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Arthroscopic resection of volar ganglion of the wrist: A new technique
Technical Note
Arthroscopic Resection of Volar Ganglion of the Wrist: A New Technique Pak-Cheong Ho, F.R.C.S.(Edin), Wing-Nin Lo, F.R.C.S.(Edin), and Leung-Kim Hung, F.R.C.S.(Edin)Ortho
Abstract: We evaluated a new arthroscopic technique for treating volar ganglion of the wrist. Arthroscopic resection of volar wrist ganglion was performed under local anesthesia to the portal sites. Arthroscopic instruments were introduced dorsally, and the intra-articular lesion at the interval between the radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments was debrided under direct view. Mucinous content of the ganglion was evacuated using suction, but the ganglion sac was not removed. The technique was successful in 5 cases between August 1997 and November 1998, with an average surgery time of 55 minutes. No complications or recurrence occurred at a mean follow-up of 16.4 months. This is the first report of arthroscopic decompression of volar wrist ganglions and provides new insight into the etiology of these lesions. Key Words: Volar wrist ganglion—Arthroscopic resection.
G
anglion of the wrist is the most common mass in the hand.1 Various techniques of decompression of the cyst have been proposed, including simple aspiration,2,3 aspiration with instillation of medication,4,5 forceful rupture or controlled rupture with multiple needle puncture,6 and surgical excision.7-9 These approaches all have pros and cons and variable degrees of success. Arthroscopic resection of dorsal wrist ganglion was reported on recently, with satisfactory results.10 It is now widely accepted that dorsal and volar wrist ganglions have similar pathomechanisms and arise from mucinous degeneration of the capsular and ligamental structures around the joint.10,11 Volar wrist ganglion is the second most
common mass in the wrist (18% to 20%), although there have been no reports in the literature regarding arthroscopic treatment.10 Because of the volar tilt of the radius, the volar capsule and ligaments of the radiocarpal joint are more accessible to arthroscopic instrumentation than the dorsal structures. Therefore, it is highly probable that volar wrist ganglions are treatable by an arthroscopic approach. Arthroscopic decompression has the advantage of avoiding dissection, scarring, and potential damage to structures that commonly overlie the volar ganglion, such as the radial artery and, in some cases, the palmer cutaneous nerve.12 We describe the technique of arthroscopic resection of volar ganglions and discuss the intraarticular pathology in these lesions.5
From the Department of Orthopaedics and Traumatology, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, S.A.R., China. Address correspondence and reprint request to Leung-Kim Hung, F.R.C.S.(Edin)Orthop, Room 74038, 5 Floor, Clinical Sciences Building, Prince of Wales Hospital, Shatin, NT, Hong Kong, S.A.R., China. E-mail: [email protected] © 2003 by the Arthroscopy Association of North America 0749-8063/03/1902-3073$30.00/0 doi:10.1053/jars.2003.50035
THE TECHNIQUE
218
The patient lies supine. A wrist traction tower with 5-kg traction is used and the fingers are suspended with disposable plastic finger traps. A sterile tourniquet is applied to the forearm but not inflated unless necessary. Portal sites are palpated and marked. Local anesthetic is injected through the skin and subcutane-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 2 (February), 2003: pp 218-221
ARTHROSCOPIC RESECTION OF VOLAR WRIST GANGLION
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FIGURE 2. Interval identified by a needle passed through the ganglion into the joint.
FIGURE 1. Typical pathologic changes between the radioscaphocapitate ligament (RSC) and the long radiolunate (LRL) ligaments. (A, B, C) The interval is usually soft and vascular or (D) could be fibrotic and irregular, resembling scar tissue. (SLIOM, scapholunate interosseous membrane; S, scaphoid; R, radius interval identified.)
