- Email: [email protected]
Arthroscopic resection of dorsal wrist ganglia
ARTHROSCOPIC RESECTION OF DORSAL WRIST GANGLIA STEVEN F. VIEGAS, MD
Arthroscopic treatment of dorsal wrist ganglia offers a viable alternative to open ganglionectomy. Although a relatively recent addition to the list of arthroscopic techniques, arthroscopic treatment of dorsal wrist ganglia has been reported to have a high rate of success, low rate of recurrence, more rapid and complete return of wrist motion, and a superior cosmetic result. A tangential arthroscopic approach to the ganglion and/or its stalk via the 1,2 and the 4,5 or 6U portals offers an alternative technique which may afford better visualization of the ganglion and added protection for the scapholunate interosseous ligament. KEY WORDS: dorsal wrist ganglia, arthroscopy, resection Copyright 2003, Elsevier Science (USA). All rights reserved.
The simple dorsal wrist ganglion is the most common tumor of the hand. 1,2 There are estimated to be over 25,000 resections of dorsal wrist ganglia performed each year. 3 Angelides and Wallace 4 showed that except for the ganglia that arose from a carpal boss, all other dorsal ganglia are connected to the dorsal wrist capsule and the dorsal interosseous scapholunate ligament. The etiology of the dorsal wrist ganglion, despite m a n y theories and investigative studies, remains unknown. Dorsal wrist ganglia occur most commonly in patients in their second to fifth decades of life. s-8 Females are more commonly affected than males with estimates of the rates ranging from 2:1 to 4:1. 5-8 Diagnosis is often as simple as merely looking at the wrist and identifying the dorsal mass. The mass is typically discrete and cystic in nature and transilluminates. These ganglia most commonly emerge from between the extensor pollicis longus and the extensor digitorum communis tendons, just distal to the scapholunate joint. However, the so-called occult wrist ganglia can be highly symptomatic but have no visible or palpable mass. Gunther 9 described these as "diagnostic enigmas in that they have chronic dorsal wrist pain without a known injury and without radiographic or physical findings other than tenderness." In fact, even ultrasound (Fig 1) and magnetic resonance imaging (Fig 2) are not sensitive enough to reliably identify occult ganglia. Previously, I used a xylocaine block of the posterior interosseous nerve 2 cm proximal to the wrist joint to determine if the symp-
From the Department of Orthopaedics and Rehabilitation, University of Texas Medical Branch, Galveston, TX. Address reprint requests to Steven F. Viegas, MD, Professor and Chief, Division of Hand Surgery, Department of Orthopaedics and Rehabilitation, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0165. Copyright 2003, Elsevier Science (USA). All rights reserved. 1048-6666/03/1301-0000535.00/0 doi:10.1053/otor.2003.36317
56
toms would respond to a nerve block. This technique washelpful in diagnosing these occult ganglia. In addition, patients who obtained pain relief after nerve block are candidates for posterior interosseous nerve resection even if no ganglion is found intraoperatively (Fig 3). I now prefer arthroscopy for diagnosis and treatment of occult ganglia. Patients can be asymptomatic or have symptoms ranging from mild to significant pain, weakness, and limitation of wrist motion. The most common s y m p t o m is a dull aching that is thought to be the result of compression of the terminal branch of the posterior interosseous nerve. 2 A number of reports have stated that the smaller ganglia can be more symptomatic than the larger ones. 1,10,11 Dorsal wrist ganglia have been diagnosed for centuries and the treatments have varied. Historically treatments have included massage with a hand of a corpse, massage with spit, application of mercury to the overlying skin, taping a bullet or coin over the cyst, radiation, injection of a variety of different substances including iodine, carbolic acid, 10% morrhuate, ethanolamine, transdermal suture transfixion, rupture with a bible, a ganglion mallet, or digital pressure. 12 Current treatments include benign neglect, with spontaneous resolution reported in 28% to 58% of casesJ 3,14 A common treatment is aspiration with or without steroid injection with success rates ranging from 27% to 50%. 15-17 One study reported that success rates in their series of dorsal ganglia treated by aspiration and steroid injection could be increased from 27% to 41% by augmenting the treatment with 3 weeks of splint immobilization following aspiration and injection. 16 Open surgical resection can increase the success rate, however; recurrence rates have averaged 24% 4 and have been reported up to 40%. 18 Resection of the ganglion, its stalk and a cuff of capsular tissue is believed to increase the success rate. 4,19 Open resection of a dorsal wrist gan-
Operative Techniques in Orthopaedics, Vol 13, No 1 (January), 2003: pp 56-61
