Tag Archives: Ganglion Cyst

Ganglion Cyst of the Distal Tibia: A case report

Posted on November 1, 2009 | Comments Off on Ganglion Cyst of the Distal Tibia: A case report

by Ali Abadi, DPM1  , Jennifer Berlin, DPM2 , Warren Mangel, DPM3

The Foot and Ankle Online Journal 2 (11): 2

A 42 year-old female with persistent pain and numbness to the left foot and ankle is presented. Magnetic resonance imaging shows a ganglion cyst communicating to a cystic region within the tibia. The cyst is surgically excised and the tibia is curettaged and packed with cancellous bone chips. The ganglion is confirmed to be communicating with the left distal tibia bone. We present an unusual case of a ganglion cyst arising from bone.

Key words: Ganglion cyst, benign tumor, distal tibia.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License. It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: October, 2009
Published: November, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0211.0002

The term ganglion was first used by Hippocrates to designate a knot of tissue filled with “mucoid flesh”. [1] It is a cystic swelling,1 – 3 cm in diameter, found typically in close proximity of joints and tendon sheath. The most common sites are the dorsal and volar aspect of the wrist, the dorsum of the foot, and around the ankle and the knee. [1] Ganglion cysts are well demarcated and movable within the surrounding tissue and are often loosely attached to a tendon sheath or the capsule of a joint. The dense fibrous capsule encloses the cyst which contains a viscid, jelly-like fluid rich in hyaluronic acid and other acid mucopolasaccharides. [2]

Case Report

A 42 years-old female patient presents with severe pain and numbness to the left foot and ankle. The patient presents to the doctor’s office complaining of intermittent pain and numbness of the left toes. The patient relates to mild pain while ambulating and going up the stairs. There is no history of trauma. Radiographs are negative for stress fracture. Conservative treatment is initially attempted to relive symptoms. This consisted of oral anti inflammatory medication and ankle bracing for stabilization. This was found to be ineffective. The pain is now intermittent and not affecting quality of life.

Magnetic Resonance Image (MRI) of the foot and ankle reveals a ganglion measuring 3cm above ankle joint. This area was asymptomatic on physical examination. The patient opted to monitor its progression. Two years later, the patient now experiences constant numbness of the left foot and toes as well as painful swelling along the posterolateral aspect of the leg. Surgery is discussed and planned for removal of the ganglion cyst.

There is now point tenderness and pain on palpation around the posterolateral aspect of the left ankle. Numbness is affecting the toes. (Fig. 1) Plain radiographs reveal a moderate increase in soft tissue swelling around the lateral malleolus. (Fig. 2) Radiographic studies are negative for stress fracture or other obvious osseous abnormalities.

Figure 1 Left leg with surgical mark.

Figure 2 Lateral radiograph ,left foot and ankle.

Laboratory examination included corpuscular blood count with differential count, white blood cell count, rheumatoid factor, C-reactive protein, erythrocyte sedimentation rate, and serum uric acid are all unremarkable. Electromyography result is negative for sciatica.

Magnetic resonance imaging of the ankle reveals a cystic lesion of 3cm x 1.5 cm in diameter with tibial bone erosion. Sagittal views showing a decreased signal intensity in T1 (Fig. 3A) and a well defined homogeneous bright signal in T2 (Fig. 3B) extending to the posterolateral aspect of the distal tibia. [3]

 

Figures 3A and B Sagittal view MRI (A) and cyst on T2 image showing cyst origin in bone. (B)

Surgical excision was performed. After inflating the thigh tourniquet, the ganglion cyst is excised through a 7 cm posterolateral incision. (Fig. 1) The mass is separated from the surrounding Flexor hallucis longus muscle and tissues. There is a well-defined capsule. The cystic mass is 3cm x 1.5 cm and penetrating the tibial bone. (Figs. 4A – D) The bone defect is evacuated with a bone currette and packed with cancellous bone chips. The tibial bone defect is about 1 cm. deep.(Figs. 5A and B)

 

 

