The sternoclavicular ganglion cyst, a rare pediatric diagnosis.

We briefly describe the case of a 4-year-old girl, referred for imaging of a small, firm, round, skin-colored, subcutaneous nodule that suddenly appeared at her right sternoclavicular junction. A plain radiograph was non-contributory, but ultrasonography revealed a small cystic structure, leading to the diagnosis of a sternoclavicular ganglion cyst. Sternoclavicular ganglion cysts are a rare diagnosis, with only seven reported pediatric cases. A watchful waiting approach can be adopted so long as they remain asymptomatic.

Tibial intraneural ganglion cysts at the superior tibiofibular joint treated with joint resection alone: a proof of concept.

BACKGROUND: Intraneural ganglion cysts involving the tibial nerve are rare. Recent evidence has supported an articular (synovial) theory to explain the joint-related origin of these cysts; however, optimal operative treatment for cysts originating from the STFJ remains poorly understood. Therefore, we present a novel strategy: addressing the joint itself without addressing the articular branch and/or the cyst. METHODS: Records of patients with tibial intraneural ganglion cysts with a connection to the STFJ who were treated with a joint resection alone at a single academic institution were reviewed. The clinicoradiographic features, operative intervention, and postoperative course were recorded. RESULTS: We identified a consecutive series of 7 patients. These patients (4/7 male, 57%) were 43 (range 34-61) years of age and all presented with symptoms of neuropathy. The patients underwent resection of the synovial surfaces of the STFJ without disconnection of the articular branch or decompression of the cyst. Postoperatively, three patients regained partial motor function (43%, n=7), although four patients noted continued sensory abnormality (57%, 4/7). All six patients with postoperative MRIs had some evidence of regression of the cyst. CONCLUSIONS: This novel surgical technique serves as a proof of concept-highlighting the fact that treating the primary source (the joint origin) can be effective in eliminating the secondary problem (the cyst itself). While this study shows that this simplified approach can be employed in select cases, we believe that superior results (faster, fuller recovery) can be achieved with combinations of disconnecting the articular branch, decompressing the cyst, and/or resecting the joint.

Femoral intraneural ganglion cyst: the first confirmed case report.

BACKGROUND: Ganglion cysts affecting nerve are rare causes of neuropathy. The formation of intraneural ganglion cysts, once controversial, has recently been clarified. We describe the first modern description of a femoral intraneural ganglion cyst at the hip region. METHODS: A patient presented with a 1 year history of radiating pain, quadriceps weakness and anteromedial leg numbness was found to have a femoral intraneural cyst with a hip joint connection on MRI. RESULTS: Surgical disconnection of the articular branch led to improvement of the neuropathy and resolution of the cyst on postoperative MRI. CONCLUSIONS: The unifying articular (synovial) theory describes the joint origin of intraneural cysts, even when they occur in unusual locations, and their propagation into the parent nerve. Knowledge of this theory can improve outcomes; surgery needs to address the joint origin or capsulolabral defect lest recurrence ensue.

CUBITAL TUNNEL SYNDROME DUE TO AN INTRANEURAL GANGLION CYST OF THE ULNAR NERVE.

Cubital tunnel syndrome is the second most common neuropathy of the upper extremity. Cubital tunnel syndrome caused by intraneural ganglion cysts is rare in clinical practice. We present the case of a 71-year-old male patient with a 4-month history of cubital tunnel syndrome of the left elbow due to an intraneural ganglion cyst. After revision of the ulnar nerve and resection of the intraneural cyst nearly complete recovery was achieved within a 5 month follow-up but some sensory deficits of the fifth fingertip. We recommend preoperative ultrasound examination of the cubital tunnel even in cases with clear diagnosis. Ganglion cyst as a cause of cubital tunnel is rare but needs to be diagnosed and treated as soon as possible to prevent irreversible complications.

AN INTRATENDINOUS GANGLION CYST OF THE PATELLAR TENDON: A RARE CAUSE OF ANTERIOR KNEE PAIN.

Ganglion cysts in the knee region can manifest as anterior knee pain. Unlike synovial cysts, these lesions lack synovial epithelial lining and occur secondary to mucoid degeneration of connective tissue because, often in response to chronic irritation and repetitive traumas. However, an intratendinous location is a rare finding. In the knee region, infrapatellar fat pad, the alar folds, and the anterior cruciate ligament are recognized to degenerate into ganglion. There are few case reports describing an involvement of the patellar tendon. We present the clinical case of a 72 years old male patient suffering from anterior knee pain attributed to an intratendinous ganglion cyst of the patellar tendon, obviously after a single traumatic event. After aspiration of the ganglion cyst the patient reported no complaints, and there has been no recurrence during the latest follow-up examination.