Fig 1. An ultrasound image demonstrating the presence of an occult dorsal wrist ganglion,
glion can result in transient or permanent loss of wrist motion, more commonly flexion. 14
SURGICAL TECHNIQUE Arthroscopic resection of the dorsal wrist ganglion has been a relatively recent addition to the list of treatment options.3,20 26 I first reported the option of arthroscopic treatment of the dorsal wrist ganglion in 1986. 20 Since then, the success of arthroscopic resection has been validated by a number of authors and has compared well to open resection. 3,2~ The approach generally has been through the 3,4 portal with a generous resection of the dorsal capsule. The following is the technique that I have used successfully for a number of years. The standard set-up and instrumentation for wrist arthroscopy is utilized. General or axillary block is used for anesthesia. An upper arm tourniquet is applied but usually not needed. A traction tower is used to suspend the hand and arm, and to apply 10 to 12 p o u n d s of distraction. The pertinent bony and soft-tissue anatomy is identified and marked on the wrist after it is suspended from the traction tower. The posteroanteriot radiograph offers essentially an actual size template of the skeletal anatomy, which can also be of assistance. An outflow canula is introduced through either the 6U or 6R portal. A number 11 scalpel blade is used to make a Skin-only incision. The portal is then completed by using blunt dissection with a small hemostat to the level of the capsule. The capsule is entered with a blunt trochar. All portals are developed using this same technique. The 1.9-mm arthroscope is preferred, although the 2.7-mm arthroscope is also acceptable. The arthroscope
ARTHROSCOPIC RESECTION OF DORSAL WRIST GANGLIA
is introduced through the 1,2 portal. Inflow is obtained through the arthroscope. Contrary to the previous descriptions of wrist arthroscopy techniques that utilize the 3,4 portal for visualization, the 1,2 portal is preferred. It allows a better tangential view of the ganglion stalk. As the arthroscope is advanced to the area of the scapholunate interosseous ligament, it actually assists in displacing and retracting the dorsal capsule from the ganglion stalk. This facilitates the visualization of the ganglion stalk compared with introducing the arthroscope through the 3,4 portal, immediately over the area of the stalk resulting in a limited field of view (Fig 4). It also avoids the complications of collapsing d o w n the dorsal joint space as the arthroscope enters the 3,4 portal a n d / o r inadvertently exiting the joint as the scope is withdrawn to obtain a better view. Using this approach the pearl-like stalk can be identified reliably. However, other authors have reported identifying the stalk in only 61% or less of the cases. 2s The appearance of the ganglion stalk can vary. There can be an occult ganglion that is completely contained within the proximal wrist joint and the scapholunate interosseous ligament (Fig 5). The stalk can be redundant (Fig 6), arise more proximally from the membranous portion of the scapholunate interosseous ligament and extend distally (Fig 7), or arise at the most dorsal, distal intrarticular portion of the scapholunate interosseous ligament at the capsular attachment (Fig 8). Sometimes using a probe or blunt trochar will help to identify and differentiate the stalk from a normal scapholunate interosseous ligament (Fig 9). In addition, there is often some degree of dorsal synovitis associated with a dorsal wrist ganglion, which can add to the difficulty of visualizing the stalk, especially through the 3,4 portal (Fig 10). The 4,5 or the 6R portal is used to approach the stalk from the ulnar side. A holmium laser is preferred to resect any dorsal synovitis and cauterize any vessels associated with the synovitis; however, a motorized 2.0-mm full radius shaver can also be used. Care must be taken not to damage the arthroscope. If a shaver is used there may be some bleeding that would require tourniquet inflation. Once the ganglion a n d / o r stalk is identified and triangu-
Fig 2. A magnetic resonance image demonstrating the presence of an occult dorsal wrist ganglion.
57
Fig 3. A cadaveric left-wrist dissection demonstrating a) the partially incised fourth dorsal compartment, in which the extensor tendons are deflected ulnar. The terminal branch of the posterior interosseous nerve, which lies immediately to the ulnar side of the septum between the fourth and third compartment and on the floor of the fourth compartment, is not readily evident, b) The terminal branch of the posterior interosseous nerve is easily identified once it has been dissected free of the underlying radius and a piece of rubber sheet has been placed behind the segment of nerve.
Fig 4. A diagram showing the tangential orientation of the arthroscope and the motorized shaver. In this illustration, the arthroscope is in the 6R portal and the shaver is in the 1,2 portal.
