Ganglions of the foot and ankle. A retrospective analysis of 63 procedures

Republication of "Mucous Cyst at the Interphalangeal Joint of the First Toe Caused by Contact Pressure With the Second Toe due to Hallux Valgus: A Case Report"

A 77-year-old woman presented with a mucous cyst on the lateral aspect of the interphalangeal joint of the first toe caused by contact pressure with the second toe from hallux valgus. She complained of discomfort and discharge from the left first toe for approximately 4 months. Physical examination showed the second toe pressing strongly against the first toe due to hallux valgus and discharge from the skin on the lateral aspect of the interphalangeal joint of the first toe. Magnetic resonance imaging showed a cystic lesion at the same level. The patient underwent a modified scarf osteotomy of the first metatarsal for hallux valgus to resolve the contact pressure between the toes-considered the cause of the mucous cyst-and resection of mucous cyst. Forefoot weight bearing was allowed 6 weeks after surgery. As of 1 year after surgery, she has had no recurrence of the cyst. The score on the Japanese Society for Surgery of the Foot hallux metatarsophalangeal-interphalangeal scale improved from 59/100 points to 92/100. This outcome suggests that hallux valgus correction should be considered when a mucous cyst is associated with contact pressure due to a hallux valgus deformity. To the best of our knowledge, there are no previous reports of a mucous cyst caused by contact pressure between the first toe and second toe due to hallux valgus.

Recurrence of intratendinous ganglion due to incomplete excision of satellite lesion in the extensor digitorum brevis tendon: A case report

BACKGROUND

Intratendious ganglions are rare lesions, especially on the foot and ankle. Although several studies have presented the intratendinous ganglion of the foot and ankle, there are only few reported cases, and no cases of recurrence or secondary surgery have been reported.

CASE SUMMARY

We present the case of a 32-year-old man with an intratendinous ganglion of the second extensor digitorum brevis (EDB) tendon that recurred after ganglion excision. Magnetic resonance imaging (MRI) performed before the first surgery was reviewed to analyze the causes of the recurrence. We confirmed that there was a lack of satellite detection. After recurrence, MRI revealed an extra-tendinous lesion, tenosynovitis, and intratendinous ganglion of the second EDB tendon. Since the second EDB tendon can compensate for the extrinsic muscle, en bloc resection was performed alone. In addition, meticulous excision and synovectomy were performed for extra-tendinous lesions and tenosynovitis, respectively. The patient returned to daily life without any functional problems or recurrence.

CONCLUSION

If removal of the affected tendon is not fatal, en bloc resection should first be considered to prevent incomplete excision and intraoperative leakage. When planning surgical excision, it is necessary to evaluate the presence of satellite lesions along the course of the affected tendon.

The management of foot and ankle ganglia: A scoping review

PURPOSE

A ganglion cyst is a benign soft tissue swelling filled with hyaluronic acid and other mucopolysaccharides. Whilst they most commonly present in the wrist region, their occurrence in the foot and ankle is not rare. This scoping review aims to systematically map and summarise current evidence regarding the management of ganglia of the foot and ankle, whilst identifying areas for further research.

METHODS

This scoping review follows the frameworks of Arksey and O'Malley, Levac and Peters. A comprehensive search strategy was used to identify relevant articles, before a two-stage screening process was performed independently by two reviewers.

RESULTS

A total of 2286 unique articles were identified, of which 12 were included in the review. A variety of conservative and surgical treatment strategies are reported, showing good outcomes. An overall pooled recurrence rate of 29.5% was seen across 8 studies. Aspiration alone showed the highest recurrence rate (78.1%), followed by aspiration and steroid injection (62%), steroid injection alone (37.5%) and surgical excision (17.6%). The pooled complication rate across six studies was 21/261 (8.0%), with the most common complication being paraesthesia, reported in 14/261 (5.4%) patients.

CONCLUSIONS

There is a lack of high-quality research currently regarding the treatment of foot and ankle ganglia. Limited evidence suggests that there could potentially be associations between time to treatment, ganglion location and extent of surgical resection and recurrence rate. However, further research is required before any definitive conclusions can be drawn.

