The acromioclavicular joint cyst: glenohumeral joint communication revealed by MR arthrography

Arthroscopic treatment of massive acromioclavicular joint ganglion cysts with color-aided visualization: a case series of 4 patients

Background

Acromioclavicular joint ganglion cysts are rare lesions that mainly arise from the degeneration of the acromioclavicular joint in elderly patients. Although surgical management may be required because of their high recurrence rate after aspiration, few reports have described arthroscopic surgical procedures to treat acromioclavicular ganglion cysts. We report the surgical results of arthroscopic ganglionectomy with color-aided visualization for massive acromioclavicular ganglion joint cysts.

Methods

This retrospective case series examined patients identified with massive ganglion cysts that were localized above the acromioclavicular joint. All patients underwent an arthroscopic removal of subacromial synovium and subsequent injection of indigo carmine into the ganglion. The distal end of the clavicle was excised arthroscopically from the inferior surface, and the ganglion stalk was confirmed using indigo carmine for enhanced visualization and magnification. A ganglion portal was created, and the ganglion cyst was resected with the aid of the dye.

Results

Four female patients, aged 78-90 years, were identified with a massive acromioclavicular joint ganglion cyst. Plain radiography showed joint degeneration in the acromioclavicular joint, and magnetic resonance imaging scans showed fluid-filled mass formation. Although all patients initially underwent multiple aspirations of the ganglion cyst, we opted for surgical intervention because of its persistent recurrence. Three patients exhibited concurrent rotator cuff tears, and one patient had a prior history of cuff repair with no retear. After arthroscopic ganglionectomy with color-aided visualization for massive acromioclavicular ganglion joint cysts, none of the patients have shown recurrences at 2 years postoperatively.

Conclusion

Novel aspects of this case series include the use of indigo carmine to provide a better visualization and identification of the ganglion stalk under arthroscopy. Furthermore, a ganglion portal is useful for achieving complete resection of the indigo carmine-stained ganglion cyst. Color-aided visualization using indigo carmine and the construction of a ganglion portal were useful techniques for performing arthroscopic ganglionectomy in patients with a massive acromioclavicular joint ganglion cyst.

A Case Report of Geyser Sign on Magnetic Resonance Imaging (MRI) in a 65-Year-Old Female Patient

The geyser sign is the flow of arthrographic contrast or joint fluid from the glenohumeral joint across the acromioclavicular joint (AC) and occurs when fluid erupts from the superior aspect of the AC joint during arthrography. The cyst’s pathogenesis is linked to a rotator cuff tear and an increase in the amount of fluid in the cyst. This fluid escapes through a one-way valve created by a defect in the AC joint capsule. The cysts, which are typically painless and rest over the AC joint, cause discomfort. We present a case of a 65-year-old female with a left shoulder mass. The patient presented to the outpatient department with a history of left shoulder mass for six months. She reported an increase in size with no constitutional symptoms. She was treated with surgical excision. Although rotator cuff tears and AC joint deterioration are rather common in medical practice, cystic swelling over the AC joint is a relatively uncommon symptom. Less than 50 cases have been reported to date. AC joint cyst is a mechanical consequence of a progressive and severe rotator cuff tear that can be misinterpreted as a tumor in older people. Imaging, particularly magnetic resonance imaging (MRI), should be used to rule out malignancy and make a precise diagnosis, including recognizing the “Geyser sign” if it is present.

Co-occurring Acromioclavicular Joint Cyst and Hemarthrosis of the Shoulder Associated With Rotator Cuff Tear Arthropathy

Both acromioclavicular joint (ACJ) cysts and hemarthrosis of the shoulder are rare conditions of massive rotator cuff tear that eventually lead to cuff tear arthropathy. We herein report the first case of a patient with co-occurring ACJ cyst and hemarthrosis of the shoulder. An 80-year-old right-hand-dominant man presented to our outpatient department with a six-month history of repeatable right shoulder pain and swelling. Clinical examination revealed a 5 x 5 x 5 cm elastic hard or hard shoulder lump overlying the ACJ on skin with subcutaneous bleeding and swelling of the shoulder. Shoulder pain at rest and a fully reduced active range of motion (ROM), particularly in flexion and abduction, were also noted. Radiographs demonstrated moderate degeneration of the glenohumeral joint including a bone cyst of the humeral head. Magnetic resonance imaging (MRI) revealed a massive rotator cuff tear with atrophy of the supraspinatus, infraspinatus, and subscapularis muscles. The T2-weighted MRI images showed that the cyst was in direct contact with the markedly degenerated glenohumeral joint. Based on these findings, the patient was diagnosed with massive rotator cuff tear with ACJ cyst and hemarthrosis of the shoulder. The patient underwent distal clavicle resection and reverse total shoulder arthroplasty (RSA). At 12-month follow-up, the patient showed no pain symptoms, no recurrence of the cyst, and excellent ROM. We experienced a very rare case of ACJ cyst and hemarthrosis of the shoulder occurring simultaneously with rotator cuff tear arthropathy. This report is very valuable in that it suggests that RSA is useful for both ACJ cysts and hemarthrosis of the shoulders associated with rotator cuff tear arthropathy.

