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ARTHROSCOPIC DIAGNOSIS AND TREATMENT OF DORSAL WRIST GANGLION
ARTHROSCOPIC DIAGNOSIS AND TREATMENT OF DORSAL WRIST GANGLION S. NISHIKAWA, S. TOH, H. MIURA, K. ARAI and T. IRIE From the Department of Orthopaedic Surgery, Mutsu General Hospital, Mutsu, Japan and the Department of Orthopaedic Surgery, Hirosaki University School of Medicine, Hirosaki, Japan
Thirty-seven patients with dorsal wrist ganglia underwent arthroscopic resection. The mean followup was 20 months, and no complications were encountered. The ganglia were classified into three types according to their arthroscopic appearance. This classification helps to determine the amount of dorsal capsular resection required. Journal of Hand Surgery (British and European Volume, 2001) 26B: 6: 547–549 technique and tourniquet. Traction (1.5–2 kg) was applied with Chinese finger traps attached to the index and middle fingers. Two arthroscopy portals were used as standard access to the radiocarpal joint. First, a 2.7 mm arthroscope was placed in the 1–2 portal. Once the scapholunate ligament had been localized, the arthroscope was directed dorsally to the root of the ganglion or its stalk. When the ganglion or its stalk could not be identified, compression of the cyst with the operator’s thumb caused it to balloon into the joint. A probe was then introduced through the 4–5 portal, in order to palpate the scapholunate ligament and dorsal capsule and determine the consistency of the ligament and the stalk of the ganglion. Osterman and Raphael (1995) suggested the introduction of an 18-gauge needle into the ganglion and its stalk, but we only needed to use this technique on one occasion. If the ganglion and its stalk could be seen, a 2.9 mm end-cutting shaver was used to excise both. When external compression was needed to expose or identify the ganglion in the joint, again, only resection of the ganglion and its stalk were performed. If, however, the ganglion could not be identified clearly, even after external compression, a 1 cm diameter area of the dorsal capsule was resected until the extensor tendons were visualized. After successful resection of the ganglion stalk and dorsal capsule, we confirmed that the dorsal ganglion enlarged freely with infusion of saline into the wrist joint. At the end of the procedure, the arthroscopy portals were each closed with a single stitch. It was not necessary to rest the wrist in a splint and the patients started a rehabilitation protocol on the 4th day after surgery.
INTRODUCTION Osterman and Raphael (1995) first described the arthroscopic resection of dorsal wrist ganglia and observed that 42% of patients had other intra-articular pathologies. Their arthroscopic treatment entailed resection of the ganglion stalk with an intra-articular or intra-cystic technique. If the ganglion stalk could not be identified, a wide area of the dorsal capsule was resected. Luchetti et al. (2000) recommended that a 1 cm diameter area of dorsal capsule was resected, but this increases the risk of injury to the extensor tendons and the scapholunate ligament. Thus, in the interests of safety, the area of resection should be as small as possible. We have developed a new arthroscopic classification of ganglia which indicates how much dorsal capsule requires resection. In this report, we describe our arthroscopic treatment of dorsal wrist ganglia which is based on this classification. PATIENTS AND METHODS Thirty-nine patients with dorsal wrist ganglia underwent arthroscopic resection at our institute between 1997 and 2000. Two could not be resected arthroscopically and required open surgery, leaving a study group of 37 patients (24 women and 13 men). Their mean age at operation was 40 (range, 14–84) years. Four of the patients underwent surgery because of recurrence of a previously excised ganglion. The ganglia had been present for between 2 months and 3 years, and 24 patients had already undergone nonsurgical treatments. The usual presenting symptoms and the indications for arthroscopic resection were aching of the wrist, tenderness of the ganglion, and an unacceptable cosmetic appearance. The range of wrist motion, the presence of residual symptoms and recurrences, and time lost from work were recorded at a mean follow-up of 20 (range, 1–42) months.
