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Intratendinous ganglion in the extensor digitorum brevis tendon
J Orthop Sci (2009) 14:666–668 DOI 10.1007/s00776-009-1361-8
Case report Intratendinous ganglion in the extensor digitorum brevis tendon MICHIHAYA KONO, WATARU MIYAMOTO, SHINJI IMADE, and YUJI UCHIO Department of Orthopaedic Surgery, Shimane University School of Medicine, 89-1 Enya, Izumo, Shimane 693-8501, Japan
Introduction Ganglia are common benign lesions that usually arise adjacent to joints and tendons and are frequently observed around the hand and wrist.1 However, an intratendinous ganglion is a rare condition, with only 20 cases reported in the English-language literature.2–11 The most common location is the hand,2,4,6,8,9,11 and most lesions were localized within approximately 3 cm, whereas massive lesions that were widely extended in the tendon were rare. We report a case of an intratendinous ganglion in the extensor digitorum brevis tendon of the fourth toe, measuring 7 cm in the longitudinal direction, that was treated by en bloc resection of the tendon.
Case report A 28-year-old man presented to our hospital with a 3year history of an enlarging mass over the dorsum of the left foot. He had begun to feel pain during exercise. There was no history of prior trauma. On physical examination, a soft mass, approximately 7 × 2 cm, was palpated from the fourth metatarsal head to the lateral malleolus of the ankle joint. Mobility was fairly good, and there was no restriction of range of motion to the toes and ankle. Results of laboratory studies were all within normal limits. Plain radiographs demonstrated slight enlargement of a soft tissue shadow and no bony abnormal structures. Magnetic resonance imaging (MRI) revealed multiple cystic lesions at the dorsal side of the fourth metatarsal bone that were identified in a high-intensity
Offprint requests to: M. Kono Received: November 25, 2008 / Accepted: February 25, 2009
area on T2-weighted images and a low-intensity area on T1-weighted images (Fig. 1a,b). In sagittal sections, a 3-cm oval cyst was found at the fourth metatarsal head, and a 7-cm proximal lesion was enlarged in a spindle shape along the fourth metatarsal shaft. In coronal sections, the wall of the proximal lesion was partially thickened, suggesting an intratendinous lesion, and it was connected with the muscle belly of the extensor digitorum brevis (Fig. 1c). We suspected an intratendinous ganglion based on the MRI findings and decided to perform surgery. Because the lesion was widely extended, we considered performing total resection of the involved tendon instead of only excision of the ganglion. We thought that additional techniques, such as tendon transfer and tenodesis, would not be necessary even if we performed tendon resection because the extensor digitorum brevis tendon is an intrinsic muscle that is compensated for by an extrinsic muscle. The extensor digitorum brevis tendon of the fourth toe was enlarged in a spindle shape, and a bulbous daughter cyst was found in a distal end of the tendon (Fig. 2). The lesions had no connections to the joint capsule or tendon sheath. A small amount of yellowish jelly-like content was obtained from the lacerated cyst. Because the lesion was too large to allow removal of only the ganglion, we performed en bloc excision of the tendon through an additional incision on the anterior process of the calcaneus, which is the proximal origin of the extensor digitorum brevis. A longitudinal 7-cm cyst was found within the tendon, and the tendinous tissue itself was extremely thinned (Fig. 3). A distal 3-cm daughter cyst had communication with the intratendinous cyst. Pathology examination revealed pseudocyst formation without lining cells or mucous degeneration changes around the tendinous tissue (Fig. 4). These findings confirmed the diagnosis of an intratendinous ganglion.