Clinical Relevance and Immunohistochemical Patterns of Silent Pituitary Adenomas: 10 Years of Single-centre Experience

BACKGROUND

Silent pituitary adenomas are clinically non-functional (i.e., without clinically evident pituitary hormone production).

INTRODUCTION

The aim of this study was to investigate subjects with silent pituitary adenomas for possible variations in their clinical status.

METHODS

A total of 102 patients who had undergone surgery for pituitary adenoma and had been diagnosed with silent pituitary adenoma was included in the study. The patients' preoperative and postoperative hormonal parameters and magnetic resonance imaging (MRI) features were collected, and pathological specimens were re-evaluated.

RESULTS

Immunohistochemistry results of the 102 patients were as follows: hormone-negative adenomas (n=35) 35.5%; FSH+LH-positivity (n=32) 31.3%; ACTH-positivity (n=11) 10.7%; α-subunit- positivity (n= 9) 8.8%; prolactin-positivity (n=8) 7.8%; GH-positivity (n=6) 5.4%; and plurihormonal adenoma (n=1). The mean sizes of SGA, SGHA, and SCA were 28.0±12.7, 30.0±16.0, and 27.7±8.9mm (p>0.05), respectively. With the exception of silent gonadotroph adenomas (SGAs), female gender dominance was shown in patients with silent growth hormone adenoma (SGHA) and silent corticotroph adenoma (SCA). Although no clinical relevance was observed in relation to hormonal excess, preoperative GH (4.21±4.6, vs. 0.27±0.36 p=0.00) was slightly more elevated in SGHA than in GH-negative adenomas. Additionally, preoperative basal ACTH values (47.3±28.7 vs. 23.9±14.4, p=0.003) were also higher in SCA compared to the other types. Our findings revealed SCAs to be of more aggressive behaviour than SGHAs and SGAs due to invasiveness in radiological imaging, their elevated re-operation, and postoperative ACTH values.

CONCLUSION

Silent pituitary adenomas represent a challenging diagnostic tumour group. Careful initial evaluation of patients with pituitary adenomas should consider any mild signs and symptoms of functionality, particularly in cases of GH- and ACTH-secreting adenomas.

Acromioclavicular joint cyst formation in a patient with rotator cuff-tear arthropathy: a rare cause of shoulder discomfort

We report a case of a 77-year-old man who presented to our shoulder department with a soft tissue mass on his right acromioclavicular (AC) joint. Previously attempted puncture aspiration had revealed serous fluid retention which recurred after each of several drainage attempts. Conventional radiography and MRI of the affected shoulder joint demonstrated a progressed cuff-tear arthropathy with an irreparable tear of the supraspinatus tendon, static superior migration of the humeral head, opening of the AC joint capsule and a superior joint-fluid 'eruption' and accumulation called 'Geyser sign'. Given that the patient's cuff-tear arthropathy was very well compensated, arthroscopic rotator cuff debridement and open cyst excision were performed. Closure of the superior aspect of the AC joint capsule was performed by the aid of a collagen matrix with additional closure of the deltotrapezial fascia. One year postoperatively, no cyst recurrence was noted.

MR Geyser Sign in chronic rotator cuff tears

Acromio-clavicular (AC) joint cysts are rare presentation of chronic shoulder pathology. These cysts may be observed secondary to either degenerative changes in the AC joint with an intact rotator cuff (type 1 cyst) or following a chronic rotator cuff tear (type 2 cyst). The latter phenomenon is known as Geyser Sign and is described by ultrasound, conventional arthrogram and magnetic resonance imaging (MRI). We present a case of chronic rotator cuff tear presenting with a large type 2 cyst and Geyser Sign on MRI.

Reverse Total Shoulder Replacement with Minimal ACJ Excision Arthroplasty for Management of Massive ACJ Cyst - A Case Report

Massive acromioclavicular joint (ACJ) cysts are an extremely rare cause of shoulder impairment and with limited consensus in its management. We present the first published case report of a patient with a massive ACJ cyst treated with a reverse total shoulder replacement with minimal ACJ excision arthroplasty.

