Mucous Cyst Treatment & Management
- Author: Divya Singh, MD; Chief Editor: Harris Gellman, MD more...
Treatment options in the past have included aspiration, electrocautery, chemical cautery, steroid injection, and various types of surgical excision. Most of these procedures are associated with significant recurrence rates, though these tend to be lower than those associated with carpal ganglions.
Aspiration of digital ganglions was found to have a 65-69% success rate, compared with 27-45% for carpal ganglions. One caveat with aspiration is the risk of infection. In fact, infections of the cyst and subsequently the joint can occur from spontaneous breakdown of the cyst or from iatrogenic aspiration. Such infections must be promptly treated; they often lead to septic arthritis and osteomyelitis with disastrous complications.
Some early authors proposed that low-voltage radiation therapy is associated with a lower recurrence rate than surgical treatment is.[20, 21, 22, 23, 24, 25, 26]
Surgery currently is considered the definitive treatment for mucous cysts. It is recommended in the presence of ongoing pain, recurrent infection, or chronic drainage. Depending on the surgeon's preference and the location of the cyst, various surgical incisions can be used, including an H, T, U, or a transverse curving incision shape. (See the image below.)
After the skin is incised, the dissection is continued around the cyst, tracing the stalk down to the joint. Care must be taken to avoid damaging the terminal extensor tendon, germinal matrix, and the terminal portions of the neurovascular bundles. Depending on the intraoperative findings, a synovectomy, osteophyte resection, and debridement may be performed. A disrupted terminal extensor tendon (whether iatrogenic or cyst-related) should be repaired to prevent subsequent extensor lag.[8, 21, 23, 27, 28, 29, 30, 31]
In the event of significant distal interphalangeal (DIP) joint arthritis and pain, an arthrodesis can be performed during the same operation. Chen advocated radical excision of the attenuating skin overlying the cyst, which can contain satellite ducts and lakes of mucoid degeneration.
The surgeon can obtain the patient's consent preoperatively for a skin graft if skin excision leaves extensor tendon or joint exposed. Rotation flaps have been utilized to compensate for excised or thinned skin overlying the cyst. Jager et al reported on their use of the Zimany bilobed flap, utilizing the geometric design developed by Zitelli, in the surgical treatment of nine digital mucous cysts. They recommended this procedure because it is easy and safe, wound healing is fast, and outcomes are good.
The decision to use skin grafting, a rotational flap, or primary closure is largely surgeon-dependent.[33, 34] In the authors' experience, most incisions can be closed primarily without the need for further coverage procedures.[35, 36, 37]
Preoperative planning is limited, in that much of the procedure is based on intraoperative findings. In the presence of significant arthritic pain, patient consent can be obtained for a DIP joint arthrodesis. This can be done with single-screw fixation (eg, an Acutrak or Herbert screw) or with Kirschner wires (K-wires) and cables, depending on the surgeon's preference.
The relevant factors to remember preoperatively are to remove the osteophyte and obtain adequate skin coverage after excision. Patient consent should be obtained for skin graft or rotation flap if needed.
Studies have shown the necessity of excising not only the cyst but also the underlying DIP osteophyte. Care must be taken to avoid injury to the germinal matrix and to prevent further nail deformity.
One study described treatment of fingernail deformities secondary to mucous cysts with removal of the osteophyte only, without excision of the ganglion or skin. In this study of 20 ganglion cysts, the ganglion did not recur in any patients, and two nails had residual grooves.
Unless an extensor tendon repair or some other procedure requiring joint immobilization is involved, only a light dressing is needed postoperatively. Gentle active range of motion is allowed, and sutures usually are removed after 2 weeks.
Infection is a common complication of mucous cysts, either preoperatively or postoperatively. For that reason, prophylactic antibiotics are used intraoperatively and for 3 days postoperatively.[38, 10]
Complications of surgical treatment include extensor tendon disruption, recurrence, and nail deformity from injury to the germinal matrix. Other potential risks include persistent pain, swelling, stiffness, and infection. If a patient continues to experience pain secondary to degenerative joint disease, a DIP joint arthrodesis may be performed later.
Outcome and Prognosis
The recurrence rate with both cyst and osteophyte excision is 3-12%, compared with a 25-50% recurrence rate with cyst excision alone.
Lee et al conducted a retrospective review of the medical records of 37 patients (42 cases) who had mucous cysts combined with Heberden's node. Osteophyte excision without cyst excision was performed. In all cases except one, the cyst regressed without recurrence or a skin complication after osteophyte excision; eight patients experienced postoperative pain and loss of range of motion.
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