Complications following mucous cyst excision

Effects of Postoperative Splinting on Outcomes following Digital Mucous Cyst Excision: A Retrospective Review

Background

Digital mucous cysts (DMCs) are masses on the fingers that can be definitively managed with surgical excision. Though uncommon, surgical site infections can develop into septic arthritis. We sought to determine whether postoperative splinting decreases rates of postoperative infection and the need for postoperative antibiotics. We also explored the effect of age, gender, obesity, and preoperative antibiotic administration on infectious complications.

Methods

Patients who underwent DMC excision between 2011 and 2021 were retrospectively identified. Chi-squared and Fisher's exact tests were used to analyze the complication rates including documented infection, postoperative antibiotic administration, mass recurrence, and return to operating room. Associations were analyzed between both preoperative antibiotic administration and postoperative splinting with respect to postsurgical complications.

Results

The database search identified 373 patients who underwent 394 DMC excisions. Postoperative antibiotics were given in splinted patients at lower rates than their nonsplinted counterparts with a small-to-moderate effect size, but the difference was not statistically significant (2.7 vs. 7.5%). Preoperative antibiotic administration was not found to significantly affect the prescription of postoperative antibiotics. Splinting did not reduce rates of DMC recurrence. Patients who were splinted were more likely to have also received preoperative antibiotics. Males were given postoperative antibiotics more frequently than females (12.6 vs. 4.0%).

Conclusions

Though not statistically significant, splinted patients were prescribed postoperative antibiotics less frequently. Postoperative antibiotics were utilized more frequently than the rate of infections typically reported following this procedure, possibly indicating overcautious prescription habits or underreported suspected infections.

Efficacy of Bleomycin Intralesional Injection for Treating Digital Mucous Cysts: A Comparative Study of Corticosteroid Intralesional Injection and Surgical Excision

BACKGROUND

Sclerotherapy has shown superior efficacy among the nonsurgical options for managing digital mucous cysts (DMC). Notably, previous research has indicated that bleomycin offers a more favorable side-effect profile and similar efficacy to conventional sclerosing agents.

OBJECTIVE

This study aimed to assess the efficacy and safety of bleomycin intralesional injection (ILI) for treating DMC through a comparative analysis of corticosteroid ILI and surgical excision.

METHODS

We retrospectively reviewed electronic medical records and clinical photographs. Telephone interviews were conducted to further investigate long-term treatment efficacy, safety, and overall treatment satisfaction.

RESULTS

Ten patients underwent surgical excision, and 13 and 15 patients received bleomycin and corticosteroid ILI, respectively. Both surgical excision and bleomycin ILI demonstrated superior treatment efficacy compared to corticosteroid ILI. No statistically significant difference in the treatment effectiveness between surgical excision and bleomycin ILI was observed. No significant adverse effects were observed. In the survey, the level of satisfaction was the highest for bleomycin ILI, followed by surgical excision and corticosteroid ILI.

CONCLUSION

This study revealed that bleomycin ILI exhibits a treatment efficacy higher than that of corticosteroid ILI and slightly lower than that of surgical excision, without any side effects. Therefore, bleomycin ILI is a safe and effective therapeutic option for the treatment of DMC.

Digital mucous cyst

Mucous cyst is a benign but recurrent lesion. It is located on the dorsal surface of the digital extremity between the distal interphalangeal joint and the base of the nail. The nail is often affected by the cyst because of its topographical proximity. Nail plate deformity may even be the first obvious abnormality indicating the presence of a small mucous cyst or subungual cyst. Mucous cyst is associated with osteoarthritis of the joint, osteophytes probably being the main contributing factor. Surgical treatment by joint debridement and cyst removal is the most effective way of preventing recurrence.

Complications in nail surgery and how to avoid them

Complications in nail surgery are not that frequent. Apart from complications that are common to every hand procedure, intense pain is the major issue with nail surgery. To prevent complications, good knowledge of anatomy and physiology is required to avoid misdiagnosis or inappropriate technique. However, some complications, such as postoperative nail dystrophy, are unavoidable, and must be known and discussed with the patient prior to the procedure in order to prevent disappointment that may lead to medico-legal cases. This paper will discuss the most frequent complications encountered.

