Endoscopic Resection of Sinus Tarsi Ganglion Extended to the Anterolateral Ankle

Abstract

Sinus tarsi ganglia are believed to develop from the degeneration of surrounding ligaments or subtalar joint and may associate with sinus tarsi syndrome. Surgical excision of the ganglion and debridement of the sinus tarsi is indicated for symptomatic ones recalcitrant to conservative treatment. The purpose of this technical note is to describe the technical details of endoscopic resection of sinus tarsi ganglion extended to the anterolateral ankle, which is a combination of endoscopic ganglionectomy and debridement of the sinus tarsi via the same set of portals. This minimally invasive approach has the advantages of faster recovery and reduced recurrence.

The sinus tarsi is an opening in the anterolateral ankle between the talar neck and the anterosuperior calcaneus. It is composed of various ligaments and retinacula, fat, vessels, and proprioceptive nerves and serves as an important stabilizer of the hindfoot. ¹ , ² It is the most frequent location of foot ganglia (Figure 1). ² These sinus tarsi ganglia are believed to develop from the degeneration of surrounding ligaments or subtalar joint. ¹ , ² , ³ These may associate with sinus tarsi syndrome, which is a highly heterogenous clinical entity that presents with lateral hindfoot pain, worse on palpation and weight‐bearing, and a sense of instability especially on uneven surfaces. ¹ , ⁴ , ⁵ Most of the symptoms can be resolved with conservative measures, for example, rest, physiotherapy, orthotics, activity modification, and physiotherapy, with appropriate proprioception training or an immobilization period anti‐inflammatory drugs, ultrasound‐guided aspiration, and local injection (corticosteroids, local anesthetics, platelet‐rich plasma, or ozone). ¹ , ⁴ , ⁵ Surgical excision of the ganglion and debridement of the sinus tarsi is indicated if conservative treatment does not relief the symptoms. Endoscopic techniques of the management of sinus tarsi syndrome and ganglion have been reported with the advantages of minimally invasive surgery. ⁴ , ⁵ , ⁶ , ⁷ The purpose of this technical note is to describe the technical details of endoscopic resection of sinus tarsi ganglion extended to the anterolateral ankle. This is a combination of endoscopic ganglionectomy and debridement of the sinus tarsi via the same set of portals. It is indicated for symptomatic sinus tarsi ganglion extended to the anterolateral ankle recalcitrant to conservative treatment. It is contraindicated for asymptomatic ganglion; the lump is because of other pathologies rather than ganglion, for example, solid tumor or nodular pigmented villonodular synovitis, the sinus tarsi ganglion extended to other locations rather than the anterolateral ankle, or ganglion arising from other joints or tendons instead of sinus tarsi (Table 1).

FIGURE 1.

Endoscopic resection of sinus tarsi ganglion of the left foot extended to the anterolateral ankle. The patient is in lateral position. Clinical photographs of this illustrated case show the ganglion at the anterolateral ankle (A) which is transilluminated (B). (G, ganglion.)

TABLE 1.

Indications and Contraindications of Endoscopic Resection of Sinus Tarsi Ganglion Extended to the Anterolateral Ankle

Indications	Contraindications
1. Symptomatic sinus tarsi ganglion extended to the anterolateral ankle recalcitrant to conservative treatment	1. Asymptomatic ganglion
	2. The lump is because of other pathologies rather than ganglion, for example, solid tumor or nodular pigmented villonodular synovitis
	3. The sinus tarsi ganglion extended to other locations rather than the anterolateral ankle
	4. Ganglion arising from other joints or tendons instead of sinus tarsi

SURGICAL TECHNIQUE

Preoperative Planning and Patient Positioning

Preoperative magnetic resonance imaging is important for the confirmation of the diagnosis and provides information of the location and extent of the ganglion, its relation to surrounding anatomic structures, and the condition of the sinus tarsi and subtalar joint (Figure 2).

FIGURE 2.

Endoscopic resection of sinus tarsi ganglion of the left foot extended to the anterolateral ankle. The patient is in lateral position. Sagittal MRI T2W image of the illustrated case's left ankle shows that the ganglion arises from the sinus tarsi. (G, ganglion; GSt, ganglion stalk; MRI, magnetic resonance imaging; ST, sinus tarsi; T2W, T2 weighted.)

The patient is placed in the lateral position. A 2.7‐mm 30° arthroscope (Henke Sass Wolf GmbH, Tuttlingen, Germany) is used for this procedure. A thigh tourniquet is applied to provide a bloodless operative field. Fluid inflow is driven by gravity, and no arthropump is used.

