Intra-osseous ganglion. Report of four cases and review of the literature

Diagnosis and Treatment of Intraosseous Ganglion in the Ankle Region

OBJECTIVE

To investigate the diagnosis and treatment of intraosseous ganglion cyst in the ankle region.

METHODS

A retrospective analysis was performed on the diagnosis and treatment of 18 patients with intraosseous ganglion in the ankle region from January 2005 to March 2016. There were 11 males and 7 females, with an average age of 40.4 years (22-74 years). Thirteen of these had mild intermittent localized pain in the ankle and five were asymptomatic and fortuitously found on images. According to the location of the intraosseous ganglion cyst, nine were located in the distal end of tibia, seven were in the distal end of the fibula, and two were in the talus. After curettage of intraosseous ganglion, 15 cases were filled with autogenous iliac bone and 3 cases with artificial bone.

RESULTS

Fifteen cases were diagnosed with radiographs and CT scans, two cases with MR images, and one case was confirmed by postoperative pathology. The cyst contents were jelly-like material with sclerotic bone margins. The mean size of the intraosseous ganglion cyst was 1.5 cm × 1.5 cm × 1 cm. Hematoxylin and eosin (H&E) staining of the tissue showed fibrous tissue, collagenous fiber, mucoid, and a few fibroblasts. Eighteen cases were followed up for 11 months to 10 years, with an average of 5.4 years. No recurrence was found. Sixteen patients were asymptomatic after surgery. Two cases of ankle pain occurred at 1 year and 6 months postoperatively, respectively. According to the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, the mean AOFAS ankle-hindfoot score improved from 78.2 ± 13.7 points preoperatively to 97.3 ± 4.5 points at the final follow-up.

CONCLUSION

For the intraosseous ganglion cyst in the ankle region, whether there are clinical symptoms or not, the cyst should be curettaged and the cavity should be filled with bone graft. The operation result is satisfactory.

Giant intraosseous ganglion of the fibula: multimodality imaging

Intraosseous ganglia around the knee are most commonly located in the proximal tibia and limited to the epiphyseal-metaphyseal region. We report the case of a giant intraosseous ganglion of the fibula. MRI demonstrated the fluid avascular content of the lesion. CT arthrography of the knee demonstrated partial opacification of the lesion through a cortical bone defect. The lesion was treated with curettage and bone grafting. Anatomopathological examination confirmed the medical imaging diagnosis of intraosseous ganglion. This case highlights the value of joint opacification with CT arthrography to demonstrate the communication between the articular cavity and the ganglion.

Intraosseous Ganglia: a series of 17 treated cases

Background. Intraosseous ganglion is a cystic lesion that contains gelatinous material, most often occurs in middle-aged patients, and is regarded as similar to soft-tissue ganglion. The etiology is unknown, but association with degenerative joint disease has been considered. Materials and Methods. At a single institute, 17 patients (8 men, 9 women) with a mean age of 48.9 years (22–72 years) were surgically treated for an intraosseous ganglion. The lesions were located in 9 long bones (5 tibiae, 2 humeri, 1 ulna, and 1 femur); 4 flat bones (2 scapulae, 2 ilia); and 4 small bones (2 scaphoid, 1 metacarpal bone, and 1 talus). The diagnosis was confirmed based both on the gross intraoperative finding of intralesional gelatinous material and on histopathology. Results. All lesions occurred at the epiphysis or near the joint. The plain radiographs showed a lesion with marginal osteosclerosis. The average lesion size was 22.4 mm (range 6–40 mm). Among the 17 patients, 2 (12%) had osteoarthritis, 3 (18%) had pathological fracture, and 4 (24%) had extraskeletal extension. Discussion and Conclusion. The periosteum and cortex of bone represent physical barriers. Therefore, it seems much more likely that primary bone lesions will spread to the soft tissues. Intraosseous ganglion does not appear to be associated with either soft-tissue ganglion or with osteoarthritis. This clinical information and the appearance on plain radiographs, particularly the marginal osteosclerosis, are of differential diagnostic importance.

Arthroscopically assisted removal of intraosseous ganglion cysts of the distal tibia

Intraosseous ganglia of the distal tibia are rare. We evaluated the feasibility of surgically treating these lesions with an arthroscopically assisted technique. Five patients with symptomatic distal tibial ganglia underwent surgical curettage and excision with this technique. All patients underwent débridement of the chondral lesion and hypertrophied synovial lining when present, probing of the portal to the ganglion, and subsequently thorough curettage with bone grafting performed through a cortical window made from a separate small incision. Biopsy confirmed the diagnosis in all patients. All patients had eventual relief of symptoms with good integration of bone graft at final followup. There were no recurrences at a minimum followup of 19 months (mean, 38.6 months; range, 19-69 months). Mean time for return to full function was 15.4 weeks (range, 8-17 weeks). There were no intraoperative or postoperative complications. The mean American Orthopaedic Foot and Ankle Society scores increased from 73 points (range, 67-77 points) preoperatively to 94 points (range, 90-100 points) postoperatively. Arthroscopically assisted surgical treatment of ganglia of the distal tibia in the appropriate patient is a reasonably simple technique that relieves symptoms and helps the patient to regain normal gait and full function with no recurrence (in our small series).

