- Email: [email protected]
Ultrasound-Guided Therapy for Knee and Foot Ganglion Cysts
The Journal of Foot & Ankle Surgery xxx (2016) 1–5
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Ultrasound-Guided Therapy for Knee and Foot Ganglion Cysts Brian L. Ju, MD 1, Kristy L. Weber, MD 2, Viviane Khoury, MD 3 1
Resident Physician, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA Chief of Orthopaedic Oncology and Professor, Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA 3 Director of Musculoskeletal Ultrasound and Assistant Professor, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
The present study evaluated the effectiveness of ultrasound-guided aspiration/injection of ganglion cysts in the lower extremities (knee and foot) that required referral to the radiology department for precise localization. The present study is the first series to describe such results. The study population consisted of 15 patients who had undergone treatment from April 2012 to January 2015. Follow-up was by telephone survey, which was performed at a mean of 15 6 months after treatment. Almost 90% of patients experienced immediate improvement in symptoms (mostly pain), and 77% of these patients had not experienced a recurrence of symptoms at a mean follow-up time of 14 6 months. In conclusion, ultrasound-guided therapy is a safe and potentially effective treatment for most cases of symptomatic lower extremity ganglion cysts. Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: aspiration extremity ganglia ganglion cyst injection ultrasound
Ganglion cysts are mucin-filled cysts around the joints and tendons that can cause substantial pain and impairment, depending on their location (1–3). Management of symptomatic ganglion cysts ranges from observation to aspiration/injection and surgical excision. Traditionally, the mainstay of surgical treatment has been open ganglionectomy. However, even within the realm of surgical management, interest in less invasive alternatives such as arthroscopic resection of ganglion cysts in the wrist has been increasing (4,5). In parallel, a trend has occurred toward nonsurgical management of these cysts using ultrasound (US) to guide aspiration and therapeutic injection (6–9). Although superficial, palpable cysts can be aspirated blindly in the office depending on physician comfort and expertise, US guidance is especially important when these cysts are deeper, smaller, and/or located near sensitive structures such as arteries and nerves. Although aspiration/injection has been associated with greater rates of recurrence compared with excision, surgery often results in increased morbidity, recovery times, and costs (10,11). The published data on US-guided therapy of ganglion cysts have generally been of the upper extremities (12–16). Only scant data, consisting mainly of case reports, have been published regarding the short- and long-term effectiveness of US-guided ganglion cyst treatment in the lower extremities (3,6–8).
Our goal was to determine the degree and duration of symptom improvement in patients who had received US-guided therapy specifically of lower extremity ganglion cysts. To our knowledge, the present study is the first series to describe such results. Patients and Methods Study Population The institutional review board approved the present study before its initiation. From April 2012 to January 2015, approximately 30 patients had been referred by the orthopedic department to the musculoskeletal radiology department for treatment of suspected knee or foot ganglion cysts. A total of 20 consecutive patients were identified who had received diagnostic musculoskeletal ultrasound examination that confirmed the presence of a ganglion cyst, with USguided therapy performed on these cysts during the same visit. An attempt was made to interview all 20 patients by telephone to complete a survey consisting of 9 questions (Fig. 1). Of the 20 patients, 15 were successfully reached and agreed to complete the telephone survey. The 5 (25%) patients who were unable to be contacted were excluded from the study. One of us (B.L.J.) performed all the telephone interviews. Ultrasound Technique
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Brian L. Ju, MD, Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104. E-mail address: [email protected] (B.L. Ju).
One musculoskeletal radiologist with 10 years of musculoskeletal ultrasonography experience performed the diagnostic and therapeutic ultrasound examinations. All procedures were performed using a Philips iU22 US machine (Philips, Amsterdam, Netherlands) with
1067-2516/$ - see front matter Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2016.04.015
2
B.L. Ju et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
1. Have you ever received any other form of treatment for ganglion cysts of the legs or feet? Yes/No 2. If you have received other treatment for the ganglion cyst, was it performed before or after the cyst aspiration? What was the other form of treatment (surgery, aspiration, other)? Before/After Surgery/Aspiration/Other 3. What was your level of pain prior to ganglion cyst aspiration? No pain/Mild pain/Moderate Pain/Severe pain 4. Prior to cyst aspiration, did the ganglion cyst limit your ability to perform daily activities (walking, performing chores or work activities, etc)? No limitations/Mild/Moderate/Severe 5. Did your pain improve, worsen, or remain unchanged after ganglion cyst aspiration? Unchanged/Improved slightly/Improved signi icantly/Worsened slightly/Worsened signi icantly 6. Did your ability to perform daily activities improve after cyst aspiration? Unchanged/Improved slightly/Improved signi icantly/Worsened slightly/Worsened signi icantly 7.