58
STEVEN F. VIEGAS
wrist ganglion is a recurrence. However, it appears that recurrence may be less likely to occur after an arthroscopic resection. The recurrence rate of arthroscopically resected dorsal wrist ganglia has ranged from 0 to 7%. 3,20-26 Guiboux et al. reported no recurrences in 50 cases. 26 Fontes reported 1 recurrence in 32 cases. 23
Q
i
~i 84184 ~ii 'i~i84i
3
Fig 5. a) An arthroscopic view from the 3,4 portal of an occult dorsal wrist ganglion, superimposed on the diagram of the scaphoid and lunate. (Reprinted from Viegas SF: Intraarticular ganglion of the dorsal interosseous scapholunate ligament: a case for arthroscopy. Arthroscopy J Arthroscop Related Surg 1986;2:93) b) Another arthroscopic view from the 1,2 portal of an occult dorsal wrist ganglion.
tated with the arthroscope and the shaver, a resection is performed. The tangential approach of the motorized shaver also offers additional protection for the scapholunate interosseous ligament because from that orientation the shaver cannot resect into the ligament. A number of authors 3,2~ state that a large portion of the dorsal capsule must be excised; however, the necessity of this has not been substantiated. I prefer to resect the stalk and that portion of the capsule through which the stalk passes. After resection of the stalk and dorsal capsule the ganglion should be palpated. If residual ganglion remains, then further resection or aspiration of the area of the ganglion should be performed. The portals are closed with butterfly strips. The wrist is placed in a volar splint and Ace bandage for 1 week. The splint is then discontinued and the patient is allowed to use the wrist as tolerated.
RESULTS/COMPLICATIONS As in open resection of a dorsal wrist ganglion, the most likely complication of arthroscopic resection of a dorsal
ARTHROSCOPIC RESECTION OF DORSAL WRIST GANGLIA
Fig 6. a) A diagram illustrating a redundant stalk of a dorsal wrist ganglion arising over the scapholunate interosseous ligament and folding back onto itself; and b) the arthroscopic view of that redundant stalk of the dorsal wrist ganglion. It is not uncommon to find a redundant stalk or portion of the ganglion within the proximal wrist joint as seen in c).
59
Fig 7. An arthroscopic view of a stalk of a dorsal wrist ganglion arising over the scapholunate interosseous ligament.
Luchetti et al. had 2 recurrences in 34 cases. 22 Geissler at and Pederzini et al. 24 reported 1 recurrence in each of their series of 14 cases. I have had one recurrence in 21 arthroscopically resected dorsal wrist ganglia. Complications after open surgery are rare; however, Crawford and Taleisnik =7reported scaphoid subluxation and Duncan and Lewis 2s reported scapholunate instability due to injury of the scapholunate interosseous ligament. Arthroscopic resection in general, and particularly the technique described here, should minimize the chance of this complication. Scapholunate ligament injury after arthroscopic ganglion excision has not been reported in the literature. The instrumentation required for the technique and the specific technical demands and difficulty of the procedure may be a relative complication. Luchetti et al. 22 reported that 9 of 43 (21%) patients on w h o m they had initially
Fig 8. An arthroscopic view of a stalk of a dorsal wrist ganglion arising over the most distal intraarticular portion of the scapholunate interosseous ligament at the capsular attachment.
60
Fig 9. An arthroscopic view of a stalk of a dorsal wrist ganglion arising over the scapholunate interosseous ligament both a) without and b) with a blunt trochar palpating the stalk.
Fig 10. An arthroscopic view of synovitis of the dorsal capsule at the proximal wrist joint, which is often seen in association with a dorsal wrist ganglion.
STEVEN F. VIEGAS
p l a n n e d to p e r f o r m a n a r t h r o s c o p i c r e s e c t i o n w e r e c o n v e r t e d to a n o p e n p r o c e d u r e d u e to difficulties. P o s t o p e r ative stiffness has been reported following open resection and prolonged immobilization14; however, again arthros c o p i c r e s e c t i o n r e s u l t s in less s c a r a n d offers a q u i c k e r r e t u r n of w r i s t m o t i o n . T h e c o s m e t i c r e s u l t s a r e a l s o b e t t e r a n d t h e u s u a l a d a g e o f " t r a d i n g a b u m p for a s c a r " d o e s n o t r e a l l y a p p l y to t h e a r t h r o s c o p i c p r o c e d u r e .
CONCLUSION A r t h r o s c o p i c r e s e c t i o n of t h e d o r s a l w r i s t g a n g l i o n is a g o o d a l t e r n a t i v e to o p e n s u r g e r y . It c a n b e a c h a l l e n g i n g surgery and one should have adequate experience in basic w r i s t a r t h r o s c o p y . T h e p a t i e n t s h o u l d b e p r e p a r e d for t h e p o s s i b l e c o n v e r s i o n to a n o p e n p r o c e d u r e . T h e r e s u l t s of a r t h r o s c o p i c t r e a t m e n t of t h e d o r s a l w r i s t g a n g l i o n a p p e a r a t l e a s t c o m p a r a b l e to o p e n r e s e c t i o n . I n fact, b a s e d o n t h e l o w r e c u r r e n c e rate, t h e m i n i m a l l y i n v a s i v e t e c h n i q u e , m o r e l i m i t e d s u r g i c a l scar, a n d o p p o r t u n i t y for e a r l i e r wrist motion, arthroscopic dorsal wrist ganglion resection may be better than open resection. The tangential arthroscopic approach described here, via the radial and ulnar a s p e c t s o f t h e w r i s t , m a y b e s a f e r a n d a l l o w for b e t t e r visualization than traditional arthroscopic portals.
