Skin excision and osteophyte removal is not required in the surgical treatment of digital myxoid cysts

Digital mucous cysts of the finger without osteoarthritis: optimizing outcome of long needle trajectory aspiration and injection

Digital mucous cysts are common, benign and highly recurrent tumors of the distal interphalangeal joints of the fingers and often associated with osteoarthritis. Multiple treatment modalities have been described, but still no consensus is stated. In the absence of degenerative changes, we promote a novel non-surgical approach. The aim of this study was to examine all patients with digital mucous cysts without underlying osteoarthritis, undergoing this injection technique and to assess outcome and complications of this procedure. This was a single center study (2018-2019) of 17 patients who received a long needle trajectory aspiration and injection for treatment of digital mucous cysts. Exclusion criteria were prior surgical treatment, post-traumatic cyst formation and the presence of radiographic distal interphalangeal joint osteophytosis. A total of 15 patients were found eligible for inclusion. The patient reports were retrospectively analyzed with a follow-up of 6 months. The primary study outcome was resolution of the cyst; secondary outcomes were complications of the procedure. Twelve (80%) resolved completely and three (20%) had limited local recurrence at 6 months. No complications were reported. None of the patients with limited recurrence desired further treatment. We believe that this technique offers a non-invasive, low-cost treatment option for digital mucous cysts, particularly in the subset of patients with ample evidence of degenerative articular changes in the distal interphalangeal joint. The described technique can be performed in an office-based setting and avoids typical surgical as well as aspiration-associated complications.

Operative outcome of mucous cyst of lesser toes: A comparison between cyst excision with osteophytectomy and distal interphalangeal fusion

BACKGROUND

To date, the optimal operative treatment for mucous cysts of the lesser toes (MCLT) has not been discussed in detail, although many previous studies have focused on treating finger lesions. Therefore, we evaluated the operative outcomes of two different procedures for MCLT: cyst excision with osteophytectomy and cyst excision with distal interphalangeal (DIP) fusion.

METHODS

We retrospectively reviewed and compared the clinico-radiographic outcomes of patients who underwent cyst excision with osteophytectomy (group 1, 22 cases) or cyst excision with DIP fusion (group 2, 16 cases) for MCLT between January 2010 and August 2021. The minimum follow-up duration for inclusion in the study was 12 months. Clinical outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) lesser toes metatarsophalangeal-interphalangeal scale and the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) subscale. We also collected information on postoperative recurrence and operation-related complications.

RESULTS

The preoperative and postoperative AOFAS and FAAM-ADL scores were not significantly different between the two groups (P > 0.05, each). However, the postoperative recurrence rate was 31.8 % in group 1 (7 of 22 cases), whereas no recurrence was observed in group 2. Every recurrence occurred within 8 postoperative weeks (mean, 4.8 weeks; range, 3-8 weeks). Nonunion of the fusion site was observed in one patient (6.3 %).

CONCLUSION

We confirmed that postoperative recurrence was significantly lower in the case of cyst excision with DIP fusion than in cyst excision with osteophytectomy for the treatment of MCLT. Clinical outcomes were not significantly different between the two procedures.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Diagnosis and surgical treatment of benign nail unit tumors

Little is known about benign non-melanocytic nail tumors, probably due to their low pathogenicity. They are commonly misdiagnosed as inflammatory or infective diseases. They have various features, depending on the type of tumor and its location in the nail apparatus. The typical sign of a tumor is the presence of a mass and/or secondary nail changes from damaged nail structures. In particular, if a single digit is affected by a dystrophic sign or a symptom is reported without any explanation, the presence of a tumor should always be ruled out. Dermatoscopy helps to enhance visualization of the condition and in many cases supports the diagnosis. It may also assist in identifying the right place to biopsy, but it never replaces surgery. Most common non-melanocytic nail tumors are analyzed in this paper, including glomus tumor, exostosis, myxoid pseudocyst, acquired fibrokeratoma, onychopapilloma, onychomatricoma, superficial acral fibromyxoma and subungual keratoacanthoma. The aim of our study is to review the main clinical and dermatoscopic characteristics of the most common benign non-melanocytic nail tumors, to correlate them with the histopathology and to advise practitioners of the best surgical management.

Evaluation of the Demographic and Clinical Features of Patients With Digital Myxoid Pseudocysts and Their Response to Treatment

BACKGROUND

Digital myxoid pseudocysts (DMPs) are the most common benign degenerative lesions of the nail unit. There is currently no consensus regarding first-line treatments for DMPs.

OBJECTIVE

To evaluate demographic and clinical features and treatment methods of DMP and examine recurrence rates and factors that may affect recurrence.