Did you experience a recurrence of pain or symptoms after cyst aspiration? If so, approximately how long after the cyst aspiration?
Yes/No/Not applicable (i.e. never improved to begin with) Time Interval 8. Would you want to undergo ganglion cyst aspiration again if you had another ganglion cyst? Yes/No/Unsure 9. Would you prefer to undergo surgery or no treatment as an alternative to cyst aspiration if you developed another ganglion cyst? Yes/No If yes, Surgery/No treatment
Fig. 1. Telephone survey regarding ganglion cyst aspiration.
high-resolution 12- to 17-MHz transducers. A complete diagnostic US examination of the extremity was performed in all cases before therapy during the same visit. A ganglion cyst was diagnosed by identifying the characteristic ultrasound features, specifically a welldefined, anechoic or mildly complex, soft tissue lesion demonstrating acoustic enhancement, lacking internal vascularity, and
showing variable degrees of compressibility. After identification of the ganglion cyst to be treated, the area over the cyst was marked, draped in a sterile fashion, and infiltrated with 3 to 7 mL of 1% lidocaine. A 20- to 22-gauge needle was advanced into the ganglion cyst using an in-plane approach and free hand technique (Fig. 2). If the cyst contents could not be spontaneously aspirated, saline was injected to
B.L. Ju et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
3
Fig. 2. (A) Ultrasound scan of ganglion cyst before aspiration. (B) Ultrasound scan of ganglion cyst after aspiration.
separate the thick mucinous contents of the cyst (Fig. 3), followed by attempted aspiration. All cysts were then injected with 0.25 to 1 mL of 0.25% bupivacaine and 0.5 mL of triamcinolone (20 mg) regardless of whether aspiration had been performed. None of the aspirated cyst contents were sent for pathologic examination given their benign ultrasound features typical of ganglion cysts and their characteristic physical attributes. Statistical Analysis The results are expressed as the mean standard deviation. Three orthogonal measurements for each cyst were measured on the US scan, from which the prolate ellipsoid volume was calculated (height length width p/6).
Results Fifteen US-guided ganglion cyst interventions were performed (Table 1). Only 1 cyst was identified and treated per patient. The population consisted of 10 females and 5 males. The mean age of the patients was 52 14 (range 28 to 72) years. Of the 15 cysts, 11 were located around the foot and 4 around the knee (Table 2). The ganglia ranged in volume from 0.2 to 29 (mean 4.3 8.5) cm3. Before presenting to our department, only 3 of the 11 patients had received previous treatment for ganglia in the feet. Pain before US-guided treatment was reported as mild by 5 patients, moderate by 6, and severe by 3 patients. One patient presented for cosmetic concerns and did not report pain. The degree of impairment on daily activities caused by the cyst ranged from mild in 2 patients, moderate in 9, and severe in 2 patients; 2 patients had not experienced a significant degree of impairment. Of the 15 cysts, symptomatic improvement after US-guided treatment was reported by 13 patients (including the patient who had presented for treatment of a cosmetic cyst, which had decreased in size). Two patients reported unchanged pain symptoms after treatment. The mean follow-up time from cyst treatment to the telephone survey was 14.9 6.3 (range 7 to 29) months. Of the 15 patients, 3 reported a recurrence of symptoms at a mean of 3 3 (range 0 to 6) months, with 1 patient reporting a recurrence of symptoms only a few days after treatment. Ten of the patients had experienced no symptomatic recurrence at a mean follow-up time of 14 6 (range 7 to 29) months. Two patients reported symptoms that were unchanged after cyst injection (mean follow-up time 12 4, range 9 to 15 months). Specifically, of the 13 patients who experienced symptomatic improvement after the procedure, 3 (23%) experienced a recurrence of Table 1 Ganglion cyst treatment results (N ¼ 15 patients) Variable Sex Female Male Location Foot Knee Cyst size (cm3) Mean Range Response to therapy Improvement No improvement Recurrence of symptoms Yes No
Fig. 3. Aspirated ganglion cyst mucinous contents.