Intraneural ganglion cysts originating from the hip joint: A single-center experience.

INTRODUCTION/AIMS: Intraneural ganglion cysts (INGCs) are non-neoplastic mucinous cysts within the epineurium of peripheral nerves. Characteristics of INGCs around the hip joint have not been adequately described. We aimed to describe clinical features, imaging findings, and treatment outcomes in patients with INGCs originating from the hip joint. METHODS: We retrospectively included cystic lesions around the hip joint satisfying the following inclusion criteria over 6 years: (1) multilocular elongated hyperintense cystic mass on T2-weighted imaging; and (2) distribution along the course of the peripheral nerve and its branches on magnetic resonance imaging (MRI). RESULTS: Six patients with an INGC around the hip joint were identified. Parent peripheral nerves were the sciatic nerve (four patients), the superior gluteal nerve (one patient), and the nerve to quadratus femoris (one patient). Buttock, groin, or lower extremity pain/paresthesias were the initial symptoms in all patients. INGCs within the articular branches of the hip joint were identified on MRI. Four patients underwent arthroscopic debridement and capsulotomy. All patients showed generally favorable outcome regardless of treatment. DISCUSSION: Physicians should consider the possibility of INGCs originating from the hip joint as a cause of nontraumatic hip, buttock, or lower extremity pain. This can occur in any nerve innervating the hip joint, and usually it originates in the posterior capsule of the hip joint. Arthroscopic surgery shows promising results; however, more information about the surgical technique and long-term follow-up results are needed.

Intraarticular injection of the interphalangeal joint for therapy of digital mucoid cysts.

Mucoid cysts are associated with osteoarthritis (OA) of the digital joints and frequently recur after needle drainage, injection, or surgical ablation. This study determined whether intraarticular injection of the adjacent interphalangeal joint rather than the cyst itself might be effective in resolving digital mucoid cysts. Using paired case series design and sterile technique, 25 consecutive OA digital joints with an adjacent mucoid cyst underwent dorsal non-transtendinous intraarticular injection with a 25-gauge needle and 20-mg triamcinolone acetonide, followed by puncture and manual expression of cyst fluid. Patient pain was measured with the 10-cm Visual Analogue Pain Scale prior to the procedure and at 6 months. Cyst resolution was determined at 6 months and 3 years. The subjects were 61.0 ± 7.7 years old and 60% (15/25) female. Mucoid cysts were adjacent to 19 distal interphalangeal, 3 metacarpophalangeal, and 3 interphalangeal joints. Pre-procedural pain was 4.7 ± 1.0; procedural pain was 6.2 ± 0.6 cm, and post-procedural pain at 6 months was 1.2 ± 0.8 cm (74.5% reduction, 95% CI of difference: 3.0 < 3.5 < 4.0 (p < 0.0001)). 84% (21/25) of the cysts resolved at 6 months; however, 60% (15/25) of the mucoid cysts recurred within 3 years and required retreatment (14 adjacent joints re-injected and 1 ablative cyst surgery). No complications were noted. Intraarticular corticosteroid injection using a dorsal non-transtendinous approach of the joint adjacent to a mucoid cyst is effective resolving cysts and reducing pain at 6 months; however, 60% of mucoid cysts reoccur within 3 years and may require reinjection or surgery.Trial registration: This was not a clinical trial.

Juxtaneural ganglia arising from the hip joint: focus on magnetic resonance imaging findings and clinical manifestations.