Figures 4A – D Intra-operative photograph showing the ganglion cyst intact. (A)  A close-up of the cyst as it presents. (B)  The ganglion measures 3 x 1.5 centimeters. (C)  Intraoperative photo showing cyst dissection. (D)

 

Figures 5A and B Intra-operative photograph showing tibial erosion. (A)  When evacuated, there is an exposed cavity within the tibia that reveals the cyst origin. (B)

The pathology report is consistent with the diagnosis of ganglion. The cyst measured 3.5 x 3 cm with a wall of 0.1 cm thick that was composed of collagenous connective tissue. It presented along with several islands of mucinous material. No epithelial lining was noted. There was no reported evidence of neoplasm, inflammation or granuloma.

Postoperatively, the patient is pain-free and shows normal strength and sensation in the left foot and ankle. No recurrence has been noted up until the writing of this report.

Discussion

The ganglion cyst is the most common soft tissue mass found in the foot and ankle. [4] It is also a common occurrence in hand or wrist. A ganglion is a well-circumscribed, soft, and fluid-filled cystic mass that is frequently freely movable in the subcutaneous tissues and most often is found on the dorsum of the foot. [4] The exact etiology is unknown; however, traumatic, degenerative or inflammatory process in adjacent joints has been suggested as possible etiological factors. [5]

MRI is the modality of choice in the assessment of soft tissue tumors. On MRI, ganglion cysts demonstrate low intensity on T1 and high signal intensity on T2 weighted images.

Although 75% of all biopsy proved soft tissue masses of the foot and ankle are benign, [6,7] ganglion cysts should be differentiated from other tumors such as lipoma, hemangioma, infection and malignant tumors, such as malignant fibrous histiocytoma. [8]

References

1. Carp L, Stout AP: A study of ganglion with special reference to treatment. Surgery, Gynecology and Obstetrics 47: 460 – 468, 1928.
2. Soren A: Pathogenesis and treatment of ganglion. Clin Orthop Relat Res 48: 173 – 179, 1966.
3. Crim JR, Cracchiolo A, Hall R: Imaging of the foot and ankle. Imaging of the Foot and Ankle. 244. London: Martin Dunitz Ltd, 1996.
4. Hattrup SJ, Amadio PC, Sim FH, Lombardi RM: Metastatic tumors of the foot and ankle. Foot Ankle 8: 243-247, 1988.
5. Steiner E, Steinbachh LS, Schnarkowski P: Ganglia and cyst around joints. Radiol Clin North Am 34: 395 – 425, 1996.
6. Llauger J, Palmer J, Monill JM, Franquet T, Bague S, Roson N: MR imaging of benign soft tissue masses of the foot and ankle. Radiographics 1481 – 1498, 1998.
7. Pontius J, Good J, Maxian S: Ganglions of the foot and ankle: A retrospective analysis of 63 procedures J Am Podiatr Assoc 89: 163 – 168, 1999.
8. Banks AS, Downey MS, Martin DE, Miller SJ, McGlamry ED: McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Lippincott Williams and Wilkins; 3rd Revised edition, 1354 – 1366, 2001.

Address Correspondence to: Dr ALI Abadi, West Jersey Virtua Hospital, New Jersey. 101 Carnie Blvd., Voorhees, NJ 08043
E-mail : aa78@georgetown.edu

1  PGY-1, Virtua Hospital, 101 Carnie Blvd., Voorhees, NJ 08043.
2  Attending, Virtua Hospital, 101 Carnie Blvd., Voorhees, NJ 08043.
3  Chief of Podiatry Surgery, Virtua Hospital, 101 Carnie Blvd., Voorhees, NJ 08043.

© The Foot and Ankle Online Journal, 2009

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Intraosseous Ganglion of the Ankle: A Case Report

Posted on March 1, 2008 | Comments Off on Intraosseous Ganglion of the Ankle: A Case Report

by Vasu Pai MS, D (Orth), National board (Orth), FICMR, FRACS, MCh (Orth) 1, Vishal Pai, M.B., Chb2

The Foot & Ankle Journal 1 (3): 2

The case of a 52 year-old man with a persistent ganglion cyst of the dorsolateral aspect of the ankle is presented. At excision, the ganglion communicated to a cystic region within the bone of the lateral malleolus. The patient was treated with curettage of the lateral malleolus and cancellous bone grafting.

