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Mucous cysts of the DIPJ

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2 Mucous cysts of the DIPJ

3 Mucous cyst DIPJ Ganglion cyst of the DIPJ
Usually occurs between the fifth and seventh decades Associated with osteophytes or spurring of the DIPJ Osteoarthritis in other joints

4 Ganglion/Mucous cyst Single or multiloculated cyst which appears smooth, white & translucent Wall is made up of compressed collagen fibres and is sparsely lined with flattened cells without evidence of an epithelial or synovial lining Mucin-filled “clefts” from the capsular attachment of the main cyst interconnect with the adjacent underlying joint via tortuous continuous ducts Stroma may show tightly packed collagen fibres or sparsely cellular areas with broken fibres and mucin-filled intercellular & extracellular lakes No inflammatory reaction or mitotic activity has been noted

5 Ganglion/Mucous cyst Contents of cyst characterized by a highly viscous, clear, sticky, jelly-like mucin made up of glucosamine, albumin, globulin, & high concentrations of hyaluronic acid Aetiology & pathogenesis remain obscure Most widely accepted theory - mucoid degeneration associated with degeneration of joint capsule or tendon sheath Injury & mechanical irritation may stimulate production of hyaluronic acid to form mucin, which may penetrate joint ligaments and capsules and then coalesce to form cyst

6 Clinical signs Longitudinal grooving of the nail - earliest sign without a visible mass, caused by pressure on the nail matrix

7 Clinical signs Enlarged cyst with attenuated overlying skin

8 Clinical signs Cyst (3-5mm) usually lies to one side of the extensor tendon and between the dorsal distal joint crease & the eponychium

9 Clinical signs Often has Heberden’s nodes and radiographic evidence of osteoarthritic changes in the joint

10 Treatment Primarily surgical
Numerous alternative treatment reported in the past with moderate success: Intralesional injection - eg. Sodium morrhuate, triamcinolone Occlusive flurandrenolone tape

11 Surgical Management Excision of the cyst alone
Wide excision of the cyst along with surrounding adjacent structures - eg.the overlying skin, osteophyte debridements Debridement of the DIPJ osteophytes only, without excision of the cyst itself or overlying skin

12 Operative technique L-shaped / H-shaped / curved incision
Elliptical excision of attenuated or involved skin

13 Operative technique Cyst mobilized, traced to the joint capsule & excised with the joint capsule All tissue excised between the extensor tendon & the adjacent collateral ligaments Insertion of the extensor tendon and the nail matrix must be protected

14 Operative technique Excison of osteophytes
Skin closure may require rotation / advancement dorsal skin flap or a full-thickness graft

15 Alternative approach Transverse incision centred over DIPJ
Base of mucous cyst identified & excised while leaving the distal & superficial portion of the cyst intact Excision of osteophtyes & joint capsule with direct skin closure Allow several weeks for involution of the remaining cyst

16 Complications Residual nail deformities Stiffness Skin necrosis
Recurrence: - inadequate excision - ganglion extension to the other side of extensor tendon - persistent underlying arthritic process

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