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Color-Aided Visualization of Dorsal Wrist Ganglion Stalks Aids in Complete Arthroscopic Excision
Technical Note With Video Illustration
Color-Aided Visualization of Dorsal Wrist Ganglion Stalks Aids in Complete Arthroscopic Excision Jeffrey Yao, M.D., and Michael C. D. Trindade, M.D., M.S.
Abstract: Dorsal wrist ganglia are the most common mass of the upper extremity. Treatment modalities include benign neglect, aspiration, and surgical excision. Arthroscopic excision is a less invasive surgical alternative to open resection with the benefit of visualizing and treating other intra-articular pathology, fewer potential complications, earlier return to activities, and possibly, a more complete resection. This may lead to a lower rate of recurrence, although this has not been proven in the literature. Recurrence depends in part on adequate ganglion stalk visualization and resection. This is often difficult in open and arthroscopic ganglionectomy. This work describes a new technique with improved arthroscopic stalk visualization and ganglion resection using intralesional injection of an inert dye.
H
ippocrates described ganglia as containing “mucoid flesh.” Throughout time, these masses have been considered to be tumors, synovial outpouchings, or myxoid degenerative change of connective tissue. Ganglia are the most common mass of the upper extremity. The annual incidence of ganglia of the wrist and hand is approximately 34 per 100,000 persons.1 The dorsum of the wrist is the most common location of these ganglia, with the female-male ratio being approximately 2:1.1 When conservative treatment is elected, 40% of these masses disappear on their own.2 Aspiration of the cyst may lead to resolution; however, the proce-
From the Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, California, U.S.A. Received September 9, 2010; accepted October 29, 2010. Address correspondence and reprint requests to Jeffrey Yao, M.D., Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway St, Ste C-442, Redwood City, CA 94063, U.S.A. E-mail: [email protected] © 2011 by the Arthroscopy Association of North America 0749-8063/10537/$36.00 doi:10.1016/j.arthro.2010.10.017 Note: To access the video accompanying this report, visit the March issue of Arthroscopy at www.arthroscopyjournal.org.
dure may need to be repeated multiple times, and recurrence rates are up to 70%.3 Some patients do not tolerate office aspiration or find the high incidence of recurrence unacceptable. Therefore operative excision remains the preferred option in the definitive treatment of ganglion cysts of the wrist. In the early history of surgical excision of ganglia, recurrence rates were up to 40%.4-6 Subsequent attention focused on delineating the deep attachments and stalk of the cyst, and complete resection may now be performed safely with lower recurrence rates and minimal morbidity.2,7 More recently, arthroscopic resection of dorsal wrist ganglia has become a popular procedure producing reliable relief of symptoms and low recurrence.8-10 The potential benefit of arthroscopic ganglion excisions includes shorter recovery time and the ability to evaluate the joint for other potential pathology. The success of arthroscopic excision of ganglia hinges on the adequate resection of the cyst, as well as the cyst stalk, because it typically arises from the scapholunate ligament. However, the results of previous studies suggest that the rate of stalk visualization in arthroscopic resection of wrist ganglia inconsistently ranges from 10% to 100% depending on the series and criteria.6,8-10 If the stalk is not adequately visualized
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 27, No 3 (March), 2011: pp 425-429
425
426
J. YAO AND M. C. D. TRINDADE
and complete excision of the stalk and cyst may not be verified arthroscopically, it is often necessary to convert to open ganglion resection. Given these inconsistent data, we hypothesized that visualization of dorsal wrist ganglia, as well as their stalks, could be improved during arthroscopy with intralesional injection of dye. This improvement in stalk visualization may assist in the complete excision of these ganglia and stalks and thereby reduce recurrence rates. To our knowledge, intralesional injection of dye has not been previously reported. SURGICAL TECHNIQUE The ganglion is marked with a skin marker before the procedure because the mass is often difficult to visualize and palpate once the surgery has begun (Table 1, and Video 1 [available at www.arthroscopyjournal .org]). The surgery is performed with the patient under a supraclavicular regional block. A standard wrist arthroscopy tower is used with 10 to 15 lb of longitudinal traction placed on the index and long fingers (Fig 1). An upper arm tourniquet is inflated to 250 mm Hg. Once the radiocarpal joint is insufflated with normal saline solution, the standard 6R portal is made directly radial to the extensor carpi ulnaris tendon. A 2.7-mm arthroscope is inserted into the ulnocarpal joint through this portal, and diagnostic arthroscopy is performed to evaluate for other potential causes of