Operative Treatment for Ganglion Cyst of Flexor Hallucis Longus Sheath

BACKGROUND

Intractable hallucal ganglion cysts (HGCs) are often a symptomatic and recurrent condition. Its connection with the ankle joint is not well understood. Our aim was to evaluate the relationship between tenosynovitis of the flexor hallucis longus (FHL) tendon at the level of the ankle with formation of an HGC. In addition, we sought to analyze the outcomes of cyst excision combined with ankle capsulorrhaphy.

METHODS

Nineteen patients with HGC who underwent surgical intervention were included between June 2016 and June 2019. Eight had known recurrences. Ankle arthrography and cyst excision were performed on all patients. Clinical evaluations included the American Orthopaedic Foot & Ankle Society (AOFAS) scores, visual analog scale (VAS), and evaluation of postoperative complications. The mean follow-up period was 16.5 ± 8.6 months.

RESULTS

Thirteen of the 19 HGCs (68.4%) had a connection with the FHL tendon sheath. Combined with ankle capsulorrhaphy, there was no recurrence after cyst excision. The VAS score decreased from 2.1 ± 1.5 to 0.4 ± 0.8, and AOFAS score significantly improved from 84.3 ± 8.7 to 97.4 ± 5.2 at final follow-up (P < .001).

CONCLUSIONS

Most of these patients had a connection between the HGC and ankle joint. Ankle arthrography appeared to be useful for diagnosis, and cyst excision combined with ankle capsulorrhaphy was an effective treatment without cyst recurrence.

LEVEL OF EVIDENCE

Level IV, case series.

Metatarsal Periosteal Plantar Ganglion Cyst Associated With Stress Fracture: A Case Report

We encountered a rare case of a periosteal ganglion cyst at the plantar aspect of the metatarsal that induced a stress fracture in a 77-year-old female. The clinical manifestation of the plantar ganglion cyst of the foot was not evident because of its location deep beneath the plantar fascia. A pressure cortical indentation was detected at the metatarsal neck on the initial radiographs. Magnetic resonance imaging showed a stress fracture of the metatarsal with a ganglion cyst. The stress fracture was thought to have resulted from several factors, including structural weakness due to bony absorption from the ganglion cyst, osteoporosis that induced a fragility fracture, and a load-induced fatigue fracture. The fracture completely healed following complete resection of the ganglion cyst with the surrounding periosteum along with medication for osteoporosis. When confirmation of a stress fracture is necessary or when presentation of a stress fracture is atypical, magnetic resonance imaging should be considered to confirm or rule out any other associated pathologic features. Resection of the periosteal ganglion cyst with the surrounding periosteum is important to prevent recurrence.

Mucous Cyst at the Interphalangeal Joint of the First Toe Caused by Contact Pressure With the Second Toe due to Hallux Valgus

A 77-year-old woman presented with a mucous cyst on the lateral aspect of the interphalangeal joint of the first toe caused by contact pressure with the second toe from hallux valgus. She complained of discomfort and discharge from the left first toe for approximately 4 months. Physical examination showed the second toe pressing strongly against the first toe due to hallux valgus and discharge from the skin on the lateral aspect of the interphalangeal joint of the first toe. Magnetic resonance imaging showed a cystic lesion at the same level. The patient underwent a modified scarf osteotomy of the first metatarsal for hallux valgus to resolve the contact pressure between the toes— considered the cause of the mucous cyst—and resection of mucous cyst. Forefoot weight bearing was allowed 6 weeks after surgery. As of 1 year after surgery, she has had no recurrence of the cyst. The score on the Japanese Society for Surgery of the Foot hallux metatarsophalangeal-interphalangeal scale improved from 59/100 points to 92/100. This outcome suggests that hallux valgus correction should be considered when a mucous cyst is associated with contact pressure due to a hallux valgus deformity. To the best of our knowledge, there are no previous reports of a mucous cyst caused by contact pressure between the first toe and second toe due to hallux valgus.