Key words: Intraosseous ganglion, lateral malleous, ganglion, benign tumor

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org)

Published online: March 1, 2008

ISSN: 1941-6806/08/0103-0002
doi: 10.3827/faoj.2008.0103.0002

Ganglia are most commonly located around the wrist as a soft tissue swelling with a pedicle. This can be traced to the scapholunate or radioscaphoid joints or surrounding tendon sheath. Intraosseous ganglion are rarely reported and occur mainly as carpal bone cysts. [1,2,3,4] A ganglion cyst of the lateral malleolus is a rare occurrence with only one report in the literature. [5] We report a case of an intraosseous ganglion of the lateral malleolus with soft tissue swelling. There was communication between an intraosseous ganglion and the overlying the soft tissue cyst.

Case Report

A 52 year-old man was referred for treatment of swelling involving the lateral aspect of his right ankle. Two years before presentation, the swelling appeared to have grown to significant size with associated aching pain. The patient also noticed pain around his ankle on weight bearing.Upon further inquiry, the patient reports a twisting injury to his right ankle in a rugby game that occurred in 1972. The injury was treated by cast immobilization and physiotherapy. The patient then underwent surgical repair in 1975 of which the details were not available. This surgery was successful and he was able to go back to work and also play rugby.Physical examination revealed a 6 cm diameter swelling over the dorsolateral aspect of the right ankle. There was no warmth or tenderness over the swelling. Swelling appeared fixed to the lateral malleolus. There was deep tenderness over the posterior aspect of lateral malleolus. (Fig 1)

 

Figure 1 Soft tissue swelling of the right lateral ankle.

Examination of the ankle revealed a range of motion of 15° dorsiflexion and 30° plantar flexion of the ankle, motion beyond which was painful. There was evidence of joint effusion and tenderness over the joint line on deep palpation. Distal neurovascular status appeared normal.
Blood examination including total lymphocyte count, ESR, CRP, rheumatoid factor and serum uric acid were unremarkable.
Magnetic resonance imaging of the foot showed discrete fluid collections both outside as well as within the lateral malleolus and was consistent with diagnosis of benign swelling of ganglion. (Fig . 2)
 

Figure 2 Coronal T2 and T1 weighted MR image showing a well defined homogeneous bright signal in T2 and decrease signal in T1, extending into the Anterolateral soft tissues.

Plain radiograph revealed moderate osteoarthritis of the ankle with joint space narrowing. There was a subtle multiloculated osteolytic lesion in the lateral malleolus with thin sclerotic margins along the intramedullary portion of the lateral malleolus. The distal fibula had mild remodeled expansion with thin cortical bone. There was a huge soft tissue swelling related to the lateral malleolus. (Fig. 3ab)

Figure 3a Ankle mortise view showing soft tissue swelling lateral to lateral malleolus.  A multiloculated osteolytic lesion is seen in the distal fibula.

Figure 3b Lateral radiograph showing diffuse osteoarthritis of the anterior and posterior ankle mortise.  Soft tissue swelling is also appreciated anteriorly.

The differential diagnosis includes giant cell tumor, gouty arthropathy, ganglion cyst, aneurysmal bone cyst or synovial sarcoma.

Under tourniquet control the ganglion was excised through a lateral incision. There was a 4 cm x 4 cm soft cystic mass which communicated directly with the lateral malleolus. There was a small defect over the posterior aspect of the malleolus. (Fig. 4)

Figure 4 Intra-operative photograph showing dissected superficial swelling from the lateral malleolus.

Discussion

Ganglion cysts are common mucin-containing tumors that affect a wide variety of joints of the body, including those of the foot and ankle. Despite their benign histology, the cysts can be problematic.

Pain and mass effects associated with the lesions can make ambulation and wearing shoes difficult.

