Article ID: WMC001079 2046-1690 ISSN Dumbbell Ganglion Of The Foot: Case Report Author(s):Dr. S S Suresh, Dr. Hosam Zaki, Dr. Joyce Jose Corresponding Author: Dr. S S Suresh, Head of Department, Ibri Regional Referral Hospital, Department of Orthopaedics, PO Box 396, 516 - Oman Submitting Author: Dr. S S S, Head of Department, Ibri Regional Referral Hospital, Department of Orthopaedics, PO Box 396, 516 - Oman Article ID: WMC001079 Article Type: Case Report Submitted on:27-oct-2010, 01:45:20 PM GMT Article URL: article_view/1079 Subject Categories:ORTHOPAEDICS Keywords:Foot; Ganglion; Benign tumor Published on: 27-Oct-2010, 02:33:06 PM GMT How to cite the article:suresh S, Zaki H, Jose J. Dumbbell Ganglion Of The Foot: Case Report. WebmedCentral ORTHOPAEDICS 2010;1(10):WMC001079 Source(s) of Funding: Nil Competing Interests: None Webmedcentral > Case Report Page 1 of 9
Dumbbell Ganglion Of The Foot: Case Report Abstract Ganglions are common tumors of the dorsum of the foot. The authors report a case of dumbbell ganglion of the foot in a 32-year-old lady, whose main concern was the cosmetic disfigurement due to the displacement of the second toe. The mass was excised through a dorsal approach. The patient remained asymptomatic at 14 month follow up. Introduction Ganglions are benign cystic swelling that arises in relation to the tendons and joints. They are most commonly seen around the wrist and feet[1,2,3]. They are thought to be due to mucinous transformation of the periarticular connective tissue[3]. Occurrence of ganglions over the plantar surface of foot is very rare[1,2,4] and to the authors knowledge there are only two reports[1,2]. Case Report(s) 32- year- old lady presented with swelling of the right foot of 4 years duration. She didn t have any antecedent trauma to her foot. The swelling was progressive over a period of four years. Over a period of one year she noticed lateral deviation of her right second toe due to pressure effect of the swelling and she consulted us for cosmetic reasons. There was a soft well localized swelling over the dorsal aspect of the first inter digital space measuring 2 cm X 3 cm size (Figure 1). The margins were well defined. There was deviation of the 2 nd toe laterally due to the swelling. No mass could be felt on the plantar aspect. Radiographs of the right foot showed soft tissue mass in the interdigital space, with lateral deviation of the second toe. There was no bony erosion. (Figure 2) Ultra sound scan showed a well defined heterogenous mass in the interdigital area, which consisted of solid areas with hypoechoic areas suggestive of fluid. Ultra sound scan failed to show any extension of the cyst into the foot. Patient was taken up for surgery under ankle block anesthesia. The mass was explored through a longitudinal incision over the dorsum of foot, protecting the digital neuro vascular bundle. During surgery part of the mass was found arising from the plantar aspect of the inter digital space. The excised mass was measuring 6 cm X 2 cm and showing a dumbbell appearance. The capsule was found very thick over the plantar aspect of the cyst and the lumen contained serosanguinous fluid.(figure 3 & 4) Histopathology confirmed ganglion cyst. Section showed a cyst without any definite lining. The cyst wall was made of fibrocollagenous tissue with areas of myxomatous degeneration surrounding the cystic area and vascular proliferation. These features are consistent with ganglion. (Figure 5) At 14 months follow up, she had normal appearing foot and the radiographs showed normal alignment of the metacarpals. (Figure 6 and 7) Discussion Ganglions are common tumors of the hand and dorsum of the foot[4,5]. Plantar ganglions are very rare. Out of the 39 foot ganglions reported by Macdonald et al none were from the plantar surface of the foot. However there are few reports of plantar ganglions in the literature[1,2]. Ganglions may cause pressure effects, and present as painful plantar swellings. Other cases may present with deviation of the toes, making wearing of the shoes difficult in a shod community[1]. Though initial presentations due to cosmetic reasons are rare[4] our patient s main concern was displacement of the second toe. This also prevented her from wearing a proper shoe in the community where most of the women are shod. Extension of the swelling into the dorsum of foot has been reported before[1,2]. In the only report of an hourglass ganglion the authors used a combined plantar and dorsal approach[2]. This approach was pre operatively planned after demonstrating the plantar extension of the mass with an MRI scan. One hypothesis put forward is the pressure effect of walking on the plantar ganglion causing the cyst to move laterally and dorsally resulting in the dumbbell Webmedcentral > Case Report Page 2 of 9
