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Intraosseous ganglia
lntraosseous Ganglia L Brown and A. J. C. Huffstadt
INTRAOSSEOUS GANGLIA I. B R O W N and A. J. C. H U F F S T A D T , Groningen, The Netherlands SUMMARY A case report o f a f i f t y eightyear oM lady with symmetrical cystic lesions in the bases o f the metacarpal bones o f both thumbs. The histology showed an intraosseous ganglion which has not previously been reported in this location.
INTRODUCTION In comparison with soft tissue ganglia, the intraosseous ganglion is a relatively rare entity, first described by Hicks in 1956. Several cases have since been reported, principally in the lower limb (especially around the ankle) and much less commonly in the carpal bones. The lesions are usually solitary and often without connection with the adjacent joint. According to the W . H . O . classification, it is defined as " a benign cystic and often multiloculated lesion made up of fibrous tissue, with extensive mucoid changes, located in fhe subchondral bone adjacent to a joint. Radiologically it appears as a well-defined osteolytic lesion with a surrounding area of sclerosis. It has been described as a synovial cyst, but it lacks a synovial lining". CASE R E P O R T A fifty eight-year-old housewife was diagnosed in 1970 as having seronegative rheumatoid arthritis. Sh~ had no past history of trauma. Since 1966, she had complained of pain in her right forearm radiating to the thumb. These symptoms were treated in the Department of Rheumatology with hydrocortisone injections. In 1972, an exploration was performed for a cystic lesion at the base of her right first metacarpal bone and the defect was filled with cancellous bone. An X-ray of the other hand was normal (Fig. 1). At operation the cyst was described as being filled with jelly and lined by a thin yellow membrane. Unfortunately, no histology is available. In 1977, an identically placed cystic defect was demonstrated radiographically at the base of her first left metacarpal (Fig. 2). This slowly increased in size and therefore was explored in March 1979. After removal of the cortex a cyst containing a yellow gelatinous substance was found. The cyst lining could be separated from the surrounding bone by blunt dissection, except at one place where a narrow connection with the adjecent carpo-metacarpal joint was encountered. A further small cyst was found in the same cavity and this was also removed. The defect was filled with cancellous bone obtained from the iliac crest. Microscopy of the excised bone cyst showed it to be an intraosseous ganglion. Follow up radiographs of the patient (Fig. 3) showed new bone formation on the recently operated side; on the contralateral side there was normal bone structure Isabel F. Brown, F.R.C.S. (Ed), Department of Plastic Surgery, Academisch Ziekenhuis Groningen. Prof. Dr. A. J. C. Huffstadt, Professor of Plastic Surgery, University of Groningen. 9 1981 British Society for Surgery of the Hand 0072-968X-81-00090051 $02.00 The Hand-- Volume 13
No. 1
1981
51
lntraosseous Ganglia L Brown and A . J. C. H u f f s t a d t
Fig. 1. X-rays of both hands before first operation, 1972. Note cyst at base of right thumb metacarpal. Also note this Dutch patient wears her ring on the right hand.
Fig. 2. X-ray of left hand, 1977, showing cyst at base of left thumb metacarpal. 52
The H a n d - - Volume 13
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1981
Intraosseous Ganglia L Brown and A. J. C. Huffstadt
Fig. 3. Post operative X-rays'of both hands. Showing new bone formation in cyst cavities and also arthritic changes in both carpometacarpal joints. with no evidence of recurrence. There were, however, radiographic changes of arthritis in the carpo-metacarpal joints of both thumbs, an advance on the condition noted in the pre-operative films. DISCUSSION The lesion in this patient's left thumb proved to be an intraosseous ganglion, and although there is no histological confirmation, it is likely that she had ap, identical lesion in her right hand seven years previously. In the literature the ages of affected patients varies from fourteen to eighty six years but most are middleaged. Although most are male, those with hand lesions are more commonly female. Multiple lesions though uncommon, are often symmetrical (Schajowicz, 1979). Cases involving the scaphoid, hamate, triquetrum, lunate and pisiform have been described previously (Crabbe, 1966; Crane, 1967; Kambolis, 1973; Feldman, 1973; Helal, 1976; Schajowicz, 1979). Bowers (1979) reported a ganglion involving both the distal capitate and the adjacent base of the fourth metacarpal bone. The aetiology of this condition is obscure. In this case the attachment to the adjacent joint suggests a process o f invagination. There is no history of trauma but in the literature, microfractures have been proposed as an initiating factor. Sometimes a connection can be seen radiographically between the ganglion and the adjacent joint. Menges states that ganglia should always be included in the The H a n d - - Volume 13
No. 1
1981
53
Intraosseous Ganglia L Brown and A . J. C. Huffstadt
