Peroneal intraneural ganglion cysts at the fibular neck: the layered “U” surgical approach to the articular branch and superior tibiofibular joint

Abstract

Background

Intraneural ganglia most commonly occur within the peroneal nerve near the fibular neck. Disconnection of the articular branch is required in their treatment. Surgical intervention can be challenging because of unfamiliarity with the region or scarring from previous surgery.

Method

We present the layered “U” technique for peroneal intraneural ganglia with clinical examples. Dissection is carried down in parallel to the U-shaped course of the articular branch to provide optimal visualization and avoid injury to major branches of the nerve.

Conclusion

This pathoanatomic approach provides direct and safe exposure of the articular branch of the common peroneal nerve.

Key points

• The CPN is the most frequently affected site for IG.

• PIG are becomingly increasingly recognized as causes of foot drop [9].

• PIG can represent an operative challenge, particularly in the setting of previous surgery.

• Understanding the consistent U-shape of the AB and its cystic involvement in PIG allows a more efficient dissection.

• A U-shaped layered approach exposes the AB.

• Dissection superiorly and medially along the AB minimizes risk to the DPN and SPN.

• Disconnection of the AB near the STFJ minimizes intraneural cyst recurrence and is the critical part of the procedure.

• Cyst decompression may expedite symptom relief.

• We have added STFJ resection (disarticulation) to our strategy to further decrease risks for intraneural and extraneural recurrence, as it removes the synovium, the source of STFJ-related ganglia.

• This surgical strategy maximizes neurologic improvement and minimizes cyst recurrence.