M. Kono et al.: Intratendinous ganglion in the foot
a
667
b
Fig. 1. Magnetic resonance imaging scans. T2-weighted (TR 3500, TE 88) (a) and T1-weighted (TR 450, TE 11) (b) images of sagittal sections. c Short T1 inversion recovery (STIR) (TR 8770, TE 16) image of coronal sections of the tarsal bone with
Fig. 2. Intraoperative photograph. The extensor digitorum brevis tendon of the fourth toe was enlarged (white arrow) with a daughter cyst (black arrow)
c
partial thickness of the cyst wall (arrow). M, metatarsal bone; C, cuboid; MC, medial cuneiform; IC, intermediate cuneiform; LC, lateral cuneiform
Fig. 4. Histopathology of the mass in a longitudinal section shows pseudocyst formation and mucous degeneration changes. H&E ×20
Discussion
Fig. 3. Excised tissue of the extensor digitorum brevis tendon of the fourth toe
The patient recovered uneventfully with normal function of his affected foot. Four weeks after the surgery, he was able to take part in full athletic activities without pain. There was no recurrence of the lesions 2 years after surgery. The patient was informed that the data obtained from the case would be submitted for publication and gave his consent.
The most common reported location of intratendinous ganglia is the hand (16 cases),2,4,6,8,9,11 followed by the ankle (three cases)3,7,10 and the shoulder (one case).5 Among the previous 20 cases,2–11 there was only one case of a lesion >7 cm (it had arisen in the peroneus brevis tendon).3 In the present case, the lesion was extremely large compared those in most of the previous reports. The provisional diagnosis of intratendinous ganglion is based on the physical examination, imaging studies, or cyst puncture and aspiration.1 In this case, the location and character of the lesion were fully determined by the preoperative imaging studies due to the careful reading regarding the cyst wall. The definitive diagnosis was determined with a pathology examination. Giant cell tumor of the tendon sheath and tenosynovitis of an inflammatory or infectious origin are included in the differential diagnosis.1
668
En bloc resection of the tendon can reduce the risk of recurrence, but it should be carefully considered because there is some concern about functional loss. Accordingly, the indication seems to be limited to lesions that have arisen in an intrinsic muscle without essential function. In the present case, the extensor digitorum brevis tendon is an intrinsic muscle, and therefore the functional disadvantages of tendon resection were thought to be negligible owing to the compensation offered by an extrinsic muscle. This case was a rare condition with a large lesion within the tendon of an intrinsic muscle in the foot. Because the lesion was well revealed by the preoperative MRI evaluation, we were able to select en bloc resection of the tendon, which was successful. An intratendinous ganglion should be considered in the differential diagnosis of a soft tissue tumor in the foot. During preoperative planning, it is important to recognize the morphology of the lesion and the function of the involved tendon. Acknowledgments. We thank Dr. Shigehito Wada for his contributions to the treatment of the presented case.
M. Kono et al.: Intratendinous ganglion in the foot
References 1. Thornburg LE. Ganglions of the hand and wrist. J Am Acad Orthop Surg 1999;7:231–8. 2. Chen WS. Intratendinous ganglion and carpometacarpal boss: a report of two cases. Ital J Orthop Traumatol 1992;18:421–5. 3. Costa CR, Morrison WB, Carrino JA, Raiken SM. MRI of an intratendinous ganglion cyst of the peroneus brevis tendon. AJR Am J Roentgenol 2003;181:890–1. 4. Ikeda K, Tomita K, Matsumoto H. Intratendinous ganglion in the extensor tendon of a finger: a case report. J Orthop Surg (Hong Kong) 2001;9:63–5. 5. Kishimoto K, Akisue T, Fujimoto T, Kawamoto T, Hara H, Hitora T, et al. Intra-tendinous ganglion in the long head of the biceps humeri. Skeletal Radiol 2008;37:263–5. 6. Lucas GL. An intratendinous cyst in the extensor digitorum brevis manus tendon. J Hand Surg [Am] 1979;4:176–7. 7. Przystawski N, McGarry JJ, Stern MB, Edelman RD. Intratendinous ganglionic cyst. J Foot Surg 1989;28:244–8. 8. Rayan GM. Intratendinous ganglion: a case report. Orthop Rev 1989;18:449–51. 9. Seidman GD, Margles SW. Intratendinous ganglia of the hand. J Hand Surg [Am] 1993;18:707–10. 10. Waldecker U. Unusual location of a posttraumatic ganglion and rupture of the peroneus brevis tendon: a case report. J Foot Ankle Surg 2005;44:163–5. 11. Young SC, Freiberg A. A case of an intratendinous ganglion. J Hand Surg [Am] 1985;10:723–4.