REFERENCES 1. Boyes JH: Bunnell's Surgery of the Hand, 5th ed. Philadelphia, Lippincott, 1970 2. Dellon AL, Self SS: Anatomic dissections relating the posterior interosseous nerve to the carpus, and the etiology of dorsal ganglion pain. J Hand Surg 3:326-332, 1978 3. Bienz T; Raphael JS: Arthroscopic resection of the dorsal ganglion of the wrist. Hand Clin 15:429-434, 1999 4. Angelides AC, Wallace PF: The dorsal ganglion of the wrist: Its pathogenesis, gross and microscopic anatomy, and surgical treatment. J Hand Surg 1:228-235, 1976 5. Angelides AC: Ganglions of the hand and wrist, in Green DP, Hotchkiss RN, Pederson WC (eds): Green's Operative Hand Surgery, 4th ed. New York, Churchill-Livingston, 1999, pp 2171-2182 6. MacCollum MS: Dorsal wrist ganglions in children. J Hand Surg 2:325, 1977 7. MacKinnon AI, Azmy A: Active treatment of ganglia in children. Postgrad Med J 53:378-381, 1977
ARTHROSCOPIC RESECTION OF DORSAL WRIST GANGLIA
8. Rosson JW, Walker G: The natural history of ganglia in children. J Bone Joint Surg 71B:707-708, 1989 9. Gunther SF: Dorsal wrist pain and the occult scapholunate ganglion. J Hand Surg 10A:697-703, 1985 10. Angelides AC: Ganglions of the hand and wrist, in Green DP (ed): Operative Hand Surgery. New York, Churchill-Livingston, 1982, pp 1635-1641 11. Jennings C: The many faces of the common ganglion. American Academy of Orthopaedic Surgeons Sound Slide Program No. 786, November, 1983 12. Lyle F: Radiation treatment of ganglia of the hand and wrist. J Bone Joint Surg 23A:102-103, 1941 13. Carp L, Stout AP: A study of ganglion with special reference to treatment. Surg Gynecolog Obstet 47:460-468, 1938 14. McEvedy BV: Simple ganglia: a review of modes of treatment and an explanation for the frequent failures of surgery. Lancet 266:135, 1965 15. Psaila JV, Manse[ RE: The surface ultrastructure of ganglia. J Bone Joint Surg 60B:228-233, 1978 16. Richman JA, Gelberman RH, Engber WD, et al: Ganglions of the wrist and digits: results of treatment by aspiration and cyst wall puncture. J Hand Surg 12A:1041-1043, 1987 17. Zubowicz VN, lschii CH: Management of ganglion cysts of the hand by simple aspiration. J Hand Surg 12A:618-620, 1987 18. Clarke WC: The pathogenesis of ganglia, with a description of the structure and development of synovial membrane. Surg Gynecol Obstet 47:460-468, 1938 19. Nelson C, Sawmiller S, Phalen G: Ganglions of the hand and wrist. J Bone Joint Surg 54A:1459-1464, 1972 20. Viegas SF: Intraarticular ganglion of the dorsal interosseous scapholunate ligament: a case for arthroscopy. Arthroscopy J Arthroscop Related Surg 2:93-95, 1986 21. Geissler WB: Arthroscopic excision of dorsal wrist ganglia. Techn Hand Upper Extremity Surg 2:196-201, 1998 22. Luchetti R, Badia A, Alfarano M, et al: Arthroscopic resection of dorsal wrist ganglia and treatment of recurrences. J Hand Surg 25B:38-40, 2000 23. Fontes D: Ganglia treated by arthroscopy, in Saffar P, Amadio PC, Foucher G (eds): Current Practice in Hand Surgery. London, Martin Dunitz, 1997, pp 283-290 24. Pederzini L, Ghinelli D, Soragni O: Arthroscopic treatment of dorsal arthrogenic cysts of the wrist. J Sports Traumatol Related Res 17:210215, 1995 25. Osterman AL, Raphael J: Arthroscopic resection of dorsal ganglions of the wrist. Hand Clin 11:7-12, 1995 26. Guiboux / P, Osterman AL, Raphael JS: Arthroscopic dorsal wrist ganglion resection, in Chow JCY (ed): Advanced Arthroscopy. Springer, New York, 2001, pp 249-252 27. Crawford GP, Taleisnik J: Rotatory subluxation of the scaphoid after excision of dorsal carpal ganglion and wrist manipulation - a case report. J Hand Surg 8:921-924, 1983 28. Duncan KH, Lewis RC: Scapholunate instability following ganglion cyst excision. Clin Orthop 228:250-253, 1988
61
Arthroscopic treatment of dorsal wrist ganglia offers a viable alternative to open ganglionectomy. Although a relatively recent addition to the list of arthroscopic techniques, arthroscopic treatment of dorsal wrist ganglia has been reported to have a high rate of success, low rate of recurrence, more rapid and complete return of wrist motion, and a superior cosmetic result. A tangential arthroscopic approach to the ganglion and/or its stalk via the 1,2 and the 4,5 or 6U portals offers an alternative technique which may afford better visualization of the ganglion and added protection for the scapholunate interosseous ligament. KEY WORDS: dorsal wrist ganglia, arthroscopy, resection Copyright 2003, Elsevier Science (USA). All rights reserved.