RESULTS Preoperatively 15 of the 37 patients complained of pain, but all had normal wrist movements. MRI of the wrist was performed in 16 cases, and a cystic lesion on the scapholunate joint was identified in all cases. At arthroscopy, the ganglia were classified into three types: Type 1 ganglia and their stalks were visible (Fig 1); Type II-a ganglia or their stalks ballooned into the wrist joint with external compression (Fig 2); and Type II-b ganglia
Technique Axillary block or general anesthesia was used. The wrist arthroscopy was done using our horizontal traction 547
548
THE JOURNAL OF HAND SURGERY VOL. 26B No. 6 DECEMBER 2001
Fig 1 The arthroscopic view of a Type I dorsal wrist ganglion (lt. wrist). The ganglion is on the dorsal capsular attachment of scapholunate ligament. Scaphoid (S), Ganglion (G), Dorsal capsule (DC).
or their stalks could not be identified in the wrist joint, even with external compression (Fig 3). There were eight Type I, 19 Type II-a, and 10 Type II-b ganglia. The type I and II-a ganglia were treated only by resection of the ganglion or its stalk. This arthroscopic resection was easy for Type I ganglia and was performed under direct arthroscopic visualization. Resection of Type II-a ganglia was aided by external compression of the cyst which increased the pressure within it. The Type II-b ganglia were difficult to identify arthroscopically, and we could not always identify the ganglion stalk during the capsule resection. It was for this reason that a wide capsular resection had to be performed. The mean time of operation was 23 (range, 10–55) minutes. All 37 patients were satisfied with the result of surgery and all were able to return to work. The mean recovery time was 16 (range, 7–56) days. No complications were encountered, but two ganglia recurred, one of which was again treated arthroscopically. The second recurrence was of a small ganglion, and further treatment was declined. The ganglia that recurred were both type II-b.
DISCUSSION Although a good alternative to open surgery (Fontes, 1997; Geissler, 1998; Luchetti et al., 2000; Osterman et al., 1995; Pederzini et al., 1995), arthroscopic resection of dorsal ganglia is a difficult procedure. Despite the risk of injury to the radial nerve, we favour the 1–2 portal
Fig 2 The arthroscopic view of a Type II-a dorsal wrist ganglion (rt. wrist). a) Before compression. b) After compression. Scaphoid (S), Ganglion (G), Dorsal capsule (DC).
because it provides good visualization and allows ‘‘gentle’’ surgery. So far we have not experienced any nerve injuries while using this portal. Our results of arthroscopic ganglion resection are similar to previous reports. Recurrence after open surgery is reported at 10 to 40% (Angelides et al., 1976), whereas recurrence after arthroscopic resection appears lower. Osterman and Raphael (1995) did not report any recurrences in 18 cases, Pederzini et al. (1995) and Fontes (1997) each had only one recurrence in 14 and 32 cases respectively, while Luchetti et al. (2000) had two recurrences in 34 cases. Our classification of the ganglia minimizes the area of resection and our results
ARTHROSCOPIC GANGLION RESECTION
549
is only required for Type II-b ganglia, in which the ganglion and its stalk cannot be seen through the arthroscope. References Angelides AC, Wallace PF (1976). The dorsal ganglion of the wrist: its pathogenesis, growth and microscopic anatomy, and surgical treatment. Journal of Hand Surgery, 1: 228–235. Fontes D. Ganglia treated by arthroscopy. In: Saffer P, Amaido PC, Foucher G (Eds) Current practice in hand surgery. London, Martin Dunitz, 1997: 283–290. Geissler WB (1998). Arthroscopic excision of dorsal wrist ganglia. Techniques in Hand Upper Extremity Surgery, 2: 196–201. Luchetti R, Badia A, Alfarano M, Orbay J, Indriago I, Mustapha B (2000). Arthroscopic resection of dorsal wrist ganglia and treatment of recurrences. Journal of Hand Surgery, 25B: 38–40. Osterman AL, Raphael J (1995). Arthroscopic resection of dorsal ganglion of the wrist, Hand Clinics, 11: 7–12. Pederzini L, Ghinelli, Soragni O (1995). Arthroscopic treatment of dorsal arthrogenic cysts of the wrist. Journal of Sports Traumatology and Related Research, 17: 210–215.
