Arthroscopic ganglionectomy of the foot and ankle

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.

Endoscopic Ganglionectomy of the Extensor Digitorum Longus Tendon: An Extraganglionic Approach

ABSTRACT

Ganglion is the most common soft tissue mass in the foot and can be painful and affect comfort wearing shoes. The usual treatment of a ganglion is conservative: careful neglect, manual rupture, or aspiration. When the lesion is recurrent or painful, surgical excision is recommended. The purpose of this Technical Note is to describe the extraganglionic approach of endoscopic ganglionectomy of the extensor digitorum longus tendon. This surgery has the advantage of being minimally invasive and having better cosmetic result, with less surgical trauma to the soft tissue.

LEVEL OF EVIDENCE

Level 1: foot and ankle; Level 2: other (ganglion).

Unusual multiloculated serpiginous ganglion of the foot

Ganglions are cystic lesion more commonly seen around the wrist joint. Gangliomas of plantar aspect of the foot are rare. We have presented a case of an unusual serpiginous ganglioma of the plantar aspect of the foot. Less literature is available regarding plantar foot gangliomas. The treatment is challenging because of occurrence of the lesion at weight bearing zone. Available options for treatment includes conservative with splint, intralesional injection,arthroscopic excision and open excision.

Endoscopic Ganglionectomy of the Tarsal Tunnel: A Medial Approach

A ganglion inside the tarsal tunnel can compress the tibial nerve, leading to posterior tarsal tunnel syndrome. Classically, the ganglion is resected with an open approach. This requires release of the flexor retinaculum and dissection around the tibial neurovascular bundle, which may induce fibrosis around the tibial nerve. Endoscopic resection of a tarsal tunnel ganglion via a posterior approach has been reported. The purpose of this Technical Note is to describe the medial approach of endoscopic ganglionectomy of the tarsal tunnel. This is indicated for tarsal tunnel ganglia compressing the tibial nerve and extending to the flexor retinaculum. It is contraindicated if there is other pathology of the tarsal tunnel that demands open surgery; the ganglion compresses the tibial nerve from its deep side and does not extend to the flexor retinaculum; or in the presence of intraneural ganglion of the tibial nerve.

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.

Endoscopic Release of the Guyon Canal and Pisohamate Hiatus

The ulnar nerve runs in more than 1 tunnel in the wrist. Ulnar nerve entrapment in the wrist can occur at the Guyon canal and the pisohamate hiatus. Open release of these 2 tunnels requires a lengthy incision and extensive soft-tissue dissection. The purpose of this technical note was to describe the details of endoscopic release of the Guyon canal and the pisohamate hiatus. This minimally invasive approach allows release of the ulnar nerve and its motor branch at the wrist level.

Minimally Invasive and Endoscopic Treatment of Haglund Syndrome

Haglund syndrome is a triad of posterosuperior calcaneal prominence (Haglund deformity), retrocalcaneal bursitis, and insertional Achilles tendinopathy. The sources of pain include the posterior calcaneal wall cartilage, retrocalcaneal and subcutaneous adventitial bursa, and the Achilles tendon. Resection of the posterosuperior calcaneal tubercle, bursectomy, excision of the Achilles tendon pathology, reattachment of the Achilles tendon, gastrocnemius aponeurotic recession, and flexor hallucis longus transfer have been proposed as surgical treatment options. All of them can be performed endoscopically or under minimally invasive approaches.

Ultrasound-Guided Ganglionectomy of a Flexor Hallucis Longus Ganglion Cyst Using Coablation Technology: A Case Report

A 44-year-old woman with a history of an open ganglionectomy 2 years prior presented with a recurrent ganglion cyst. The ganglion cyst, extending from the flexor hallucis longus tendon sheath, was confirmed with magnetic resonance imaging. The patient declined another surgical incision. An experimental procedure was performed: ultrasound-guided ganglionectomy using a coablation wand. She achieved full symptom resolution, with no recurrence 1 year afterwards. To our knowledge, this is the first case report in the literature describing the use of this instrument for treating a ganglion cyst.