The simple dorsal wrist ganglion is the most common tumor of the hand. 1,2 There are estimated to be over 25,000 resections of dorsal wrist ganglia performed each year. 3 Angelides and Wallace 4 showed that except for the ganglia that arose from a carpal boss, all other dorsal ganglia are connected to the dorsal wrist capsule and the dorsal interosseous scapholunate ligament. The etiology of the dorsal wrist ganglion, despite m a n y theories and investigative studies, remains unknown. Dorsal wrist ganglia occur most commonly in patients in their second to fifth decades of life. s-8 Females are more commonly affected than males with estimates of the rates ranging from 2:1 to 4:1. 5-8 Diagnosis is often as simple as merely looking at the wrist and identifying the dorsal mass. The mass is typically discrete and cystic in nature and transilluminates. These ganglia most commonly emerge from between the extensor pollicis longus and the extensor digitorum communis tendons, just distal to the scapholunate joint. However, the so-called occult wrist ganglia can be highly symptomatic but have no visible or palpable mass. Gunther 9 described these as "diagnostic enigmas in that they have chronic dorsal wrist pain without a known injury and without radiographic or physical findings other than tenderness." In fact, even ultrasound (Fig 1) and magnetic resonance imaging (Fig 2) are not sensitive enough to reliably identify occult ganglia. Previously, I used a xylocaine block of the posterior interosseous nerve 2 cm proximal to the wrist joint to determine if the symp-
From the Department of Orthopaedics and Rehabilitation, University of Texas Medical Branch, Galveston, TX. Address reprint requests to Steven F. Viegas, MD, Professor and Chief, Division of Hand Surgery, Department of Orthopaedics and Rehabilitation, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0165. Copyright 2003, Elsevier Science (USA). All rights reserved. 1048-6666/03/1301-0000535.00/0 doi:10.1053/otor.2003.36317
56
toms would respond to a nerve block. This technique washelpful in diagnosing these occult ganglia. In addition, patients who obtained pain relief after nerve block are candidates for posterior interosseous nerve resection even if no ganglion is found intraoperatively (Fig 3). I now prefer arthroscopy for diagnosis and treatment of occult ganglia. Patients can be asymptomatic or have symptoms ranging from mild to significant pain, weakness, and limitation of wrist motion. The most common s y m p t o m is a dull aching that is thought to be the result of compression of the terminal branch of the posterior interosseous nerve. 2 A number of reports have stated that the smaller ganglia can be more symptomatic than the larger ones. 1,10,11 Dorsal wrist ganglia have been diagnosed for centuries and the treatments have varied. Historically treatments have included massage with a hand of a corpse, massage with spit, application of mercury to the overlying skin, taping a bullet or coin over the cyst, radiation, injection of a variety of different substances including iodine, carbolic acid, 10% morrhuate, ethanolamine, transdermal suture transfixion, rupture with a bible, a ganglion mallet, or digital pressure. 12 Current treatments include benign neglect, with spontaneous resolution reported in 28% to 58% of casesJ 3,14 A common treatment is aspiration with or without steroid injection with success rates ranging from 27% to 50%. 15-17 One study reported that success rates in their series of dorsal ganglia treated by aspiration and steroid injection could be increased from 27% to 41% by augmenting the treatment with 3 weeks of splint immobilization following aspiration and injection. 16 Open surgical resection can increase the success rate, however; recurrence rates have averaged 24% 4 and have been reported up to 40%. 18 Resection of the ganglion, its stalk and a cuff of capsular tissue is believed to increase the success rate. 4,19 Open resection of a dorsal wrist gan-
Operative Techniques in Orthopaedics, Vol 13, No 1 (January), 2003: pp 56-61
Fig 1. An ultrasound image demonstrating the presence of an occult dorsal wrist ganglion,
glion can result in transient or permanent loss of wrist motion, more commonly flexion. 14