ous tissues into the capsule but not necessarily into the joint. From our previous experience this mode of anesthesia was usually sufficient for wrist arthroscopy. Additional intra-articular infiltration of local anesthetic or direct injection of lignocaine to a painful spot can be performed if necessary. However, we usually add regional intravenous anesthesia to the entire forearm if the patient experiences additional discomfort. The portal sites used for the radiocarpal joint were routinely 3-4 and either 4-5 or 1-2. The 3-4 portal allowed direct access to and inspection of the radial side wrist ligaments, where the volar ganglion usually began. The most common lesion site was the interval between the radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments. This portal was also the best for instrumentation. During instrumented debridement of this interval, visualization was provided by a scope introduced through an additional 4-5 or 1-2 portal. The 1-2 portal gave a better view, although it was associated with a higher risk of damaging the radial artery and sensory branch of the radial nerve. The outflow portal was 6U in all cases. The radiocarpal joint was initially distended with 2 to 4 mL saline. Short, 3-mm skin incisions were made over the portals, followed by blunt dissection of subcutaneous tissues with a hemostat and finally puncture of the joint capsule with the hemostat. This maneuver was particularly important when the 1-2 portal was
being created, to avoid injury to the radial artery and the radial nerve. Leaving the tourniquet uninflated helped to locate and avoid puncturing the radial artery. A 2.7-mm 30° video arthroscope was used, with irrigation fluid instilled by gravity infusion. A quick arthroscopic survey of the radiocarpal joint and midcarpal joint was performed. The arthroscope was then returned to the radiocarpal joint, where decompression of the volar ganglion was performed. In all cases, synovial and capsular abnormalities were seen at the interval between the RSC and LRL ligaments (Fig 1). Connection of the ganglion to this site was confirmed by external pressure on the ganglion, which resulted in synovial and capsular bulging at the site. This could also be aided using needle puncture (Fig 2). A 2.0- to 2.9-mm arthroscopic shaver was then introduced to debride the region while gentle external pressure was maintained on the ganglion (Fig 3). The radial artery was also palpated at intervals. When sufficient enlargement of the interval was achieved, a sudden gush of mucinous material into the radiocarpal joint could be seen. The mucinous material was removed using suction while external pressure was maintained. The shaver must not be advanced too anteriorly into the volar aspect of the wrist joint, because this could damage the important structures volar to the joint. We
FIGURE 3. Debridement by shaver. (S, scaphoid; R, radius; LRL, long radiolunate ligament; RSC, radioscaphocapitate ligament.)
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did not attempt to remove the ganglion wall or more of the joint capsule than was necessary to induce the gush of mucinous content. The radial artery was palpated regularly so we could ensure that the shaver was at an appropriate distance. A small capsular defect approximately 5 mm in size usually resulted at the RSC-LRL interligamental interval after the procedure (Fig 4). At completion of the procedure, sterile strips were used to close the portal sites, and the wrist was protected with cotton wool rolls and crepe bandage. The light dressing was changed on day 2. Patients were advised to move their wrists from day 2, although heavy manual activity was avoided for 1 month (Fig 5). DISCUSSION Volar wrist ganglion is the second most common lesion occurring around the wrist.10 Surgical excision results in a predictable outcome but includes a high rate of reported complications.12 Jacobs and Govaers13 reported a recurrence rate of 28%, damage to the palmar cutaneous branch of the median nerve in 28%, and unsatisfactory scar in 28%. The risk of damage to the radial artery was also stressed in the literature.10,14
FIGURE 4. Gap between the ligaments after debridement. Occasionally the volar capsule is opened and flexor tendons are seen through the interval.
FIGURE 5. Postoperative results are shown. The portal sites are indicated by arrows.
Open ganglionectomy was described as “trading a scar for a lump.”10 Similar problems had been encountered with excision of dorsal wrist ganglions. With the advent of arthroscopic surgery of the wrist, the question of whether arthroscopic decompression of a dorsal wrist ganglion could be performed was asked. Osterman and Rafael15 and Osterman16 reported satisfactory results with arthroscopic resection of dorsal wrist ganglions. In a series of 150 cases, they noted only 1 recurrence and no major complications. The technique used was a decompression of the ganglion from inside the joint. Although the ganglion wall remained, the procedure was highly effective. This could be explained by the presence of a “1-way valve” structure at the scapholunate ligament of the dorsal capsular reflection where the ganglion formed.7 When these structures were debrided and the connection to the ganglion enlarged, the ganglion drained back into the joint and did not reform. Subsequent reports from other surgeons confirmed the efficacy and safety of this technique.17-19 Because a similar pathomechanism was observed in volar wrist ganglion,10 we believed that these lesions could be treated similarly using an arthroscopic approach. As described, arthroscopic decompression of a volar ganglion is a more direct procedure than treatment of dorsal ganglion. The RSC to LRL interval was directly visualized through the scope via the 3-4 portal. Instrumentation to achieve debridement of the lesion also followed a more or less straight route, making the procedure easier and safer than decompression of a dorsal ganglion.
