Arthroscopic Dorsal Ligamentocapsulodesis in the Treatment of Occult Dorsal Wrist Ganglion Cysts Associated with Scapholunate Instability: Surgical Technique and Preliminary Clinical Results.

Background: This study aimed to evaluate our preliminary results and experience with the arthroscopic dorsal ligamentocapsulodesis in managing occult dorsal wrist ganglion cysts (ODGCs) associated with scapholunate (SL) instability. Methods: All patients who underwent arthroscopic dorsal ligamentocapsulodesis due to an ODGC with concomitant SL ligament tear were retrospectively reviewed. In addition to demographic data and length of follow-up, outcomes data that included range of motion, grip strength, modified Mayo wrist score (MMWS), complications and radiographs were collected. Results: The study included 18 patients (18 wrists; 10 female and 8 male). The mean age was 32 years (range: 19-48) and the mean follow-up was 34 months (range: 24-48). The mean preoperative extension deficit decreased from 5.5° (range: 0°-20°) to 2.7° (range: 0°-15°) at the final follow-up (p = 0.004). The mean preoperative flexion deficits decreased from 4.4° (range: 0°-15°) to 2.2° (range: 0°-10°) postoperatively (p = 0.003). The mean hand grip strength significantly increased from 27.7 kg (range: 22-36) to 38.3 kg (range: 31-46) at the final follow-up assessment (p < 0.001). The mean MMWS improved from 46 (range: 25-65) pre-operatively to 91 (range: 70-100) at the final follow-up (p = 0.0002). No major intra- or postoperative complications were observed. Conclusions: SL instability may have an important role in the aetiology of ODGCs, and arthroscopic dorsal ligamentocapsulodesis can provide pain relief and functional improvement without recurrence at the short- to mid-term follow-up in the treatment of ODGCs. Level of Evidence: Level IV (Therapeutic).

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.

Tarsal tunnel ganglion cyst: intraneural or extraneural site?

Intraneural ganglion cysts are very uncommon lesions, whose diagnosis has increased since the articular theory and the description of the MRI findings were established. We present a case report of a 59-year-old man with symptoms of tarsal tunnel syndrome. Foot and ankle MRI demonstrated the presence of an intraneural cystic lesion in the posterior tibial neve and its connection with the subtalar joint through an articular branch. The identification of the specific radiological signs like the «signet ring sign¼ allowed establishing an adequate preoperative diagnosis, differentiating it from an extraneural lesion and facilitating the articular disconnection of the nerve branch during surgery.

Volar wrist ganglion associated with radial artery atherosclerosis: A case report.

RATIONALE: There have been no reports of volar wrist ganglions being associated with atherosclerosis of the radial artery. Good results were obtained with radial artery reconstruction through ganglion excision and autogenous vein grafting. Hence, we report a previously unreported case, along with a review of the literature. PATIENT CONCERNS: A 58-year-old female presented with the chief complaint of a mass on the volo-radial side of her right wrist. The patient complained of a tingling sensation in the thumb, index, and extensor zones that worsened when pressing the mass. DIAGNOSES: Sonography revealed a well-defined, anechoic cystic lesion adjacent to the radial artery. INTERVENTIONS: Exploration was performed using a zig-zag incision on the mass. The superficial radial nerve (SRN), which innervates the thumb, was distorted by the mass and the nerve dissected from the mass. However, the artery and ganglion cysts were not separated completely in a part where hardening of the artery wall progressed as a result of degenerative changes, showing multiple small, hard, and yellowish masses. We resected the radial artery (approximately 1.5 cm) along with the ganglion and sent it for histological examination. The radial artery was then reconstructed using an autogenous venous graft. OUTCOMES: At the 34-month follow-up, the patient was asymptomatic. Radial artery patency was normal without recurrence of the ganglion cyst. LESSONS: In patients with risk factors for radial artery atherosclerosis, a more careful diagnosis is required for the surgical treatment of the volar wrist ganglion. In addition, if the ganglion and radial artery are not completely dissected, excision of the radial artery and subsequent reconstruction of the radial artery using an autogenous vein may be a good surgical strategy.

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.

A rare case of an intratendinous ganglion cyst extending into the muscle belly of flexor carpi radialis: a case report and review of the literature.

ITGCs (intratendinous ganglion cysts) involving the flexor compartment of the wrist are uncommon, and reports are scarce in the literature. The differential diagnosis is wide and can mimic sinister lesions. We report a case of a 62-year-old male, that presented to our tertiary orthopaedic oncology service with an intratendinous ganglion cyst, extending into the muscle belly of flexor carpi radialis. We describe this rare presentation and review the literature.

