Arthroscopic excision of the ganglion in the posterior septum by posterior trans-septal portal: report of two cases

We report two cases of ganglion cysts in the posterior septum of the knee joint, one as parameniscal cyst from the posterior horn of the lateral meniscus extending to posterior septum, and the other as a cyst located in the posterior septum adjacent to the posterior cruciate ligament, which were both arthroscopically excised expediently by posterior trans-septal portal. The posterior compartment of the knee is not readily accessible by ordinary arthroscopic portals, and therefore has been considered as 'blind spot' conventionally. The posterior trans-septal portal is useful for assorted diagnostic or manipulative procedures in the posterior compartment of the knee.

[Symptomatic ganglions in the knee joint. Report of three cases and literature review]

BACKGROUND

The cystic lesions seen around the knee are usually meniscal or popliteal cysts. Cysts inside the articular cavity of the knee are rare and they are usually detected as incidental MRI findings. The ganglions originating in the cruciate ligaments or the infrapatellar fat have rarely been reported. We are reporting the cases of three intraarticular ganglions. The clinical diagnosis was made with magnetic resonance imaging. All patients were treated With arthroscopic surgery using the synovial shaver to remove the tissue. The three patients were reported as asymptomatic during the follow-up, with full range of motion.

CONCLUSIONS

The literature review shows that the origin of ganglions is controversial. The three reported cases show that this is a pathology that should be suspected, as it is difficult to diagnose. MRI is essential to make the diagnosis and the arthroscopic treatment of intraarticular ganglions is effective.

Sciatic cross-over in patients with peroneal and tibial intraneural ganglia confirmed by knee MR arthrography

BACKGROUND

A predictable mechanism and stereotypic patterns of peroneal intraneural ganglia are being defined based on careful analysis of MRIs. Peroneal and tibial intraneural ganglia extending from the superior tibiofibular joint which extend to the level of the sciatic nerve have been observed leading to the hypothesis that sciatic cross-over could exist. Such a cross-over phenomenon would allow intraneural cyst from the peroneal nerve by means of its shared epineurial sheath within the sciatic nerve to cross over to involve the tibial nerve, or vice versa from a tibial intraneural cyst to the peroneal nerve.

METHOD AND FINDINGS

One patient with a peroneal intraneural ganglion and another with a tibial intraneural ganglion each underwent a knee MR arthrogram. These studies were not only definitive in demonstrating the communication of the cyst to the superior tibiofibular joint connection but also in confirming sciatic cross-over. Contrast injected into the knee could be demonstrated tracking to the superior tibiofibular joint and then proximally into the common peroneal or tibial nerve respectively, crossing over at the sciatic nerve, and then descending down the tibial and peroneal nerves. The arthrographic findings mirrored MR images upon their retrospective review.

CONCLUSIONS

This study provides direct in vivo proof of the nature of sciatic cross-over theorized by critical review of MRIs and/or experimental dye injections done in cadavers. This study is important in clarifying the potential paths of propagation of intraneural cysts at points of major bifurcation.

Compression of the deep branch of the ulnar nerve in Guyon's canal by a ganglion: two cases

INTRODUCTION

Ulnar nerve compression at the wrist can be caused by a variety of intrinsic and extrinsic factors. Isolated compression of only the deep branch of ulnar nerve by a ganglion is very uncommon. Ultrasound examination can clearly show the cystic lesion compressing the nerves.

MATERIALS AND METHODS

We present two cases of compression of deep branch of ulnar nerve by a ganglion in the Guyon's canal. Two male patients presented with history of progressive weakness and paraesthesia in the medial 1(1/2) digits of the non-dominant hand. Interestingly, both the patients noticed sudden onset and rapid progress of the symptoms and signs. Clinical examination revealed typical symptoms of ulnar nerve (deep branch) palsy. Nerve conduction studies showed severe denervation of the deep branch of the ulnar nerves in both the patients and ultrasound confirmed the diagnosis. Surgical decompression led to complete recovery.