Blind Curettage Technique for Treatment of Mucous Cysts Associated with Heberden Nodes: Description of Operative Technique

The standard treatment for mucous cysts with Heberden nodes is excision of the dorsolateral osteophytes and capsule of the distal interphalangeal joint or thumb interphalangeal joint, including the stalk of the cyst. The skin incision varies for cases depending upon the geometry. We propose a surgical method utilizing blind lateral approaches for treating such mucous cysts.

New body surface indexes for germinal matrix: DIP joint extension boundary line and dorsal distal interphalangeal crease

BACKGROUND

Knowledge of the proximal edge of the germinal matrix is essential to avoid injuries in the germinal matrix. The previous index such as terminal tendon insertion is not visible from the body surface. The purpose of this study was to examine the relationship between the proximal edge of the germinal matrix and the body surface indexes by ultrasonographic measurements.

METHODS

All participants underwent X-rays of the hand and were grouped based on the presence or absence of osteoarthritis in the distal interphalangeal (DIP) joint. The distance from the proximal edge of the germinal matrix to dorsal distal interphalangeal crease (parameter D1), and to ''DIP joint extension boundary line'' (parameter D2) were measured using ultrasonography.

RESULTS

Thirty middle fingers of 24 patients were enrolled; 13 fingers were in control group and 17 fingers were in Heberden's node group. The average of parameter D1 was 6.17 mm (SD 1.12) in the control group (N = 13), and was 7.04 mm (SD 1.31) in Heberden's node group (N = 17) without significant difference. The DIP joint extension boundary line was not visible in 7 fingers with severe DIP joint osteoarthritis. The average of parameter D2 was 0.00 mm (SD 0.00) in the control group (N = 13), and was 0.04 mm (SD 0.13) in Heberden's node group (N = 10).

CONCLUSIONS

We suggest that DIP joint extension boundary line and dorsal distal interphalangeal crease are valuable indexes to predict the proximal edge of the germinal matrix from the body surface. Though the DIP joint extension boundary line was not visible in some cases, once it has been sighted, the line shows where the germinal matrix exactly is.

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.

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.

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.

Osteophyte-Sparing Treatment of Mucous Cysts: Case Analysis and Surgical Technique

The purpose of this study was to examine patient outcomes and the risk of recurrence of mucous cysts affecting the distal interphalangeal (DIP) joint in the absence of osteophytectomy using the described flap technique.

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.

Arthritis of the Thumb Interphalangeal and Finger Distal Interphalangeal Joint

The distal interphalangeal (DIP) joints are subjected to the highest joint forces in the hand, and at least 60% of individuals older than age 60 years have DIP joint arthritis. Debridement of degenerative distal interphalangeal joints with mild to moderate disease can provide satisfactory outcomes; however, those joints with more severe angular and rotation changes are reliably treated with fusions. Regardless of the fixation method, DIP fusions have high success rates, are well tolerated, and are extremely durable.

Treatment of Distal Interphalangeal Ganglion Cysts by Volar Corticosteroid Injection

BACKGROUND

Various options exist for operative and nonoperative treatment of symptomatic distal interphalangeal (DIP) ganglion cysts. We describe the technique and efficacy of a novel treatment of DIP ganglion cysts using a volar, transtendon, intra-articular injection of corticosteroid.

METHODS

This was a single center, retrospective study (2010-2015) of 21 patients who received a volar, intra-articular corticosteroid injection for treatment of DIP ganglion cysts. The patients were contacted via mailing with a short survey. For those potential study participants who did not respond to the mailing or were not seen in follow-up, contact was made via telephone. The primary study outcome was resolution of the cyst; secondary outcomes included pain and postinjection complications.

RESULTS

A total of 21 patients (14 female; 7 male) with 23 DIP ganglion cysts were treated in this study. The dominant hand was involved in 56.5% cases. Twelve (52.2%) resolved or had near complete resolution following injection at an average follow-up of 20 months.

