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Arthroscopic resection of volar wrist lipoma: A case report
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Chirurgie de la main 27 (2008) 246–247 http://france.elsevier.com/direct/CHIMAI/
Clinical case
Arthroscopic resection of volar wrist lipoma: A case report Re´section arthroscopique d’un lipome palmaire du poignet : a` propos d’un cas R. Luchetti *, I.P. Zorli 4, via Pietro da Rimini, 47900 Rimini, Italy Received 8 December 2007; received in revised form 23 August 2008; accepted 29 August 2008
Abstract We present the case of a patient who showed a volar radiocarpal mass confirmed to be a lipoma by the ultrasonographic examination. The whole procedure was done by arthroscopy, using portal 1–2 for the shaver and 3–4 for the arthroscope. The patient returned to daily activities within a few days, with a mobility of the operated wrist identical to that of the contralateral wrist, with no pain and only two little dorsal scars. # 2008 Elsevier Masson SAS. All rights reserved. Résumé Connaissant les possibilités d’excision des kystes palmaires grâce à l’arthroscopie, nous avons eu l’idée d’utiliser une technique similaire pour le traitement d’un lipome antéro-externe du poignet. Après confirmation du diagnostic de lipome à l’échographie, la résection du lipome a été réalisée par une voie d’abord 1–2 radiocarpienne pour le shaver et par une voie d’abord 3–4 radiocarpienne pour l’arthroscope. Le patient a pu reprendre ses activités en quelques jours, sans douleur et avec la même mobilité, au prix de deux minimes cicatrices dorsales. Nous pensons donc que l’arthroscopie du poignet peut également être utilisée avec succès dans des indications extra-articulaires sélectionnées. # 2008 Elsevier Masson SAS. All rights reserved. Keywords: Arthroscopy; Wrist; Ganglia; Lipoma; Arthroscopic portals Mots clés : Arthroscopie ; Poignet ; Kyste ; Lipome ; Voies arthroscopiques
1. Case report A retired 69-year-old, dominant right-handed man visited our department in 2003. He complained of a mass on the volar aspect of the left wrist present for about 12 months and showing some enlargement over the previous month, together with limitation of wrist extension. On physical examination, he presented a painless volar radiocarpal swelling of about 3 cm diameter. Ultrasonographic examination showed an encapsulated mass overlying the volar radiocarpal ligaments, with an ultrasonographic density similar to that of a lipoma.
* Corresponding author. E-mail address: [email protected] (R. Luchetti).
Surgery was performed in May 2003 under axillary block. The traditional vertical position of the wrist was used with the elbow at 908 of flexion; fingertrap traction was applied to the second and third fingers and a countertraction of 3 kg applied at the elbow. A wide angle 1.9 mm arthroscope was used through a radiocarpal 3–4 portal (Fig. 1). We located the lipoma in front of the volar radiocarpal ligaments by means of outside pressure over the mass. The shaver was introduced through a 1–2 portal. The lipoma was reached crossing the space between the radioscaphocapitate and radiolunotriquetral ligaments (Fig. 2). A part of the anterior capsule was resected with the shaver and the mass was identified by outside pressure. Once the lipoma was seen, it was easily removed with the shaver. The skin was closed with 4/0 nylon and a light bandage was applied to the wrist. The patient immediately started wrist motion. Rehabilitation was not necessary.
1297-3203/$ – see front matter # 2008 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.main.2008.08.015
R. Luchetti, I.P. Zorli / Chirurgie de la main 27 (2008) 246–247
247
Fig. 1. Intraoperative pictures showing the two arthroscopic portals (1–2, 3–4) commonly used to perform the resection of volar ganglia.
Fig. 2. Arthroscopic view of the lipoma which is bulging between the volar radiocarpal ligaments after partial resection.
Follow-up visits were scheduled at 3 months and 3 years after the surgery. The patient was satisfied, without pain and had a normal range of motion of his wrist.
of both the ligament and the mass. Open surgery is difficult because of the presence of artery and nerves, and complications can occur. Once the learning curve has been acquired, resection of the lipoma may be accomplished as safely as a volar ganglion, remembering that the location of the artery is more palmar [4]. Few complications occur with volar ganglia removing by wrist arthroscopy. In the literature, we found only one case of a patient reporting a hematoma [5]. In our case, the satisfaction level of the patient was high; he had only a small scar, and he was able to go back to his previous activities within a few days. This technique allows very early wrist mobilization and gives a chance for secondary conversion to other surgical procedures.