A Case Report on Intratendinous Ganglion Cyst of the Semimembranosus Tendon

Ganglion cysts are benign cystic masses that occur in association with musculoskeletal structures. The aetiology of ganglion cysts is controversial; however, it is generally thought to result from myxoid degeneration of connective tissue associated with joint capsules or tendon sheaths, to which the lesions are usually attached. They may occur in any part of the extremities within muscles, menisci, tendons or bones. Hereby, we present a rare case of intra-tendinous location of a ganglion cyst of the semimembranosus tendon occurring within the tendon substance itself. To date, there have only few cases reports in the literature reviewing intra-tendinous ganglion cysts occurred in the lower limbs.

Origin of Satellite Ganglion Cysts with Effusion in the Flexor Hallucis Longus Tendon Sheath around the Hallux

Background

To describe the clinical and magnetic resonance imaging findings of ganglion cysts with effusion in the flexor hallucis longus tendon sheath around the hallux to evaluate their origin.

Methods

Patients with recurrent or painful ganglion cysts around the hallux with effusion in the flexor hallucis longus tendon sheath who underwent surgical treatment at St. Vincent's Hospital from February 2007 to August 2016 were investigated. Surgical indication was a painful or recurrent mass caused by the cystic lesions. Those without effusion of the flexor hallucis longus tendon sheath were excluded. We assessed the clinical and magnetic resonance imaging findings.

Results

Magnetic resonance imaging findings in all patients showed several ganglion cysts around the hallux and large fluid accumulations within the flexor hallucis longus tendon sheath. Regarding the location, six ganglion cysts were on the dorsomedial aspect, one on the plantar medial aspect, seven on the plantar lateral aspect, and one in the toe pulp. Ten patients showed joint effusions in both the metatarsophalangeal and interphalangeal joints, two in the metatarsophalangeal joints, and three in the interphalangeal joints. There were communication stalks with a tail shape or abutment between ganglion cysts with surrounding joint effusions. Intraoperatively, connections between ganglion cysts, the synovial cyst of the flexor hallucis longus tendon sheath, and surrounding joints were seen.

Conclusions

Synovial fluid accumulation in the metatarsophalangeal or interphalangeal joint supplies the synovial cyst of the flexor hallucis longus tendon sheath and subsequently ganglion cysts in the hallux. In clinical practice, the surgeon should carefully check surrounding joints with tendon sheaths to prevent recurrence of the ganglion cysts around the hallux.

Persistent Symptoms of Ganglion Cysts in the Dorsal Foot

Background

A ganglion is a common benign cystic lesion, containing gelatinous material. Ganglia are most commonly asymptomatic, except for a lump, but symptoms depend on the location. A dorsal foot ganglion is typically painful. On the dorsal foot, the dorsalis pedis artery and the medial branch of the deep peroneal nerve are located under the fascia.

Objective

Five female patients of average age 45.8 ± 20 years (range, 12 to 60 years) with a painful ganglion in the dorsal foot were analyzed.

Results

Average lesion size was 2.94 ± 1.1 cm (range, 1.5 to 4.0 cm) and patients had experienced pain for a median of 2-3 years (range, 6 months to 3 years). Four patients had a single cystic lesion and 1 patient had developed multiple cystic lesions over the time that were associated with hypoesthesia. In 3 cases, symptomatic lesions were located deep beneath the fascia and were resected. In 2 cases, the depth of the non-resected lesions was shallow.

Conclusion

The cause of a painful dorsal foot ganglion can be attributed to its location in the thin subcutaneous tissue over the foot bone, in addition to its proximity to a nearby artery and nerve. Mild symptoms caused by a dorsal foot ganglion seem to be persistent, and the deeper the location, the more likely is the need for resection. To avoid nerve injury, anatomical knowledge is prerequisite to any puncturing procedure or operation performed.

Isolated medial plantar neuropathy caused by a large ganglion cyst diagnosed with MRI: A case report

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Compression neuropathy caused by a ganglion cyst is a rare entity.

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MRI remains an excellent diagnostic modality to evaluate the masses in the foot.

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This is a very rare report of isolated medial plantar neuropathy by a ganglion cyst.

Introduction

Although ganglion cysts are common soft tissue tumors, nerve compression syndrome caused by a ganglion cyst in the lower extremities is very rare. Herein, we report a 57-year-old man who presented with hypoesthesia in the sole of his right foot for 6 months. We believe that reporting this rare case will help clinicians update their knowledge on possible causes of the plantar neuropathy, and avoid diagnostic delay.