Cubital tunnel syndrome of the ulnar nerve caused by an epineural ganglion cyst: a case report and review of the literature.

BACKGROUND: The ulnar nerve has a long and complex anatomical course, originating from the brachial neural plexus in the neck with nerve trunk formation at the posterior neck triangle, and on to the axilla. This intricate anatomical pathway renders the nerve susceptible to compression, direct injury, and traction throughout its course. Compression of the ulnar nerve is the second most common compression neuropathy of the median nerve adjacent to the wrist joint, after carpal tunnel syndrome. CASE PRESENTATION: A 45-year-old Sudanese housewife complained of progressive right forearm and hand muscle wasting, pain, and neuropathic symptoms. She was diagnosed with right-sided cubital tunnel syndrome. The diagnosis was derived intraoperatively from a nerve conduction study suggesting the level of conduction block and recommending decompression. Magnetic resonance imaging was not done preoperatively due to financial limitations. An epineural ganglion (15 × 20 mm2) compressing and flattening the ulnar nerve was diagnosed intraoperatively. Surgical decompression of the ulnar nerve and removal of the epineural ganglion achieved a remarkable postoperative result and pleasing outcome. CONCLUSION: Surgical management is the cornerstone of treatment for compressive neuropathy and ranges from simple nerve decompression to complex neurolysis procedures and nerve transposition to adjust the anatomical course of the nerve.

Intraneural Ganglion of the Thumb Digital Nerve - A Case Report and Review of Literature.

Intraneural ganglia are rare, benign cysts that form within the epineurium of the affected nerve. Patients present with features of compressive neuropathy, including numbness. We report a 74-year-old male patient with pain and numbness on his right thumb of 1-year duration. Magnetic resonance imaging revealed a cystic lesion with a possible scaphotrapezium-trapezoid joint connection. The articular branch was not identified during the surgery and decompression with excision of the cyst wall was done. A recurrence of the mass was noted 3 years later, but the patient was asymptomatic and no additional intervention was done. Decompression alone can relieve the symptoms of an intraneural ganglion, but excision of the articular branch may be essential in preventing its recurrence. Level of Evidence: Level V (Therapeutic).

Ganglion Cyst Resection of the Anterior Cruciate Ligament using the Posterior Trans-Septal Approach: A Report of 2 Cases.

CASE: We present 2 patients each with an intra-articular ganglion cyst arising at the femoral attachment of the anterior cruciate ligament that was successfully resected using the posterior trans-septal portal approach. At the final follow-up, the patients had no recurrence of symptoms and no recurrence of the ganglion cyst on magnetic resonance imaging. CONCLUSION: Surgeons should consider the trans-septal portal approach when they cannot visually confirm the intra-articular ganglion cyst by the arthroscopic anterior approach. The trans-septal portal approach enabled complete visualization of the ganglion cyst located in the posterior compartment of the knee.

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.

Two-Year Clinical Outcomes after Arthroscopic Re-Excision of Recurrent Dorsal Wrist Ganglion Cyst.

OBJECTIVES: Arthroscopic excision of dorsal wrist ganglion (DWG) cysts has recently become an alternative to open surgery, with the advantage of lower recurrence. However, in recurrent cases, whether re-excision using an arthroscopic approach would achieve favorable outcomes has not been determined. This study aimed to evaluate the clinical outcomes of function evaluation and recurrence rate after arthroscopic excision of recurrent DWG cysts. METHODS: A total of 11 consecutive patients with clinically diagnosed recurrent DWG cysts were retrospectively reviewed between November 2017 and March 2020. Extensive re-excision of the ganglion cyst and its surrounding pathological capsule was performed using an arthroscopic approach. Magnetic resonance imaging (MRI) was routinely performed before surgery to identify the location and limits of the cyst. All patients were followed up for a minimum of 2 years. A second recurrence was recorded if a mass reappeared at the same site with a positive transillumination test. Pain during activity was evaluated using the visual analog scale (VAS). The active range of motion (ROM) of the wrist was measured using a goniometer, and the hand grip strength was measured using a digital dynamometer. Comparative analysis between the pre- and postoperative indexes was performed using Student's t-test. RESULTS: After a mean follow-up period of 29.3 months (range, 24-34 months), no second recurrence of the cyst was recorded. The VAS score improved from 1.4 to 0.3 (t = 3.833, p = 0.003), and residual pain was reported by three patients (VAS score = 1 for each). Active wrist flexion increased from 73.6° to 78.2° (t = 2.887, p = 0.016). No significant changes were found in active wrist extension or hand grip strength (p > 0.05). No major complications occurred during the study. CONCLUSION: Arthroscopic excision of a recurrent DWG cyst yielded satisfactory results with no second recurrence, significant pain relief, and good wrist function at a minimum of 2-year follow-up. Clear identification of the location and limits of the ganglion based on preoperative MRI could be helpful to achieve complete excision and therefore prevent a second recurrence.