shape[1]. In our case a plantar extension of the cyst was not expected pre-operatively, as the ultra sound scan report was misleading. However we could excise the full mass through the dorsal original surgical incision, as in the case of Kumar and Ahmed[1]. Ganglions are known to recur if not properly excised. Recurrence rate is reported to be less than 10%, after complete excision of the cyst and the daughter cysts[3]. Our patient had no recurrence at 14 months follow up and could wear a shoe comfortably. This case is unusual due to the peculiar appearance of the mass and the aesthetic result at the time of follow up. Conclusion A rare presentation of ganglion in the foot is presented. Authors contribution(s) SSS and HZ- Managed the case, prepared the manuscript. JJ- Reviewed the histopathology slides, and prepared the histopathology write up. References 1. Kumar A, Ahmed M. Plantar synovial cyst: an unusual presentation. Foot Ankle Surg 2002; 8(3): 231-233. 2. Talawadekar GD, Damodaran P, Jain SA. Hourglass ganglion cyst of the foot: A case report. J Foot Ankle Surg 2010. doi:10.1053/j.jfas.2010.04.021 3. Pai V, Pai VA. A massive foot ganglion: Case report. Foot Ankle J 2008; 1(1). Available at http://faoj.org/2008/01/01/a-massive-foot-ganglion-cas e-report. Accessed on August 1, 2010. 4. Macdonald DJM, Holt G, Vass K, Marsh A, Kumar CS. The differential diagnosis of foot lumps: 101 cases treated surgically in North Glasgow over 4 years. Ann R Coll Surg Engl 2007; 89(3): 272-275. 5. Kirby EJ, Shereff MJ, Lewis MM. Soft-tissue tumors and tumor-like lesions of the foot. An analysis of eighty-three cases. J Bone Joint Surg 1989; 71(4): 621-626. Webmedcentral > Case Report Page 3 of 9
WMC001079 Illustrations Illustration 1 photograph showing the mass[black arrow head] with lateral deviation of the 2nd toe. Illustration 2 X-ray of the foot, the deviation of the 2nd toe, and the soft tissue shadow[white arrow heads] Webmedcentral > Case Report Page 4 of 9
WMC001079 Illustration 3 Per operative picture showing the cyst arising from the plantar aspect of the inter digital space. Illustration 4 The excised cyst showing the dumbbell appearance Webmedcentral > Case Report Page 5 of 9
WMC001079 Illustration 5 Histopathology picture Illustration 6 Clinical photograph at 14 months follow up showing the normal appearing foot. Webmedcentral > Case Report Page 6 of 9
Illustration 7 Antero posterior radiograph of the foot, showing normal alignment of the toes Webmedcentral > Case Report Page 7 of 9
Reviews Review 1 Review Title: Good presentation Posted by Dr. John K Thomas on 25 Jan 2011 02:53:56 PM GMT 1 Is the subject of the article within the scope of the subject category? Yes 2 Are the interpretations / conclusions sound and justified by the data? Yes 3 Is this a new and original contribution? Yes 4 Does this paper exemplify an awareness of other research on the topic? Yes 5 Are structure and length satisfactory? Yes 6 Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience? 7 Can you suggest any reductions in the paper, or deletions of parts? No 8 Is the quality of the diction satisfactory? Yes 9 Are the illustrations and tables necessary and acceptable? Yes 10 Are the references adequate and are they all necessary? Yes 11 Are the keywords and abstract or summary informative? Yes Rating: 7 Comment: Original work, Nice presentation Author got an eye looking for academic material Competing interests: No Invited by the author to make a review on this article? : No Experience and credentials in the specific area of science: Though treated good number of cases of ganglion,as an Orthopaedic Surgeon, the one like this definitely deserve to be noted. Publications in the same or a related area of science: No How to cite: Thomas J.Good presentation[review of the article 'Dumbbell Ganglion Of The Foot: Case Report ' by ].WebmedCentral 2011;2(1):WMCRW00414 No Webmedcentral > Case Report Page 8 of 9
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