ARTHROSCOPIC RESECTION OF VOLAR WRIST GANGLION However, observing the precautions described previously for the radial artery and the radial nerve is important, to avoid injuring these structures. The surgery could be performed under general or regional anesthesia; however, in our experience, local anesthesia to the portal sites works well20 and includes the added advantage of avoiding a tourniquet. Therefore, the radial pulse can be palpated, and the patient experiences less postoperative muscle ache. Local anesthesia has been used effectively for knee arthroscopy as well.21 We treated 6 consecutive cases of volar wrist ganglion from August 1997 to November 1998 using this technique. Decompression was successfully achieved in 5 cases, and after a mean follow up of 16.4 months (range, 10 to 25 months), no recurrence was seen. These ganglions were of at least 1 year duration and ranged in size from 1.5 to 2 cm. No complications occurred in these cases. In the 1 case that was not successful, arthroscopy of the radiocarpal joint was normal and no connection with the ganglion was found. Open excision of the ganglion was then performed, and the stalk was found to originate in the scaphotrapeziotrapezoid (STT) joint. We since noted that ganglions that arise from the distal wrist crease were likely to originate in the STT joint or other component of the midcarpal joint. They are not amenable to arthroscopic decompression at present. Volar ganglions that lie at or proximal to the proximal wrist crease usually arise from the radiocarpal joint and are suitable for arthroscopic decompression. The differentiation could be assisted by using either injection of dye or contrast medium into the ganglion22 or preoperative ultrasonography.23-25 In conclusion, this new technique of arthroscopic treatment of volar wrist ganglion is effective and safe and can be performed under local anesthesia via the portal sites. REFERENCES 1. Butle ED, Hamill JP. Tumours of the hand. J Surg Am 1960; 100:293-302. 2. Nield DV, Evans DM. Aspiration of ganglia. J Hand Surg [Br] 1986;11:264. 3. Richman JA, Gelberman R II, Engber WS, et al. Ganglions of the wrist and digits: Results of treatment by aspiration and cyst wall puncture. J Hand Surg [Am] 1987;12:1041-1043.
221
4. Holm PC, Pandey SD. Treatment of ganglia of the hand and wrist with aspiration and injection of hydrocortisone. Hand 1973;5:63-68. 5. Varley GW, Needoff M, Davis TR, Clay NR. Conservative management of wrist ganglia: Aspiration versus steroid infiltration. J Hand Surg [Br] 1997;22:636-637. 6. Stephen AB, Lyons AR, Davis TR. A prospective study of two conservative treatments for ganglia of the wrist. J Hand Surg [Br] 1999;24:104-105. 7. Angelides AC, Wallace P. The dorsal ganglion of the wrist: Its pathogenesis, gross and microscopic anatomy, and surgical treatment. J Hand Surg [Am] 1976;1:228-235. 8. Faithfull DK, Seeto BG. The simple wrist ganglion: More than a minor surgical procedure? Hand Surg 2000;5:139-143. 9. Clay NR, Clement DA. The treatment of dorsal wrist ganglia by radical excision. J Hand Surg 1988;13:187-191. 10. Angelides AC. Ganglions of the hand and wrist. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s operative hand surgery. Ed 4. New York: Churchill Livingstone, 1999:21712183. 11. Watson HK, Rogers WD, Ashmead D IV. Reevaluation of the cause of the wrist ganglion. J Hand Surg [Am] 1989;14:812817. 12. Wright TW, Cooney WP, Ilstrup DM. Anterior wrist ganglion. J Hand Surg [Am] 1994;19:954-958. 13. Jacobs LG, Govaers KJ. The volar wrist ganglion: Just a simple cyst? J Hand Surg [Br] 1990;15:342-346. 14. Rosson JW, Walker G. The natural history of ganglia in children. J Bone Joint Surg Br 1989;71:707-708. 15. Osterman AL, Raphael J. Arthroscopic resection of dorsal ganglion of the wrist. Hand Clin 1995;11:7-12. 16. Osterman AL. Wrist arthroscopy: Operative procedures. In: Green DP, Hotchkiss RN, Pederson WC, Eds. Green’s operative hand surgery, Ed 4. New York: Churchill Livingstone, 1999:207-222. 17. Fontes D. Ganglia treated by arthroscopy. In: Saffar P, Amadio PC, Foucher G, Eds. Current practice in hand surgery. London: Martin Dunitz, 1997:283-290. 18. Luchetti R, Badia A, Alfarano M, et al. Arthroscopic resection of dorsal wrist ganglia and treatment of recurrences. J Hand Surg [Br] 2000;25:38-40. 19. Pederzini L, Ghinelli M. Arthroscopic treatment of dorsal arthrogenic cysts of the wrist. J Sports Trauma Rel Res 1995; 17:210-215. 20. Yung SH, Ho PC. Wrist arthroscopy under portal site local anaesthesia (PSLA) without tourniquet: Is it really feasible? Proceedings of the HKSSH Annual Congress, June 1999. 21. Rolf GC. Knee Arthroscopy under local anaesthesia. Hong Kong J Orthop Surg 1998;2:158-163. 22. Andren L, Eiken O. Arthrographic studies of wrist ganglions. J Bone Joint Surg Am 1971;53:299-302. 23. Ho PC, Griffiths J, Lo WN, et al. Current treatment of ganglion of the wrist. Hand Surg 2001;6:49-58. 24. Ogino T, Minami A, Fukada K, et al. The dorsal occult ganglion of the wrist and ultrasonography. J Hand Surg [Br] 1988;13:181-183. 25. Osterwalder JJ, Widrig R, Stober R, Gachter A. Diagnostic validity of ultrasound in patients with persistent wrist pain and suspected occult ganglion. J Hand Surg [Am] 1997;22:19341040.
Arthroscopic Resection of Volar Ganglion of the Wrist: A New Technique Pak-Cheong Ho, F.R.C.S.(Edin), Wing-Nin Lo, F.R.C.S.(Edin), and Leung-Kim Hung, F.R.C.S.(Edin)Ortho
Abstract: We evaluated a new arthroscopic technique for treating volar ganglion of the wrist. Arthroscopic resection of volar wrist ganglion was performed under local anesthesia to the portal sites. Arthroscopic instruments were introduced dorsally, and the intra-articular lesion at the interval between the radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments was debrided under direct view. Mucinous content of the ganglion was evacuated using suction, but the ganglion sac was not removed. The technique was successful in 5 cases between August 1997 and November 1998, with an average surgery time of 55 minutes. No complications or recurrence occurred at a mean follow-up of 16.4 months. This is the first report of arthroscopic decompression of volar wrist ganglions and provides new insight into the etiology of these lesions. Key Words: Volar wrist ganglion—Arthroscopic resection.
