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Peri-Articular Cysts and Ganglia

DEFINITION AND PATHOGENESIS

  • Meniscal and ligamentous or capsular myxoid degeneration as a result of trauma, or synovial outpouchings as a result of developmental or degenerative etiology

IMPORTANCE

  • Symptomatic non-neoplastic lesions which require no tumor work up

CLINICAL FEATURES

  • ± pain, limitation of activities or motion, to asymptomatic periarticular swelling (often assymptomatic)
  • Dorsally in the wrist, association with the posterior interosseous nerve may be the etiology of the pain
  • Proximal tibiofibular joint ganglia may cause anterior compartment syndrome or peroneal nerve compression
  • Spinoglenoid ganglia compress the inferior branch of the suprascapular nerve with atrophy of infraspinatus and ER weakness
  • Often associated with posterior labral tear although direct communication with shoulder joint is rare
  • Compression of the radial or posterior interosseous nerve by ganglia in the region of the supinator muscle reported
  • Compression of the axillary nerve by a paraglenoid labral cyst reported
  • Compression of the sciatic nerve by a posterior hip cyst reported
  • Compression of the ulnar nerve by a ganglia of the ulnar groove reported
  • Selective motor neuropathy of the median nerve in the carpal tunnel has been reported
  • Compression of the palmar cutaneous nerve reported
  • May be associated with tarsal tunnel syndrome (most from the talocalcaneal joint ± coalition)
  • Medial plantar nerve dysesthesia, ± lateral plantar and medial calcaneal branch dysesthesias
  • Ganglia of the foot may arise from the TMTJ
  • Ganglion cysts may be associated with palpable snapping with motion of an adjacent joint
  • Meniscal cysts can become quite large ( ³10cm) and MRI will often reveal intraarticular pathology (meniscal tears)
  • Assoiciated with ~7% of meniscal tears
  • Arthroscopic decompression ± open excision (in larger cysts)
  • Bilateral cysts have been reported
  • ACL and PCL ganglion cysts can be a cause of knee pain, ? ROM
  • Intraneural ganglions/mucoid cysts/nerve sheath ganglia have been reported in median, ulnar, radial, posterior interosseous nerves, and within the brachial plexus with compressive sxs
  • Synovial cysts of the spine (± hemorrhagic component) involving facet joints may cause pain
    • ± radicular sxs
    • ± trauma hx
  • A giant synovial cyst remotely occurring after THA has been associated with development of DVT
  • Has been reported after A1 pulley (trigger finger) release
  • Lesion will often transilluminate
  • A ganglion most often occurs on the dorsal (60-70%) and volar surfaces of the wrist in persons between 25-45 yrs (M:F = 3.4:1)
  • Specific (and other) locations include:
    • Over the scapholunate ligament (may arise in various locations, connecting with a long stalk)
    • Volar radiocarpal joint between the FCR and APL tendons
    • Volar capsule of the scaphotrapezial joint
    • Volar annular A1 pulley (usually 3-8mm in size)
    • Mucous cyst at the dorsal DIPJ (MF most commonly involved)
    • Extensor tendon ganglia, esp over the metacarpals
    • Flexor tendon ganglia, esp the middle finger
    • Unusual location: palmar MCPJ, PIPJ (¾ responded to aspiration alone)

RADIOLOGIC FEATURES

  • Ossification of a ganglion cyst in a small finger has been reported
  • High T2 signal uptake ± cartilaginous or ligamentous intraarticular abnormalities on MRI
  • May occur at the insertion site of tendons and erode bone
  • Posterior horn medial meniscal cysts may be confused with PCL systs because of close proximity to the PCL
  • Erosion of bone can occur, even with intra-articular ganglia (eg, ACL cysts)
  • Paralabral cysts of the acetabulum associated with labral disorders
  • US imaging has been reported useful in choosing appropriate tx of flexor tendon sheath ganglions
  • Solitary cyst/anechoid mass: aspirate (~8% will require excision)
  • Solid tumor/heterogeneous hypoechoic mass: surgical excision (usually not a ganglion)
  • No echoic mass: probably tenosynovitis

GROSS PATHOLOGY

  • Gelatinous material in meniscal or ligamentous cysts to viscous joint fluid in Baker's cysts
  • Contains glucosamine, albumin, globulin, hyaluronic acid
  • A mucin duct can often be found on surgical exploration, transversing through the joint capsule

HISTOLOGIC FEATURES

  • Acellular material, few fibroblasts and mesenchymal cells
  • Outer wall with randomly oriented layers of collagen fibers

DIFFERENTIAL CLINICOPATHOLOGIC DIAGNOSIS

  • These non-neoplastic processes pose no diagnostic dilemma unless in the case of very small wrist ganglia which may be confused with sprains of the scapholunate ligament or early carpal instability
  • Carpometacarpal boss (± associated ganglion)
  • Dorsal retinacular ganglia of the 1st extensor compartment in pts with DeQuervain's stenosing tenosynovitis require release of thumb extensor tendon adhesions (and avoidance of radial sensory nerve)
  • Traumatic venous or arterial aneurysm
  • Rheumatoid cyst

DISEASE COURSE AND TREATMENT

  • Treatment of underlying pathologic condition in meniscal and Baker's cysts
  • Both meniscal cysts and the Baker's cyst may require open tx (or arthroscopic decompression through the defect)
  • ACL and PCL cysts usually ammendable to arthroscopic decompression
  • Needle aspiration/puncture ± steroid injection (both with ~33% "cure") and digital massage (except in volar ganglia near the radial artery), esp in A1 pulley ganglia may result in cure
  • May disappear spontaneously, esp in children (22/29)
  • Detection of small ganglia about the wrist may be difficult
  • Resection of DIPJ osteophytes advocated in mucous cyst excision
  • Dorsal wrist ganglia may be associated with early carpal instability and their removal may be blamed for the instability after a routine ganglion excision
  • Tx of dorsal wrist ganglia with a silk thread crossed through the cyst X 3 weeks and massage has been described
  • Pseudoaneurysm of the radial artery has been reported a complication of wrist ganglion excision (let down the tourniquet!)
  • 96% cure rate with excision of a small cuff of tissue along with the stalk
  • Nail deformity not present preoperatively may occur after mucous cyst excision
  • Injection with fibrin glue has been reported as successful in 76% of patients
  • Injection of hyaluronidase + methylprednisolone with cure rate of 89% (57% reported with methylprednisolone alone)

SPECIAL CONSIDERATIONS

  • BAKER'S CYST

    • In adults, usually associated with intraarticular pathology, such as meniscal tears or DJD, responding to tx of these abnormalities, occasionally requiring ablation surgically; occasionally huge or extensive
    • Fluid is between the semimembranosis and the medial gastrocnemius head
    • In children, observation is the rule
    • Septic Baker's cyst a complication of septic gonarthritis
    • 'Complicated Baker's Cyst'
      • Refers to a variant resembling infection, but representing necrotic debri
      • Air within the cyst (but no infection)
  • OCCULT GANGLIA

    • Gangllia too small to palpate but suspected because of location and exam

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