Portal Placement

This procedure is performed via the ganglion portal and the dorsolateral midtarsal portal. The ganglion portal is located at the central part of the anterolateral ankle portion of the ganglion. The dorsolateral midtarsal ganglion is at the junction between the talonavicular joint and calcaneocuboid joints. ⁵ , ⁷ , ⁸ , ⁹ Four‐millimeter skin incisions are made in the portal sites. The ganglion is perforated by a hemostat via the ganglion portal, and viscous clear fluid is drained out (Figure 3).

FIGURE 3.

Endoscopic resection of sinus tarsi ganglion of the left foot extended to the anterolateral ankle. The patient is in lateral position. This procedure is performed via the ganglion portal and the dorsolateral midtarsal portal. (A) The ganglion portal is located at the central part of the anterolateral ankle portion of the ganglion. The dorsolateral midtarsal ganglion is at the junction between the talonavicular joint and calcaneocuboid joints. (B) Four‐millimeter skin incisions are made in the portal sites. The ganglion is perforated by a hemostat via the ganglion portal, and viscous clear fluid is drained out. (DLMP, dorsolateral midtarsal portal; G, ganglion; GP, ganglion portal; LM, lateral malleolus; VF, viscous fluid of the ganglion.)

Intraganglionic Resection of the Ganglion Sac

The dorsolateral midtarsal portal is the viewing portal, and the ganglion portal is the working portal. The ganglion sac is resected with an arthroscopic shaver (Dyonics, Smith and Nephew, Andover, MA) from inside out. Suction through the shaver can draw the ganglion sac toward the shaver blade and reduce the risk of injury to the adjacent structures (Figure 4).

FIGURE 4.

Endoscopic resection of sinus tarsi ganglion of the left foot extended to the anterolateral ankle. The patient is in lateral position. (A) The dorsolateral midtarsal portal is the viewing portal, and the ganglion portal is the working portal. (B) The arthroscopic shaver is placed inside the ganglion sac. (C) The ganglion sac is resected from inside out. (AS, arthroscopic shaver; DLMP, dorsolateral midtarsal portal; GP, ganglion portal; GSa, ganglion sac.)

Extraganglionic Resection of the Ganglion Sac

The ganglion portal is the viewing portal, and the dorsolateral midtarsal portal is the working portal. The ganglion sac is resected from outside with the arthroscopic shaver. The portion of ganglion sac adhered to the inferior extensor retinaculum can be dissected and removed with the shaver (Figure 5).

FIGURE 5.

Endoscopic resection of sinus tarsi ganglion of the left foot extended to the anterolateral ankle. The patient is in lateral position. (A) The ganglion portal is the viewing portal, and the dorsolateral midtarsal portal is the working portal. (B) The ganglion sac is resected from outside with the arthroscopic shaver. (C) The portion of ganglion sac adhered to the inferior extensor retinaculum can be dissected and removed with the shaver. (AS, arthroscopic shaver; DLMP, dorsolateral midtarsal portal; GP, ganglion portal; GSa, ganglion sac; IER, inferior extensor retinaculum.)

Resection of the Ganglion Stalk

The ganglion portal is the viewing portal, and the dorsolateral midtarsal portal is the working portal. The ganglion sac is traced toward the sinus tarsi. The orifice of the ganglion stalk can be seen and removed with an arthroscopic punch (Arthrex, Naples, FL). The ganglion stalk is traced along the ligaments of sinus tarsi. It is dissected out from the ligaments and resected with the arthroscopic shaver (Figure 6).

FIGURE 6.

Endoscopic resection of sinus tarsi ganglion of the left foot extended to the anterolateral ankle. The patient is in lateral position. The ganglion portal is the viewing portal, and the dorsolateral midtarsal portal is the working portal. The ganglion sac is traced toward the sinus tarsi. (A) The orifice of the ganglion stalk can be seen. (B) The outside view of the orifice of the ganglion stalk. (C) The orifice of the ganglion stalk is removed with an arthroscopic punch. (D) The ganglion stalk is traced along the ligaments of sinus tarsi. It is dissected out from the ligaments and resected with the arthroscopic shaver. (AP, arthroscopic punch; AS, arthroscopic shaver; GSa, ganglion sac; GSt, ganglion stalk; PSJ, posterior subtalar joint.)

Debridement of the Sinus Tarsi

The ganglion portal is the viewing portal, and the dorsolateral midtarsal portal is the working portal. The fatty tissue, fibrous tissue, and inflamed synovium of the sinus tarsi are resected, and the ligaments are preserved. The posterior subtalar joint is also examined for any degeneration (Figure 7, Video 1, Table 2). Postoperatively, pressure dressing is applied to the ankle for 2 to 4 weeks.

FIGURE 7.