G
anglion of the wrist is the most common mass in the hand.1 Various techniques of decompression of the cyst have been proposed, including simple aspiration,2,3 aspiration with instillation of medication,4,5 forceful rupture or controlled rupture with multiple needle puncture,6 and surgical excision.7-9 These approaches all have pros and cons and variable degrees of success. Arthroscopic resection of dorsal wrist ganglion was reported on recently, with satisfactory results.10 It is now widely accepted that dorsal and volar wrist ganglions have similar pathomechanisms and arise from mucinous degeneration of the capsular and ligamental structures around the joint.10,11 Volar wrist ganglion is the second most
common mass in the wrist (18% to 20%), although there have been no reports in the literature regarding arthroscopic treatment.10 Because of the volar tilt of the radius, the volar capsule and ligaments of the radiocarpal joint are more accessible to arthroscopic instrumentation than the dorsal structures. Therefore, it is highly probable that volar wrist ganglions are treatable by an arthroscopic approach. Arthroscopic decompression has the advantage of avoiding dissection, scarring, and potential damage to structures that commonly overlie the volar ganglion, such as the radial artery and, in some cases, the palmer cutaneous nerve.12 We describe the technique of arthroscopic resection of volar ganglions and discuss the intraarticular pathology in these lesions.5
From the Department of Orthopaedics and Traumatology, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, S.A.R., China. Address correspondence and reprint request to Leung-Kim Hung, F.R.C.S.(Edin)Orthop, Room 74038, 5 Floor, Clinical Sciences Building, Prince of Wales Hospital, Shatin, NT, Hong Kong, S.A.R., China. E-mail: [email protected] © 2003 by the Arthroscopy Association of North America 0749-8063/03/1902-3073$30.00/0 doi:10.1053/jars.2003.50035
THE TECHNIQUE
218
The patient lies supine. A wrist traction tower with 5-kg traction is used and the fingers are suspended with disposable plastic finger traps. A sterile tourniquet is applied to the forearm but not inflated unless necessary. Portal sites are palpated and marked. Local anesthetic is injected through the skin and subcutane-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 2 (February), 2003: pp 218-221
ARTHROSCOPIC RESECTION OF VOLAR WRIST GANGLION
219
FIGURE 2. Interval identified by a needle passed through the ganglion into the joint.
FIGURE 1. Typical pathologic changes between the radioscaphocapitate ligament (RSC) and the long radiolunate (LRL) ligaments. (A, B, C) The interval is usually soft and vascular or (D) could be fibrotic and irregular, resembling scar tissue. (SLIOM, scapholunate interosseous membrane; S, scaphoid; R, radius interval identified.)
ous tissues into the capsule but not necessarily into the joint. From our previous experience this mode of anesthesia was usually sufficient for wrist arthroscopy. Additional intra-articular infiltration of local anesthetic or direct injection of lignocaine to a painful spot can be performed if necessary. However, we usually add regional intravenous anesthesia to the entire forearm if the patient experiences additional discomfort. The portal sites used for the radiocarpal joint were routinely 3-4 and either 4-5 or 1-2. The 3-4 portal allowed direct access to and inspection of the radial side wrist ligaments, where the volar ganglion usually began. The most common lesion site was the interval between the radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments. This portal was also the best for instrumentation. During instrumented debridement of this interval, visualization was provided by a scope introduced through an additional 4-5 or 1-2 portal. The 1-2 portal gave a better view, although it was associated with a higher risk of damaging the radial artery and sensory branch of the radial nerve. The outflow portal was 6U in all cases. The radiocarpal joint was initially distended with 2 to 4 mL saline. Short, 3-mm skin incisions were made over the portals, followed by blunt dissection of subcutaneous tissues with a hemostat and finally puncture of the joint capsule with the hemostat. This maneuver was particularly important when the 1-2 portal was
being created, to avoid injury to the radial artery and the radial nerve. Leaving the tourniquet uninflated helped to locate and avoid puncturing the radial artery. A 2.7-mm 30° video arthroscope was used, with irrigation fluid instilled by gravity infusion. A quick arthroscopic survey of the radiocarpal joint and midcarpal joint was performed. The arthroscope was then returned to the radiocarpal joint, where decompression of the volar ganglion was performed. In all cases, synovial and capsular abnormalities were seen at the interval between the RSC and LRL ligaments (Fig 1). Connection of the ganglion to this site was confirmed by external pressure on the ganglion, which resulted in synovial and capsular bulging at the site. This could also be aided using needle puncture (Fig 2). A 2.0- to 2.9-mm arthroscopic shaver was then introduced to debride the region while gentle external pressure was maintained on the ganglion (Fig 3). The radial artery was also palpated at intervals. When sufficient enlargement of the interval was achieved, a sudden gush of mucinous material into the radiocarpal joint could be seen. The mucinous material was removed using suction while external pressure was maintained. The shaver must not be advanced too anteriorly into the volar aspect of the wrist joint, because this could damage the important structures volar to the joint. We
FIGURE 3. Debridement by shaver. (S, scaphoid; R, radius; LRL, long radiolunate ligament; RSC, radioscaphocapitate ligament.)