METHODS AND MATERIALS

All patients in the authors' clinic who were diagnosed with DMP between 2013 and 2020 were included. Treatment methods were categorized as surgical excision (SE), drainage and compression (DC), simple drainage (SD), and no treatment. Responses and recurrence rates after different treatment methods were investigated.

RESULTS

Fifty-one lesions from 48 patients were included. Thirty-two lesions were treated with SE, 11 with DC, and 1 with SD, while 7 lesions were left untreated. The initial complete response rate after SE was significantly higher than that after DC. No statistically significant difference was found between the recurrence rates of the 2 treatment methods. Using intra-articular methylene blue during SE did not seem to affect recurrence rates.

CONCLUSION

Drainage and compression seems to be a safe and effective first-line treatment option for DMPs located on the proximal nail fold and distal interphalangeal joint. SE is more favorable as a second-line treatment.

Treatment of Mucous Cyst of the Distal Interphalangeal Joint With Osteophyte Excision and Joint Debridement

Background

Mucous cyst of the distal interphalangeal joint (DMC) or interphalangeal connection of the thumb is common in middle-aged and elderly people, and it often occurs in the fingers of people with osteoarthritis (OA). Although there are many conservative treatments, DMC is usually treated by surgery. The common complications of surgical treatment are recurrence of DMC and skin necrosis. This article introduces the method and clinical effect of osteophyte excision and joint debridement in the treatment of DMC of the distal interphalangeal (DIP) joint.

Methods

In total, 19 cases of affected fingers made an 'S' incision in the DIP joint under local anesthesia to remove the osteophyte of the DIP joint, clean the dorsal joint capsule, wash the joint, and retain only the bilateral collateral ligament and extensor tendon device. It is suspected that the injured finger of the extensor tendon should be protected by external fixation.

Results

Out of 15 patients, 1 patient presented with partial skin necrosis that healed after dressing changes while the other patients recovered well. The visual analog scale (VAS) scores of all affected fingers after surgery were lower than those before the surgery (VAS score: 4.93 ± 0.88 vs. 4.07 ± 1.03, p < 0.05). The range of motion (ROM) of the affected finger decreased in one patient, and the post-operative activity of the other fingers increased in varying degrees (ROM: 67.60 ± 5.40 vs. 71.27 ± 7.06, p > 0.05).

Conclusions

Using osteophyte excision and joint debridement to treat DMC can avoid skin necrosis caused by cyst removal and can avoid the recurrence of DMC to the greatest extent, so it is a safe and effective way of treatment.

Digital Myxoid Cysts: Correlation of Initial and Long-Term Response to Steroid Injections

BACKGROUND

Digital mucous cysts (DMCs) are benign myxoid pseudocysts that develop on the distal interphalangeal joint's lateral or dorsal aspects. Management consists either of a surgical approach, conservative therapy, or simple follow-up.

OBJECTIVE

To correlate the initial and long-term response with clinical and ultrasound parameters in DMCs treated with intralesional steroids as first-line therapy.

METHODS

A single-center prospective open-label study recruited 15 patients affected by DMCs, who had been treated with a cycle of up to 3 steroid injections at a 6 to 9 week time interval.

RESULTS

At the first follow-up visit, 53.3% of patients were cleared of DMCs, achieving a complete response, whereas 46.7% experienced a >30% decrease in their DMC volume, and were considered partial responders. After 1 year of follow-up, the cure rate decreased to 40%, and the recrudescence rate was 27.3%. Clinical and sonographic characteristics that positively correlated with a maintained complete response at follow-up were as follows: young age, absence of osteophytes, low volume, complete clearance at T1, and short disease duration (p < .05).

CONCLUSION

Intralesional steroid therapy is an easy approach for DMC, with minimal side effects; identifying predictive hallmarks is useful to offer a straightforward surgical treatment to patients who have nonresponder characteristics.

Bipedicle Advancement Flap for Skin Coverage after Digital Mucous Cyst Excision: A Retrospective Study of 18 Cases

Objectives

To assess the clinical outcomes of using a bipedicle advancement flap to cover the skin defects after digital mucous cyst (DMC) excision.