OBJECTIVE: To present cases of juxtaneural ganglia arising from the hip with a discussion of the magnetic resonance imaging (MRI) findings, presenting symptoms, and possible treatment option. MATERIALS AND METHODS: Two radiologists performed a consensus review of MRI scans obtained between January 2013 and March 2021 to identify patients with juxtaneural ganglia around the hip. A total of 11 patients with 11 juxtaneural ganglia were identified. Medical records and MRI findings were retrospectively reviewed. RESULTS: Eight patients had lesions involving the sciatic nerve, and three patients had lesions involving the obturator nerve. Sciatic ganglia arose from a paralabral cyst in the posteroinferior quadrant and continued through a narrow channel running along the posterior acetabulum, showing increased diameter in the sciatic foramen and intrapelvic portion. Obturator ganglia showed a J- or reverse J-shape on the coronal imaging plane and extended from a paralabral cyst in the anteroinferior quadrant via the obturator canal. Nine patients (9/11, 81.8%) had symptoms resembling those of lumbosacral radiculopathy. Four patients underwent arthroscopic surgery, and one patient underwent ultrasound-guided aspiration, all of whom showed partial improvement. Spontaneous decrease in the extent of the ganglion was observed in three patients (3/11, 27.3%). CONCLUSION: This article describes rare cases of juxtaneural ganglia arising from the hip joint and involving the sciatic and obturator nerves. The lesions share similar MRI findings, and each type of cyst (sciatic or obturator ganglia) involves a specific labral quadrant.

Does complete regression of intraneural ganglion cysts occur without surgery?

PURPOSE: The dynamic nature of intraneural ganglion cysts, including spontaneous expansion and regression, has been described. However, whether these cysts can regress completely in the absence of surgical management has important therapeutic implications. Therefore, we aim to review the literature for cyst regression without surgical intervention. METHODS: We reviewed our database of 970 intraneural ganglion cysts in the literature to search for evidence of complete regression based on strict radiologic confirmation, either spontaneously, or after percutaneous cyst aspiration or steroid injection. RESULTS: We did not find any examples of complete regression without surgical treatment that met inclusion criteria. Spontaneous regression was reported in four cases; however, only two cases had follow-up imaging, both of which demonstrated residual cysts. Nineteen cases of percutaneous intervention were found in the literature, 13 of which reported clinical improvement following aspiration/steroid injection; however, only seven cases had available imaging. Only two cases reported complete resolution of cyst on MR imaging at follow-up, but reinterpretation found residual intraneural cyst in both cases. CONCLUSION: We believe that pathology (structural abnormalities and/or increased joint fluid) always exists at the joint origin of intraneural ganglion cysts which persist even with regression of the cyst. The persistence of a capsular abnormality or defect can lead to recurrence of the cyst in the future, and while imaging may show dramatic decreases in cyst size, truly focused assessment of images will show a tiny focus of persistent intraneural cyst at the joint origin. Thus, expectant management or percutaneous intervention may lead to regression, but not complete resolution, of intraneural ganglion cysts.

Arthroscopic resection of recurrent wrist ganglions - A retrospective study of 17 patients.

BACKGROUND: Arthroscopic resection has become a favorable alternative for wrist ganglions. However, for recurrent wrist ganglions, arthroscopic resection is relatively contraindicated. The purpose of this study was to evaluate the clinical outcomes of arthroscopic resection for recurrent wrist ganglions and to identify their safety and efficacy. METHODS: From June 2011 to February 2017, 17 patients with recurrent wrist ganglion were treated with arthroscopic resection. We evaluated the visual analog scale, modified Mayo wrist score, and Disabilities of Arm, Shoulder and Hand Outcome Measure preoperatively and at the final follow-up. Patients were questioned for pain reduction, pain during pushups, and any difficulty in returning to work. Recurrence and complications were also assessed at each follow-up visit. RESULTS: We enrolled 17 patients and median follow-up was 58 months. The reduction in pain was significant. Only 2 of the 17 patients had residual pain after arthroscopic resection. One female patient showed recurrences 3 years later. Although 2 cases of stiffness were noted after the operation, no significant complication was present 3 months postoperatively. Most patients had good recovery and could resume work; however, 2 patients reported fair recovery. CONCLUSION: The results of this study confirmed that arthroscopic excision could be an effective and safe treatment for recurrent ganglions; therefore, should not be contraindicated for treating recurrent wrist ganglions. Nevertheless, further prospective studies with larger patient numbers are needed to establish a stronger evidence for arthroscopic resection of recurrent wrist ganglions.

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.

Atraumatic, Progressive, and Painful Elbow Contracture From a Ganglion Cyst.

Ganglion cysts are benign soft tissue tumors that often occur adjacent to joints or tendons. We report a case of an elbow joint ganglion cyst in a patient who presented with a painful, progressive elbow contracture. The patient was successfully treated with resection of the subbrachialis ganglion cyst combined with an anterior capsular release and an ulnar nerve decompression to recover elbow motion. This case highlights the value of advanced imaging in patients presenting with an atraumatic, painful, and progressive elbow contracture.

Intraneural ganglion cysts of the peroneal nerve.