In 1989, a series of 83 cases of soft-tissue tumor of the foot and ankle were retrospectively analyzed to determine the relative frequency of the lesions. [15] Seventy-two (87 percent) of the tumors were benign. Ganglion cysts and plantar fibromatoses were the most common. Ganglion have also been described in rarer areas of tendon, nerve and bone [6,7,8]

The etiology of intraosseous ganglia is uncertain. It has been shown by Landels that cysts in osteoarthritis arose from an intrusion of synovial fluid into bone at the joint surface. [9]

Kambolis reviewed 15 cases of ganglionic cystic defects of bone, and suggested that the intraosseous lesion was the result of extension of the overlying soft tissue ganglion into bone. [8] Other theories as to the cause of intraosseous ganglia include degeneration in intramedullary connective tissue and metaplasia of skeletal connective tissue

In a review of 54 cases of ganglion cyst, Rozbruch reported 4 patients with intraosseous ganglia located in the proximal tibia, patella and the first metatarsal head. [10] They also suggested that curettage of the bone gives better results. Isolated tarsal ganglion without soft tissue has also been reported. [11,12,13,14] A ganglion cyst of the lateral malleolus with a soft tissue extension is a rare occurrence, and there was only one report found in a literature review. [5]

Surgical excision is required in the majority of cases to confirm the diagnosis as well as alleviate pain when conservative measures are unsuccessful. The recurrence rate following excision of soft tissue ganglions can range from of 7 to 43 percent. [15] It appears that the recurrence following curettage of an intraosseous ganglion is rare. [16]
Bone lesions with a similar radiographic appearance (giant cell tumors, aneurysmal bone cyst, enchondromas, synovial sarcoma and gouty arthropathy) must be differentiated from intraosseous ganglia. Curettage of the cyst followed by packing of the defect with bone graft is the treatment of choice.

References

1. Tuzuner T, Subasi M, Alper M, Kara H, Orhan Z. : Penetrating type intraosseous ganglion cyst of the lunate bone West Indian Med J. 54(6):384-6, 2005.
2. De Smet L, Van Ransbeeck H.Intraosseous ganglion of the triquetrum. A transpisiformal approach. : Acta Orthop Belg. 66(2):194-6, 2000.
3. Fealy MJ, Lineaweaver W.Intraosseous ganglion cyst of the scaphoid. : Ann Plast Surg. 34(2):215-7, 1995.
4. Ikeda M, Oka Y.: Cystic lesion in carpal bone. Hand Surg. ;5(1):25-32, 2000.
5. Ahn JI, Park JS. Intraosseous ganglion. Report of a case.Int Orthop.;17(3):184-7, 1993.
6. Costa CR, Morrison WB, Carrino JA, Raiken SM. MRI of an intratendinous ganglion cyst of the peroneus brevis tendon. : Clin Orthop Relat Res.;445:254-60, 2006.
7. Adn M, Hamlat A, Morandi X, Guegan Y. Intraneural ganglion cyst of the tibial nerve. Acta Neurochir (Wien). 148(8):885-9; 2006.
8. Kambolis C, Bullough PG, Jaffe HI. Ganglionic cystic defects of bone. J Bone Joint Surg Am. 55(3):496-505, 1973.
9. Landells JW. The bone cysts of osteoarthritis. J Bone Joint Surg 35B,643-6,1953.
10. Rozbruch SR, Chang V, Bohne WH, Deland JT. Ganglion cysts of the lower extremity. Orhopedics 21:141- 148, 1998.
11. Murff R, Ashry HR. Intraosseous ganglia of the foot. J Foot Ankle Surg.;33(4):396-401,1994.
12. Uysal M, Akpinar S, Ozalay M. Arthroscopic debridement and grafting of intraosseous talar ganglion. Arthroscopy.21(10);1269,2005.
13. Wu KK. Intraosseous ganglion cyst of the middle cuneiform bone of the foot. J foot ankle surg 33(6):633-5, 1994.
14.Seymour N Intraosseous ganglia of medial malleolus, JBJS[Br](50),134-7,1968.
15. Kirby EJ, Shereff MJ, Lewis MM.Soft-tissue tumors and tumor-like lesions of the foot. An analysis of eighty-three cases. JBJS (Am). Apr;71(4):621-6, 1989.
16. Pontius J, Good J, Maxian S. Ganglions of the foot and ankle, an retrospective analysis of 63 procedures. J Am Pod Assoc 89:163 168, 1999.