differential diagnosis o f cystic epiphyseal b o n e lesions. By t o m o g r a p h y , he d e m o n s t r a t e d a c o n n e c t i o n with the a d j a c e n t j o i n t in 57% (13/23) o f his cases. I n t e r p r e t a t i o n m a y be difficult where the lesions are n o t well developed or where coexisting degenerative j o i n t changes are present. Not all a u t h o r s could d e m o n s t r a t e such a high incidence o f c o n n e c t i o n with the j o i n t . Most lesions do n o t recur after curettage of the cavity a n d packing o f the defect with cancellous b o n e . However, small coexisting cysts such as we f o u n d m a y explain some " r e c u r r e n c e s " which have been reported. REFERENCES
BOWERS, W. H. and HURST, L. C. (1979) An intraarticular-intraosseous carpal ganglion. The Journal of Hand Surgery, 4: 375-377. CRABBE, W. A. (1966) Intra-osseus Ganglia of Bone. British Journal of Surgery, 53: 15-17. CRANE, A. R. and SCARANO, J. J. (1967) SyuovialCysts (Ganglia) of Bone. The Journal of Bone and Joint Surgery, 49A: 355-361. FELDMAN, F. and JOHNSTON, A. (1973) Intraosseous Ganglion. The American Journal of Roentgenology, Radium Therapy and Nuclear Medicine, 118: 328-343. HELAL, B. and VERNON-ROBERTS, B. (1976) Intraosseous ganglion of the Pisiform Bone. The Hand, 8: 150-154. HICKS, J. D. (1956) Synovial Cysts in Bone. The Australian and New Zealand Journal of Surgery, 26: 138-143. KAMBOLIS, C., BULLOUGH, P. G. and JAFFE, H. L. (1973) Ganglionic Cystic Defects of Bone. The Journal of Bone and Joint Surgery, 55A: 496-505. MENGES, V., PRAGER, P. CSERHATI, M. D., BECKER, W., GRISS, P. and WUSTER, K. (1977) Das Intraoss~re Ganglion. Zeitschift fiJr Orthop~idieund ihre Grenzgebiete, 115: 67-75. SCHAJOWICZ, F., SAINZ, M. C. and SLULLITEL, J. A. (1979) Juxta Articular Bone Cysts (Intra osseous Ganglia). A ClinicopathologicalStudy of Eighty Eight cases. The Journal of Bone and Joint Surgery, 61B: 107-116.
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The H a n d - - Volume 13
No. 1
1981
INTRAOSSEOUS GANGLIA I. B R O W N and A. J. C. H U F F S T A D T , Groningen, The Netherlands SUMMARY A case report o f a f i f t y eightyear oM lady with symmetrical cystic lesions in the bases o f the metacarpal bones o f both thumbs. The histology showed an intraosseous ganglion which has not previously been reported in this location.
INTRODUCTION In comparison with soft tissue ganglia, the intraosseous ganglion is a relatively rare entity, first described by Hicks in 1956. Several cases have since been reported, principally in the lower limb (especially around the ankle) and much less commonly in the carpal bones. The lesions are usually solitary and often without connection with the adjacent joint. According to the W . H . O . classification, it is defined as " a benign cystic and often multiloculated lesion made up of fibrous tissue, with extensive mucoid changes, located in fhe subchondral bone adjacent to a joint. Radiologically it appears as a well-defined osteolytic lesion with a surrounding area of sclerosis. It has been described as a synovial cyst, but it lacks a synovial lining". CASE R E P O R T A fifty eight-year-old housewife was diagnosed in 1970 as having seronegative rheumatoid arthritis. Sh~ had no past history of trauma. Since 1966, she had complained of pain in her right forearm radiating to the thumb. These symptoms were treated in the Department of Rheumatology with hydrocortisone injections. In 1972, an exploration was performed for a cystic lesion at the base of her right first metacarpal bone and the defect was filled with cancellous bone. An X-ray of the other hand was normal (Fig. 1). At operation the cyst was described as being filled with jelly and lined by a thin yellow membrane. Unfortunately, no histology is available. In 1977, an identically placed cystic defect was demonstrated radiographically at the base of her first left metacarpal (Fig. 2). This slowly increased in size and therefore was explored in March 1979. After removal of the cortex a cyst containing a yellow gelatinous substance was found. The cyst lining could be separated from the surrounding bone by blunt dissection, except at one place where a narrow connection with the adjecent carpo-metacarpal joint was encountered. A further small cyst was found in the same cavity and this was also removed. The defect was filled with cancellous bone obtained from the iliac crest. Microscopy of the excised bone cyst showed it to be an intraosseous ganglion. Follow up radiographs of the patient (Fig. 3) showed new bone formation on the recently operated side; on the contralateral side there was normal bone structure Isabel F. Brown, F.R.C.S. (Ed), Department of Plastic Surgery, Academisch Ziekenhuis Groningen. Prof. Dr. A. J. C. Huffstadt, Professor of Plastic Surgery, University of Groningen. 9 1981 British Society for Surgery of the Hand 0072-968X-81-00090051 $02.00 The Hand-- Volume 13
No. 1
1981
51
lntraosseous Ganglia L Brown and A . J. C. H u f f s t a d t
Fig. 1. X-rays of both hands before first operation, 1972. Note cyst at base of right thumb metacarpal. Also note this Dutch patient wears her ring on the right hand.