Presentation of case

The patient had pain and numbness in the inner right sole, as well as a tingling and dull sensation. Tenderness around the area of abnormal sensation was not evident. Percussion at the abductor tunnel gave a positive Tinel’s sign in the medial plantar nerve. No mass was palpable in the right foot. Based on the electrophysiological findings, we diagnosed medial plantar nerve entrapment in the right foot. Magnetic resonance imaging (MRI) was conducted to identify a 5.5-cm long elongated cystic lesion as the cause of entrapment. The patient underwent surgical removal of the cystic mass, with histologic examination confirming the diagnosis of a large ganglion cyst.

Discussion

The feasibility of nerve conduction studies and electromyography for detection of nerve entrapment is still controversial. MRI is considered the best diagnostic modality, if biopsy is not feasible.

Conclusion

We suggest that foot imaging and electrophysiological studies should be considered for patients with isolated median plantar neuropathy to exclude the presence of space-occupying lesions, especially when conservative treatment is not effective.

Intratendinous Ganglion Cyst of the Semitendinosus Tendon: First Reported Case and Literature Review

Introduction:

Ganglion cysts are commonly seen in wrist joints and knee joint, but intra-tendinous ganglion cysts are extremely rare. We report the first case of intratendinous ganglion cyst of semi-tendinous tendon.

Case Report:

A 4-year-old boy presented with painless soft tissue swelling over knee with no history of recent trauma. Radiograph was normal and USG showed a well-defined hypoechoic cystic lesion. Patient was taken for surgery and the lesion was removed. Lesion came out to be a ganglion cyst originating from the semitendinosus tendon. Post-operative USG was done to confirm complete removal of the ganglion.

Conclusion:

Intra-articular ganglion cysts are common, and we find it regularly in our daily practice. However, we should be aware of the occurrence of intratendinous ganglion cysts also which on examination may look like a lipoma. Thus for all cysts around the tendons, an USG is must. Also repeat USG should be done to rule out incomplete excision and recurrence.

Arthroscopic ganglionectomy of the foot and ankle

PURPOSE

To study the efficacy of arthroscopic ganglionectomy in the management of ganglia of the foot and ankle.

METHODS

From 2006 to 2010, arthroscopic ganglionectomy was performed for 89 ganglia in the foot and ankle of 88 patients. Clinical and intra-operative details were reviewed retrospectively.

RESULT

Ganglion stalk was identified in 6 % of the cases. The overall rate of presence of pathology was 26 %. The overall rate of recurrence or residual lesion was 12 % with high recurrent rate for extensor tendon ganglia and toe pulp ganglia.

CONCLUSIONS

Arthroscopic ganglionectomy of the foot and ankle ganglion by either internal drainage or complete resection is a feasible approach. Good results can be achieved in case of adequate internal drainage of the ganglion to the joints or fibrous tendon sheath.

Late-onset eccrine angiomatous hamartoma associated with a ganglion cyst on the sole of the foot

Eccrine angiomatous hamartoma (EAH) is a benign, uncommon, combined vascular and eccrine malformation. Most cases of this disorder have been single or multiple nodules or plaques that appear red, yellow, blue, violaceous, or skin colored. EAH may be congenital or appear later in childhood; it rarely arises during puberty or adulthood. A 52-year-old female patient visited our department for tender subcutaneous cystic tumor on the right sole with a one month history. Histopathologic examination confirmed EAH. During excisional biopsy procedure, mucinous discharges were observed which were histopathologically diagnosed as ganglion.

Differential diagnosis of tendon tumors: xanthomas caused by hyperlipidemia in children

Tumors of tendons and tendon sheaths causing pain and mechanical problems are often because of overstraining, and in most cases the resulting common ganglia can be easily removed. We describe an 8-year-old child in whom the tumor's origin had remained undetected and was related to a homozygous familial hypercholesterolemia, which can be associated with multiple xanthomas of the skin and tendons. After a thorough investigation and therapy, a program to prevent arteriosclerosis and myocardial infarct in this patient was initiated.