SURGICAL TECHNIQUE Arthroscopic resection of the dorsal wrist ganglion has been a relatively recent addition to the list of treatment options.3,20 26 I first reported the option of arthroscopic treatment of the dorsal wrist ganglion in 1986. 20 Since then, the success of arthroscopic resection has been validated by a number of authors and has compared well to open resection. 3,2~ The approach generally has been through the 3,4 portal with a generous resection of the dorsal capsule. The following is the technique that I have used successfully for a number of years. The standard set-up and instrumentation for wrist arthroscopy is utilized. General or axillary block is used for anesthesia. An upper arm tourniquet is applied but usually not needed. A traction tower is used to suspend the hand and arm, and to apply 10 to 12 p o u n d s of distraction. The pertinent bony and soft-tissue anatomy is identified and marked on the wrist after it is suspended from the traction tower. The posteroanteriot radiograph offers essentially an actual size template of the skeletal anatomy, which can also be of assistance. An outflow canula is introduced through either the 6U or 6R portal. A number 11 scalpel blade is used to make a Skin-only incision. The portal is then completed by using blunt dissection with a small hemostat to the level of the capsule. The capsule is entered with a blunt trochar. All portals are developed using this same technique. The 1.9-mm arthroscope is preferred, although the 2.7-mm arthroscope is also acceptable. The arthroscope
ARTHROSCOPIC RESECTION OF DORSAL WRIST GANGLIA
is introduced through the 1,2 portal. Inflow is obtained through the arthroscope. Contrary to the previous descriptions of wrist arthroscopy techniques that utilize the 3,4 portal for visualization, the 1,2 portal is preferred. It allows a better tangential view of the ganglion stalk. As the arthroscope is advanced to the area of the scapholunate interosseous ligament, it actually assists in displacing and retracting the dorsal capsule from the ganglion stalk. This facilitates the visualization of the ganglion stalk compared with introducing the arthroscope through the 3,4 portal, immediately over the area of the stalk resulting in a limited field of view (Fig 4). It also avoids the complications of collapsing d o w n the dorsal joint space as the arthroscope enters the 3,4 portal a n d / o r inadvertently exiting the joint as the scope is withdrawn to obtain a better view. Using this approach the pearl-like stalk can be identified reliably. However, other authors have reported identifying the stalk in only 61% or less of the cases. 2s The appearance of the ganglion stalk can vary. There can be an occult ganglion that is completely contained within the proximal wrist joint and the scapholunate interosseous ligament (Fig 5). The stalk can be redundant (Fig 6), arise more proximally from the membranous portion of the scapholunate interosseous ligament and extend distally (Fig 7), or arise at the most dorsal, distal intrarticular portion of the scapholunate interosseous ligament at the capsular attachment (Fig 8). Sometimes using a probe or blunt trochar will help to identify and differentiate the stalk from a normal scapholunate interosseous ligament (Fig 9). In addition, there is often some degree of dorsal synovitis associated with a dorsal wrist ganglion, which can add to the difficulty of visualizing the stalk, especially through the 3,4 portal (Fig 10). The 4,5 or the 6R portal is used to approach the stalk from the ulnar side. A holmium laser is preferred to resect any dorsal synovitis and cauterize any vessels associated with the synovitis; however, a motorized 2.0-mm full radius shaver can also be used. Care must be taken not to damage the arthroscope. If a shaver is used there may be some bleeding that would require tourniquet inflation. Once the ganglion a n d / o r stalk is identified and triangu-
Fig 2. A magnetic resonance image demonstrating the presence of an occult dorsal wrist ganglion.
57
Fig 3. A cadaveric left-wrist dissection demonstrating a) the partially incised fourth dorsal compartment, in which the extensor tendons are deflected ulnar. The terminal branch of the posterior interosseous nerve, which lies immediately to the ulnar side of the septum between the fourth and third compartment and on the floor of the fourth compartment, is not readily evident, b) The terminal branch of the posterior interosseous nerve is easily identified once it has been dissected free of the underlying radius and a piece of rubber sheet has been placed behind the segment of nerve.
Fig 4. A diagram showing the tangential orientation of the arthroscope and the motorized shaver. In this illustration, the arthroscope is in the 6R portal and the shaver is in the 1,2 portal.