RESULTS AND DISCUSSION

Whilst compression by a ganglion in the Guyon's canal is rare but well recognized, a feature of both of our cases was the rapid progression and severe nature of the compressive symptoms and signs. This is in contrast to the more typical features of compressive neuropathy and should alert the clinician to the possible underlying cause of compression. Early decompression has the potential to promote a complete recovery.

Intraosseous ganglion of the talus treated with the talonavicular joint approach without exposing the ankle joint

Intraosseous ganglion, which is generally seen in metaphyseal-epiphyseal regions of long bones, is not a rare disorder. It is extremely rare in the talus, however. Differential diagnosis of a cystic talar lesion should include enchondroma, chondroblastoma, giant cell tumor, and unicameral bone cyst. This article presents a case of intraosseous ganglion of the talus in a 38-year-old woman treated with a new surgical approach and technique. The patient had mild ankle pain at the arc of motion in her right ankle that increased with activity. Radiographs and magnetic resonance images showed a cystic lesion in the medial side of the talar dome. It was treated by curettage and autocorticocancellous bone grafting through an opening in the talonavicular joint without disturbing the intact talar dome cartilage. One month after the operation, the patient had an excellent clinical outcome. This approach and technique can be used to treat other lesions of the talus that do not involve the joint space.

Infrapatellar ganglion that developed from infrapatellar fat and had minimal intraarticular extension

Ganglia of the knee joint are rare and are mostly an incidental finding during arthroscopy or MRI examinations. Usually their origin is intraarticular, arising from the menisci or ACL or PCL. Ganglia arising from the infrapatellar fat pad are rare and only few are mentioned in the literature. We report a case of infrapattellar ganglion in a 41-year-old female, which developed from the infrapattellar fad pad and with minimal intraarticular extension.

Suprascapular nerve neuropathy secondary to spinoglenoid notch ganglion cyst: case reports and review of literature

INTRODUCTION

Suprascapular nerve neuropathy secondary to ganglion cyst impingement has increasingly been found to be a cause of shoulder pain.

CLINICAL PICTURE

We present 2 patients who complained of dull, poorly localised shoulder pain, which worsened with overhead activities. Magnetic resonance imaging showed ganglion cysts in the spinoglenoid notch.

TREATMENT

Both patients failed conservative management with physiotherapy and underwent shoulder arthroscopy. One patient underwent arthroscopic decompression of the cyst and the other had open excision of the cyst.

OUTCOME

Both patients experienced resolution of symptoms within 6 months of surgery.

CONCLUSION

With appropriate treatment, suprascapular nerve neuropathy secondary to ganglion cyst impingement is a treatable condition with potentially good results.

Intraligamentous ganglion cyst of the anterior cruciate ligament (about a case)

UNKNO WLOGEMENT: Ganglion cysts have been reported in all joints, with varying frequency in location. A few cases have been described concerning ganglia of the anterior cruciate ligament (ACL) particularly intraligamentous cysts.

AIM

The aim of the study is to report specific particularities of intraligamentous ganglion cyst of the ACL.

CASE

We report a new case of intraligamentous ganglion cyst of the anterior cruciate ligament treated successfully with arthroscopic aspiration followed by partial excision of the cyst wall after MRI examination. The MR findings, clinical features and arthroscopic findings were evaluated comparatively. Diagnosis was confirmed by means of histological study after arthroscopic excision. The cyst was fluid-filled, with low T1-weighted signal intensity and high T2-weighted signal intensity. Pain was the most frequent clinical sign without any history of trauma. Postarthroscopy outcome was painless. Histologic diagnosis corresponded to ganglion cyst.

CONCLUSION

An intraligamentous ganglion cyst of the ACL is extremely rare and suggests some diagnostic and therapeutic particularities.

[Occult scapholunate ganglion in patients with dorsoradial wrist pain]

OBJECTIVES

The aim of this study was to assess the results of surgical treatment of patients who had complaints of chronic wrist pain and were diagnosed as having an occult dorsal scapholunate interosseous ganglion, despite the presence of a normal x-ray and absence of trauma.

