Ganglion Cysts of the Proximal Tibiofibular Joint: Low Risk of Recurrence After Total Cyst Excision

Abstract

Background: Peroneal nerve neuropathy due to compression from tumors or tumor-like lesions such as ganglion cysts is rare. Few case series have been published and reported local recurrence rates are high, while secondary procedures are frequently employed.

Questions/purposes: (1) What are the demographics of patients with ganglion cysts of the proximal tibiofibular joint, and what proportion of them present with intraneural cysts and peroneal nerve palsy? (2) What Musculoskeletal Tumor Society (MSTS) scores do patients with this condition achieve after decompression surgery with removal of the ganglion cyst, but no arthrodesis of the tibiofibular joint? (3) What proportion of patients experience local recurrence after surgery?

Methods: Between 2009 to 2018, 30 patients (29 primary cases) were treated for chronic peroneal palsy or neuropathy due to ganglion cysts of the proximal tibiofibular joint at two tertiary orthopaedic medical centers with total resection of the cystic lesion. MRI with contrast and electromyography (EMG) were performed preoperatively in all patients. The minimum follow-up for this series was 1 year (median 48 months, range 13 to 120); 14% (4 of 29) were lost to follow-up before that time. The MSTS score was recorded preoperatively, at 6 weeks postoperatively, and at most-recent follow-up.

Results: A total of 90% of the patients were male (26 of 29 patients) and the median age was 67 years (range 20 to 76). In all, 17% (5 of 29) were treated due to intraneural ganglia. Twenty-eight percent (8 of 29) presented with complete peroneal palsy (foot drop). The mean MSTS score improved from 67 ± 12% before surgery to 89 ± 12% at 6 weeks postoperative (p < 0.001) and to 92 ± 9% at final follow up (p = 0.003, comparison with 6 weeks postop). All patients improved their scores. A total of 8% (2 of 25 patients) experienced local recurrence after surgery.

Conclusion: Ganglion cysts of the proximal tibiofibular joint occurred more often as extraneural lesions in older male patients in this small series. Total excision was associated with improved functional outcome and low risk of neurologic damage and local recurrence, and we did not use any more complex reconstructive procedures. Tendon transfers may be performed simultaneously in older patients to stabilize the ankle joint, while younger patients may recover after decompression alone, although larger randomized studies are needed to confirm our preliminary observations.

Level of evidence: Level IV, therapeutic study.

Fig. 1

A lazy S incision was performed below the fibular head, which is outlined in this image.

Fig. 2

Identifying the common peroneal nerve proximally beneath the biceps tendon, as shown here, is an essential step of the procedure.

Fig. 3 A-B

(A) Axial MRI (proton density-weighted fat-suppressed images) and (B) sagittal MRI (T2-weighted images) at the corresponding level depict a swollen common peroneal nerve with an intraneural ganglion cyst.

Fig. 4 A-B

Dissection of the ganglion cyst in the anterior compartment during the (A) initial stages of the procedure and (B) toward the end of the operation.

Fig. 5

This image shows the surgical specimen from the resected ganglion cyst.

Fig. 6 A-B

(A) Axial MRI (short-TI inversion recovery images) and (B) coronal MRI (T1 fat-suppressed images) show a large (longer than 14 cm) extraneural ganglion cyst.

Fig. 7

A ganglion cyst is dissected from the caudal to cephalad direction until the communicating pedicle is reached and ligated (the blue arrow shows the common peroneal nerve). A color image accompanies the online version of this article.

Fig. 8

The large cyst is delivered en bloc—the black arrow shows the ligated pedicle.

Fig. 9 A-B

(A) Axial MRI (short-TI inversion recovery images) and (B) sagittal MRI (T1 fat-suppressed images after gadolinium enhancement) depict the communicating stalk from the proximal tibiofibular joint (blue arrow). A color image accompanies the online version of this article.