Ganglion cysts of the proximal tibiofibular joint review of literature with three case reports
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- Vatansever, A., Bal, E. & Okcu, G. Arch Orthop Trauma Surg (2006) 126: 637. doi:10.1007/s00402-005-0084-3
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Proximal tibiofibular ganglion is a rare disorder. It may settle down in the subcutaneous tissue or may develop along the peroneal muscles and nerve. Common clinical findings are various sizes of mass, pain and hypoesthesis due to compression neuropathy. We report three cases of proximal tibiofibular ganglion and review the literature about the diagnostic tools, recurrence rates and treatment modalities.
KeywordsGanglion cystsProximal tibiofibular jointCyst excisionRecurrence
A ganglion is a benign cystic mass with a dense fibrous connective tissue capsule which contains clear high viscosity mucinous fluid. It is frequently located on the dorsum of the wrist, the palm of the hand and the dorsolateral aspect of the foot. Ganglion cysts that arise from the proximal tibiofibular joint are less common. The first to report a ganglion attached to the proximal tibiofibular joint was Lennander in 1891. Since then, few cases have been reported.
Localization of the proximal tibiofibular joint ganglions varies widely. They may remain subcutaneous or may spread into peroneal muscles and adjacent bony structures. It may develop along the terminal branches of the common peroneal nerve either outside or within the nerve and cause motor or sensory deficits.
In this paper, we present three cases and review the literature about the clinical findings, diagnostic tools, recurrence rates and treatment modalities of the PTFG.
A 25-year-old lady complained of suffering from pain on the lateral aspect of her left knee for the past 6 months. Her pain started after an overuse injury because of bicycle riding. She has not any other symptom. After a few days, her complaints regressed to a lower degree, but still gave discomfort. Physical examinations revealed tenderness over the proximal tibiofibular joint and posterior capsule by palpation. Radiographs of the extremity were normal. USG detected a ganglion arising from the proximal tibiofibular joint. MRI scans were obtained to exclude other intraarticular knee pathologies. MRI scans showed us minimal degeneration at the posterior horn of the medial meniscus and a ganglion (12 mm in diameter) which has a connection to the proximal tibiofibular joint with a stalk. Cyst aspiration was performed to establish an accurate diagnosis and to treat it without surgery. After cyst aspiration compressive elastic bandage was applied and her daily activities were restricted for 3 weeks. At 6-weeks follow-up, the patient had improvement in her symptoms. Six months later, the patient presented with recurrence of the symptoms, especially worsening pain. MRI scans were repeated to investigate the recurrence of the ganglion. It confirmed the presence of recurrent cyst arising from the tibiofibular joint. We offered her surgical excision of the cyst, but the patient refused further treatment modalities.
A ganglion is a cystic lesion which arises from joint capsule or tendon sheath and contains glassy, clear fluid. It is thought to be the result of myxoid degeneration. The clinical presentation depends on cyst size and location. Around the knee, it might be associated with pain which occasionally radiates distally down the calf and may be exacerbated by squatting. Patients usually present with a mass that fluctuates in size and produces various severity levels of pain. Ganglion cysts originating from the proximal tibiofibular joint might cause compression of the common peroneal nerve . Ganglions are most common on the dorsum of the wrist, palm of the hand and dorsolateral aspect of the foot. A rare localization of a ganglion is proximal tibiofibular joint. The prevalance of PTFG was found to be 0.76% . Although they arise from the joint capsule, these cysts may lose their connection to the joint or may remain attached by a fibrous cord . Barrie et al.  reported three different cases that involved peroneal nerve, peroneal tendon and fibular head, respectively. They concluded that ganglion cysts may migrate in various directions and named them as ganglion migrans.
These cysts usually extend to the anterior compartment and may cause a compartment syndrome . Ward et al.  carried out an anatomical study in order to determine why the cysts usually spread to the anterior compartment. They found that the relationship of the anterior compartment fascia to the proximal tibiofibular joint predisposes such an extension of the cyst and may develop a compartment syndrome. Additionally, they advised the excision of a massive ganglion before the onset of a compartment syndrome.
Either ultrasonography or MRI can be the imaging choice to confirm the diagnosis .
In the present study, three cases were reported. MRI and USG were used, respectively, in two different cases. Both imaging techniques were performed simultaneously only in one patient. USG is an effective, cheap and noninvasive diagnostic method to identify the cyst, but it provides limited knowledge about the surrounding tissues. MRI may be used to identify the anatomical relation of the cysts to the joint and surrounding structures, as well as to evaluate the presence of associated knee abnormalities. Providing a detailed examination seems to be an advantage for MRI, but it is more expensive than USG.
Current management of PTFG mainly consists of conservative and surgical procedures. Rare cases were reported that treated successfully with either simple cyst aspiration or cyst aspiration and corticosteroid injection [5, 9]. Needle aspiration of the cyst is a minimal invasive treatment method, but high recurrence rate and low patient satisfaction, as in our third case, make this method less effective. It may be used either to confirm the diagnosis or for the treatment of patients who refuse surgery .
Traditional surgical treatment method is marginal excision of the ganglion cysts [1, 8–10]. Miskovsky et al.  found a recurrence rate of 13% following primary excision and a 100% repeat recurrence rate after second interventions. Second interventions are not suggested in recurred cases. If simple cyst excision fails, there are two alternative treatment options; first resection arthroplasty of fibula and the second fusion of the proximal tibiofibular joint fusion [3, 6, 8]. Kapoor et al.  resected the proximal tibiofibular joint with preserving the common peroneal nerve, the styloid process of the fibula and the fibular collateral ligament in two recurrent cases. They reported successful results, with no recurrence. Miskovsky treated four patients with proximal tibiofibular joint fusion: two with a recurrence history and two for primary treatment. At the end of the average follow-up time, they reported no recurrence. Marginal cyst excision resulted with no recurrence in our two patients.
In conclusion, because of its low morbidity, the initial treatment method of the PTFG should be a marginal excision of the cyst with ligation of its stalk. In recurrent cases, either resection arthroplasty or proximal tibiofibular joint fusion may be selected.