2. Discussion Arthroscopic resection of wrist ganglia is a useful tool and the technique well-known. Complications are rare and can be prevented with a good learning curve [1]. Various authors have also reported series without complications and few recurrences [2]. Open surgery may induce hypertrophic scarring and limitation of flexion or extension of the wrist. We decided to apply the advantageous technique of arthroscopic volar ganglia resection to remove the present lipoma. Using this technique, correct diagnosis and evaluation of the mass is fundamental prior to arthroscopy so as to identify the position of the lipoma and its limits. At first sight, a volar lipoma of the wrist may be mistaken for a volar cyst because it appears as a solid and mobile mass. Ultrasonography and MRI imaging can be helpful to establish the correct diagnosis [3]. The only possible drawback with the arthroscopic management of this lesion is difficulty in sampling for histological examination. However, we still prefer this technique as the diagnosis can be affirmed preoperatively by ultrasonography. The arthroscopic technique allows a more precise inspection of the radiocarpal articulation and provides a good visualization
References [1] Geissler WB. Arthroscopic excision of dorsal wrist ganglia. Tech Hand Upper Extremity Surg 1998;2:196–201. [2] Luchetti R, Badia A, Alfarano M, Orbay J, Indriago I, Mustapha B. Arthroscopic resection of dorsal wrist ganglia and treatment recurrences. J Hand Surg 2000;25B:38–40. [3] McAlinden PS, Teh J. Imaging of the wrist. Imaging 2003;15:180–92. [4] Verhellen R, Bain GI. Arthroscopic capsular release for contracture of the wrist: a new technique. Arthroscopy 2000;19:106–10. [5] Mathoulin C, Hoyos A, Pelaez J. Arthroscopic resection of wrist ganglia. Hand Surg 2004;2:159–64.
Chirurgie de la main 27 (2008) 246–247 http://france.elsevier.com/direct/CHIMAI/
Clinical case
Arthroscopic resection of volar wrist lipoma: A case report Re´section arthroscopique d’un lipome palmaire du poignet : a` propos d’un cas R. Luchetti *, I.P. Zorli 4, via Pietro da Rimini, 47900 Rimini, Italy Received 8 December 2007; received in revised form 23 August 2008; accepted 29 August 2008
Abstract We present the case of a patient who showed a volar radiocarpal mass confirmed to be a lipoma by the ultrasonographic examination. The whole procedure was done by arthroscopy, using portal 1–2 for the shaver and 3–4 for the arthroscope. The patient returned to daily activities within a few days, with a mobility of the operated wrist identical to that of the contralateral wrist, with no pain and only two little dorsal scars. # 2008 Elsevier Masson SAS. All rights reserved. Résumé Connaissant les possibilités d’excision des kystes palmaires grâce à l’arthroscopie, nous avons eu l’idée d’utiliser une technique similaire pour le traitement d’un lipome antéro-externe du poignet. Après confirmation du diagnostic de lipome à l’échographie, la résection du lipome a été réalisée par une voie d’abord 1–2 radiocarpienne pour le shaver et par une voie d’abord 3–4 radiocarpienne pour l’arthroscope. Le patient a pu reprendre ses activités en quelques jours, sans douleur et avec la même mobilité, au prix de deux minimes cicatrices dorsales. Nous pensons donc que l’arthroscopie du poignet peut également être utilisée avec succès dans des indications extra-articulaires sélectionnées. # 2008 Elsevier Masson SAS. All rights reserved. Keywords: Arthroscopy; Wrist; Ganglia; Lipoma; Arthroscopic portals Mots clés : Arthroscopie ; Poignet ; Kyste ; Lipome ; Voies arthroscopiques
1. Case report A retired 69-year-old, dominant right-handed man visited our department in 2003. He complained of a mass on the volar aspect of the left wrist present for about 12 months and showing some enlargement over the previous month, together with limitation of wrist extension. On physical examination, he presented a painless volar radiocarpal swelling of about 3 cm diameter. Ultrasonographic examination showed an encapsulated mass overlying the volar radiocarpal ligaments, with an ultrasonographic density similar to that of a lipoma.