Case report Intratendinous ganglion in the extensor digitorum brevis tendon MICHIHAYA KONO, WATARU MIYAMOTO, SHINJI IMADE, and YUJI UCHIO Department of Orthopaedic Surgery, Shimane University School of Medicine, 89-1 Enya, Izumo, Shimane 693-8501, Japan
Introduction Ganglia are common benign lesions that usually arise adjacent to joints and tendons and are frequently observed around the hand and wrist.1 However, an intratendinous ganglion is a rare condition, with only 20 cases reported in the English-language literature.2–11 The most common location is the hand,2,4,6,8,9,11 and most lesions were localized within approximately 3 cm, whereas massive lesions that were widely extended in the tendon were rare. We report a case of an intratendinous ganglion in the extensor digitorum brevis tendon of the fourth toe, measuring 7 cm in the longitudinal direction, that was treated by en bloc resection of the tendon.
Case report A 28-year-old man presented to our hospital with a 3year history of an enlarging mass over the dorsum of the left foot. He had begun to feel pain during exercise. There was no history of prior trauma. On physical examination, a soft mass, approximately 7 × 2 cm, was palpated from the fourth metatarsal head to the lateral malleolus of the ankle joint. Mobility was fairly good, and there was no restriction of range of motion to the toes and ankle. Results of laboratory studies were all within normal limits. Plain radiographs demonstrated slight enlargement of a soft tissue shadow and no bony abnormal structures. Magnetic resonance imaging (MRI) revealed multiple cystic lesions at the dorsal side of the fourth metatarsal bone that were identified in a high-intensity
Offprint requests to: M. Kono Received: November 25, 2008 / Accepted: February 25, 2009
area on T2-weighted images and a low-intensity area on T1-weighted images (Fig. 1a,b). In sagittal sections, a 3-cm oval cyst was found at the fourth metatarsal head, and a 7-cm proximal lesion was enlarged in a spindle shape along the fourth metatarsal shaft. In coronal sections, the wall of the proximal lesion was partially thickened, suggesting an intratendinous lesion, and it was connected with the muscle belly of the extensor digitorum brevis (Fig. 1c). We suspected an intratendinous ganglion based on the MRI findings and decided to perform surgery. Because the lesion was widely extended, we considered performing total resection of the involved tendon instead of only excision of the ganglion. We thought that additional techniques, such as tendon transfer and tenodesis, would not be necessary even if we performed tendon resection because the extensor digitorum brevis tendon is an intrinsic muscle that is compensated for by an extrinsic muscle. The extensor digitorum brevis tendon of the fourth toe was enlarged in a spindle shape, and a bulbous daughter cyst was found in a distal end of the tendon (Fig. 2). The lesions had no connections to the joint capsule or tendon sheath. A small amount of yellowish jelly-like content was obtained from the lacerated cyst. Because the lesion was too large to allow removal of only the ganglion, we performed en bloc excision of the tendon through an additional incision on the anterior process of the calcaneus, which is the proximal origin of the extensor digitorum brevis. A longitudinal 7-cm cyst was found within the tendon, and the tendinous tissue itself was extremely thinned (Fig. 3). A distal 3-cm daughter cyst had communication with the intratendinous cyst. Pathology examination revealed pseudocyst formation without lining cells or mucous degeneration changes around the tendinous tissue (Fig. 4). These findings confirmed the diagnosis of an intratendinous ganglion.
M. Kono et al.: Intratendinous ganglion in the foot
a
667
b
Fig. 1. Magnetic resonance imaging scans. T2-weighted (TR 3500, TE 88) (a) and T1-weighted (TR 450, TE 11) (b) images of sagittal sections. c Short T1 inversion recovery (STIR) (TR 8770, TE 16) image of coronal sections of the tarsal bone with
Fig. 2. Intraoperative photograph. The extensor digitorum brevis tendon of the fourth toe was enlarged (white arrow) with a daughter cyst (black arrow)
c
partial thickness of the cyst wall (arrow). M, metatarsal bone; C, cuboid; MC, medial cuneiform; IC, intermediate cuneiform; LC, lateral cuneiform
Fig. 4. Histopathology of the mass in a longitudinal section shows pseudocyst formation and mucous degeneration changes. H&E ×20
Discussion
Fig. 3. Excised tissue of the extensor digitorum brevis tendon of the fourth toe
The patient recovered uneventfully with normal function of his affected foot. Four weeks after the surgery, he was able to take part in full athletic activities without pain. There was no recurrence of the lesions 2 years after surgery. The patient was informed that the data obtained from the case would be submitted for publication and gave his consent.