BACKGROUND: Intraneural ganglion cysts of the peroneal nerve are rare, and there is lack of evidence for the surgical management of this entity. We performed this study to evaluate the imaging, diagnosis, treatment and outcome of seven patients with intraneural ganglion cysts of the peroneal nerve. MATERIALS AND METHODS: We retrospectively studied the files of seven patients with intraneural ganglion cysts of the peroneal nerve, diagnosed and treated from 2016 to 2019. Diagnostic approach included clinical examination of the leg and foot, magnetic resonance imaging, nerve conduction studies, surgical excision of the cyst and histological examination. The mean follow-up was 2 years (range 1-3.5 years). We evaluated the time and methods for surgical treatment, and the clinical outcomes of the patients. RESULTS: All patients presented symptoms of peripheral compression neuropathy; three patients presented with foot drop. The intraneural ganglion cysts were excised in all cases in addition to knee articular nerve branch transection to avoid cysts recurrence. Postoperatively, all patients experienced complete neurological recovery without clinical evidence of intraneural ganglion cysts recurrences. CONCLUSION: The treating physicians should be aware of intraneural ganglion cysts of the peroneal nerve in patients presenting with limb weakness, sensory deficits at the lateral and anterior side of the leg and foot, paresis or paralysis of the foot and ankle. MR imaging is the imaging modality of choice for a clear and accurate preoperative diagnosis to avoid misdiagnosis and wrong treatment. In case of doubt, these patients should be managed in an orthopedic oncology setting with microsurgery facilities available for complete excision of the intraneural ganglion cyst.

Ganglion cysts developed from the flexor tendon sheaths in the fingers: Clinical and sonographic features.

PURPOSE: The purpose of this study was to assess the clinical and sonographic features of flexor tendon sheath ganglion cysts in the fingers. METHODS: We retrospectively reviewed the clinical and sonographic features of 35 cases of flexor tendon sheath ganglion cysts in the fingers in 34 patients that were pathologically confirmed between 2003 and 2018. RESULTS: The mean age of the patients was 44.2 years (range, 11-73 years). Lesions were located at the level of the metacarpophalangeal joint (n = 22 [63%]) and proximal phalanx (n = 11 [31%]), and involvement of the third finger was common (n = 19 [54%]). The mean lesion size was 6 mm and the mean volume was 90 mm3 . None of the lesions had a pedicle. Lesions were homogeneous (n = 24 [69%]) and anechoic (n = 23 [66%]). A septum was noted in 12 cases (34%). CONCLUSIONS: Flexor tendon sheath ganglion cysts are most commonly located in the third finger and at the level of the metacarpophalangeal joint and proximal phalanx. It usually presents as a simple cyst without a pedicle, but occasionally exhibits a mixed echogenicity and contains a septum.

Soft-Tissue Tumors of the Hand-Imaging Features.

Imaging studies of the hands and fingers are common, and radiologists are generally comfortable with traumatic and degenerative conditions which arise frequently in daily practice. However, a variety of common and uncommon soft-tissue tumors also occur in the hand, the appropriate diagnosis of which can be a source of confusion for both clinicians and radiologists. These lesions often have overlapping imaging characteristics; however, a structured approach can help provide a focused differential diagnosis and impact further workup and management. We discuss several such tumors, categorizing them as cystic-appearing, noncystic masses along tendons and aponeuroses, adipocytic tumors, vascular lesions, and miscellaneous lesions with imaging features that can aid diagnosis.

Osseous Remodeling Secondary to a Chronic Intermetatarsal Ganglion Cyst: A Case Report.

Bone is a dynamic tissue constantly adapting to meet the demands of the body. There is extensive evidence of primary bone tumors causing remodeling but rarely does a soft-tissue tumor become encompassed in bone. This reaction is seen through a combination of increased stress and the increased activity of basic multicellular units. As the force placed on bone is increased, there is a response by osteocytes stimulating the breakdown of damaged bone and production of new bone. As the production of new bone is impeded by an obstructing mass, the bone will begin to wrap around the lesion. We present a rare case in which an intermetatarsal ganglion cyst caused reactive osseous remodeling encompassing the lesion in bone. Surgical excision of the cyst showed no evidence of stress fracture and led to complete relief of pain.

Effect of Mitomycin C on Recurrence of Ganglion Cysts in the Foot and Ankle.