CONCLUSIONS

For patients with DIP ganglion cysts, this newly described technique of volar, transtendon, intra-articular injection of corticosteroid provides a safe and effective treatment. This technique allows for ease and consistency of needle placement for intra-articular corticosteroid delivery while minimizing the potential soft tissue and infection concerns described with other techniques.

[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.

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.

Diode Laser-Assisted Surgical Therapy for Early Treatment of Oral Mucocele in a Newborn Patient: Case Report and Procedures Checklist

Mucocele (also known as ranula or salivary gland mucous cyst) of the newborn is a lesion present on the intraoral cavity, with the potential to interfere with respiration and feeding. In the present report, a case of mucocele in a 4-month female patient has been described. As conventional surgery can be followed by several complications such as intraoperative bleeding, difficulties in wound healing, and maintenance of sterility during surgery, in the present case, the use of diode laser has been planned. A topic anesthesia with lidocaine gel was performed. A diode laser (810 nm wavelength, continuous wave mode, power output of 3 watt, and 0.4 mm diameter fiber optic) was set for excising the lesion. The tip was directed at an angle of 10 to 15°, moving around the base of the lesion with a circular motion. The procedure was completed in 3 minutes. The patient was visited with a follow-up of 2 weeks and 4 months after excision. The intraoral wound healed without complications, and no signs of infection or mass recurrence were noted. The histopathological examination confirmed the diagnosis of mucocele. On the basis of the results of the present case report, the use of diode laser can be easily performed also in a noncompliant newborn patient for successful excision of mucocele lesions, and checklist of clinical procedures has been described.

The Zitelli Bilobed Flap on Skin Coverage After Mucous Cyst Excision: A Retrospective Cohort of 33 Cases

PURPOSE

To study the time to wound healing and recurrence rate achieved in the treatment of distal interphalangeal joint mucous cysts using the Zitelli modified bilobed flap.

METHODS

We surgically treated 33 patients from January 2006 to June 2015. We assessed demographic data, comorbidities, location and size of the cyst, time to wound healing, and complications.

RESULTS

The most affected finger was the right middle finger. All flaps survived and wounds healed in 14 days on average. The mucous cyst recurred in 1 of 33 cases. There were no major complications.

CONCLUSIONS

The Zitelli bilobed flap can provide good-quality skin coverage over the distal interphalangeal joint in a short period.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

Current Topics in Nail Surgery

Background:

Nail surgery can be performed in an office-based dermatology practice with a limited amount of specialized equipment and training. Several excellent reviews have been published in recent years that detail the techniques of nail surgery for both the novice and the experienced practitioner.

Objective:

In this article recent developments in nail surgery are discussed. Topics that are treated include the general principles of nail surgery, including epidemiologic issues, studies of nail anatomy, instrumentation, and anesthesia. The reconstruction of injuries and congenital defects involving the nail is explained, and the role of the hand surgeon clarified. Appropriate removal of tumours and cysts is considered, with special attention to the management of malignant lesions. The controversy regarding more or less conservative management of melanonychia striata is addressed, and the need for early diagnosis of subungual melanoma is emphasized. Other topics are surgical management of ingrown nails and onychomycosis. Newer areas of nail surgery, such as laser surgery of the nail, psycho-dermatology of the nail, and the role of primary care physicians in simple nail surgery are also examined.

Bone change after surgical treatment of mucous cyst at the interphalangeal joint of the great toe in a patient with rheumatoid arthritis

Digital mucous cysts are a type of benign cysts of the digits, typically located at the distal interphalangeal joints or in the proximal nail fold, which usually occur on the hands. The diagnosis of digital mucous cysts is relatively easy because of its light-transmitting property, but the treatment is often difficult because of complications including recurrence, infection, diminished range of motion, and nail deformity. We report a case of rheumatoid arthritis (RA) showing good course after surgical treatment of mucous cyst at the interphalangeal joint of the great toe. In a case of RA, combination of synovectomy with surgical treatment of mucous cyst might be effective.

Patient-based outcomes following surgical debridement and flap coverage of digital mucous cysts

PURPOSE

The purpose of this prospective cohort study was to evaluate patient-based outcomes and complications following excision of mucous cysts, joint debridement, and closure with one of three types of local flaps.