Methods

Data for 15 patients (18 fingers) with DMC, admitted to the Department of Orthopaedics and Surgery of the Affiliated Zhongshan Hospital of Dalian University from January 2016 to January 2018, were analyzed retrospectively. This study included 4 men and 11 women, with a mean age of 64 ± 7.8 years (range, 47–77 years). A total of 5 cases involved the thumb, 4 involved the index finger, 5 involved ithe middle finger, and 4 involved the ring finger. Among a total of 18 digital mucous cysts, 7 cases were in the left hand and 11 were in the right hand. Approximately 77.8% of cases had osteophytes. The cysts ranged in size from 0.5–1.0 cm to 0.7–1.2 cm. All patients underwent cyst and osteophyte excision and a bipedicle advancement flap to cover the resultant defect. The same surgical procedure was applied to all patients. Postoperative flap survival, healing, and infection were evaluated. The preoperative and postoperative ranges of motion (ROM) of the distal interphalangeal (DIP) and thumb interphalangeal joints (TIPJ) were recorded. Postoperative patient satisfaction was assessed by the visual analog scale (VAS, 0–10) during follow‐up visits. The Shapiro–Wilk test was used to determine whether the data for the difference between the preoperative and postoperative ROM of the DIP/TIPJ were normally distributed or not. The homogeneity of variance was expressed as mean ± standard deviation. A paired t‐test was used to compare the preoperative and postoperative ROM of the DIP/TIPJ.

Results

The patients were followed up for 20 ± 6.0 months (range, 12–36 months). All the flaps survived after surgery, and the incisions healed well. The sutures were removed 2 weeks postoperatively. No infections occurred and there was no cyst recurrence at follow up. After systemic physical therapy and functional exercises, the ROM of all the fingers was restored to the preoperative ROM by 1 month after surgery. The scores for patient satisfaction with surgery by means of the VAS were 8.5 ± 1.0 points, 2.8 ± 1.4 points, 2.0 ± 1.6 points, 1.5 ± 1.2 points, and 1.1 ± 1.3 points preoperatively, and 1, 3, 6, and 12 months postoperatively, respectively. The data for the difference between preoperative and postoperative VAS scores were normally distributed. There were significant differences between the preoperative and postoperative VAS scores. The preoperative DIP/TIPJ ROM was 71.7° ± 14.0°, and the postoperative ROM at 1, 3, 6, and 12 months were 69.3° ± 15.3°, 70.4° ± 12.7°, 71.5° ± 15.6°, and 71.8° ± 15.6°, respectively. The data for the difference between preoperative and postoperative ROM of the DIP/TIPJ were normally distributed. No difference was found between the preoperative and postoperative ROM.

Conclusion

The bipedicle advancement flap provides a simple and effective technique for covering skin defects following DMC excision.

The outcome of minimally invasive surgery for digital mucous cyst: a 2-year follow-up of percutaneous capsulotomy

Background: Digital mucous cyst(DMC) is the most common tumor or cyst of the hand. Although many operative methods have been proposed to treat DMCs and lower the recurrence rate, many patients hesitate to have surgery. A minimally invasive treatment using percutaneous capsulotomy for the DMCs could be an alternative choice. However, the clinical results of using this method are still uncertain.Objectives: Here, we introduce the percutaneous capsulotomy method and assess the clinical outcomes and the associated complications of this method. Methods: A total of 42 digits were finally included. All patients accepted percutaneous capsulotomy under a digital ring block. Functional and radiographic assessments were made pre- and postoperatively, with a mean of 28.8 months (range, 24-33 months) of follow-up. Results: The mean duration of the appearance of DMCs before treatment was 11.6 months. Of the 19 digits with nail deformity, 14 showed an improved nail appearance. There were no skin complications. The average visual analogue scale (VAS) satisfaction score was 9.4, only two cases had experienced recurrence at the final follow up. Conclusions: This study reported that percutaneous capsulotomy could be an effective method for DMCs treatment. The recurrence rate was low and patient satisfaction was good. Nail deformities could be improved with treatment.

[Mucous pseudocysts-when and how to treat?]

The treatment of mucous pseudocysts must consider their tendency for recurrence. There are numerous established treatment options available. The decision on the optimal therapy, however, depends on the clinical presentation and symptoms as well as on possible side effects. This review presents surgical as well as nonsurgical treatment options for digital mucous pseudocysts and an algorithm is suggested. For recurrent and symptomatic lesions with pain or deformation of the nail plate, surgical excision of the pseudocyst and closure with a flap can be considered.

Proximal nail fold flap for digital mucous cyst excision

The skin covering a digital mucous cyst is often very thin and is often excised with the cyst. Thus, transfer of a skin flap is needed for the defect. We have developed a proximal nail fold flap technique by which the thin skin covering the cyst can be preserved. We conducted a retrospective study to assess the effectiveness and reliability of this technique for digital mucous cyst excision. The study group comprised 26 patients treated for 28 digital mucous cysts. The flap was elevated on the nail matrix to expose the distal interphalangeal joint capsule. To preserve the skin in cases in which the skin covering the cyst was exceptionally thin, we did not excise the upper part of the cyst wall. Excision of the cyst and stalk was successful in all cases. Additional excision of the joint capsule or osteophyte(s) was achieved in 20 cases and 5 cases, respectively. No flap necrosis, skin defect or nail deformity resulted. Three of the cysts recurred and were treated successfully by reoperation involving the same flap elevation technique. We conclude that the proximal nail fold flap is useful for excision and reliable for wound coverage after digital mucous cyst excision. J. Med. Invest. 63: 278-280, August, 2016.