Acute-Onset Footdrop Caused by Intraneural Ganglion Cyst of the Common Peroneal Nerve: The Effects of Extraneural Pressure Gradients on Cyst Propagation.

Ganglion cysts are relatively common entities, but intraneural ganglia within peripheral nerves are rare and poorly understood. We present a case of a 51-year-old man who presented with acute left dropfoot. Initial magnetic resonance imaging (MRI) was misinterpreted as common peroneal neuritis consistent with a traction injury corroborated by the patient's history. However, after surgical decompression and external neurolysis were performed, the patient's symptoms worsened. Repeated MRI revealed an intraneural ganglion cyst of the common peroneal nerve with connection to the superior tibiofibular joint by means of its anterior recurrent branch that was evident retrospectively on preoperative MRI. It is crucial to carefully inspect atypical cases to further recognize and appreciate the dynamic aspect of this disease or "roller-coaster" phenomenon. Intraneural ganglion cysts rely heavily on intraneural and extraneural pressure gradients for propagation, which can be drawn from the expanded work of the unifying articular theory. This report emphasizes the importance of understanding the pathoanatomical and hydraulic factors to appropriately identify and treat intraneural ganglion cysts. Increased recognition of this pathologic entity as a differential diagnosis for acute onset dropfoot is also highlighted.

Intra-Articular Ganglion Cysts of the Knee.

➢: Magnetic resonance imaging (MRI) without contrast is sufficient to diagnose an intra-articular ganglion cyst of the knee. MRI with intravenous contrast may be considered for cysts in the infrapatellar fat pad, which are not a typical presentation. ➢: The current literature supports treating symptomatic cases or those discovered accidently during knee arthroscopy with arthroscopic excision. ➢: Although aspiration of these cysts results in a higher recurrence rate than excision, it is associated with quicker recovery. Thus, aspiration might be chosen as an initial treatment for anyone who would like to avoid surgery or requires a rapid recovery, including professional athletes. ➢: Open excision may be considered for infrapatellar fat pad cysts that are >4.5 cm in size.

Preoperative Imaging of Intraneural Ganglion Cysts: A Critical Systematic Analysis of the World Literature.

BACKGROUND: Advancements in imaging and an understanding of the pathomechanism for intraneural ganglion cyst formation have led to increased awareness and recognition of this lesion. However, the precise role of imaging has been advocated for but not formally evaluated. METHODS: We performed a systematic review of the world literature to study the frequency of imaging used to diagnose intraneural ganglion cysts at different sites and compared trends in identifying joint connections. RESULTS: We identified 941 cases of intraneural ganglion cysts, of which 673 had published imaging. Magnetic resonance imaging (MRI, n = 527) and ultrasonography (US, n = 123) were the most commonly reported. They occurred most frequently in the common peroneal nerve (n = 570), followed by the ulnar nerve at the elbow (n = 88), and the tibial nerve at the ankle (n = 58). A joint connection was identified in 375 cases (48%), with 62% of MRIs showing a joint connection, followed by 16% on US, and 6% on computed tomography (CT). MRI was statistically more likely to identify a joint connection than was US (P < 0.01). In the last decade, joint connections have been identified with increasing frequency using preoperative imaging, with up to 75% of cases reporting joint connections. CONCLUSIONS: Preoperative imaging plays an important role in establishing the diagnosis of intraneural ganglion cyst as well as treatment planning. Imaging has proved superior to the sole reliance of operative exposure to identify a joint connection, which is necessary to treat the underlying disease. Failure to identify cyst connections on imaging can result in an inability to truly address the underlying pathoanatomy at the time of definitive surgery, leading to a risk for clinical recurrence. Therefore, management should be guided by an intersection between new knowledge presented in the literature, clinical expertise, and surgeon experience.

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.