Value 10 5 11 4 4.3 8.5 0.2 to 29 13 (87) 2 (13) 3 (23; mean 3 3 mo) 10 (77; mean 14 6 mo)
4
B.L. Ju et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
Table 2 Ganglion cyst locations and sizes (N ¼ 15 patients) Region
Location
Size (cm)
Knee
Lateral to quadriceps tendon Lateral knee Posterior knee Proximal fibula Peroneal tendon Tibialis anterior tendon Flexor hallucis longus tendon Posterior subtalar joint Talonavicular joint Talonavicular joint Tarsometatarsal joint Metatarsal Metatarsal Metatarsal Metatarsal
1.2 2.3 4.7 4.7 0.8 2.2 1.3 0.8 0.3 1.0 1.7 1.6 1.5 2.7 2.4
Foot
0.9 2.2 2.5 2.7 1.3 0.6 2.8 0.6 1.2 1.0 1.6 0.3 0.9 1.1 1.3
Volume (cm3)
0.9 0.7 3.4 4.4 0.5 2.2 2.8 1.1 1.0 1.0 1.0 1.0 0.8 0.8 0.8
0.5 1.8 20 29 0.3 1.5 5.3 0.3 0.2 1 1.4 0.3 0.6 1.2 1.3
symptoms and 10 (77%) remained symptom-free at the follow-up survey. Of the patients who responded clinically, 7 reported significant improvement in symptoms, 1 had moderate symptomatic improvement, and 5 had mild symptomatic improvement. When queried whether the patients would choose to have the same type of US-guided cyst interventional procedure to treat future ganglion cysts, 11 (73%) responded in the affirmative and 4 (27%) responded in the negative. The 4 patients who would not choose the procedure performed again included 2 who had experienced symptomatic recurrence after an initial response and the 2 patients who had not experienced symptomatic improvement after the procedure. One of the 3 patients with symptom recurrence stated she would choose to have cyst aspiration/injection again for treatment of her symptoms. However, only 2 patients in the entire series stated they would rather pursue surgery for further management of their ganglion cysts (1 who had reported symptom recurrence and 1 with no response to the initial therapy). Of the 15 cysts, 6 were injected without aspiration, either because of the viscous nature of the cyst contents or the small size of the cyst. In a few of these cases, a small amount of saline was injected in an attempt to break up the mucinous contents. Nine of the cysts were both aspirated and injected. The volume of aspirated fluid varied from 0.2 to 14 mL. None of the patients experienced immediate or delayed complications (e.g., local hematoma, nerve palsy, infection, or wound issues) from the procedures. Discussion Depending on their location, ganglion cysts can cause substantial clinical symptoms, such as pain, with resultant impairment in daily activities. This especially holds true when they are located in the lower extremities, which bear the burden of weightbearing and the mechanical forces from above. The management options range from conservative treatment to interventional procedures such as aspiration/injection to surgery. For those who choose intervention, much of the already scarce data on aspiration/injection have focused on cysts that occur in the upper extremities, namely the hand and wrist region. The present study is the first series to describe US-guided ganglion cyst therapy in the lower extremity. Patients who present to a surgeon with a ganglion cyst in the lower extremity sometimes have the cyst blindly aspirated in the office, depending on the location and physician comfort level. Many of the patients referred to our musculoskeletal imaging department have clinically suspected occult ganglion cysts or cysts seen on previous imaging studies that necessitate US guidance for therapy owing to their deep or delicate location near an arterial vessel or nerve. These
cysts are uniformly amenable to US-guided treatment as long as a safe path can be established from the skin to the internal target and no contraindications exists to performing such a procedure. Moreover, the initial evaluation of a painful extremity with US can be both diagnostic and therapeutic, obviating the need for more costly imaging procedures such as magnetic resonance imaging to determine the source of pain and/or confirm the presence of a cyst suspected clinically. In our study, 15 patients presented for cyst aspiration/injection in the setting of a wide spectrum of pain levels and associated impairment. The vast majority of patients experienced symptom improvement after treatment, and of these patients, 77% remained symptom-free at an average follow-up time of >1 year. Only a few patients with an initial