factors among 12 independent variables were iden-
tified as associated factors in the univariate logistic regression
lesions were treated with chondroplasty (n = 14) or a microfracture analysis. The factors were age, combined medial meniscal tears
technique using owls (n = 12) (Table 2). There were no complica- and presence of degenerative cartilage lesions. In multivariate
tions such as neurovascular injury [16] after decompression and logistic regression analysis, the presence of degenerative cartilage
resection of popliteal cyst. lesions of at least ICRS grade I, was a significant factor associ-
The Rauschning and Lindgren grade improved significantly at tated with residual popliteal cyst following arthroscopic surgery.
the last follow-up as compared with the preoperative grade, from Sex, symptom duration, follow-up period, preoperative Rauschn-
grades 1, 2, and 3 preoperatively in 17 (31.5%), 31 (57.4%), and ing and Lindgren grade, preoperative degenerative changes based
6 cases (11.1%), respectively, to grade 0, 1, and 2 in 22 (40.7%), on the K-L grade, synovitis, preoperative cyst size, large cyst size
31 (57.4%), and 1 case (1.9%), respectively, at the final follow-up, more than 6 cm preoperatively, and lateral meniscal tears were not
(p < 0.001) (Table 3). significantly associated factors (Table 5).

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Table 4
Patients’ demographic characteristics.

Variables Disappeared Reduced group p-valuec

group (n = 34) (95%CI)
(n = 20)

Sex (male/female)a 8/12 14/20 0.932

Mean age, yearsb 43.7 ± 16.3 53.1 ± 11.9 0.032
Follow-up period, monthsb 20.3 ± 19.3 23.0 ± 24.2 0.672
Symptom duration, monthsb 11.6 ± 15.3 15.6 ± 22.3 0.480
K-L grade (0/1/2/3/4)b 6/2/10/1/1 4/15/10/5/0 0.941
ICRS grade on arthroscopy (0/1/2/3/4)a 5/1/4/2/8 2/8/8/11/5 0.71
Preoperative RL grade (0/1/2/3)a 0/9/10/1 0/8/21/5 0.077
Preoperative cyst sizeb 55.8 ± 12.3 62.1 ± 27.4 0.335

K-L grade: Kellgren-Lawrence grade; ICRS: International Cartilage Repair Society; RL grade: Rauschning and Lindgren grade.
a
Values are given as number.
b
Values are given as mean and standard deviation.
c
p-values obtained independent t-test or Mann–Whitney U-test, Chi2 test or Fisher exact test as appropriate.

Table 5
Associated factors for residual popliteal cyst after arthroscopic surgery.

Variables OR (95% CI), p-value (univariate logistic regression) Adjusted OR (95% CI), p-value
(multivariate logistic regression)

Sex 0.952 (0.309–2.935), 0.952

Age 1.050 (1.005–1.097), 0.028 1.012 (0.948–1.080), 0.488
Follow-up period 1.006 (0.980–1.032), 0.666
Symptom duration 1.012 (0.979–1.047), 0.483
K-L grade 1.022 (0.580–1.800), 0.940
Degenerative cartilage lesion 6.857 (1.229–38.261), 0.028 8.702 (1.368–55.362), 0.022
Preoperative RL grade 2.367 (0.899–6.236), 0.081
Preoperative cyst size 1.013 (0.987–1.041), 0.333
Huge cyst more than 6 cm 2.333 (0.725–7.510), 0.155
Combined MM tear* 3.818 (1.098-13.279), 0.035 1.841 (0.328–10.316), 0.488
Combined LM tear* 0.478 (0.154–1.486), 0.202
Combined synovitis 1.116 (0.337–3.691), 0.857

K-L grade: Kellgren-Lawrence grade; RL grade: Rauschning and Lindgren grade; MM: medial meniscus; LM: lateral meniscus.