METHODS

Thirteen wrists of 12 patients (2 males, 10 females; mean age 28 years; range 21 to 41 years) were treated with surgical excision for ganglia originating from the dorsal scapholunate interosseous ligament. Involvement was on the right side in six patients, and on the left in five patients, with one patient having bilateral involvement. None of the patients had a history of trauma, except two with a history of fall. All the patients had complaints of wrist pain that occurred during work and subsided at rest. The mean duration of wrist pain was 23 months (range 6 to 60 months). All the patients received conservative treatment previously with wrist splints and non-steroidal anti-inflammatory drugs. Finger extension test was positive and magnetic resonance imaging of the wrist showed ganglion in all the patients. Functional results were evaluated by the Mayo Clinic wrist pain assessment scores after a mean follow-up of 35 months (range 25 to 49 months).

RESULTS

Complaints of wrist pain improved dramatically in all the patients. Scores of the Mayo Clinic wrist pain assessment were excellent in seven patients (53.9%), good in five patients (38.5%), and moderate in one patient (7.7%). All the patients returned to work without any limitation of wrist movements. No recurrences were seen during the follow-up period.

CONCLUSION

Occult ganglia originating from the scapholunate ligament should be remembered in patients with dorsal scapholunate joint tenderness and pain unresponsive to conservative treatment and with a positive finger extension test.

Acute Hemorrhagic Cyst of the Ligamentum Flavum

STUDY DESIGN

A case report and clinical discussion.

OBJECTIVE

To describe a rare complication of a cyst of the ligamentum flavum, which bled spontaneously, provoking an acute lower limb monoparesis and lumbar sciatic pain. SUMMARY OF BACKGROUNDS DATA: Cysts of the ligamentum flavum have been rarely reported. Intraspinal degenerative cysts described in literature are usually juxta-articular (synovial and ganglion) cysts and have a similar radiologic appearance. They are preferentially located in the lumbar spine, while the cervical localization is unusual. Hemorrhage into the cyst is an uncommon complication and an extremely rare cause of nerve root compression.

METHODS

A 59-year-old woman presented with sudden severe radicular lumbar deficit and pain secondary to acute hemorrhage into a ligamentum flavum cyst. Magnetic resonance imaging showed at L3-L4 level a lobulated slightly hyperintense mass with a ventral area of marked hyperintensity in T1 images, hypointense on T2 images. Signal within the lesion was suggestive of intralesional hemorrhage.

RESULTS

Complete resection of the lesion was performed, resulting in immediate recovery. The cyst was quite rounded, brownish, and contained rest of both partially fresh and coagulated hematoma. Histologic examination revealed myxoid degeneration of the ligamentum flavum with an hemorrage in the cystic cavity without a synovial layer.

CONCLUSIONS

This report identifies a rare case of radicular lumbar deficit and pain secondary to acute hemorrhage into a ligamentum flavum cyst. The pathogenesis and clinicopathologic characteristics of this lesion are described.

Glenohumeral joint ganglion cyst and other rare cysts of the axilla

Although ganglion cysts have been reported to arise from almost any joint, those arising from the glenohumeral joint producing an axillary mass are extremely rare. We report what we believe to be the eighth such case and describe its management. The unusual differential diagnosis and aids to diagnosis of axillary cysts are reviewed. Specific issues regarding axillary space ganglions are emphasized.

[Fine needle aspiration cytology of myxoid lesions of soft tissues: a study of 24 cases]

OBJECTIVE

To summarize the diagnostic features of fine needle aspiration cytology (FNAC) of myxoid lesions in soft tissue, and to define the cytological criteria for differentiating benign lesions from sarcomas and between various myxoid lesions.

METHODS

FNAC data of 24 soft tissue myxoid lesions (14 benign lesions, 10 malignant lesions) from 1993 to 2006 from Kiang Wu Hospital, Macau were reviewed in correlation with the clinical course or the results of biopsy.