response reported recurrence of symptoms several months after the procedure. This suggests that cyst aspiration/ injection is an effective treatment method for most patients with long-term symptomatic relief and that if treatment failure will occur, it will present shortly after the procedure. Furthermore, most patients reported moderate to significant improvement in their symptoms after therapy. Approximately 3 of 4 patients stated they would undergo the same procedure if they had another ganglion cyst that needed treatment. However, of the other 4 patients who would not choose US-guided therapy, only 2 would rather undergo surgery. We believe this points to a trend toward patient preference for less invasive management of ganglion cysts, even among those who experienced recurrence of symptoms after aspiration/injection or those with no initial response. Undoubtedly, investigation into other minimally invasive procedures for treating these cysts would be of value. Specifically, injection of the cyst with a sclerosing agent, either with or without a corticosteroid injection, has not been extensively studied but is an effective technique used to treat cystic lesions in other organs (17–19). The limitations of the present study included the follow-up length, which spanned 7 to 29 months. As such, symptom recurrence beyond that period was not captured in our study. Additionally, US is operator-dependent, and the technical success and effectiveness of the intervention might depend in part on the level of experience of the radiologist. Another limitation was the lack of a control group that underwent cyst aspiration without a corticosteroid injection. Still further, selection bias and unknown reliability of the patient telephone questionnaire could have influenced the findings of this observational investigation. In conclusion, US-guided therapy was a safe and potentially effective treatment for most cases of symptomatic lower extremity ganglion cysts in our small series. It is an affordable and dynamic modality that is increasingly used in our cost-conscious healthcare environment. It has an important role in the management of clinically occult ganglion cysts, in addition to patients who are poor surgical candidates. A large, untapped potential exists in the realm of minimally invasive US-guided treatments that should be pursued. References 1. Mulligan EP, McCain K. Common fibular (peroneal) neuropathy as the result of a ganglion cyst. J Orthop Sports Physical Ther 42:1051, 2012. 2. Ozden R, Uruc V, Kalaci A, Dogramaci Y. Compression of common peroneal nerve caused by an extraneural ganglion cyst mimicking intermittent claudication. J Brachial Plex Peripher Nerve Inj 8:5, 2013. 3. Touraine S, Lagadec M, Petrover D, Genah I, Parlier-Cuau C, Bousson V, Laredo J. A ganglion of the patellar tendon in patellar tendon-lateral femoral condyle friction syndrome. Skeletal Radiol 42:1323–1327, 2013. 4. Rizzo M, Berger RA, Steinmann SP, Bishop AT. Arthroscopic resection in the management of dorsal wrist ganglions: results with a minimum 2-year follow-up period. J Hand Surg 29A:59–62, 2004. 5. Yamamoto M, Kurimoto S, Okui N, Tatebe M, Shinohara T, Hirata H. Sonographyguided arthroscopy for wrist ganglion. J Hand Surg 37A:1411–1415, 2012.
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6. Jose J, Silverman E, Kaplan L. Symptomatic ganglion cyst of the popliteus tendon treated with ultrasound-guided aspiration and steroid injection: a case report. Sports Health 3:393–395, 2011. 7. Liang T, Panu A, Crowther S, Low G, Lambert R. Ultrasound-guided aspiration and injection of an intraneural ganglion cyst of the common peroneal nerve. HSSJ 9:270–274, 2013. 8. Saboeiro GR, Sofka CM. Ultrasound-guided ganglion cyst aspiration. HSSJ 4: 161–163, 2008. 9. Suen M, Fung B, Lung CP. Treatment of ganglion cysts. ISRN Orthop 2013:1–7, 2013. 10. Angelides AC, Wallace PF. The dorsal ganglion of the wrist: its pathogenesis, gross and microscopic anatomy, and surgical treatment. J Hand Surg 1: 228–235, 1976. 11. Dias J, Buch K. Palmar wrist ganglion: does intervention improve outcome? A prospective study of the natural history and patient-reported treatment outcomes. J Hand Surg Br 28:172–176, 2003. 12. Bianchi S, Abdelwahab IF, Zwass A, Giacomello P. Ultrasonographic evaluation of wrist ganglia. Skeletal Radiol 23:201–203, 1994.