* Corresponding author. E-mail address: [email protected] (R. Luchetti).
Surgery was performed in May 2003 under axillary block. The traditional vertical position of the wrist was used with the elbow at 908 of flexion; fingertrap traction was applied to the second and third fingers and a countertraction of 3 kg applied at the elbow. A wide angle 1.9 mm arthroscope was used through a radiocarpal 3–4 portal (Fig. 1). We located the lipoma in front of the volar radiocarpal ligaments by means of outside pressure over the mass. The shaver was introduced through a 1–2 portal. The lipoma was reached crossing the space between the radioscaphocapitate and radiolunotriquetral ligaments (Fig. 2). A part of the anterior capsule was resected with the shaver and the mass was identified by outside pressure. Once the lipoma was seen, it was easily removed with the shaver. The skin was closed with 4/0 nylon and a light bandage was applied to the wrist. The patient immediately started wrist motion. Rehabilitation was not necessary.
1297-3203/$ – see front matter # 2008 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.main.2008.08.015
R. Luchetti, I.P. Zorli / Chirurgie de la main 27 (2008) 246–247
247
Fig. 1. Intraoperative pictures showing the two arthroscopic portals (1–2, 3–4) commonly used to perform the resection of volar ganglia.
Fig. 2. Arthroscopic view of the lipoma which is bulging between the volar radiocarpal ligaments after partial resection.
Follow-up visits were scheduled at 3 months and 3 years after the surgery. The patient was satisfied, without pain and had a normal range of motion of his wrist.
of both the ligament and the mass. Open surgery is difficult because of the presence of artery and nerves, and complications can occur. Once the learning curve has been acquired, resection of the lipoma may be accomplished as safely as a volar ganglion, remembering that the location of the artery is more palmar [4]. Few complications occur with volar ganglia removing by wrist arthroscopy. In the literature, we found only one case of a patient reporting a hematoma [5]. In our case, the satisfaction level of the patient was high; he had only a small scar, and he was able to go back to his previous activities within a few days. This technique allows very early wrist mobilization and gives a chance for secondary conversion to other surgical procedures.
2. Discussion Arthroscopic resection of wrist ganglia is a useful tool and the technique well-known. Complications are rare and can be prevented with a good learning curve [1]. Various authors have also reported series without complications and few recurrences [2]. Open surgery may induce hypertrophic scarring and limitation of flexion or extension of the wrist. We decided to apply the advantageous technique of arthroscopic volar ganglia resection to remove the present lipoma. Using this technique, correct diagnosis and evaluation of the mass is fundamental prior to arthroscopy so as to identify the position of the lipoma and its limits. At first sight, a volar lipoma of the wrist may be mistaken for a volar cyst because it appears as a solid and mobile mass. Ultrasonography and MRI imaging can be helpful to establish the correct diagnosis [3]. The only possible drawback with the arthroscopic management of this lesion is difficulty in sampling for histological examination. However, we still prefer this technique as the diagnosis can be affirmed preoperatively by ultrasonography. The arthroscopic technique allows a more precise inspection of the radiocarpal articulation and provides a good visualization
References [1] Geissler WB. Arthroscopic excision of dorsal wrist ganglia. Tech Hand Upper Extremity Surg 1998;2:196–201. [2] Luchetti R, Badia A, Alfarano M, Orbay J, Indriago I, Mustapha B. Arthroscopic resection of dorsal wrist ganglia and treatment recurrences. J Hand Surg 2000;25B:38–40. [3] McAlinden PS, Teh J. Imaging of the wrist. Imaging 2003;15:180–92. [4] Verhellen R, Bain GI. Arthroscopic capsular release for contracture of the wrist: a new technique. Arthroscopy 2000;19:106–10. [5] Mathoulin C, Hoyos A, Pelaez J. Arthroscopic resection of wrist ganglia. Hand Surg 2004;2:159–64.