Operative treatment for ganglion cysts of the foot and ankle

The authors analyzed the clinical results of surgical excision for symptomatic or recurrent ganglion cysts of the foot and ankle, and tried to elucidate the prognostic factors. Fifty-three cases of ganglions in the foot and ankle were followed for more than 24 months after excision. The mean duration of follow-up was 3.7 years. As a preceding treatment, 17 cases received a mean of 1.3 aspirations, and 16 cases recurred after a mean of 1.7 operations. The cyst was most common in the dorsum of the foot and ankle, where 35 cases were found. Thirty cases originated from the tendon sheath, 19 cases from the joint, and 4 cases from others. Preoperative mean AOFAS foot scores were low in the cysts associated with the tarsal tunnel syndrome, and in the cysts of the plantar aspect of the first toe. Postoperative mean AOFAS foot scores were significantly increased in the preceding 2 groups. There were 3 (5.7%) cases of recurrence, all of which originated from the tendon sheath. In the case of ganglion cysts originating from the tendon sheath, careful attention should be paid to locate satellite masses to avoid recurrence.

Hourglass ganglion cyst of the foot: a case report

Ganglion cyst, a common benign soft tissue lesion, is not uncommon in the foot, with the most common location being the dorsal aspect. We describe a case where the ganglion had an unusual radiographic appearance in the form of an hourglass, extending from dorsum into the planter compartments of the foot. A 74-year-old woman presented with longstanding pain in her midfoot. Clinical examination revealed a soft tissue swelling with minimal tenderness in the first webspace of the right foot. The initial radiograph was normal. Ultrasound examination revealed a cystic swelling filled with hemorrhagic fluid with an hourglass appearance. Magnetic resonance imaging examination confirmed the cystic nature of the swelling and depicted the hourglass-shaped ganglion extending from the dorsal to plantar aspect of foot. Complete excision was possible with a combined dorsal and plantar approach. Ganglion cyst can present in the foot in locations other than the dorsum and could have extensions into the plantar aspect. This variation needs to be considered when planning surgical excision, which could be aided by preoperative magnetic resonance imaging.

Intratendinous ganglion cyst of the semimembranosus tendon

Intratendinous ganglion cyst is a very rare lesion with an unknown aetiology that originates within the tendon. We encountered a case of 43-year-old woman who complained of a palpable, non-tender mass in the thigh with increasing swelling. An intratendinous ganglion cyst in the semimembranosus tendon of the lower extremity was diagnosed and located by ultrasound and MRI. Nine months after a surgical excision, there were recurrent ganglion cysts along the semimembranosus tendon. We describe this case with a review of the relevant literature.

Hemorrhagic ganglion of the tibialis anterior tendon: report of an unusual variant

While clinicians have encountered heme-laden ganglion cysts in the past, to our knowledge the condition has never been described in the literature as a distinct pathological entity, namely, the hemorrhagic ganglion. Because hemorrhage may alter the appearance of an aspirate obtained from a ganglion cyst, and hemosiderin deposition within a ganglion cyst may alter the signal characteristics observed on a magnetic resonance image, such that both of these diagnostic methods may suggest the presence of a solid mass tumor rather than a ganglion cyst, it is important for clinicians and surgeons to be aware of the possibility of the presence of a hemorrhagic ganglion cyst. In this report, we present a case wherein a hemorrhagic ganglion cyst of the tibialis anterior tendon was identified and excised.

Tumours and tumour-like lesions in the foot and ankle

We present a spectrum of tumour and tumour-like lesions in the foot and ankle in which a specific diagnosis can be made or strongly suggested on the basis of location, imaging features and the relevant clinical findings. Characteristic imaging appearances are emphasized.

A recurrent foot ganglion managed with extensor digitorum brevis muscle flap coverage

The case of a 42-year-old woman with a persistent ganglion cyst of the dorsolateral aspect of the foot is presented. After multiple aspirations and 4 attempts at excision, the lesion degenerated into a painful, persistently draining wound with communication to the calcaneocuboid joint. The case was treated with dissection of the lesion to the joint, excision, and coverage of the defect with an extensor digitorum brevis muscle flap. The rationale for this surgical approach and the literature regarding recurrent ganglia are discussed.