Ganglion cysts are among the most common benign soft tissue masses. Although surgery has been shown to be effective, ∼12% to 42% of cases with long-term follow-up have been reported to recur. The purpose of this study was to determine the impact of the topical application of mitomycin C used as an adjuvant to surgery on recurrence rate of ganglion cysts. A retrospective analysis was done on all patients surgically treated by 1 surgeon for ganglion cysts. The primary end point was local recurrence after the procedure, determined clinically and by ultrasound. Secondary outcomes included wound complication rate, adverse effects, and overall patient satisfaction. A total of 98 consecutive patients were included in this study and assigned to a study group in a nonrandomized manner. The control group (n = 52) consisted of patients who underwent surgical resection only. The study group (n = 46) consisted of patients who underwent surgical resection with application of topical mitomycin C. No patients were lost to follow-up. Of the 52 patients in the control group, 13 (25.0%) had recurrence of the ganglion cyst. In contrast, in the experimental study group, 2 patients (4.3%) had a recurrence. There was no difference in superficial wound infections between the 2 groups. In this study, we found that the use of topical mitomycin C as an adjuvant to surgical resection significantly reduced the recurrence rate. Wound infection and overall nonrecurrence complication rates were similar to those of other studies.

Ultrasound in the diagnosis and management of fibular mononeuropathy.

INTRODUCTION: Ultrasound (US) evaluation of peripheral nerves is a noninvasive, cost-effective approach to diagnosing focal mononeuropathies and guiding surgical management. We used the intranerve ratio to evaluate for possible cut-off values in diagnosis of fibular mononeuropathies (FNs). METHODS: A retrospective analysis of FN confirmed by electrodiagnosis (EDx) was performed to identify intranerve ratio values between affected and unaffected limbs at the fibular head and popliteal fossa. RESULTS: The optimal fibular head/popliteal fossa intranerve ratio to discriminate between limbs with and without disease was 1.25 (sensitivity, 51%; specificity, 71%). There was no statistically significant difference between affected vs unaffected limbs (ratio, 1.13; P = .15) nor in subgroup analyses. However, 25% of patients had structural lesions amenable to surgery. DISCUSSION: The utility of US in diagnosis of FN is limited using intranerve ratio data, but US has a distinct advantage over EDx for identifying treatable structural lesions.

Thenar lumps: a review of differentials.

Most soft-tissue lumps in the hand are benign, with ganglions being the commonest, but in the thenar region, solid soft-tissue masses are more common than a ganglion. In this review, we focus on soft-tissue lesions (neoplastic and non-neoplastic) presenting as a palpable lump in this region. A specific diagnosis can often be reached using ultrasonography and/or magnetic resonance imaging. Most of these lesions are managed in local hospitals or primary care, whereas some are referred to specialist centres. This review article will help both general and musculoskeletal radiologists to diagnose and characterise these lesions, provide a guide for further imaging, and provide an insight into imaging features that may need specific investigations such as core biopsy, tertiary referral, and further review at multidisciplinary meetings.

Sonography of Wrist Ganglion Cysts: Which Location Is Most Common?

OBJECTIVES: The literature states that wrist ganglion cysts are most commonly dorsal; however, our experience suggests a volar location is more common. The purpose of this study was to identify the locations of ganglion cysts of the wrist as imaged with sonography. METHODS: After Institutional Review Board approval with informed consent waived, retrospective review of wrist sonography reports from January to April 2016 was completed. Only patients who had a comprehensive evaluation that included the dorsal and volar wrist were included. Ultrasound images were reviewed to characterize wrist ganglion cysts. RESULTS: The study group consisted of 98 subjects (78% female, 22% male) (median age, 51 years; range 13-79) with 124 wrist ganglion cysts, where 69% (86 of 124) were volar and 31% (38 of 124) were dorsal. Ganglion cysts were located between the radial artery and flexor carpi radialis in 63% (78 of 124), followed by a dorsal location superficial to the scapholunate ligament in 20% (25 of 124), other dorsal locations in 11% (13 of 124), and other volar locations in 6% (8 of 124). With dorsal ganglion cysts, the scapholunate ligament when imaged appeared normal in 91% (20 of 22). Ganglion cysts were multilocular/multilobular in all subjects. CONCLUSIONS: The most common location for wrist ganglion cysts is in the volar wrist, particularly between the radial artery and flexor carpi radialis tendon, appearing multilocular or multilobular with a mean largest dimension of 1.0 cm. Given the propensity of ganglion cysts to occur at this site, attention to this area when imaging the wrist with sonography or magnetic resonance imaging should be considered.