The most common reported location of intratendinous ganglia is the hand (16 cases),2,4,6,8,9,11 followed by the ankle (three cases)3,7,10 and the shoulder (one case).5 Among the previous 20 cases,2–11 there was only one case of a lesion >7 cm (it had arisen in the peroneus brevis tendon).3 In the present case, the lesion was extremely large compared those in most of the previous reports. The provisional diagnosis of intratendinous ganglion is based on the physical examination, imaging studies, or cyst puncture and aspiration.1 In this case, the location and character of the lesion were fully determined by the preoperative imaging studies due to the careful reading regarding the cyst wall. The definitive diagnosis was determined with a pathology examination. Giant cell tumor of the tendon sheath and tenosynovitis of an inflammatory or infectious origin are included in the differential diagnosis.1
668
En bloc resection of the tendon can reduce the risk of recurrence, but it should be carefully considered because there is some concern about functional loss. Accordingly, the indication seems to be limited to lesions that have arisen in an intrinsic muscle without essential function. In the present case, the extensor digitorum brevis tendon is an intrinsic muscle, and therefore the functional disadvantages of tendon resection were thought to be negligible owing to the compensation offered by an extrinsic muscle. This case was a rare condition with a large lesion within the tendon of an intrinsic muscle in the foot. Because the lesion was well revealed by the preoperative MRI evaluation, we were able to select en bloc resection of the tendon, which was successful. An intratendinous ganglion should be considered in the differential diagnosis of a soft tissue tumor in the foot. During preoperative planning, it is important to recognize the morphology of the lesion and the function of the involved tendon. Acknowledgments. We thank Dr. Shigehito Wada for his contributions to the treatment of the presented case.
M. Kono et al.: Intratendinous ganglion in the foot
References 1. Thornburg LE. Ganglions of the hand and wrist. J Am Acad Orthop Surg 1999;7:231–8. 2. Chen WS. Intratendinous ganglion and carpometacarpal boss: a report of two cases. Ital J Orthop Traumatol 1992;18:421–5. 3. Costa CR, Morrison WB, Carrino JA, Raiken SM. MRI of an intratendinous ganglion cyst of the peroneus brevis tendon. AJR Am J Roentgenol 2003;181:890–1. 4. Ikeda K, Tomita K, Matsumoto H. Intratendinous ganglion in the extensor tendon of a finger: a case report. J Orthop Surg (Hong Kong) 2001;9:63–5. 5. Kishimoto K, Akisue T, Fujimoto T, Kawamoto T, Hara H, Hitora T, et al. Intra-tendinous ganglion in the long head of the biceps humeri. Skeletal Radiol 2008;37:263–5. 6. Lucas GL. An intratendinous cyst in the extensor digitorum brevis manus tendon. J Hand Surg [Am] 1979;4:176–7. 7. Przystawski N, McGarry JJ, Stern MB, Edelman RD. Intratendinous ganglionic cyst. J Foot Surg 1989;28:244–8. 8. Rayan GM. Intratendinous ganglion: a case report. Orthop Rev 1989;18:449–51. 9. Seidman GD, Margles SW. Intratendinous ganglia of the hand. J Hand Surg [Am] 1993;18:707–10. 10. Waldecker U. Unusual location of a posttraumatic ganglion and rupture of the peroneus brevis tendon: a case report. J Foot Ankle Surg 2005;44:163–5. 11. Young SC, Freiberg A. A case of an intratendinous ganglion. J Hand Surg [Am] 1985;10:723–4.