Address correspondence to: Dr. Vasu Pai, Gisborne Hospital, Ormand Road, Gizborne, New Zealand.
E-mail: vasuchitra@gmail.com

1Orthopaedic Specialist, Gisborne, Hospital, Ormand Road, Gisborne, New Zealand.2House Surgeon, Middlemore Hospital, Auckland, New Zealand.

 

© The Foot & Ankle Journal, 2008

 

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A Massive Foot Ganglion: Case Report

Posted on January 1, 2008 | Comments Off on A Massive Foot Ganglion: Case Report

by Vasu Pai MS, D (Orth), National board (Orth), FICMR, FRACS, MCh (Orth)1 , Vishal Pai, M.B., Chb2

The Foot & Ankle Journal 1(1):2

Ganglion is one of the most common benign soft tissue swellings. The most common location is dorsum of the hand. However, it is not uncommon in the foot, but a massive ganglion is very rare. The case presented is one of a large, expanding ganglion over the dorsal aspect of the foot. This was successfully removed surgically.

Key words: Foot, Ganglion, benign tumor

ISSN 1941-6806/08/0101-0002
doi: 10.3827/faoj.2008.0101.0002

The foot is a relatively uncommon site of neoplastic and non-neoplastic soft tissue tumors. Although it contains a relatively small amount of somatic soft tissue elements, the foot is considerably rich in tendons, fasciae, retinaculae, and synovium. Corresponding to this distribution of soft tissue elements, some soft tissue lesions, such as ganglion, giant cell tumor of tendon sheath, fibromatosis, and synovial sarcoma, are commonly seen in this location.
Ganglia, caused by mucinous transformation of periarticular connective tissue, are the most common cystic lesions found around the joints or tendon sheath. Common locations of ganglion are the hand, foot,and knee. Ganglion may be single or multi loculated and can be subcutaneous or deep or sometimes intraosseous. We report here a massive multiloculated subcutaneous ganglion of the foot arising from the extensor tendon sheath of the foot.

Case Report

A 36-year-old woman presented with a rapidly increasing, large, painless, soft swelling involving the dorsum of his right foot. The lesion engulfed the whole of the dorsal aspect of the foot with more swelling over the lateral side. (Fig. 1,2) The swelling appeared lobulated and was approximately 14 cm x 8 cm. The lesion was subcutaneous, and the overlying skin was stretched considerably. The swelling was cystic and translucent. There was no history of trauma.

Figure 1 Massive left foot ganglion cyst.

Because of the large size of the lesion, the patient had considerable difficulty wearing her normal footwear. The patient also noticed that the swelling fluctuated on and off. There was no vascular or neurological compromise of the toe.

Blood tests were normal. X-ray was unremarkable and did not reveal any bony erosion adjacent to the swelling. An ultrasound examination revealed a pure cystic lesion. As swelling appeared benign and cystic, MRI was not performed.

Figure 2 Massive left foot ganglion cyst to the dorsum of the foot.

Surgical excision was performed. The mass separated from the surrounding skin quite easily. It appeared to be arising from the extensor tendon of the foot. (Fig. 3) There was a well-defined capsule. The fluid of swelling is gelatinous and is typical of ganglion fluid. Histological examination showed a benign ganglion. At 2 year’s follow-up, there was no recurrence. The patient was able to wear his proper footwear.

Figure 3 Removal of large dorsal foot ganglion cyst. No recurrence was reported after 2 years.