LEVEL OF EVIDENCE

Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Solitary epiphyseal enchondroma of the proximal femur in a 23-month-old girl

A 23-month-old girl was referred to us because of a right leg limp for 10 days that had not improved despite anti-inflammatory treatment and that did not show signs of infection. Upon examination, gait was in abduction and external rotation of the hip. Plain radiographs showed a solitary lucent lesion of the posteroinferior two thirds of the epiphysis that was hyperintense on T2-weighted magnetic resonance scanning images. We approached the proximal femoral epiphysis using the "trapdoor" technique and excised the lesion by curettage and iliac crest graft. Histologically, the lesion was diagnosed as an enchondroma. We discuss the main causes of lucent epiphyseal lesions in children. Finally, we review the literature on previous reports of patients with solitary epiphyseal enchondromas.

STUDY TYPE

Case report.

MR imaging of the knee: incidental osseous lesions

The knee joint remains the articulation most frequently assessed by MR imaging, and osseous tumor and tumor-like lesions are not uncommon incidental imaging findings. This article reviews the most commonly encountered incidental lesions, emphasizing the characteristic MR imaging features. It is intended not as a complete review of the imaging findings associated with these lesions but as a summary, highlighting the MR imaging features that are most useful in suggesting a specific diagnosis. The authors organize incidental lesions into the following broad categories: cartilaginous, fibro-osseous, and degenerative. They do not address those lesions that are typically symptomatic and, as a result, likely to be directly related to the patients' clinical presentation and subsequent imaging.

Arthroscopic debridement and grafting of an intraosseous talar ganglion

We report the case of a 41-year-old man with right ankle pain and swelling who had an intraosseous talar ganglion in the medial part of talar dome. A surgical procedure was performed using the 3-portal arthroscopic approach. The softened chondral surface was removed and the content of the cyst was discharged arthroscopically. The sclerotic rim was abraded until the bleeding spongious layer was seen. A grafting procedure was also performed arthroscopically. A trocar was introduced into the defect from the superomedial portal. Autografts were impacted using a cylindrical rod through the trocar into the defect. The clinical and radiologic results at the 1-year follow-up were satisfactory. We encountered no complications postoperatively. We conclude that arthroscopic debridement and grafting of an intraosseous ganglion adjacent to the articular surface may be a better option compared with open surgery.

Anterior cruciate ligament ganglia and mucoid degeneration: coexistence and clinical correlation

OBJECTIVE

The purpose of our study was to describe the MR appearance and coexistence of anterior cruciate ligament ganglia with mucoid degeneration and to address the clinical significance of these entities.

MATERIALS AND METHODS

A database search of 4221 knee MRI examinations over 2 years revealed 90 examinations with reported anterior cruciate ligament ganglion or mucoid degeneration. Imaging criteria for ligament ganglion included fluid signal in the ligament disproportionate to joint fluid showing mass effect on intact ligament bundles. The size, location, complexity, and degree of lobulation of ganglia were recorded. Criteria for mucoid degeneration included ligament bundles poorly seen on T1-weighted and proton density-weighted images but with both bundles seen as intact on T2-weighted images. Intraosseous cysts at the ligament attachments and presence of joint effusion were noted. Clinical assessment of ligament instability was recorded when available.

RESULTS

Of 74 examinations that met imaging criteria, 56 (76%) had discrete intraligamentous ganglia, 18 (24%) had mucoid degeneration, and 26 (35%) had features of both. Ganglia were located in the proximal ligament in 16 examinations (22%) and the distal ligament in 10 (14%) and involved the entire ligament in 30 (40%). Ganglia ranged in maximum diameter from 20 to 73 mm (mean, 31 mm). Complexity of ganglia was mild (41%), moderate (39.2%), or marked (19.8%). Intraosseous cysts were noted proximally in 48 examinations (65%) and distally in 20 (27%). Of 52 patients with accessible records, 48 had no clinical evidence of instability. Twelve patients who underwent arthroscopy had an intact anterior cruciate ligament at that time.

CONCLUSION

Anterior cruciate ligament ganglia and mucoid degeneration commonly coexist on MRI and are typically not associated with ligament instability.