Endoscopic Ganglionectomy and Release of the Sixth Extensor Compartment

Stenosing tenosynovitis of the extensor carpi ulnaris is one of the causes of dorsoulnar wrist pain. Conservative treatment is usually effective to alleviate the pain. Surgical release of the retinaculum of the sixth extensor compartment is indicated if conservative treatment cannot alleviate the pain. The purpose of this Technical Note is to describe the technical details of endoscopic release of the sixth extensor compartment via a 2-portal approach. Endoscopic resection of a ganglion over the sixth compartment can also be performed via the same approach.

Endoscopic Excision of Ganglion at Anterolateral Elbow: A Case Report

Ganglion of the anterolateral elbow is rare and may be associated with compression neuropathy of the radial nerve or its branches. Open ganglionectomy implies extensive soft tissue dissection. We present a case of anterolateral elbow ganglion without any compression neuropathy. This was successfully treated with endoscopic ganglionectomy.

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.

Endoscopic Ganglionectomy of the Volar Radial Wrist Ganglion

Volar ganglion cyst of the wrist is a common hand problem faced by orthopaedic surgeons. Excision is indicated if it is painful. Arthroscopic ganglionectomy of the wrist ganglion has been reported with the advantage of minimally invasive surgery. Most of them involve elimination of the valvular mechanism and internal drainage of the ganglion fluid to the wrist joint. The access of the ganglion sac is limited especially for a multiloculated cyst. The purpose of this Technical Note is to report the technique of endoscopic resection of the volar radial wrist ganglion. This can ensure complete resection of the ganglion sac especially for the multiloculated one.

Endoscopic Ganglionectomy of Palmar Ganglion via Flexor Carpi Radialis Tendoscopy

Palmar ganglion is rare. Deep palmar ganglion usually arises from the wrist joint and may cause compression neuropathy. Superficial palmar ganglion may arise from the flexor tendons of the wrist. The chance of compression neuropathy is expected to be less than deep palmar ganglion. However, there is a higher chance of perforation through the skin and the ganglion may affect hand grip. Open resection of the ganglion does not require extensive deep soft tissue dissection. However, the skin incision can still be extensile to trace the stalk to the tendon of origin. The purpose of this Technical Note is to report the details of endoscopic ganglionectomy for superficial palmar ganglion arising from the flexor carpi radialis tendon.

Endoscopic Stalk Resection of a Toe Ganglion With Color-aided Visualization

Ganglion cysts are common cystic lesions filled with a jelly-like substance and originate from a joint capsule or tendon sheath through a stalk. Ganglion cysts mostly occur in the hand region, for which surgical excision usually results in good outcomes. In contrast, toe ganglions are relatively rare, and surgical treatment is associated with a high recurrence rate because of unidentifiable ganglion stalks, requiring large skin incisions. We have treated toe ganglion cysts using endoscopy in the ganglion cyst by injecting methylene blue into the tendon sheath that connects to the ganglion stalk. The result has been favorable, without recurrence. The advantages of our technique include the following: (1) Endoscopy using a color aid can show the location of a ganglion stalk, and removing the stalk can prevent recurrence. (2) Endoscopic stalk-only resection is minimally invasive, allowing early mobilization and reducing surgical-site complications. The purpose of this Technical Note is to describe our endoscopic stalk resection technique with color-aided visualization, and we have included a video presentation.

Endoscopic Resection of the Tarsal Tunnel Ganglion

The tarsal tunnel ganglion is a cause of posterior tarsal tunnel syndrome. Open resection of the ganglion calls for release of the flexor retinaculum and dissection around the tibial neurovascular bundle. This can induce fibrosis around the tibial nerve. We report the technique of endoscopic resection of the tarsal tunnel ganglion. It is indicated for tarsal tunnel ganglia arising from the adjacent joints or tendon sheaths and compressing the tibial nerve from its deep side. It is contraindicated if there is other pathology of the tarsal tunnel that demands open surgery; if the ganglion compresses the tibial nerve from its superficial side, which calls for a different endoscopic approach using the ganglion portal; or if an intraneural ganglion of the tibial nerve is present. The purpose of this technical note is to describe a minimally invasive approach for endoscopic resection of the tarsal tunnel ganglion.