RESULTS

Ganglion, myxoma, and myxoid nodular fasciitis were the most common benign myxoid lesions of the soft tissues, all of which had low cellularity and lack of marked cellular atypia in smears in common. Ganglion was characterized by the disappearance of or the gradual minimization of the nodule after aspiration and the lack of blood vessel in smears. Myxoid nodular fasciitis was characterized by a pleomorphic pattern of proliferative cells and the presence of ganglion cell-like cells. Myxoid liposarcoma, extraskeletal myxoid chondrosarcoma and myxofibrosarcoma were the most common myxoid sarcomas. Cytologically, they had high cellularity and various degrees of cellular atypia. Myxoid liposarcoma exhibited branching chicken-wire like capillary vessels and/or lipoblasts; myxofibrosarcoma were prominent in both pleomorphic and atypia of the cells. The data revealed that the diagnostic accuracy of FNAC was nearly 100% in differentiating benign and malignant myxoid lesions of the soft tissues. The coordinate rate to the histopathology diagnosis of the common myxoid lesions of the soft tissues was above 75% (benign 71.4% and malignancy 80% respectively).

CONCLUSIONS

FNAC is an effective method in diagnosing myxoid lesions of soft tissue, in correlation with the clinical data and the accessory examinations. FNAC can provide an objective basis for the treatment of myxoid lesions and prevention of unnecessary surgical operations.

Peroneal intraneural ganglia. Part I. Techniques for successful diagnosis and treatment

The common peroneal nerve is the peripheral nerve most often affected by intraneural ganglion cysts. Although the pathogenesis of these cysts has been the subject of controversy in the literature, it is becoming increasingly evident that they are of articular origin. Recent recognition of this fact has proven to be significant in reducing recurrences and improving treatment outcomes for patients. The authors present a stepwise method of assessing and treating peroneal intraneural ganglion cysts.

Peroneal intraneural ganglia. Part II. Lessons learned and pitfalls to avoid for successful diagnosis and treatment

The authors describe common modes of failure in the diagnosis and treatment of patients with peroneal intraneural ganglia. Illustrated examples correlate the modes of failure and the diagnostic or surgical errors. Understanding these pitfalls reinforces the rationale behind current treatment recommendations as outlined in the companion article. Avoiding these pitfalls will ultimately improve outcomes.

Flap advancement coverage after excision of large mucous cysts

Mucous cysts are common problems seen by hand surgeons. Surgical excision of symptomatic cysts is the most commonly accepted treatment. Removal of large mucous cysts often requires simultaneous flap coverage or skin grafting for the resulting defect. We present the use of a dorsal advancement flap to permit excellent skin coverage after cyst excision with a tension-free closure.

Pretibial ganglion-like cyst formation after anterior cruciate ligament reconstruction: a consequence of the incomplete bony integration of the graft?

We report a case of subcutaneous pretibial ganglion, with direct communication to the tibial tunnel after an autologous reconstruction of the anterior cruciate ligament with hamstring tendons. The tibial graft fixation was with a 9 mm poly-L-lactide interference screw 5 years earlier. The screw had undergone complete resorption at the time the cyst occurred. No joint inflammatory reaction or graft insufficiency was detected. The patient underwent cyst excision and curettage of the tibial tunnel with full recovery. This complication seems to be the consequence of a direct communication between the joint and the pretibial subcutaneous tissue through a fibrous tibial tunnel and would have occurred, as there is no full osteointegration of the graft due to the resorption of the bioabsorbable interference screw.

The SLAP lesion as a reason for glenolabral cysts: a report of five cases and review of the literature

INTRODUCTION

Cysts in the spinoglenoidal or supraglenoidal incisura can be a cause of compression of the suprascapular nerve. There is agglomerated appearance of these cysts in combination with SLAP lesions. Hypothesis is SLAP lesions can lead to cysts in this region and should be repaired.