Fig 3 The arthroscopic view of a Type II-b dorsal wrist ganglion (rt. wrist). The ganglion is not seen arthroscopically, even with external compression of the cyst. Scaphoid (S), Dorsal capsule (DC), Probe (P).
demonstrate acceptable results with this minimally invasive surgery. Wide debridement of dorsal capsule
Received: 12 January 2001 Accepted after revision: 20 April 2001 Dr Shinji Nishikawa, Department of Orthopaedic Surgery, Mutsu General Hospital, Ogawa-cho-1-2-5, Mutsu, Aomori, 035-0071 Japan. E-mail: [email protected] # 2001 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2001.0620, available online at http://www.idealibrary.com on
Thirty-seven patients with dorsal wrist ganglia underwent arthroscopic resection. The mean followup was 20 months, and no complications were encountered. The ganglia were classified into three types according to their arthroscopic appearance. This classification helps to determine the amount of dorsal capsular resection required. Journal of Hand Surgery (British and European Volume, 2001) 26B: 6: 547–549 technique and tourniquet. Traction (1.5–2 kg) was applied with Chinese finger traps attached to the index and middle fingers. Two arthroscopy portals were used as standard access to the radiocarpal joint. First, a 2.7 mm arthroscope was placed in the 1–2 portal. Once the scapholunate ligament had been localized, the arthroscope was directed dorsally to the root of the ganglion or its stalk. When the ganglion or its stalk could not be identified, compression of the cyst with the operator’s thumb caused it to balloon into the joint. A probe was then introduced through the 4–5 portal, in order to palpate the scapholunate ligament and dorsal capsule and determine the consistency of the ligament and the stalk of the ganglion. Osterman and Raphael (1995) suggested the introduction of an 18-gauge needle into the ganglion and its stalk, but we only needed to use this technique on one occasion. If the ganglion and its stalk could be seen, a 2.9 mm end-cutting shaver was used to excise both. When external compression was needed to expose or identify the ganglion in the joint, again, only resection of the ganglion and its stalk were performed. If, however, the ganglion could not be identified clearly, even after external compression, a 1 cm diameter area of the dorsal capsule was resected until the extensor tendons were visualized. After successful resection of the ganglion stalk and dorsal capsule, we confirmed that the dorsal ganglion enlarged freely with infusion of saline into the wrist joint. At the end of the procedure, the arthroscopy portals were each closed with a single stitch. It was not necessary to rest the wrist in a splint and the patients started a rehabilitation protocol on the 4th day after surgery.
INTRODUCTION Osterman and Raphael (1995) first described the arthroscopic resection of dorsal wrist ganglia and observed that 42% of patients had other intra-articular pathologies. Their arthroscopic treatment entailed resection of the ganglion stalk with an intra-articular or intra-cystic technique. If the ganglion stalk could not be identified, a wide area of the dorsal capsule was resected. Luchetti et al. (2000) recommended that a 1 cm diameter area of dorsal capsule was resected, but this increases the risk of injury to the extensor tendons and the scapholunate ligament. Thus, in the interests of safety, the area of resection should be as small as possible. We have developed a new arthroscopic classification of ganglia which indicates how much dorsal capsule requires resection. In this report, we describe our arthroscopic treatment of dorsal wrist ganglia which is based on this classification. PATIENTS AND METHODS Thirty-nine patients with dorsal wrist ganglia underwent arthroscopic resection at our institute between 1997 and 2000. Two could not be resected arthroscopically and required open surgery, leaving a study group of 37 patients (24 women and 13 men). Their mean age at operation was 40 (range, 14–84) years. Four of the patients underwent surgery because of recurrence of a previously excised ganglion. The ganglia had been present for between 2 months and 3 years, and 24 patients had already undergone nonsurgical treatments. The usual presenting symptoms and the indications for arthroscopic resection were aching of the wrist, tenderness of the ganglion, and an unacceptable cosmetic appearance. The range of wrist motion, the presence of residual symptoms and recurrences, and time lost from work were recorded at a mean follow-up of 20 (range, 1–42) months.
RESULTS Preoperatively 15 of the 37 patients complained of pain, but all had normal wrist movements. MRI of the wrist was performed in 16 cases, and a cystic lesion on the scapholunate joint was identified in all cases. At arthroscopy, the ganglia were classified into three types: Type 1 ganglia and their stalks were visible (Fig 1); Type II-a ganglia or their stalks ballooned into the wrist joint with external compression (Fig 2); and Type II-b ganglia
Technique Axillary block or general anesthesia was used. The wrist arthroscopy was done using our horizontal traction 547
548
THE JOURNAL OF HAND SURGERY VOL. 26B No. 6 DECEMBER 2001
Fig 1 The arthroscopic view of a Type I dorsal wrist ganglion (lt. wrist). The ganglion is on the dorsal capsular attachment of scapholunate ligament. Scaphoid (S), Ganglion (G), Dorsal capsule (DC).
