91: Treatment of Mucous Cysts of the Distal Interphalangeal Joint

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Procedure 91 Treatment of Mucous Cysts of the Distal Interphalangeal Joint

Shimpei Ono, Sandeep J. Sebastin, Kevin C. Chung

Indications

image Symptomatic mucous cyst

• Progressive cyst with impending rupture due to thinning of skin (Fig. 91-1)
• Discomfort or pain due to pressure from the cyst
• Nail deformity (see Fig. 91-1)

image Asymptomatic mucous cyst

• Aesthetic appearance
• Patient desire

image Patients should be advised that cyst excision might not provide complete pain relief in the context of an underlying arthritic joint because pain can be due to either the cyst or the underlying arthritic joint. The only treatment that can ensure a cyst will not recur is distal interphalangeal (DIP) joint arthrodesis.

image

FIGURE 91-1

Examination/Imaging

Clinical Examination

image A mucous cyst is a degenerative cyst of the DIP joint arising as a result of osteoarthritis. It usually occurs between the fifth and seventh decades of life, and patients have DIP joint osteoarthritis including Heberden nodes (Fig. 91-2).

image The cyst may present on the dorsum at the level of the DIP joint on either side between the extensor tendon and the collateral ligament or under the eponychium to cause longitudinal grooving of the nail plate (Fig. 91-3).

image

FIGURE 91-2

image

FIGURE 91-3

Imaging

image Anteroposterior and lateral view radiographs are useful in determining the location of the osteophytes and degree of osteoarthritic change (joint subluxation, deformity, and joint space narrowing) (Fig. 91-4).

image

FIGURE 91-4

Surgical Anatomy

image The mucous cyst originates from the DIP joint in relation to one of the osteophytes, and the stalk of the cyst passes between the collateral ligament and the extensor insertion to present on the dorsum of the DIP joint. Occasionally, the stalk can connect with another mucous cyst on the opposite side of the DIP joint. This cyst may not be clinically obvious (occult cyst), and the entire DIP joint should be examined during surgery.

image The terminal extensor insertion is about 1.2 mm from the proximal edge of the nail matrix (Fig. 91-5).

image

FIGURE 91-5

Positioning

image The procedure can be performed under a digital block using a forearm, arm, or digital tourniquet.

Exposures

image Mucous cyst with good-quality overlying skin

• We use a gentle curving transverse incision centered over the DIP joint. A distally based skin flap is elevated in a plane superficial to the cyst (Fig. 91-6).

image Mucous cyst with thinned overlying skin

• We use a longitudinal elliptical incision that includes the thinned skin. A long rotational flap is designed proximally to cover the resulting skin defect skin (see Fig. 91-6).
image

FIGURE 91-6

Pearls

Traction sutures can be placed on the skin flaps to provide better exposure.

The proximal extent of the flap depends on the size of the skin defect. Extending the flap to the proximal joint is usually sufficient, and, if required, a back-cut can be added.

Pitfalls

Care must be taken not to injure the nail bed.

The skin flaps need to be elevated in full thickness to maintain the vascularity

Procedure

Step 1: Mobilization of Cyst

image The cyst is separated from the overlying skin and the extensor tendon.

image If a stalk extends under the nail bed, it will have to be carefully dissected to the joint.

Step 1 Pearls

The extensor tendon can be retracted laterally to provide better exposure.

Care is taken not to injure the insertion of the extensor tendon or the nail matrix.

Step 2: Removal of the Cyst

image The cyst is excised en-mass and includes any thinned overlying skin, the cyst and the stalk, and all soft tissue between the extensor tendon and collateral ligament (synovium and joint capsule). (Fig. 91-7 depicts the soft tissue zone that needs to be excised in the dotted line.)

image Any remaining synovium within the joint is also excised.

image

FIGURE 91-7

Step 2 Pearls

It is important to remove all synovium to allow a clear visualization of the DIP joint.

Both sides of the extensor tendon must be examined for any occult cysts.

It is preferable to leave behind a portion of the cyst wall that is in close relation to the nail bed rather than risk injury to the nail bed from an aggressive débridement.

Step 3: Removal of DIP Joint Osteophytes

image All osteophytes of the DIP joint should be removed with a small rongeur.

Step 3 Pearls

The removal of the osteophytes is the key to successful excision of a mucous cyst.

One must inspect under the extensor insertion and the collateral ligaments for osteophytes that are seen on the radiograph but cannot be seen in the wound.

Step 4: Flap Elevation

image If required, a rotational flap can be designed to cover the skin defect. The flap is elevated in the loose areolar plane superficial to the extensor tendon paratenon (Fig. 91-8).

image

FIGURE 91-8

Step 5: Skin Closure

image The tourniquet is released and hemostasis secured.

image The flap is advanced into the defect (Fig. 91-9) and sutured with a few 5-0 Ethilon sutures.

image

FIGURE 91-9

Step 5 Pearls

It is better to close the skin loosely and leave any residual skin defects to heal by secondary intention instead of attempting a watertight closure.

A Xeroform dressing with overlying gauze is applied as a wick to absorb any residual blood. A volar finger splint is applied to keep the DIP joint straight.

Step 5 Pitfalls

Do not close skin flaps under tension. This will result in partial skin flap necrosis, wound breakdown, and increased risk for infection.

Postoperative Care and Expected Outcomes

image The splint is used to immobilize the DIP joint for 5 to 7 days, and the patient is asked to start gentle active range-of-motion exercises thereafter.

image Surgical excision has a high success rate (>90%) and low recurrence rate (2% to 3%), provided that all osteophytes are removed during surgery. A loss of 5 to 20 degrees of motion, joint stiffness, contour changes of the proximal nail fold, and nail dystrophies occur postoperatively in up to 25% of patients.

Evidence

Fritz GR, Stern PJ, Dickey M. Complications following mucous cyst excision. J Hand Surg [Br]. 1997;22:222-225.

The authors reported that 86 mucous cysts in 79 patients were surgically excised along with accompanying osteophytes. Rotation flaps were created in 58 of the 86 (67%). Follow-up was carried out at an average of 2.6 years. Fifteen digits (17%) had a residual loss of extension of 5 to 20 degrees at the IP or DIP joint. One patient developed a superficial infection, and 2 developed a DIP septic arthritis, which eventually required DIP arthrodesis. Nail deformities were present in 25 of 86 digits preoperatively (29%), 15 of which resolved after surgery (60%). Four of 61 digits developed a nail deformity that was not present preoperatively (7%). Three of 86 digits (3%) developed recurrence. Other complications included persistent swelling, pain, numbness, stiffness, and radial or ulnar deviation at the DIP joint. (Level IV evidence)

Kasdan ML, Stallings SP, Leis VM, Wolens D. Outcome of surgically treated mucous cysts of the hand. J Hang Surg [Am]. 1994;19:504-507.

The results of a surgical procedure for the treatment of digital mucous cysts are described. In this series, a longitudinal incision was made directly over the mucous cyst, and the cyst was excised with routine removal of osteophytes. One hundred ninety-one mucous cysts from 178 patients were treated from 1973 to 1992. The average age of the study population was 57 years. There were only two recurrences and two postoperative infections. Both patients with recurrences presented more than 40 months after surgery. Sixty-four of the cysts had been previously treated elsewhere. The most common postoperative complaint was tenderness of the joint. Associated nail deformities were corrected in 40 of 46 cases. (Level IV evidence)

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