MATERIAL AND METHODS

MRI of five patients (all male, four 30-40 years, one 75 years) showed cysts in the supralabral region. All were in combination with lesions of the superior glenoidal labrum (Type II or more).

RESULTS

In two cases, in addition to cyst resection, the SLAP lesion was also repaired and symptoms disappeared completely and no recurrent cyst was detected in postoperative MRI. Two patients without SLAP repair showed recurrent cystic formation in MRI with similar complaints compared to their preoperative status. One patient (75 years) was treated primarily by puncture and afterwards with open resection of the cyst. His outcome was good in terms of activities of daily living without major pain.

CONCLUSIONS

Our results are based on the assumption that cysts in the region of the spinoglenoidal/supraglenoidal incisura can originate from SLAP lesions. If a patient is suspected of having cysts in this region, the question of a SLAP lesion should be clarified. SLAP lesions should be repaired to avoid relapse. Arthroscopic repair of SLAP lesion can lead to the disappearance of symptoms in younger patients. In older patients puncture or resection of the ganglion alone may be an adequate therapeutic strategy.

[Ganglion--cysts of the hand and wrist]

Ganglion cysts of the hand and wrist occur most frequently during the second through fourth decade and women are more frequently affected than men. Ganglion cysts may arise in any location in the hand and wrist but are usually adjacent to joins or tendons and sometimes bones. Patients often present with a history of an asymptomatic mass and many patients seek the advice of a physician because of the cosmetic appearance of the cyst. Observation is acceptable in most instances. Indication for operative treatment includes pain, interference with activity, nerve compression and ulceration of the mucous cysts.

The clinico-anatomic explanation for tibial intraneural ganglion cysts arising from the superior tibiofibular joint

OBJECTIVE

To demonstrate that tibial intraneural ganglia in the popliteal fossa are derived from the posterior portion of the superior tibiofibular joint, in a mechanism similar to that of peroneal intraneural ganglia, which have recently been shown to arise from the anterior portion of the same joint.

DESIGN

Retrospective clinical study and prospective anatomic study.

MATERIALS

The clinical records and MRI findings of three patients with tibial intraneural ganglion cysts were analyzed and compared with those of one patient with a tibial extraneural ganglion cyst and one volunteer. Seven cadaveric limbs were dissected to define the articular anatomy of the posterior aspect of the superior tibiofibular joint.

RESULTS

The condition of the three patients with intraneural ganglia recurred because their joint connections were not identified initially. In two patients there was no cyst recurrence when the joint connection was treated at revision surgery; the third patient did not wish to undergo additional surgery. The one patient with an extraneural ganglion had the joint connection identified at initial assessment and had successful surgery addressing the cyst and the joint connection. Retrospective evaluation of the tibial intraneural ganglion cysts revealed stereotypic features, which allowed their accurate diagnosis and distinction from extraneural cases. The intraneural cysts had tubular (rather than globular) appearances. They derived from the postero-inferior portion of the superior tibiofibular joint and followed the expected course of the articular branch on the posterior surface of the popliteus muscle. The cysts then extended intra-epineurially into the parent tibial nerves, where they contained displaced nerve fascicles. The extraneural cyst extrinsically compressed the tibial nerve but did not directly involve it. All cadaveric specimens demonstrated a small single articular branch, which derived from the tibial nerve to the popliteus. The branch coursed obliquely across the posterior surface of the popliteus muscle before innervating the postero-inferior aspect of the superior tibiofibular joint.

CONCLUSIONS

The clinical, MRI and anatomic features of tibial intraneural ganglion cysts are the posterior counterpart of the peroneal intraneural ganglion cysts arising from the anterior portion of the superior tibiofibular joint. These predictable features can be exploited and have implications for the pathogenesis of these intraneural cysts and treatment outcomes. These ganglion cysts are joint-related and provide further evidence to support the unifying articular theory. In each case the joint connection needs to be identified preoperatively, and the articular branches and the superior tibiofibular joint should be addressed operatively to prevent cyst recurrence.