METHODS

From 2000-2011, 35 consecutive patients with 37 digital mucous cysts were treated surgically. The surgical procedure included excision of the cyst together with the attenuated skin, joint debridement on the affected side including capsulectomy, and removal of osteophytes. Depending on the size and location of the cyst, the skin defect was covered by a transposition flap (31 cysts), an advancement flap (two cysts), or a rotation flap (four cysts).

RESULTS

At an average follow-up time of 4 years, 4 months, there was no wound infection, flap necrosis, or joint stiffness. Preoperative nail ridging resolved in seven of nine fingers, and no nail deformities developed after surgery. One cyst, treated with a transposition flap, recurred 10 months after surgery. The average satisfaction score for the affected finger significantly improved from 4.3 to 6.8, and the average pain score decreased from 4.7 to 2.3.

CONCLUSION

This treatment protocol provides reliable results. Patients were satisfied with the reduction of associated pain and the postoperative appearance of the treated finger, and postoperative complications were minimal.

Surgical treatment of mucous cysts by subcutaneous excision and osteophyte resection: Results in 68 cases at a mean 6.63 years' follow-up

The goal of this study was to assess the results of treatment of mucous cysts by subcutaneous excision and osteophyte resection without an associated skin procedure. From 1993 to 2013, 81 mucous cysts were operated on. In 27 cases, a nail deformity was present. Obvious osteoarthritis was present in 84% of cases. Among them, 67 patients (68 cysts) were subsequently assessed through a phone questionnaire after a mean follow-up of 6.6 years. Patients who reported a recurrence or suspected one were reassessed in consultation. Among the 68 evaluated cases, two developed an infection and one had delayed skin healing; these complications occurred on cysts with a previous fistula. In one case (1.5%), a recurrence was observed four months after excision of a subungual cyst. All nail deformities had resolved; 53 patients felt no discomfort and 65 were very satisfied or satisfied with the procedure and would undergo surgery again. The recurrence rate of 1.5% is consistent with that of other studies where the same procedure was used, without cutaneous grafting, ranging from 0 to 2%. This result is better than in studies where a graft or a flap was performed without systematic joint debridement. Our procedure is sufficient to effectively treat mucous cysts with less morbidity. Complications are rare and occur only in cysts associated with a fistula, justifying their early surgical treatment.

A reliable surgical treatment for digital mucous cysts

There is no clear consensus about the best operative technique for the treatment of digital mucous cysts. We carried out a retrospective review of all patients who underwent excision of a digital mucous cyst using a local advancement skin flap over a 10-year period. A total of 69 patients were included and were reviewed at an average of 38 months (minimum 6 months) post-operatively. No patients were lost to follow-up. There was only one case of cyst recurrence. Of these 67 patients were happy with the scar and 63 patients said they would have the procedure again; 36 patients had a pre-operative nail deformity and 21 reported that the deformity grew out after the procedure.

Total dorsal capsulectomy for the treatment of mucous cysts

PURPOSE

To describe the technique of total dorsal capsulectomy alone for mucous cysts of the distal interphalangeal (DIP) joint and evaluate its outcomes and complications.

METHODS

Nineteen patients (18 women and 1 man) with 19 mucous cysts were treated by a total dorsal capsulectomy without cyst excision or osteophyte removal. The average age at surgery was 63 years. The thumb was involved in 4 patients, index finger in 1, middle finger in 7, ring finger in 4, and little finger in 3. Twelve patients had nail deformities associated with the mucous cyst. The average period of postoperative follow-up was 26 months. The dorsal half of the DIP joint capsule was resected with a punch and curette. The cyst and osteophytes were left intact.

RESULTS

The average preoperative range of motion for the DIP joint was from 10° of extension to 45° of flexion. Radiographs showed osteophytes at the DIP joint in all affected digits. After surgery, all cysts disappeared at an average of 3 weeks. There was no recurrence at the time of final follow-up. All nail deformities had resolved at an average of 5 months after surgery. The average motion for the DIP joint at the time of final follow-up was from 8° of extension to 56° of flexion. There were no acquired nail deformities or other complications.