Cysts, geodes, and erosions

Subchondral cystic lesions are common features that are associated with many arthropathies and synovial-based processes. Although not comprehensive in scope, this article correlated the pathophysiology and imaging features of several of these disorders to better understand the associated subchondral lucencies. The imaging features of these subchondral cystic lesions were described in each process, and, in some cases, demonstrated overlapping features. By becoming familiar with the disease processes and recognizing the imaging appearances and associated clinical findings, the radiologist will be better able to differentiate these benign entities from more aggressive processes, such as tumor. Subchondral cystic lesions are common features that are associated with many arthropathies and synovial-based processes. Although not comprehensive in scope, this article correlated the pathophysiology and imaging features of several of these disorders to better understand the associated subchondral lucencies. The imaging features of these subchondral cystic lesions were described in each process, and, in some cases, demonstrated overlapping features. By becoming familiar with the disease processes and recognizing the imaging appearances and associated clinical findings, the radiologist will be better able to differentiate these benign entities from more aggressive processes, such as tumor.

Massive intraosseous ganglion of the talus: reconstruction of the articular surface of the ankle joint

We report on the outcome after autologous chondrocyte and spongiosal bone transplantation in a case of a massive intraosseous ganglion of the talus in a young patient. A 24-year-old man suffered from decreased ankle joint motion, recurrent swelling, and pain. Diagnostic evaluation by plain radiographs, computed tomography, and magnetic resonance imaging revealed cystic lesions in the head and the body of the talus with additional involvement of the cartilage surface. Operative treatment consisted primarily of an initial diagnostic arthroscopy, which established grade VI articular damage according to the arthroscopic classification of Bauer and Jackson. Pathological examination of intralesional biopsy tissue revealed the existence of an intraosseous ganglion. Additionally, healthy cartilage biopsy specimens were obtained and sent for chondrocyte extraction and cultivation with 60 mL of autologous serum. To retain the function of the ankle joint and to minimize the number of necessary operative interventions, 3 weeks after the initial arthroscopic operation, we performed a simultaneous curettage of the cystic lesion followed by autologous spongiosal bone and cultivated chondrocytes transplantation of the talus. Continuous passive motion was applied postoperatively and full weight bearing was allowed after 8 weeks. There were no complications. The clinical result after 18 months was excellent, with a fully functional, pain-free, and weight-bearing ankle joint. The postoperative evaluation score of Finsen (modified Weber score) of 2/6 = 0.3 showed an improvement comparison with the preoperative value of of 21/6 = 3.5 (0 = normal, 4 = pathologic). We encountered no complications postoperatively. Clinical success was achieved by this method of treatment on a patient too young to be treated through arthrodesis.

Intraosseous ganglion cysts of the ankle: a report of three cases with long-term follow-up

Three cases of intraosseous ganglion cysts of the ankle are presented with an average follow-up of 68 months (range, 48-78 months). Review of the literature revealed 251 cases of intraosseous ganglion cysts, with 75 located in the ankle and a recurrence rate of 6.1%. In the three cases presented, a satisfactory long-term result was obtained with bone graft and curettage in two cases and currettage alone in one case. No recurrences or complications occurred.

Magnetic resonance imaging of the wrist

MR imaging of the wrist has the unique capability of simultaneously demonstrating bone and soft tissue structures. Its exquisite sensitivity for detecting bone marrow edema makes it and ideal screening tool for diagnosing radiographically occult osseous injuries and areas of AVN. This, together with its ability to provide a comprehensive, non-invasive assessment of the ligaments, tendons, nerves, and components of the TFC make MRI a very powerful tool for evaluating patients with wrist pain of uncertain etiology. Its exact role in the work-up of these patients has not been entirely established, but with further advances in technology and the radiologist's understanding of wrist anatomy and pathology, MRI is assuming a more central role in this clinical setting.

Synovial cysts and ganglia: the value of magnetic resonance imaging

Synovial and ganglion cysts commonly present in close proximity to joints and skeletal structures in rheumatic disorders. Familiarity with the presentation of these soft tissue masses can facilitate timely diagnosis and effective management, thus avoiding costly and potentially high-risk procedures to patients. Management usually consists of local, nonsurgical approaches. A patient with chronic joint deformities and clinical features primarily consistent with mixed connective tissue disease is described. Multiple localized masses developed at her right elbow and were identified on T2-weighted magnetic resonance imaging as multiloculated cysts that dissected from the elbow joint. The cysts were treated successfully by needle aspiration and intraarticular corticosteroid injection. The clinical associations, diagnosis, treatment, and management of synovial cysts and ganglions are reviewed.