Endoscopic resection of sinus tarsi ganglion of the left foot extended to the anterolateral ankle. The patient is in lateral position. The ganglion portal is the viewing portal, and the dorsolateral midtarsal portal is the working portal. (A) The fatty tissue, fibrous tissue, and inflamed synovium of the sinus tarsi are resected. (B) The ligaments of the sinus tarsi are preserved. (C) The posterior subtalar joint is also examined for any degeneration. (AS, arthroscopic shaver; IS, inflamed synovium; L, ligaments of the sinus tarsi; PSJ, posterior subtalar joint.)

VIDEO 1.

Download video file ^{(77.9MB, mp4)}

Endoscopic resection of sinus tarsi ganglion of the left foot extended to the anterolateral ankle. The patient is in lateral position. With the dorsolateral midtarsal portal as the viewing portal and the ganglion portal as the working portal, the ganglion sac is resected from inside out with an arthroscopic shaver. With the ganglion portal as the viewing portal and the dorsolateral midtarsal portal as the working portal, the ganglion sac is resected from outside. The portion of ganglion sac adhered to the inferior extensor retinaculum is dissected and resected. The ganglion sac is traced toward the sinus tarsi, and the orifice of the ganglion stalk is identified and resected. The ganglion stalk is further traced along the ligaments of the sinus tarsi. The ganglion stalk is dissected from the ligaments and resected. Finally, the sinus tarsi is debrided, and the posterior subtalar joint is examined. Video content can be viewed at https://doi.org/10.1002/atn2.70307.

TABLE 2.

Pearls and Pitfalls of Endoscopic Resection of Sinus Tarsi Ganglion Extended to the Anterolateral Ankle

Pearls	Pitfalls
1. Suction via the arthroscopic shaver can aid the intraganglionic resection of the ganglion sac and reduce the risk of injury to adjacent structures	1. Incomplete resection of the ganglion stalk may increase the risk of recurrence
2. Resection of the ganglion stalk along the sinus tarsi ligaments may reduce the risk of recurrence	2. Injury to the sinus tarsi ligaments may lead to subtalar instability
3. Sinus tarsi debridement may reduce the risk of recurrence

DISCUSSION

Endoscopic management of the ganglion can be either resection of the ganglion or internal drainage of the ganglion cyst into the adjacent joint or fibrous tendon sheath. ⁶ In this reported technique, we prefer endoscopic resection of the ganglion sac and the ganglion stalk to reduce the risk of recurrence. Moreover, there is no effective recipient site for internal drainage of the sinus tarsi ganglion extended to the anterolateral ankle. Assessment and debridement of the sinus tarsi is important to determining and managing the underlying cause of sinus tarsi ganglion especially if there is associated lateral hindfoot pain. ¹⁰

Moreover, sinus tarsi ganglion usually suggests degeneration of the tarsal sinus which may be a secondary phenomenon of other pathology and pathologic biomechanics at another site of the ankle or hindfoot, for example, chronic lateral collateral ligament injury. ² Therefore, it is important to assess other sites of the ankle and hindfoot for associated pathology.

The advantages of this minimally invasive approach include better cosmetic results, minimal soft‐tissue trauma, decreased postoperative pain, and less recurrence rate. The potential risks include injury to the intermediate dorsal cutaneous branch of superficial peroneal nerve, nerve to extensor digitorum brevis (lateral terminal branch of the deep peroneal nerve), inferior extensor retinaculum, sinus tarsi ligaments, articular cartilage of subtalar joints, and recurrence (Table 3). ⁵ , ⁷ This approach is not technically difficult and can be managed by the average foot and ankle arthroscopist.

TABLE 3.

Advantages and Risks of Endoscopic Resection of Sinus Tarsi Ganglion Extended to the Anterolateral Ankle

Advantages	Risks
1. Better cosmetic results	1. Injury to the intermediate dorsal cutaneous branch of superficial peroneal nerve
2. Minimal soft‐tissue trauma	2. Injury to the extensor digitorum brevis (terminal branch of the deep peroneal nerve)
3. Decreased postoperative pain	3. Injury to the inferior extensor retinaculum
4. Less recurrence rate	4. Injury to the sinus tarsi ligaments
	5. Injury to the articular cartilage of subtalar joints
	6. Recurrence

DISCLOSURES

The authors (X.P., T.H.L., J.H., A.M.Y.S., C.C.H.L., W.S., Y.P.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.

FUNDING

This work was financially supported by the “Overseas Distinguished Professors” Project of Guangdong Provincial Department of Science and Technology (No. MS202500167); the Sanming Project of Medicine in Shenzhen (SZSM202106019); and the Youth Research Fund of Shenzhen Bao'an District People's Hospital (No. 202211).