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13. Breidahl WH, Adler RS. Ultrasound-guided injection of ganglia with corticosteroids. Skeletal Radiol 25:635–638, 1996. 14. Korman J, Pearl R, Hentz VR. Efficacy of immobilization following aspiration of carpal and digital ganglions. J Hand Surg 17:1097–1099, 1992. 15. Richman JA, Gelberman RH, Engber WD, Salamon PB, Bean DJ. Ganglions of the wrist and digits and results of treatment by aspiration and cyst wall puncture. J Hand Surg 12:1041–1043, 1987. 16. Teh J, Vlychou M. Ultrasound-guided interventional procedures of the wrist and hand. Eur Radiol 19:1002–1010, 2009. 17. Akhan O, Islim F, Balci S, Erbahceci A, Akpinar B, Ciftci T, Akinci D. Percutaneous treatment of simple hepatic cysts: the long-term results of PAIR and catheterization techniques as single-session procedures. Cardiovasc Intervent Radiol 1:1–7, 2015. 18. Mun SW, Lim T, Hwang EH, Lee YJ, Jeon UB, Park JH. A case of post-traumatic pseudocyst in the spleen successfully treated with alcohol sclerotherapy. Pediatr Gastroenterol Hepatol Nutr 18:276–279, 2015. 19. Tanaka Y, Takakura Y, Kumai T, Sugimoto K, Taniguchi A, Hattori K. Sclerotherapy for intractable ganglion cyst of the hallux. Foot Ankle Int 30:128–132, 2009.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Ultrasound-Guided Therapy for Knee and Foot Ganglion Cysts Brian L. Ju, MD 1, Kristy L. Weber, MD 2, Viviane Khoury, MD 3 1
Resident Physician, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA Chief of Orthopaedic Oncology and Professor, Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA 3 Director of Musculoskeletal Ultrasound and Assistant Professor, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
The present study evaluated the effectiveness of ultrasound-guided aspiration/injection of ganglion cysts in the lower extremities (knee and foot) that required referral to the radiology department for precise localization. The present study is the first series to describe such results. The study population consisted of 15 patients who had undergone treatment from April 2012 to January 2015. Follow-up was by telephone survey, which was performed at a mean of 15 6 months after treatment. Almost 90% of patients experienced immediate improvement in symptoms (mostly pain), and 77% of these patients had not experienced a recurrence of symptoms at a mean follow-up time of 14 6 months. In conclusion, ultrasound-guided therapy is a safe and potentially effective treatment for most cases of symptomatic lower extremity ganglion cysts. Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: aspiration extremity ganglia ganglion cyst injection ultrasound
Ganglion cysts are mucin-filled cysts around the joints and tendons that can cause substantial pain and impairment, depending on their location (1–3). Management of symptomatic ganglion cysts ranges from observation to aspiration/injection and surgical excision. Traditionally, the mainstay of surgical treatment has been open ganglionectomy. However, even within the realm of surgical management, interest in less invasive alternatives such as arthroscopic resection of ganglion cysts in the wrist has been increasing (4,5). In parallel, a trend has occurred toward nonsurgical management of these cysts using ultrasound (US) to guide aspiration and therapeutic injection (6–9). Although superficial, palpable cysts can be aspirated blindly in the office depending on physician comfort and expertise, US guidance is especially important when these cysts are deeper, smaller, and/or located near sensitive structures such as arteries and nerves. Although aspiration/injection has been associated with greater rates of recurrence compared with excision, surgery often results in increased morbidity, recovery times, and costs (10,11). The published data on US-guided therapy of ganglion cysts have generally been of the upper extremities (12–16). Only scant data, consisting mainly of case reports, have been published regarding the short- and long-term effectiveness of US-guided ganglion cyst treatment in the lower extremities (3,6–8).
Our goal was to determine the degree and duration of symptom improvement in patients who had received US-guided therapy specifically of lower extremity ganglion cysts. To our knowledge, the present study is the first series to describe such results. Patients and Methods Study Population The institutional review board approved the present study before its initiation. From April 2012 to January 2015, approximately 30 patients had been referred by the orthopedic department to the musculoskeletal radiology department for treatment of suspected knee or foot ganglion cysts. A total of 20 consecutive patients were identified who had received diagnostic musculoskeletal ultrasound examination that confirmed the presence of a ganglion cyst, with USguided therapy performed on these cysts during the same visit. An attempt was made to interview all 20 patients by telephone to complete a survey consisting of 9 questions (Fig. 1). Of the 20 patients, 15 were successfully reached and agreed to complete the telephone survey. The 5 (25%) patients who were unable to be contacted were excluded from the study. One of us (B.L.J.) performed all the telephone interviews. Ultrasound Technique
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Brian L. Ju, MD, Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104. E-mail address: [email protected] (B.L. Ju).
