Periosteal ganglion cyst masquerading as pes anserine bursitis

Ganesh Singh Dharmshaktu; Tanuja Pangtey

doi:10.4103/jodp.jodp_41_20

CASE REPORT

Year : 2021 | Volume : 4 | Issue : 1 | Page : 15-17

Periosteal ganglion cyst masquerading as pes anserine bursitis

Ganesh Singh Dharmshaktu¹, Tanuja Pangtey²
¹ Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India
² Department of Pathology, Government Medical College, Haldwani, Uttarakhand, India

Date of Submission	28-Dec-2020
Date of Decision	10-Feb-2021
Date of Acceptance	11-Feb-2021
Date of Web Publication	26-Apr-2021

Correspondence Address:
Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.jodp_41_20

Abstract

Periosteal ganglion cysts result from mucoid degeneration and cyst formation from periosteal tissue and are uncommon clinical entities. Long-standing periosteal ganglion cyst may present ith pain and pressure effect on underlying bone. Periosteal ganglion cysts at location near important bursa, in rare instances, may mimic bursitis and be misdiagnosed or treated inappropriately. Magnetic resonance imaging provides extensive details and delineation and is crucial for diagnosing these lesions. We report a case of 30-year-old female diagnosed and treated for pes anserine bursitis for months before radiological, and biopsy revealed a periosteal ganglion cyst spanning knee joint on medial aspect. Surgical excision as done to relieve the symptoms and there as no recurrence of the lesion noted in the follo-up.

Keywords: Excision, ganglion, mass, periosteal, tibia

How to cite this article:
Dharmshaktu GS, Pangtey T. Periosteal ganglion cyst masquerading as pes anserine bursitis. J Orthop Dis Traumatol 2021;4:15-7

How to cite this URL:
Dharmshaktu GS, Pangtey T. Periosteal ganglion cyst masquerading as pes anserine bursitis. J Orthop Dis Traumatol [serial online] 2021 [cited 2021 May 6];4:15-7. Available from: https://www.jodt.org/text.asp?2021/4/1/15/314645

Introduction

The ganglion cysts, resulting from myxomatous connective tissue degeneration, are common benign cystic lesions found commonly at the rist region ith lesser common involvement of dorsum of hand, foot, and other sites.^[1] The periosteal ganglions, a rare variant, resulting from mucoid degeneration and cyst formation from periosteum of long bones have also been reported sporadically.^[2] They may present ith cortical erosion, periosteal reaction, or soft-tissue extension. These lesions usually are reported on loer limbs and sho no intramedullary presence thus differentiating it from interosseous ganglion, other unusual type of ganglion cysts.^[3] Repetitive trauma and injury are postulated etiology of ganglion cysts leading to mucin collection surrounded by outer fibrous all. The region adjacent to pes anserine bursa is common site of these lesions and may pose diagnostic challenges in differentiating it from pes anserine bursitis, stress fracture, lipoma, abscess, or other neoplastic lesions.

Case Report

A 30-year-old female presented to us ith mild selling and occasional pain over the right side medial knee area that as increasing ith knee activity such as squatting and prolong ambulation. The pain as dull ith no diurnal variation or radiation and as transiently relieved by pain medication and rest. The numerous treatment she took ere ith provisional diagnosis of pes anserine bursitis. The treatment mostly included various forms of physical therapy measures such as fomentation and pain medications as per the requirement. There as a nontender mild selling noted over medial aspect of tibia that corresponded to the area of pes anserine bursa. The radiographs of both the knee region shoed no significant bony abnormality. There as, hoever, on closer observation presence of a ide ell-defined area of radiolucency corresponding to the clinical presence of selling or affected area over medial tibia noted [Figure 1]a. She as advised magnetic resonance imaging (MRI) for further evaluation of the underlying cause. The MRI revealed an extra-skeletal cystic lesion over medial aspect of tibia and medial aspect of adjacent knee joint and medial femur [Figure 1]b. The lesion as hyperintense on T2-eighed images ith multilobulated form in close proximity to underlying bone [Figure 2]. The mass as more on the medial aspect of tibia and some of its part extended to medial distal femur thus spanning the knee joint [Figure 3]a. The lesion thus as a single, continuous, multilobulated structure hich as crossing the knee joint medially ithout evident intra-articular communication. There as no joint effusion ith normal osseous and ligamentous structures. The incision biopsy as planned to confirm the diagnosis, and a gelatinous fluid pored out soon after the incision over the mass suggesting a possible ganglion cyst [Figure 3]b. The ide excision of the cyst as done and representative tissue taken for histopathological assessment. The medial collateral ligaments ere left intact during the surgery along ith pes anserine bursa that as not affected. The close approximation of the cyst to this bursa as clinically presenting as pes anserine bursitis. Scraping of the underlying periosteum till bone as done on part of medial aspect of tibia ith curette before through lavage and closure. The postopertaive course as uneventful and the biopsy report confirmed the diagnosis of ganglion cyst. There as clinical improvement noted along ith no recurrence of the lesion.

Figure 1: The radiograph of both knees showing an area of radiolucency over left medial aspect of tibia as compared to opposite side (a). The magnetic resonance imaging shows the presence of a cystic lesion closed to the bone over the medial knee region spanning the joint (b)

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Figure 2: The axial views delineate the lesion as not originating from knee structure as multilobulated and closely adhering the underlying bone (a and b)

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Figure 3: The multilobulated and voluminous cystic mass exits more over the medial aspect of tibia (a). The egress of gelatinous fluid from the lesion during the excisional biopsy procedure (b)

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Discussion

At initial stages a developing ganglion may be asymptomatic but may present ith a visible or palpable soft-tissue mass ith varying degree of pain. Periosteal ganglions have male preponderances and mostly are found in fourth-fifth decade. Some of these lesions may have communication ith adjacent joint and may require surgical treatment addressing this connecting channel to avoid recurrence.^[4] Periosteal ganglions usually affect juxta-articular areas, but occasionally, diaphyseal involvement is also noted.^[5] Early presentation in the form of grouped immobile subcutaneous nodule over tibia may be another presentation.^[6] The expanding cortical erosion should have periosteal ganglion as differential diagnosis. These ganglions are mostly described in men.^[7] They might occasionally have an intraosseous component.^[8] Most of the reports describe tibial involvement but other bones may also be involved. In a series of four cases, three ere had proximal tibial involvement hile one as located distal shaft of ulna.^[9] One case of periosteal ganglion at distal radius has also been described as oval juxtacortical mass ith a thin layer of peripheral calcification and multiple thin septations causing shallo erosion over bone.^[10] Another case ith similar presentation over radius revealed homogenous ith high signal on T2 images ith no apparent enhancement on gadolinium injection suggesting a cystic mass.^[11] One case of gradual onset posterior knee pain ith erosion of posterior aspect of femur as identified as periosteal ganglion at the femoral intercondylar region.^[12] Although many reports describe no recurrence folloing excision, risk of recurrence is alays present. One report of proximal tibia periosteal ganglion shoing repeated recurrences has been described.^[13] Our case as different from previously reported cases as it involved ide area spanning the knee joint.

Conclusion

The ganglion cysts are common cystic lesion commonly encountered in extremities. A relatively uncommon variant, periosteal ganglion cyst, may be encountered occasionally and should be in differential diagnosis of these lesions. Area near pes anserine bursa is common site, and judicious use of imaging is crucial to diagnose this uncommon variant of ganglion cysts.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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