220
P-C. HO ET AL.
did not attempt to remove the ganglion wall or more of the joint capsule than was necessary to induce the gush of mucinous content. The radial artery was palpated regularly so we could ensure that the shaver was at an appropriate distance. A small capsular defect approximately 5 mm in size usually resulted at the RSC-LRL interligamental interval after the procedure (Fig 4). At completion of the procedure, sterile strips were used to close the portal sites, and the wrist was protected with cotton wool rolls and crepe bandage. The light dressing was changed on day 2. Patients were advised to move their wrists from day 2, although heavy manual activity was avoided for 1 month (Fig 5). DISCUSSION Volar wrist ganglion is the second most common lesion occurring around the wrist.10 Surgical excision results in a predictable outcome but includes a high rate of reported complications.12 Jacobs and Govaers13 reported a recurrence rate of 28%, damage to the palmar cutaneous branch of the median nerve in 28%, and unsatisfactory scar in 28%. The risk of damage to the radial artery was also stressed in the literature.10,14
FIGURE 4. Gap between the ligaments after debridement. Occasionally the volar capsule is opened and flexor tendons are seen through the interval.
FIGURE 5. Postoperative results are shown. The portal sites are indicated by arrows.
Open ganglionectomy was described as “trading a scar for a lump.”10 Similar problems had been encountered with excision of dorsal wrist ganglions. With the advent of arthroscopic surgery of the wrist, the question of whether arthroscopic decompression of a dorsal wrist ganglion could be performed was asked. Osterman and Rafael15 and Osterman16 reported satisfactory results with arthroscopic resection of dorsal wrist ganglions. In a series of 150 cases, they noted only 1 recurrence and no major complications. The technique used was a decompression of the ganglion from inside the joint. Although the ganglion wall remained, the procedure was highly effective. This could be explained by the presence of a “1-way valve” structure at the scapholunate ligament of the dorsal capsular reflection where the ganglion formed.7 When these structures were debrided and the connection to the ganglion enlarged, the ganglion drained back into the joint and did not reform. Subsequent reports from other surgeons confirmed the efficacy and safety of this technique.17-19 Because a similar pathomechanism was observed in volar wrist ganglion,10 we believed that these lesions could be treated similarly using an arthroscopic approach. As described, arthroscopic decompression of a volar ganglion is a more direct procedure than treatment of dorsal ganglion. The RSC to LRL interval was directly visualized through the scope via the 3-4 portal. Instrumentation to achieve debridement of the lesion also followed a more or less straight route, making the procedure easier and safer than decompression of a dorsal ganglion.
ARTHROSCOPIC RESECTION OF VOLAR WRIST GANGLION However, observing the precautions described previously for the radial artery and the radial nerve is important, to avoid injuring these structures. The surgery could be performed under general or regional anesthesia; however, in our experience, local anesthesia to the portal sites works well20 and includes the added advantage of avoiding a tourniquet. Therefore, the radial pulse can be palpated, and the patient experiences less postoperative muscle ache. Local anesthesia has been used effectively for knee arthroscopy as well.21 We treated 6 consecutive cases of volar wrist ganglion from August 1997 to November 1998 using this technique. Decompression was successfully achieved in 5 cases, and after a mean follow up of 16.4 months (range, 10 to 25 months), no recurrence was seen. These ganglions were of at least 1 year duration and ranged in size from 1.5 to 2 cm. No complications occurred in these cases. In the 1 case that was not successful, arthroscopy of the radiocarpal joint was normal and no connection with the ganglion was found. Open excision of the ganglion was then performed, and the stalk was found to originate in the scaphotrapeziotrapezoid (STT) joint. We since noted that ganglions that arise from the distal wrist crease were likely to originate in the STT joint or other component of the midcarpal joint. They are not amenable to arthroscopic decompression at present. Volar ganglions that lie at or proximal to the proximal wrist crease usually arise from the radiocarpal joint and are suitable for arthroscopic decompression. The differentiation could be assisted by using either injection of dye or contrast medium into the ganglion22 or preoperative ultrasonography.23-25 In conclusion, this new technique of arthroscopic treatment of volar wrist ganglion is effective and safe and can be performed under local anesthesia via the portal sites. REFERENCES 1. Butle ED, Hamill JP. Tumours of the hand. J Surg Am 1960; 100:293-302. 2. Nield DV, Evans DM. Aspiration of ganglia. J Hand Surg [Br] 1986;11:264. 3. Richman JA, Gelberman R II, Engber WS, et al. Ganglions of the wrist and digits: Results of treatment by aspiration and cyst wall puncture. J Hand Surg [Am] 1987;12:1041-1043.