58
STEVEN F. VIEGAS
wrist ganglion is a recurrence. However, it appears that recurrence may be less likely to occur after an arthroscopic resection. The recurrence rate of arthroscopically resected dorsal wrist ganglia has ranged from 0 to 7%. 3,20-26 Guiboux et al. reported no recurrences in 50 cases. 26 Fontes reported 1 recurrence in 32 cases. 23
Q
i
~i 84184 ~ii 'i~i84i
3
Fig 5. a) An arthroscopic view from the 3,4 portal of an occult dorsal wrist ganglion, superimposed on the diagram of the scaphoid and lunate. (Reprinted from Viegas SF: Intraarticular ganglion of the dorsal interosseous scapholunate ligament: a case for arthroscopy. Arthroscopy J Arthroscop Related Surg 1986;2:93) b) Another arthroscopic view from the 1,2 portal of an occult dorsal wrist ganglion.
tated with the arthroscope and the shaver, a resection is performed. The tangential approach of the motorized shaver also offers additional protection for the scapholunate interosseous ligament because from that orientation the shaver cannot resect into the ligament. A number of authors 3,2~ state that a large portion of the dorsal capsule must be excised; however, the necessity of this has not been substantiated. I prefer to resect the stalk and that portion of the capsule through which the stalk passes. After resection of the stalk and dorsal capsule the ganglion should be palpated. If residual ganglion remains, then further resection or aspiration of the area of the ganglion should be performed. The portals are closed with butterfly strips. The wrist is placed in a volar splint and Ace bandage for 1 week. The splint is then discontinued and the patient is allowed to use the wrist as tolerated.
RESULTS/COMPLICATIONS As in open resection of a dorsal wrist ganglion, the most likely complication of arthroscopic resection of a dorsal
ARTHROSCOPIC RESECTION OF DORSAL WRIST GANGLIA
Fig 6. a) A diagram illustrating a redundant stalk of a dorsal wrist ganglion arising over the scapholunate interosseous ligament and folding back onto itself; and b) the arthroscopic view of that redundant stalk of the dorsal wrist ganglion. It is not uncommon to find a redundant stalk or portion of the ganglion within the proximal wrist joint as seen in c).
59
Fig 7. An arthroscopic view of a stalk of a dorsal wrist ganglion arising over the scapholunate interosseous ligament.
Luchetti et al. had 2 recurrences in 34 cases. 22 Geissler at and Pederzini et al. 24 reported 1 recurrence in each of their series of 14 cases. I have had one recurrence in 21 arthroscopically resected dorsal wrist ganglia. Complications after open surgery are rare; however, Crawford and Taleisnik =7reported scaphoid subluxation and Duncan and Lewis 2s reported scapholunate instability due to injury of the scapholunate interosseous ligament. Arthroscopic resection in general, and particularly the technique described here, should minimize the chance of this complication. Scapholunate ligament injury after arthroscopic ganglion excision has not been reported in the literature. The instrumentation required for the technique and the specific technical demands and difficulty of the procedure may be a relative complication. Luchetti et al. 22 reported that 9 of 43 (21%) patients on w h o m they had initially
Fig 8. An arthroscopic view of a stalk of a dorsal wrist ganglion arising over the most distal intraarticular portion of the scapholunate interosseous ligament at the capsular attachment.
60
Fig 9. An arthroscopic view of a stalk of a dorsal wrist ganglion arising over the scapholunate interosseous ligament both a) without and b) with a blunt trochar palpating the stalk.
Fig 10. An arthroscopic view of synovitis of the dorsal capsule at the proximal wrist joint, which is often seen in association with a dorsal wrist ganglion.
STEVEN F. VIEGAS
p l a n n e d to p e r f o r m a n a r t h r o s c o p i c r e s e c t i o n w e r e c o n v e r t e d to a n o p e n p r o c e d u r e d u e to difficulties. P o s t o p e r ative stiffness has been reported following open resection and prolonged immobilization14; however, again arthros c o p i c r e s e c t i o n r e s u l t s in less s c a r a n d offers a q u i c k e r r e t u r n of w r i s t m o t i o n . T h e c o s m e t i c r e s u l t s a r e a l s o b e t t e r a n d t h e u s u a l a d a g e o f " t r a d i n g a b u m p for a s c a r " d o e s n o t r e a l l y a p p l y to t h e a r t h r o s c o p i c p r o c e d u r e .
CONCLUSION A r t h r o s c o p i c r e s e c t i o n of t h e d o r s a l w r i s t g a n g l i o n is a g o o d a l t e r n a t i v e to o p e n s u r g e r y . It c a n b e a c h a l l e n g i n g surgery and one should have adequate experience in basic w r i s t a r t h r o s c o p y . T h e p a t i e n t s h o u l d b e p r e p a r e d for t h e p o s s i b l e c o n v e r s i o n to a n o p e n p r o c e d u r e . T h e r e s u l t s of a r t h r o s c o p i c t r e a t m e n t of t h e d o r s a l w r i s t g a n g l i o n a p p e a r a t l e a s t c o m p a r a b l e to o p e n r e s e c t i o n . I n fact, b a s e d o n t h e l o w r e c u r r e n c e rate, t h e m i n i m a l l y i n v a s i v e t e c h n i q u e , m o r e l i m i t e d s u r g i c a l scar, a n d o p p o r t u n i t y for e a r l i e r wrist motion, arthroscopic dorsal wrist ganglion resection may be better than open resection. The tangential arthroscopic approach described here, via the radial and ulnar a s p e c t s o f t h e w r i s t , m a y b e s a f e r a n d a l l o w for b e t t e r visualization than traditional arthroscopic portals.