Fig. 2. X-ray of left hand, 1977, showing cyst at base of left thumb metacarpal. 52
The H a n d - - Volume 13
No. 1
1981
Intraosseous Ganglia L Brown and A. J. C. Huffstadt
Fig. 3. Post operative X-rays'of both hands. Showing new bone formation in cyst cavities and also arthritic changes in both carpometacarpal joints. with no evidence of recurrence. There were, however, radiographic changes of arthritis in the carpo-metacarpal joints of both thumbs, an advance on the condition noted in the pre-operative films. DISCUSSION The lesion in this patient's left thumb proved to be an intraosseous ganglion, and although there is no histological confirmation, it is likely that she had ap, identical lesion in her right hand seven years previously. In the literature the ages of affected patients varies from fourteen to eighty six years but most are middleaged. Although most are male, those with hand lesions are more commonly female. Multiple lesions though uncommon, are often symmetrical (Schajowicz, 1979). Cases involving the scaphoid, hamate, triquetrum, lunate and pisiform have been described previously (Crabbe, 1966; Crane, 1967; Kambolis, 1973; Feldman, 1973; Helal, 1976; Schajowicz, 1979). Bowers (1979) reported a ganglion involving both the distal capitate and the adjacent base of the fourth metacarpal bone. The aetiology of this condition is obscure. In this case the attachment to the adjacent joint suggests a process o f invagination. There is no history of trauma but in the literature, microfractures have been proposed as an initiating factor. Sometimes a connection can be seen radiographically between the ganglion and the adjacent joint. Menges states that ganglia should always be included in the The H a n d - - Volume 13
No. 1
1981
53
Intraosseous Ganglia L Brown and A . J. C. Huffstadt
differential diagnosis o f cystic epiphyseal b o n e lesions. By t o m o g r a p h y , he d e m o n s t r a t e d a c o n n e c t i o n with the a d j a c e n t j o i n t in 57% (13/23) o f his cases. I n t e r p r e t a t i o n m a y be difficult where the lesions are n o t well developed or where coexisting degenerative j o i n t changes are present. Not all a u t h o r s could d e m o n s t r a t e such a high incidence o f c o n n e c t i o n with the j o i n t . Most lesions do n o t recur after curettage of the cavity a n d packing o f the defect with cancellous b o n e . However, small coexisting cysts such as we f o u n d m a y explain some " r e c u r r e n c e s " which have been reported. REFERENCES
BOWERS, W. H. and HURST, L. C. (1979) An intraarticular-intraosseous carpal ganglion. The Journal of Hand Surgery, 4: 375-377. CRABBE, W. A. (1966) Intra-osseus Ganglia of Bone. British Journal of Surgery, 53: 15-17. CRANE, A. R. and SCARANO, J. J. (1967) SyuovialCysts (Ganglia) of Bone. The Journal of Bone and Joint Surgery, 49A: 355-361. FELDMAN, F. and JOHNSTON, A. (1973) Intraosseous Ganglion. The American Journal of Roentgenology, Radium Therapy and Nuclear Medicine, 118: 328-343. HELAL, B. and VERNON-ROBERTS, B. (1976) Intraosseous ganglion of the Pisiform Bone. The Hand, 8: 150-154. HICKS, J. D. (1956) Synovial Cysts in Bone. The Australian and New Zealand Journal of Surgery, 26: 138-143. KAMBOLIS, C., BULLOUGH, P. G. and JAFFE, H. L. (1973) Ganglionic Cystic Defects of Bone. The Journal of Bone and Joint Surgery, 55A: 496-505. MENGES, V., PRAGER, P. CSERHATI, M. D., BECKER, W., GRISS, P. and WUSTER, K. (1977) Das Intraoss~re Ganglion. Zeitschift fiJr Orthop~idieund ihre Grenzgebiete, 115: 67-75. SCHAJOWICZ, F., SAINZ, M. C. and SLULLITEL, J. A. (1979) Juxta Articular Bone Cysts (Intra osseous Ganglia). A ClinicopathologicalStudy of Eighty Eight cases. The Journal of Bone and Joint Surgery, 61B: 107-116.
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The H a n d - - Volume 13
No. 1
1981