CONCLUSIONS

A total dorsal capsulectomy alone was a simple treatment for mucous cysts and did not lead to any recurrence.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Osteophyte excision without cyst excision for a mucous cyst of the finger

Osteophyte excision is a mainstay of treatment for mucous cyst combined with Heberden's node in a distal interphalangeal joint or in an interphalangeal joint of the thumb. The aim of this study was to evaluate the results of osteophyte excision without cyst excision for the treatment of a mucous cyst combined with Heberden's node. The medical records of 37 patients (42 cases) with a mucous cyst with Heberden's node were retrospectively reviewed. Thirty-eight of 40 cases with available pre-operative simple radiographs showed evidence of joint arthrosis. A T-shaped skin incision of the joint capsule between the extensor tendon and lateral collateral ligament was used. Osteophyte excision without cyst excision was performed. All cysts, except one, regressed without recurrence or a skin complication after osteophyte excision, but eight cases showed post-operative pain and loss of range of motion. Osteophyte excision without cyst excision may be a good treatment choice for mucous cyst of the finger.

The Zitelli design for bilobed flap applied on skin defects after digital mucous cyst excision. A review of 9 cases

Mucous cysts do not always require treatment. Nevertheless, patients often ask for excision because of pain or esthetics. Flap coverage is usually a concomitant procedure, which improves the quality of the skin overlying the distal interphalangeal joint. We propose the Zimany bilobed flap in this indication, and particularly its newer geometric design developed by Zitelli. We report the use of this flap in 9 cysts. Wound healing was fast with a good outcome. This flap design is an easy, safe procedure, and the Zitelli geometric design is a clear improvement for the reproducibility and learning curve.

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.

Musculoskeletal Ultrasound: Audit of Sonographer Reporting

Musculoskeletal (MSK) ultrasound performed by non-medical practitioners is a developing practice. The aim of this paper is: (1) to audit an experienced sonographer's (SJR) performance after one year's independent reporting against two experienced MSK radiologists (CJG, MC); and (2) to establish an audit standard against which such role development might be contrived. Images and reports from 250 MSK ultrasound examinations performed by a sonographer (SJR) were reviewed independently by two consultant MSK radiologists (CJG and MC). The examinations were graded for discrepancy, e.g. grade 1 – agree with the sonographer report; grade 2 – minor discrepancy unlikely to alter patient care; grade 3 – potentially significant discrepancy; grade 4 – definite, significant discrepancy likely to have adverse consequences for patient care. Two of 250 (0.8%) cases were excluded. Both radiologists agreed completely with the sonographer (grade 1) in 235 of the 248 cases (94.8%). In 13 cases there was discrepancy between the reports of SJR and the radiologists. The discrepancy was grade 2 in six of the 248 cases (2.4%), grade 3 in six of the 248 cases (2.4%) and grade 4 in one of the 248 cases (0.4%). In conclusion, this audit shows a high level of agreement between the sonographer and the consultant MSK radiologist reporting of MSK ultrasound. This level of agreement may set the standard for future quality assurance audit of sonographer MSK reporting.

Surgical treatment of mucous cysts on fingers without skin excision

Mucous cysts on the fingers are commonly treated by excision followed by a rotation flap or skin graft. However, such procedures require skin donors or large incisions. Therefore, a less invasive procedure is needed. Here, we report a surgical treatment method that does not require the excision of the cyst. A skin flap was made around the cyst and raised; the pedicle of the cyst was then electrodesiccated or ligated, and the contents of the cyst were evacuated. If the pedicle could not be clearly identified, the backside of the flap was electrodesiccated to break the connection between the cyst and the distal interphalangeal joint. The skin flap was replaced and sutured. The flaps became almost normal during the follow-up period. No complications or recurrences occurred in any of the six cases that were treated. Our procedure appears to be an effective and less-invasive treatment for mucous cysts of the fingers.