REFERENCES 1. Boyes JH: Bunnell's Surgery of the Hand, 5th ed. Philadelphia, Lippincott, 1970 2. Dellon AL, Self SS: Anatomic dissections relating the posterior interosseous nerve to the carpus, and the etiology of dorsal ganglion pain. J Hand Surg 3:326-332, 1978 3. Bienz T; Raphael JS: Arthroscopic resection of the dorsal ganglion of the wrist. Hand Clin 15:429-434, 1999 4. Angelides AC, Wallace PF: The dorsal ganglion of the wrist: Its pathogenesis, gross and microscopic anatomy, and surgical treatment. J Hand Surg 1:228-235, 1976 5. Angelides AC: Ganglions of the hand and wrist, in Green DP, Hotchkiss RN, Pederson WC (eds): Green's Operative Hand Surgery, 4th ed. New York, Churchill-Livingston, 1999, pp 2171-2182 6. MacCollum MS: Dorsal wrist ganglions in children. J Hand Surg 2:325, 1977 7. MacKinnon AI, Azmy A: Active treatment of ganglia in children. Postgrad Med J 53:378-381, 1977
ARTHROSCOPIC RESECTION OF DORSAL WRIST GANGLIA
8. Rosson JW, Walker G: The natural history of ganglia in children. J Bone Joint Surg 71B:707-708, 1989 9. Gunther SF: Dorsal wrist pain and the occult scapholunate ganglion. J Hand Surg 10A:697-703, 1985 10. Angelides AC: Ganglions of the hand and wrist, in Green DP (ed): Operative Hand Surgery. New York, Churchill-Livingston, 1982, pp 1635-1641 11. Jennings C: The many faces of the common ganglion. American Academy of Orthopaedic Surgeons Sound Slide Program No. 786, November, 1983 12. Lyle F: Radiation treatment of ganglia of the hand and wrist. J Bone Joint Surg 23A:102-103, 1941 13. Carp L, Stout AP: A study of ganglion with special reference to treatment. Surg Gynecolog Obstet 47:460-468, 1938 14. McEvedy BV: Simple ganglia: a review of modes of treatment and an explanation for the frequent failures of surgery. Lancet 266:135, 1965 15. Psaila JV, Manse[ RE: The surface ultrastructure of ganglia. J Bone Joint Surg 60B:228-233, 1978 16. Richman JA, Gelberman RH, Engber WD, et al: Ganglions of the wrist and digits: results of treatment by aspiration and cyst wall puncture. J Hand Surg 12A:1041-1043, 1987 17. Zubowicz VN, lschii CH: Management of ganglion cysts of the hand by simple aspiration. J Hand Surg 12A:618-620, 1987 18. Clarke WC: The pathogenesis of ganglia, with a description of the structure and development of synovial membrane. Surg Gynecol Obstet 47:460-468, 1938 19. Nelson C, Sawmiller S, Phalen G: Ganglions of the hand and wrist. J Bone Joint Surg 54A:1459-1464, 1972 20. Viegas SF: Intraarticular ganglion of the dorsal interosseous scapholunate ligament: a case for arthroscopy. Arthroscopy J Arthroscop Related Surg 2:93-95, 1986 21. Geissler WB: Arthroscopic excision of dorsal wrist ganglia. Techn Hand Upper Extremity Surg 2:196-201, 1998 22. Luchetti R, Badia A, Alfarano M, et al: Arthroscopic resection of dorsal wrist ganglia and treatment of recurrences. J Hand Surg 25B:38-40, 2000 23. Fontes D: Ganglia treated by arthroscopy, in Saffar P, Amadio PC, Foucher G (eds): Current Practice in Hand Surgery. London, Martin Dunitz, 1997, pp 283-290 24. Pederzini L, Ghinelli D, Soragni O: Arthroscopic treatment of dorsal arthrogenic cysts of the wrist. J Sports Traumatol Related Res 17:210215, 1995 25. Osterman AL, Raphael J: Arthroscopic resection of dorsal ganglions of the wrist. Hand Clin 11:7-12, 1995 26. Guiboux / P, Osterman AL, Raphael JS: Arthroscopic dorsal wrist ganglion resection, in Chow JCY (ed): Advanced Arthroscopy. Springer, New York, 2001, pp 249-252 27. Crawford GP, Taleisnik J: Rotatory subluxation of the scaphoid after excision of dorsal carpal ganglion and wrist manipulation - a case report. J Hand Surg 8:921-924, 1983 28. Duncan KH, Lewis RC: Scapholunate instability following ganglion cyst excision. Clin Orthop 228:250-253, 1988
61