Discussion

Approximately 75% of all biopsy-proved soft-tissue masses of the foot and ankle are benign tumors. [1] In some cases, it may be difficult if not impossible to identify the lesion; however, careful analysis of the magnetic resonance (MR) imaging findings and correlation of these findings with the patient’s clinical history can usually suggest a more specific diagnosis, particularly in the most common benign tumors of the foot such as fibromatosis, cavernous hemangioma and in nonneoplastic soft-tissue lesions such as Morton’s neuroma, ganglion cyst, and plantar fasciitis. [2,3]

Statistics as to sex incidence vary, but most report a higher incidence in women. Subcutaneous ganglions are most common in the regions of the dorsum of the hand, palmar aspect of the wrist, palmar aspect of the fingers and dorsum of the foot. Recently intra-osseous ganglion, intraneural and intraligamentous ganglions have been described. 4,5,6

Ganglion may recur locally, but after local excision, the recurrence rate is less than 10% after complete removal of the sac. [2] Ogose [7] successfully treated a patient with large painful ganglion by OK-432 (lyophilized incubation mixture of group A Streptococcus pyogenes). Malignant changes in a ganglion are exceedingly rare.

There are a wide variety of different lesions which present as lumps of the foot. There have been very few studies which look at the presenting characteristics or the differential diagnosis of such lesions. A differential diagnosis of lipomas, myxoid variant of monophasic fibrous synovial sarcoma, bursitis, fibroma should be considered. [8] They suggested that there is a low diagnostic accuracy for foot lumps and, therefore, surgical excision and histological diagnosis should be sought if there is any uncertainty. Magnetic resonance imaging is the modality of choice in the assessment of soft tissue tumors. In the present case, MRI was not performed as clinically diagnosis was clear. The author generally relies on MRI for the diagnosis of all soft tissue lesions. In general, MRI does not provide histologic specificity, but considering some MR features may often help in correctly distinguishing benign from malignant lesions. In addition, characteristic features of the most common benign tumors (i.e., fibromatosis, ganglion cyst, Morton’s neuroma) often suggest a specific diagnosis. [9]

To our best knowledge, this is one of the largest ganglions involving the dorsum of foot reported in adult literature.

References

1. Llauger J, Palmer J, Monill JM, Franquet T, Bagué S, Rosón N. MR imaging of benign soft-tissue masses of the foot and ankle. Radiographics;18(6):1481-98,1998.
2. Kirby EJ, Shereff MJ, Lewis MM. Soft-tissue tumors and tumor-like lesions of the foot. An analysis of eighty-three cases. J Bone Joint Surg Am.71(4):621-6, 1989.
3. Pontius J, Good J, Maxian S. Ganglions of the foot and ankle, an retrospective analysis of 63 procedures. J Am Podiatr Assoc 89:163 168, 1999
4. Murff R, Ashry HR. Intraosseous ganglia of the foot. J Foot Ankle Surg.;33(4):396-401,1994
5. Battaglia TC, Freilich AM, Diduch DR. An intra-articular knee cyst in a 2-year-old associated with an aberrant anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc.
15(1):36-8,2007-12-
6. Adn M, Hamlat A, Morandi X, Guegan Y. Intraneural ganglion cyst of the tibial nerve. Acta Neurochir (Wien). 148(8):885-9; 2006
7. Ogose A, Hotta T, Kawashima H, Endo N. A painful large ganglion cyst of the ankle treated by the injection of OK-432.Mod Rheumatol. 17(4):341-3,2007
8. Macdonald DJ, Holt G, Vass K, Marsh A, Kumar CS. The differential diagnosis of foot lumps: 101 cases treated surgically in North Glasgow over 4 years. Ann R Coll Surg Engl. 89(3):272-5,2007
9. Wetzel LH, Levine E. Soft-tissue tumors of the foot: value of MR imaging for specific diagnosis.Foot Surg. 31(3):272-5. 1992

Address correspondence to: Dr. Vasu Pai, Gisborne Hospital, Ormand Road, Gizborne, New Zealand.
E-mail: vasuchitra@gmail.com 

1Orthopaedic Specialist, Gisborne, Hospital, Ormand Road, Gisborne, New Zealand.

2House Surgeon, Middlemore Hospital, Auckland, New Zealand.

© The Foot & Ankle Journal , 2008

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