Surgical treatment of an aseptic fistulized acromioclavicular joint cyst: a case report and review of the literature

An acromioclavicular joint cyst is an uncommonly reported condition, which seems to result from a massive rotator cuff tear and degenerative osteoarthritis of the acromioclavicular joint. We present the case of an 81-year-old man affected by an acromioclavicular joint cyst, associated to a massive rotator cuff tear, proximal migration of the humeral head and osteoarthritis of the gleno-humeral joint. The mass was 7 x 2.5 cm in size and the overlying skin presented a fistula that drained clear synovial-like fluid. Plain X-ray examination of the left shoulder showed proximal migration of the humeral head migration and osteoarthritis of the gleno-humeral joint, and further MRI evaluation confirmed the clinical diagnosis of a complete rotator cuff tear and observed a large subcutaneous cyst in communication with the degenerative acromioclavicular joint. The patient underwent surgical excision of the cyst and lateral resection of the clavicle to prevent disease recurrence. To the best of our knowledge, this is the first reported case of an acromioclavicular joint cyst complicated by an aseptic fistula resulting from multiple aspirations.

[Acromioclavicular (AC) joint cyst. A case report and review of literature]

The acromioclavicular (AC) joint cyst is a rare sequela of complete supraspinatus tendon rupture and arthritis of the AC joint. It appears as a swelling on the AC joint and must be distinguished from tumours of the shoulder and neck region. Besides physical examination, magnetic resonance imaging is the most useful tool for correct diagnosis. As reported in the literature, therapeutic procedures include observation, aspiration, excision of the cyst with or without resection of the AC joint, and repair of the underlying supraspinatus tendon rupture. All procedures should be based on consideration of the comorbidity and recurrence of the cyst. Combinations of cyst excision and rotator cuff repair or AC resection seem to be the most promising therapeutic options. We report on a 75-year-old patient with a painless swelling over the AC joint who had suffered shoulder trauma 15 years previously.

MR imaging of the rotator cuff

MR imaging is the optimal method for evaluating suspected rotator cuff pathology. Current techniques of fast spin-echo imaging without and with fat suppression allow accurate identification and characterization of tendinous and myotendinous abnormalities of the rotator cuff. Impingement disorders, tendon degeneration, instability,and trauma comprise the multifactorial nature of rotator cuff disease. This article addresses the role of MR imaging in evaluating the rotator cuff and the importance of MR imaging in identifying other lesions that may mimic rotator cuff pathology. A rationale for protocol design, including MR arthrography and the use of specialized positioning, such as abduction and external rotation (ABER), are discussed.

Acromioclavicular joint cyst: nine cases of a pseudotumor of the shoulder

OBJECTIVE

(1) To analyse the imaging appearances of nine patients with acromioclavicular joint cysts presenting as shoulder masses for tumor staging with operative, histopathological and joint aspiration findings.

DESIGN AND PATIENTS

Retrospective review of imaging and correlation with clinical, operative and surgical notes. Images were reviewed by two musculoskeletal radiologists by consensus. Nine patients who presented clinically with a shoulder mass were evaluated by radiographs (n=9), ultrasound (n=1), conventional arthrography (n=3), MRI (n=6; with direct MR arthrography n=2, indirect MR arthrography n=4).

RESULTS

All patients had a focal mass superior to the AC joint, with a size ranging from 1.5 cm to 6 cm and a mean of 3.27 cm. Correlation was available with surgery (n=7), histopathology (n=2) and cyst aspiration (n=2). Two patients were managed conservatively. Geyser sign was positive in all three arthrograms. All MRIs revealed extensive rotator cuff tears with a column of fluid extending from the glenohumeral joint through the rotator cuff tear into the acromioclavicular joint and acromioclavicular cyst. Chondrocalcinosis was seen in the acromioclavicular joint cyst (n=2) and in the glenohumeral joint (n=1). Aspirate in two patients contained calcium pyrophosphate dihydrate crystals.

CONCLUSION

Acromioclavicular joint cysts may present as a tumor mass. They are associated with extensive rotator cuff tears and there is usually communication of the cyst with the joint space. This feature excludes a diagnosis of tumor. AC joint cysts may be associated with calcium pyrophosphate dihydrate deposition disease.

Intramuscular ganglion arising from the acromioclavicular joint

We report a case of a 80-year-old White woman presenting with a localized painless swelling in the upper parascapular region of the right shoulder. Ultrasound (US) showed a ganglion arising from the acromioclavicular joint (ACJ) and extending inside the trapezius muscle, together with a massive tear of the rotator cuff (RC). Magnetic resonance imaging (MRI) confirmed the US findings. Ganglia arising from the ACJ are rare and usually associated with massive RC tears. Their intramuscular extension, to the best of our knowledge, has never been reported in the radiological literature and can mimic a tumor.

Magnetic resonance imaging of the shoulder: rotator cuff

Magnetic resonance imaging has proven to be useful in the assessment of rotator cuff injuries. Improvements in magnetic resonance techniques, including fast spin-echo imaging and fat saturation, have facilitated demonstration of tendinous abnormalities of the rotator cuff. Rotator cuff disease is multifactorial. Primary impingement within the coracoacromial arch, degeneration of the rotator cuff tendons, trauma, and glenohumeral instability may be contributing factors. Shoulder pain in athletes can be related to acute myotendinous and muscle injuries, which can be easily detected using magnetic resonance imaging.