One musculoskeletal radiologist with 10 years of musculoskeletal ultrasonography experience performed the diagnostic and therapeutic ultrasound examinations. All procedures were performed using a Philips iU22 US machine (Philips, Amsterdam, Netherlands) with
1067-2516/$ - see front matter Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2016.04.015
2
B.L. Ju et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
1. Have you ever received any other form of treatment for ganglion cysts of the legs or feet? Yes/No 2. If you have received other treatment for the ganglion cyst, was it performed before or after the cyst aspiration? What was the other form of treatment (surgery, aspiration, other)? Before/After Surgery/Aspiration/Other 3. What was your level of pain prior to ganglion cyst aspiration? No pain/Mild pain/Moderate Pain/Severe pain 4. Prior to cyst aspiration, did the ganglion cyst limit your ability to perform daily activities (walking, performing chores or work activities, etc)? No limitations/Mild/Moderate/Severe 5. Did your pain improve, worsen, or remain unchanged after ganglion cyst aspiration? Unchanged/Improved slightly/Improved signi icantly/Worsened slightly/Worsened signi icantly 6. Did your ability to perform daily activities improve after cyst aspiration? Unchanged/Improved slightly/Improved signi icantly/Worsened slightly/Worsened signi icantly 7.
Did you experience a recurrence of pain or symptoms after cyst aspiration? If so, approximately how long after the cyst aspiration?
Yes/No/Not applicable (i.e. never improved to begin with) Time Interval 8. Would you want to undergo ganglion cyst aspiration again if you had another ganglion cyst? Yes/No/Unsure 9. Would you prefer to undergo surgery or no treatment as an alternative to cyst aspiration if you developed another ganglion cyst? Yes/No If yes, Surgery/No treatment
Fig. 1. Telephone survey regarding ganglion cyst aspiration.
high-resolution 12- to 17-MHz transducers. A complete diagnostic US examination of the extremity was performed in all cases before therapy during the same visit. A ganglion cyst was diagnosed by identifying the characteristic ultrasound features, specifically a welldefined, anechoic or mildly complex, soft tissue lesion demonstrating acoustic enhancement, lacking internal vascularity, and
showing variable degrees of compressibility. After identification of the ganglion cyst to be treated, the area over the cyst was marked, draped in a sterile fashion, and infiltrated with 3 to 7 mL of 1% lidocaine. A 20- to 22-gauge needle was advanced into the ganglion cyst using an in-plane approach and free hand technique (Fig. 2). If the cyst contents could not be spontaneously aspirated, saline was injected to
B.L. Ju et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
3
Fig. 2. (A) Ultrasound scan of ganglion cyst before aspiration. (B) Ultrasound scan of ganglion cyst after aspiration.
separate the thick mucinous contents of the cyst (Fig. 3), followed by attempted aspiration. All cysts were then injected with 0.25 to 1 mL of 0.25% bupivacaine and 0.5 mL of triamcinolone (20 mg) regardless of whether aspiration had been performed. None of the aspirated cyst contents were sent for pathologic examination given their benign ultrasound features typical of ganglion cysts and their characteristic physical attributes. Statistical Analysis The results are expressed as the mean standard deviation. Three orthogonal measurements for each cyst were measured on the US scan, from which the prolate ellipsoid volume was calculated (height length width p/6).