Treatment of thumb metacarpophalangeal and interphalangeal joint arthritis

Degenerative joint disease affecting the thumb metacarpophalangeal and interphalangeal joints is a debilitating condition, which can significantly restrict activities of daily living. Conservative measures to address symptoms include oral anti-inflammatory medications, activity modification and splinting, and intraarticular corticosteroid injections. Surgical interventions include arthroscopic synovectomy, arthroplasty, and finally arthrodesis of the affected articulations. Although short-term results from synovectomy and arthroplasty seem promising, long-term data are not yet available. Arthrodesis of the metacarpophalangeal and interphalangeal joints yields a stable yet functional thumb with reliably good pain relief.

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.

[Use of a bilobed flap for the treatment of mucous cysts]

INTRODUCTION

In the case of mucous cysts with attenuated skin, the authors suggest radical excision of the cyst together with the overlying skin. The skin defect is repaired with a bilobed flap whose donor site is left to heal by secondary intention. This surgical procedure also allows exploration of other areas of mucoid degeneration and repair of the proximal nail fold when necessary.

METHOD

Twenty-six patients with an average age of 59 years (27 cysts), were operated with this procedure. Nail bed deformities were present in 55% of the cases. The cyst and the overlying skin were radically excised in conjunction with a dorsal capsulectomy; the use of the bilobed flap made the dissection easier, and flap translation allowed cover of the capsulectomy area and simultaneous repair of the nail fold in eight cases.

RESULTS

Patients were reviewed with an average follow-up of 13.7 months. Seventy percent of the patients had no pain, and in 85% of the cases there was no loss of motion. Cosmetic appearance was satisfactory, and nail bed deformities disappeared or clearly subsided in 86% of the cases. One patient developed recurrence.

DISCUSSION

Many surgical procedures have been described for mucous cysts treatment. This simple procedure allows radical excision of the cyst and the attenuated skin with low risk for the germinal matrix, precise location of cyst origin, repair of the nail fold and good skin cover in the capsulectomy area.

Ganglion cysts and other tumor related conditions of the hand and wrist

Most regard ganglion, giant cell tumor of tendon sheath and epidermal inclusion cysts as tumor-like conditions as opposed to true neoplasms. Ganglion cysts are the most common lesion of the hand and wrist, accounting for 50% to 70% of all masses identified. The majority of ganglion cysts can be treated nonoperatively but when surgery is performed a low recurrence rate can be anticipated. Giant cell tumor of the tendon sheath hand epidermoid cysts are also common hand lesions that require surgical excision in most instances. Of the three, giant cell tumor of tendon sheath have the most notable recurrence rates. This article reviews the clinical presentations of these lesions as well as their proposed pathophysiology.

Treatment of mucous cysts of the toes

The outcome of surgically treated mucous cysts of the foot is poorly documented in the orthopaedic literature. This study reports on the treatment of mucous cysts of the toes by simple excision and joint debridement. This is in contrast to treatment of similar lesions in the fingers which is often treated by excision of the cyst, joint debridement, and rotational flap. Following this procedure on 15 patients (15 cysts), at a minimum of 2 years postoperatively, only one cyst had recurred at 9 months. All patients were satisfied by the cosmetic appearance of their toe. The authors reviewed the available literature on this condition and suggest that this method of treatment provides good functional and cosmetic results with a minimal rate of recurrence.

Treatment of mucous cysts of the fingers: review of 134 cases with minimum 2-year follow-up evaluation

PURPOSE

To evaluate the results of a single surgeon's treatment of mucoid cysts, comparing outcomes between injection and surgery.

METHODS

One hundred thirty-four cysts were treated, with a minimum 2-year follow-up period. Thirty-one patients had nail ridging or deformity at presentation. Eighty patients had multiple soft-tissue punctures into the cyst with a 25-gauge needle and injection with local anesthetic and steroid. Fifty-four patients had surgical excision and joint debridement.

RESULTS

In the injection group, complete resolution of the cyst occurred in 48 cases (60%). Among the 32 that recurred, repeat injections were performed in 8 cases; 3 resolved. No recurrences were noted in the surgery group. Nail ridging resolved after surgery in 25 digits; the remaining 6 digits had partial improvement or persistent ridging. Five infections occurred and were treated successfully with antibiotics (4) or debridement (1), or both.

CONCLUSIONS

Aspiration and injection was convenient but had a 40% recurrence rate. Surgery provided definitive treatment with no major long-term problems.