221
4. Holm PC, Pandey SD. Treatment of ganglia of the hand and wrist with aspiration and injection of hydrocortisone. Hand 1973;5:63-68. 5. Varley GW, Needoff M, Davis TR, Clay NR. Conservative management of wrist ganglia: Aspiration versus steroid infiltration. J Hand Surg [Br] 1997;22:636-637. 6. Stephen AB, Lyons AR, Davis TR. A prospective study of two conservative treatments for ganglia of the wrist. J Hand Surg [Br] 1999;24:104-105. 7. Angelides AC, Wallace P. The dorsal ganglion of the wrist: Its pathogenesis, gross and microscopic anatomy, and surgical treatment. J Hand Surg [Am] 1976;1:228-235. 8. Faithfull DK, Seeto BG. The simple wrist ganglion: More than a minor surgical procedure? Hand Surg 2000;5:139-143. 9. Clay NR, Clement DA. The treatment of dorsal wrist ganglia by radical excision. J Hand Surg 1988;13:187-191. 10. Angelides AC. Ganglions of the hand and wrist. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s operative hand surgery. Ed 4. New York: Churchill Livingstone, 1999:21712183. 11. Watson HK, Rogers WD, Ashmead D IV. Reevaluation of the cause of the wrist ganglion. J Hand Surg [Am] 1989;14:812817. 12. Wright TW, Cooney WP, Ilstrup DM. Anterior wrist ganglion. J Hand Surg [Am] 1994;19:954-958. 13. Jacobs LG, Govaers KJ. The volar wrist ganglion: Just a simple cyst? J Hand Surg [Br] 1990;15:342-346. 14. Rosson JW, Walker G. The natural history of ganglia in children. J Bone Joint Surg Br 1989;71:707-708. 15. Osterman AL, Raphael J. Arthroscopic resection of dorsal ganglion of the wrist. Hand Clin 1995;11:7-12. 16. Osterman AL. Wrist arthroscopy: Operative procedures. In: Green DP, Hotchkiss RN, Pederson WC, Eds. Green’s operative hand surgery, Ed 4. New York: Churchill Livingstone, 1999:207-222. 17. Fontes D. Ganglia treated by arthroscopy. In: Saffar P, Amadio PC, Foucher G, Eds. Current practice in hand surgery. London: Martin Dunitz, 1997:283-290. 18. Luchetti R, Badia A, Alfarano M, et al. Arthroscopic resection of dorsal wrist ganglia and treatment of recurrences. J Hand Surg [Br] 2000;25:38-40. 19. Pederzini L, Ghinelli M. Arthroscopic treatment of dorsal arthrogenic cysts of the wrist. J Sports Trauma Rel Res 1995; 17:210-215. 20. Yung SH, Ho PC. Wrist arthroscopy under portal site local anaesthesia (PSLA) without tourniquet: Is it really feasible? Proceedings of the HKSSH Annual Congress, June 1999. 21. Rolf GC. Knee Arthroscopy under local anaesthesia. Hong Kong J Orthop Surg 1998;2:158-163. 22. Andren L, Eiken O. Arthrographic studies of wrist ganglions. J Bone Joint Surg Am 1971;53:299-302. 23. Ho PC, Griffiths J, Lo WN, et al. Current treatment of ganglion of the wrist. Hand Surg 2001;6:49-58. 24. Ogino T, Minami A, Fukada K, et al. The dorsal occult ganglion of the wrist and ultrasonography. J Hand Surg [Br] 1988;13:181-183. 25. Osterwalder JJ, Widrig R, Stober R, Gachter A. Diagnostic validity of ultrasound in patients with persistent wrist pain and suspected occult ganglion. J Hand Surg [Am] 1997;22:19341040.