Results Fifteen US-guided ganglion cyst interventions were performed (Table 1). Only 1 cyst was identified and treated per patient. The population consisted of 10 females and 5 males. The mean age of the patients was 52 14 (range 28 to 72) years. Of the 15 cysts, 11 were located around the foot and 4 around the knee (Table 2). The ganglia ranged in volume from 0.2 to 29 (mean 4.3 8.5) cm3. Before presenting to our department, only 3 of the 11 patients had received previous treatment for ganglia in the feet. Pain before US-guided treatment was reported as mild by 5 patients, moderate by 6, and severe by 3 patients. One patient presented for cosmetic concerns and did not report pain. The degree of impairment on daily activities caused by the cyst ranged from mild in 2 patients, moderate in 9, and severe in 2 patients; 2 patients had not experienced a significant degree of impairment. Of the 15 cysts, symptomatic improvement after US-guided treatment was reported by 13 patients (including the patient who had presented for treatment of a cosmetic cyst, which had decreased in size). Two patients reported unchanged pain symptoms after treatment. The mean follow-up time from cyst treatment to the telephone survey was 14.9 6.3 (range 7 to 29) months. Of the 15 patients, 3 reported a recurrence of symptoms at a mean of 3 3 (range 0 to 6) months, with 1 patient reporting a recurrence of symptoms only a few days after treatment. Ten of the patients had experienced no symptomatic recurrence at a mean follow-up time of 14 6 (range 7 to 29) months. Two patients reported symptoms that were unchanged after cyst injection (mean follow-up time 12 4, range 9 to 15 months). Specifically, of the 13 patients who experienced symptomatic improvement after the procedure, 3 (23%) experienced a recurrence of Table 1 Ganglion cyst treatment results (N ¼ 15 patients) Variable Sex Female Male Location Foot Knee Cyst size (cm3) Mean Range Response to therapy Improvement No improvement Recurrence of symptoms Yes No
Fig. 3. Aspirated ganglion cyst mucinous contents.
Value 10 5 11 4 4.3 8.5 0.2 to 29 13 (87) 2 (13) 3 (23; mean 3 3 mo) 10 (77; mean 14 6 mo)
4
B.L. Ju et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
Table 2 Ganglion cyst locations and sizes (N ¼ 15 patients) Region
Location
Size (cm)
Knee
Lateral to quadriceps tendon Lateral knee Posterior knee Proximal fibula Peroneal tendon Tibialis anterior tendon Flexor hallucis longus tendon Posterior subtalar joint Talonavicular joint Talonavicular joint Tarsometatarsal joint Metatarsal Metatarsal Metatarsal Metatarsal
1.2 2.3 4.7 4.7 0.8 2.2 1.3 0.8 0.3 1.0 1.7 1.6 1.5 2.7 2.4
Foot
0.9 2.2 2.5 2.7 1.3 0.6 2.8 0.6 1.2 1.0 1.6 0.3 0.9 1.1 1.3
Volume (cm3)
0.9 0.7 3.4 4.4 0.5 2.2 2.8 1.1 1.0 1.0 1.0 1.0 0.8 0.8 0.8
0.5 1.8 20 29 0.3 1.5 5.3 0.3 0.2 1 1.4 0.3 0.6 1.2 1.3
symptoms and 10 (77%) remained symptom-free at the follow-up survey. Of the patients who responded clinically, 7 reported significant improvement in symptoms, 1 had moderate symptomatic improvement, and 5 had mild symptomatic improvement. When queried whether the patients would choose to have the same type of US-guided cyst interventional procedure to treat future ganglion cysts, 11 (73%) responded in the affirmative and 4 (27%) responded in the negative. The 4 patients who would not choose the procedure performed again included 2 who had experienced symptomatic recurrence after an initial response and the 2 patients who had not experienced symptomatic improvement after the procedure. One of the 3 patients with symptom recurrence stated she would choose to have cyst aspiration/injection again for treatment of her symptoms. However, only 2 patients in the entire series stated they would rather pursue surgery for further management of their ganglion cysts (1 who had reported symptom recurrence and 1 with no response to the initial therapy). Of the 15 cysts, 6 were injected without aspiration, either because of the viscous nature of the cyst contents or the small size of the cyst. In a few of these cases, a small amount of saline was injected in an attempt to break up the mucinous contents. Nine of the cysts were both aspirated and injected. The volume of aspirated fluid varied from 0.2 to 14 mL. None of the patients experienced immediate or delayed complications (e.g., local hematoma, nerve palsy, infection, or wound issues) from the procedures. Discussion Depending on their location, ganglion cysts can cause substantial clinical symptoms, such as pain, with resultant impairment in daily activities. This especially holds true when they are located in the lower extremities, which bear the burden of weightbearing and the mechanical forces from above. The management options range from conservative treatment to interventional procedures such as aspiration/injection to surgery. For those who choose intervention, much of the already scarce data on aspiration/injection have focused on cysts that occur in the upper extremities, namely the hand and wrist region. The present study is the first series to describe US-guided ganglion cyst therapy in the lower extremity. Patients who present to a surgeon with a ganglion cyst in the lower extremity sometimes have the cyst blindly aspirated in the office, depending on the location and physician comfort level. Many of the patients referred to our musculoskeletal imaging department have clinically suspected occult ganglion cysts or cysts seen on previous imaging studies that necessitate US guidance for therapy owing to their deep or delicate location near an arterial vessel or nerve. These