or their stalks could not be identified in the wrist joint, even with external compression (Fig 3). There were eight Type I, 19 Type II-a, and 10 Type II-b ganglia. The type I and II-a ganglia were treated only by resection of the ganglion or its stalk. This arthroscopic resection was easy for Type I ganglia and was performed under direct arthroscopic visualization. Resection of Type II-a ganglia was aided by external compression of the cyst which increased the pressure within it. The Type II-b ganglia were difficult to identify arthroscopically, and we could not always identify the ganglion stalk during the capsule resection. It was for this reason that a wide capsular resection had to be performed. The mean time of operation was 23 (range, 10–55) minutes. All 37 patients were satisfied with the result of surgery and all were able to return to work. The mean recovery time was 16 (range, 7–56) days. No complications were encountered, but two ganglia recurred, one of which was again treated arthroscopically. The second recurrence was of a small ganglion, and further treatment was declined. The ganglia that recurred were both type II-b.
DISCUSSION Although a good alternative to open surgery (Fontes, 1997; Geissler, 1998; Luchetti et al., 2000; Osterman et al., 1995; Pederzini et al., 1995), arthroscopic resection of dorsal ganglia is a difficult procedure. Despite the risk of injury to the radial nerve, we favour the 1–2 portal
Fig 2 The arthroscopic view of a Type II-a dorsal wrist ganglion (rt. wrist). a) Before compression. b) After compression. Scaphoid (S), Ganglion (G), Dorsal capsule (DC).
because it provides good visualization and allows ‘‘gentle’’ surgery. So far we have not experienced any nerve injuries while using this portal. Our results of arthroscopic ganglion resection are similar to previous reports. Recurrence after open surgery is reported at 10 to 40% (Angelides et al., 1976), whereas recurrence after arthroscopic resection appears lower. Osterman and Raphael (1995) did not report any recurrences in 18 cases, Pederzini et al. (1995) and Fontes (1997) each had only one recurrence in 14 and 32 cases respectively, while Luchetti et al. (2000) had two recurrences in 34 cases. Our classification of the ganglia minimizes the area of resection and our results
ARTHROSCOPIC GANGLION RESECTION
549
is only required for Type II-b ganglia, in which the ganglion and its stalk cannot be seen through the arthroscope. References Angelides AC, Wallace PF (1976). The dorsal ganglion of the wrist: its pathogenesis, growth and microscopic anatomy, and surgical treatment. Journal of Hand Surgery, 1: 228–235. Fontes D. Ganglia treated by arthroscopy. In: Saffer P, Amaido PC, Foucher G (Eds) Current practice in hand surgery. London, Martin Dunitz, 1997: 283–290. Geissler WB (1998). Arthroscopic excision of dorsal wrist ganglia. Techniques in Hand Upper Extremity Surgery, 2: 196–201. Luchetti R, Badia A, Alfarano M, Orbay J, Indriago I, Mustapha B (2000). Arthroscopic resection of dorsal wrist ganglia and treatment of recurrences. Journal of Hand Surgery, 25B: 38–40. Osterman AL, Raphael J (1995). Arthroscopic resection of dorsal ganglion of the wrist, Hand Clinics, 11: 7–12. Pederzini L, Ghinelli, Soragni O (1995). Arthroscopic treatment of dorsal arthrogenic cysts of the wrist. Journal of Sports Traumatology and Related Research, 17: 210–215.
Fig 3 The arthroscopic view of a Type II-b dorsal wrist ganglion (rt. wrist). The ganglion is not seen arthroscopically, even with external compression of the cyst. Scaphoid (S), Dorsal capsule (DC), Probe (P).
demonstrate acceptable results with this minimally invasive surgery. Wide debridement of dorsal capsule
Received: 12 January 2001 Accepted after revision: 20 April 2001 Dr Shinji Nishikawa, Department of Orthopaedic Surgery, Mutsu General Hospital, Ogawa-cho-1-2-5, Mutsu, Aomori, 035-0071 Japan. E-mail: [email protected] # 2001 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2001.0620, available online at http://www.idealibrary.com on