Endoscopic Resection of the Tibialis Anterior Tendon Bursa

The tibialis anterior tendon bursa is located between the tibialis anterior tendon and the medial cuneiform bone and close to the tendon insertion. Bursitis can occur as a result of excessive local friction, infection, arthritides, or direct trauma. Endoscopic resection of the bursa is indicated in case of symptomatic bursitis that is not responding to conservative treatment or infection is suspected. It is contraindicated if there is skin infection at the portal sites. The purpose of this technical note is to describe a minimally invasive approach of endoscopic resection of the tibialis anterior tendon bursa through anterior tibial tendoscopy.

Endoscopic Resection of the Lateral Ankle Bursa With Synovial Chondromatosis

Bursal chondromatosis is synovial chondromatosis of the bursae. It is a rare disease entity that can involve the adventitial bursa of the lateral ankle. Complete synovectomy, removal of loose bodies, and bursectomy comprise the treatment of choice. Detailed preoperative radiologic assessment and surgical planning are the keys to success. Any accompanying synovial chondromatosis of the ankle or subtalar joint or tenosynovial chondromatosis of the peroneal tendon sheath should be treated together with the bursectomy. Endoscopic bursectomy can be performed through the bursal portal. The proximal and distal peroneal tendoscopy portals serve as viewing portals. The resection of the diseased tissues should be performed in a step-by-step zonal manner. Complete synovectomy and removal of loose bodies should be performed before bursectomy. Internal drainage of the bursal sac into the peroneal tendon sheath may be indicated if the sac is adherent to the skin. It should only be performed after complete synovectomy and removal of loose bodies.

Endoscopic Ganglionectomy of the Elbow

Resection of the ganglion of the elbow is indicated if the size or location of the cyst impairs function or causes significant pain. Arthroscopic decompression or endoscopic resection of the cyst is the minimally invasive surgical option. It has the potential advantage of better cosmetic results and less soft-tissue dissection. Endoscopic resection is indicated if the cyst is not communicating with the joint or the communication is not identifiable arthroscopically or if there is a long and narrow communication placing the cyst away from the elbow joint. Preoperative magnetic resonance imaging is essential for surgical planning.

Tenosynovial Osteochondromatosis of the Flexor Hallucis Longus Tendon Treated by Tendoscopy

Tendosynovial chondromatosis of the foot and ankle is a rare disease entity. We reported 3 patients with tenosynovial osteochondromatosis of flexor hallucis longus. They were successfully treated by arthroscopic synovectomy and removal of the loose bodies.

Small joint arthroscopy in foot and ankle

The clinical application of small joint arthroscopies (metatarsophalangeal joint, Lisfranc joint, Chopart joint, and interphlangeal joint) in the foot has seen significant advancements in the past decades. This article reviews the clinical indications, technical details, outcomes, and potential complications of small joint arthroscopies of the foot.

Interphalangeal arthroscopy of the toes

Interphalangeal (IP) joint pathology of the toes has gained little attention of the orthopedic surgeon. However, similar intra-articular pathologies e.g. osteoarthritis, synovitis, chondral lesion, arthrofibrosis and instability can occur as in other joints. Moreover, many corrective procedures of toe deformity involved excisional arthroplasty or arthrodesis of the IP joint although it is not the site of primary pathology. Classically, the operations of the IP joint were performed in an open manner. We described the technique of interphalangeal arthroscopy and its application to treat various pathologies of the interphalangeal joint was discussed. Among the various indications for interphalangeal arthroscopy, arthroscopic ganglionectomy of recurrent IP ganglion is the single most important one.