cysts are uniformly amenable to US-guided treatment as long as a safe path can be established from the skin to the internal target and no contraindications exists to performing such a procedure. Moreover, the initial evaluation of a painful extremity with US can be both diagnostic and therapeutic, obviating the need for more costly imaging procedures such as magnetic resonance imaging to determine the source of pain and/or confirm the presence of a cyst suspected clinically. In our study, 15 patients presented for cyst aspiration/injection in the setting of a wide spectrum of pain levels and associated impairment. The vast majority of patients experienced symptom improvement after treatment, and of these patients, 77% remained symptom-free at an average follow-up time of >1 year. Only a few patients with an initial response reported recurrence of symptoms several months after the procedure. This suggests that cyst aspiration/ injection is an effective treatment method for most patients with long-term symptomatic relief and that if treatment failure will occur, it will present shortly after the procedure. Furthermore, most patients reported moderate to significant improvement in their symptoms after therapy. Approximately 3 of 4 patients stated they would undergo the same procedure if they had another ganglion cyst that needed treatment. However, of the other 4 patients who would not choose US-guided therapy, only 2 would rather undergo surgery. We believe this points to a trend toward patient preference for less invasive management of ganglion cysts, even among those who experienced recurrence of symptoms after aspiration/injection or those with no initial response. Undoubtedly, investigation into other minimally invasive procedures for treating these cysts would be of value. Specifically, injection of the cyst with a sclerosing agent, either with or without a corticosteroid injection, has not been extensively studied but is an effective technique used to treat cystic lesions in other organs (17–19). The limitations of the present study included the follow-up length, which spanned 7 to 29 months. As such, symptom recurrence beyond that period was not captured in our study. Additionally, US is operator-dependent, and the technical success and effectiveness of the intervention might depend in part on the level of experience of the radiologist. Another limitation was the lack of a control group that underwent cyst aspiration without a corticosteroid injection. Still further, selection bias and unknown reliability of the patient telephone questionnaire could have influenced the findings of this observational investigation. In conclusion, US-guided therapy was a safe and potentially effective treatment for most cases of symptomatic lower extremity ganglion cysts in our small series. It is an affordable and dynamic modality that is increasingly used in our cost-conscious healthcare environment. It has an important role in the management of clinically occult ganglion cysts, in addition to patients who are poor surgical candidates. A large, untapped potential exists in the realm of minimally invasive US-guided treatments that should be pursued. References 1. Mulligan EP, McCain K. Common fibular (peroneal) neuropathy as the result of a ganglion cyst. J Orthop Sports Physical Ther 42:1051, 2012. 2. Ozden R, Uruc V, Kalaci A, Dogramaci Y. Compression of common peroneal nerve caused by an extraneural ganglion cyst mimicking intermittent claudication. J Brachial Plex Peripher Nerve Inj 8:5, 2013. 3. Touraine S, Lagadec M, Petrover D, Genah I, Parlier-Cuau C, Bousson V, Laredo J. A ganglion of the patellar tendon in patellar tendon-lateral femoral condyle friction syndrome. Skeletal Radiol 42:1323–1327, 2013. 4. Rizzo M, Berger RA, Steinmann SP, Bishop AT. Arthroscopic resection in the management of dorsal wrist ganglions: results with a minimum 2-year follow-up period. J Hand Surg 29A:59–62, 2004. 5. Yamamoto M, Kurimoto S, Okui N, Tatebe M, Shinohara T, Hirata H. Sonographyguided arthroscopy for wrist ganglion. J Hand Surg 37A:1411–1415, 2012.
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