4. Discussion combined intra-articular lesions treated arthroscopically by enlarg-

The most important finding of this study was that the pres-
ence of degenerative cartilage lesions had a significant association
with residual popliteal cysts after arthroscopic decompression and
cystectomy. Twelve parameters were included as potential associ-
ated factors to control for potential confounders in the multivariate
logistic regression analysis. Three associated factors among the
twelve independent variables were identified as potential associ-
ated factors in the univariate analysis: age, degenerative cartilage
lesion, and combined medial meniscal tear. Among the three
potentially associated factors, age and combined medial menis-
cal tear were excluded by the multivariate logistic regression
analysis.
These findings are consistent with the results of Labropoulos
et al., who concluded through an investigation of 426 knees, that
the prevalence of popliteal cysts increased with age and was sig-
nificantly higher especially in the population aged > 50 years [17].
However, their study did not show the result of arthroscopic knee
surgery and only described the prevalence of popliteal cysts in rela-
tion to age. Furthermore, they did not show any other statistically
significant associated factors related to residual popliteal cysts after
arthroscopic treatment.
Many studies have reported that popliteal cysts are disten-
sion of the bursa between the semimembranosus and the medial
head of the gastrocnemius [6,14,18,19]. The bursa space com-
municates with the articular cavity through a one-way valvular
opening covered by a posteromedial capsular fold. Therefore,
treatments for popliteal cysts focus on the management of the
communication between the cyst and the knee joint and com-
bined intra-articular lesions [6,8,20–22]. Ahn et al. reported the
radiographic and functional outcomes of 31 popliteal cysts with
ing the valvular mechanism and cyst wall resection [6]. While
utilizing a slightly different arthroscopic technique to enlarge the
valvular opening, Cho et al. reported no evidence of recurrence in
111 patients [7]. Gu et al. reported no recurrence in 34 patients after
arthroscopic surgery at a mean follow-up of 14.8 months [23]. How-
ever, they did not consider remnant fluid in the popliteal cyst and
described only the outcomes of arthroscopic treatment and could
not show any significant factors associated with residual popliteal
cyst.
Marti-Bonmati et al. found 145 popliteal cysts in 382 knees
through MRI examination and demonstrated a significant associ-
ation between the popliteal cyst and knee joint effusion [24,25].
Chronic increases in joint fluid elevate knee joint cavity pressure
and can cause a unidirectional flow of joint fluid from the artic-
ular cavity to the popliteal cyst. Combined intra-articular lesions
such as meniscal tears and degenerative cartilage lesions can cause
chronic synovitis, which leads to an increase in joint fluid and
recurrence of popliteal cyst after arthroscopic surgery [26,27]. A
recent systematic review and meta-analysis about the arthroscopic
management of popliteal cysts showed that medial meniscal tears
(164/311 popliteal cysts, 52.7%) and articular cartilage injuries
(102/311 popliteal cysts, 32.8%) were the most common concomi-
tant lesions in the knee joint, a finding that is consistent with
our study [23]. In our cohort, between the two groups, a signifi-
cant difference was found in the presence of degenerative cartilage
lesions only (p = 0.022, odds ratio: 8.702, 95% confidence interval:
1.368–55.362), but was not associated with the severity of the car-
tilage lesion.
Chatzopoulos et al. found that popliteal cysts are significantly
more common in knees with chronic osteoarthritis than in those
without osteoarthritis (89/328 knees [32%] and 1/54 knees [2%],

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M.-S. Kim, J.-W. Lee, J.-H. Ahn et al.
respectively) [28]. In the case of knees with high-grade osteoarthri-
tis, recurrent effusions can occur, and the cyst may recur after
arthroscopic surgery because complete correction of combined
intra-articular lesions may not be obtained. However, in our study,
the recurrence rate of popliteal cysts after arthroscopic surgery did
not differ according to the severity of radiographic osteoarthritis.
While the reason for this discrepancy is unclear, the fact that only
7 patients had radiographic high-grade osteoarthritis (K-L grade
III or IV) in our cohort may account for this result.
This study has a few limitations. First, it involved a potential
selection bias because of the retrospective and non-randomized
data collection. Thirty-five patients (approximately 40%) were
excluded because they were lost to follow-up or refused to
undergo postoperative MRI or ultrasonography. Although poten-
tial confounders were included, there may have been additional
confounders that might have not been controlled for. The 12
variables included as related factors in our study may also have
confounded each other. The small sample size (n = 54) resulted
in limited statistical power for several included variables. More-
over, since the number of patients who had popliteal cyst removed
for about 8 years was small, we tried to analyze as many
patients as possible. In this process, although age has not been
reported as a risk factor for residual popliteal cyst, the age range
widened. Second, the operative procedures were performed by
two surgeons using the same arthroscopic procedure. There-
fore, there could be differences in surgeon proficiency. Third,
although our study included preoperative MRI examinations for
all enrolled patients, postoperative follow-up radiographic stud-
ies were performed using MRI or ultrasonography. In addition, the
duration between surgery and follow-up radiographic examination
varied.
5. Conclusion
Through the posteromedial cystic portal, cysts were completely
removed in approximately 40% of patients, and the size was
reduced in 60% of patients. Presence of degenerative cartilage lesion
represents an associated risk factor for residual popliteal cyst. These
findings could be helpful in ensuring explaining poor prognostic
factors.
Disclosure statement
This paper has not been presented at any national or interna-
tional meeting or received any awards.
Disclosure of interest
SHL is an association Editor to the OTSR committee.
The authors declare that they have no competing interest.
Funding
Not applicable.
Contribution
Jin-Hwan Ahn, Sang-Hak Lee designed and supervised the study.
Myung-Seo Kim, Joong-Won Lee data analysis and manuscript
writing. Kyeong-Uk Min data collection and assembly. Jin-Hwan
Ahn and Sang-Hak Lee conducted surgical procedures and follow-
up evaluations. All the authors reviewed and then approved the
manuscript.
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Orthopaedics & Traumatology: Surgery & Research 109 (2023) 103595
Acknowledgements
All authors received no financial support related to this study.
Each author certifies that he or a member of their immediate family,
has no commercial associations (e.g., consultancies, stock own-
ership, equity interest, patent/licensing arrangements, etc.) that
might pose a conflict of interest in connection with the submitted
article. This study has been approved from IRB (KHNMC 2020-11-
001).
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