Effectiveness and Safety of Surgical Excision in the Treatment of Digital Mucoid Cysts

BACKGROUND

Digital mucoid cysts have a tendency for recurrence after operative intervention. Several procedures are in use.

OBJECTIVE

Retrospective evaluation for effectiveness, safety and patient satisfaction by using a questionnaire after treatment for digital mucoid cysts with targeted surgical excision and closure by flap-design.

MATERIALS AND METHODS

All patients treated with surgical excision for digital mucoid cysts at the Dermatology Department of the Ludwigshafen City Hospital between 2007 and 2011 were evaluated using a specially designed questionnaire.

RESULTS

We evaluated 31 patients. The patient group consisted of 65% women, the median age was 61 years. Seventy-eight percent of patients with nail involvement had a marked improvement or complete resolution of this complaint after surgery. A few complications (e.g., redness, pain or hematoma) were observed after treatment, but no patients required oral antibiotics. Patient evaluation of cosmetic outcome revealed high satisfaction with the procedure, nevertheless recurrence of the digital mucoid cysts was observed in 22.5% of all cases.

CONCLUSION

Surgical excision in treatment of digital mucoid cysts was shown to be effective and safe. However, possible advantages and disadvantages of this treatment option should be discussed with the patients before a decision on the kind of therapy is reached.

Digital Mucous Cyst: A Clinical-Surgical Study

Background

It has been suggested digital mucous cysts (DMCs) are associated with osteoarthritis and osteophytes in the elderly, and usually have a communicating pedicle with the joint. Surgical excision is a standard therapy with a high cure rate.

Objective

The purpose of this prospective study is to evaluate the features of DMCs via clinical, radiological and pathological examination and the efficacy of surgical excision of DMCs.

Methods

Between 2010 and 2014, 24 Korean patients were treated with the resection of the cyst and the pedicle. Preoperative X-ray and ultrasonography were performed to detect the presence of the osteophyte and the connection to the joint space. Postoperative patients' satisfaction score was assessed by the visual analogue scale (0~10).

Results

The osteophytes were found in 15.8%. In ultrasonographic findings, there were prominent flow signals between the cyst and the joint space in 13.6%. There were no serious postoperative complications, and recurrences were observed in 16.7%. Mean postoperative satisfaction score was 8.3.

Conclusion

It seems that preoperative X-ray for osteophytes and ultrasonographic study for connection are not always helpful for the treatment of DMCs, and that the surgical excision with a pedicle ligation and electrocoagulation is an effective treatment modality.

[Myxoid pseudocyst: when and how to treat?]

Myxoid pseudocysts (MPCs) are the most frequent pseudotumors of the digit and dermatologists are frequently referred. It is now believed that MPCs occur as a result of a leakage of synovial fluid through a breach in the joint capsule of the distal interphalangeal joint promoted by osteoarthritis. Many treatments have been proposed from simple repeated punctures, injections of steroids or sclerosants, cryosurgery, laser evaporation, infrared coagulation to surgical excision. Surgical procedures depend on the location of MPCs in the nail apparatus. In this review, we will discuss the best approaches to the treatment of MPCs whereas no guidelines are available for their management.

Digital Mucous Cysts

Background:

Digital mucous cyst (DMC) is a common benign condition, but consensus has not been reached regarding its pathogenesis and treatment.

Objective:

This review provides a concise overview of DMCs.

Methods:

The review presents the literature pertaining to the etiology, pathogenesis, classification, clinical features, epidemiology, differential diagnoses, diagnosis, and management of DMCs.

Results:

DMCs have a predilection for middle-aged patients, a good prognosis, and a high recurrence rate. DMCs may occur in one of three locations on the distal digit. They arise owing to a metaplastic or degenerative process. Preexisting osteoarthritis is common and may be an etiologic factor in patients with DMCs. A number of conservative and surgical treatments are available depending on the structures and locations involved.

Conclusion:

Studies with greater sample size and longer follow-up would enrich current knowledge of the benefits, recurrences, and complications for each treatment modality.

Digital superficial angiomyxoma

Superficial angiomyxoma is a rare, distinctive cutaneous soft-tissue neoplasm, which shows a prominent myxoid matrix with numerous blood vessels. This condition usually presents with a nodular lesion on the trunk, head and neck, or the genital region. We describe a case of superficial angiomyxoma, which presented at an unusual digital location while also demonstrating the features of transepidermal elimination, and which mimicked a digital myxoid cyst.