TABLE 1. Improved Visualization for Arthroscopic Ganglion Excision: Pearls and Pitfalls Place wrist in standard wrist arthroscopy tower with 10 to 15 lb of traction on the index and long fingers. Draw out the ganglion after the wrist is in the tower and before arthroscopy so that it is not lost during the procedure. Use of a tourniquet may aid in visualization. Start with the arthroscope in the 6R portal. Identify the SLIL and follow it dorsally to try to identify the stalk. Inject the indigo carmine in an intralesional manner while watching with the arthroscope. The stalk and cyst should become colored blue and be readily visible. Introduce a motorized shaver through a distal 3-4 portal and excise the cyst and stalk from its origin. Follow the cyst distally to the midcarpal joint if necessary by following all areas colored blue to confirm complete excision. Beware of the extensor tendons and avoid injury with the shaver. Consider open excision if complete arthroscopic excision is not confirmed. A soft dressing with no splint is applied and range of motion is begun immediately postoperatively.
FIGURE 1. Setup for arthroscopic wrist ganglionectomy. The standard wrist arthroscopy tower is used with 10 to 15 lb of longitudinal traction placed on the index and long fingers. Marking of the ganglion on the skin before surgery is useful, because it is often difficult to visualize and palpate once the surgery has begun.
wrist pain. The arthroscope is advanced radially and dorsally toward the dorsal portion of the scapholunate interosseous ligament (SLIL). At this point, visualization of the stalk of the cyst is attempted because it most commonly arises from the SLIL. If the stalk is not fully visualized, a 1:10,000 solution of indigo carmine (American Reagent, Shirley, NY) (Fig 2) is injected in an intralesional manner into the ganglion. This provides excellent visualization of the ganglion and stalk (Fig 3). Indigo carmine is inert and safe when used intra-articularly. At this point, a distal 3-4
FIGURE 2. Visualization of the ganglion stalk as the arthroscope, which is in the 6R portal, is advanced radially and dorsally toward the dorsal portion of the SLIL. The 1:10,000 solution of indigo carmine is being injected in an intralesional manner.
DORSAL WRIST GANGLION STALKS
427
portal is made under direct vision, and following the areas colored blue by the dye, a 3.5-mm full-radius arthroscopic shaver is then used to debride the ganglion down to the level of the scapholunate ligament including the stalk and its attachment to the capsule. Once the stalk is amputated at the level of the SLIL,
FIGURE 4. Arthroscopic visualization of the inside of the ganglion cyst with the smooth cyst wall stained blue. The dorsal SLIL is to the left. One of the extensor digitorum communis tendons is seen and protected during the cyst excision.
the dye may be followed along the stalk to view the entire cyst (often into the midcarpal joint) and ensure its complete excision (Figs 4 and 5). The portals are closed with No. 4-0 nylon suture in an interrupted
FIGURE 3. Visualization of the ganglion stalk as the arthroscope, which is in the 6R portal, is advanced radially and dorsally toward the dorsal portion of the SLIL. The ganglion stalk is faintly visible arising from the SLIL before intralesional injection of indigo carmine (A) and more clearly visible after injection (B). The dorsal SLIL is to the left. The dorsal wrist capsule is to the right.
FIGURE 5. Complete excision of the cyst with the stalk is verified arthroscopically. The dorsal SLIL is to the left and protected. The remnant of the cyst stalk is in the center. The site of capsulectomy is seen to the right, at the 2- to 3-o’clock position.
428
J. YAO AND M. C. D. TRINDADE
fashion, and a soft dressing without a splint is applied. The sutures are removed 14 days postoperatively. Although we have only been using this technique for 16 months, to date, we have had no ganglion recurrences using this technique, and we attribute this success to the improved visualization of the ganglion stalks to guide us toward complete excision. DISCUSSION It is well accepted in the literature that arthroscopic treatment of a dorsal wrist ganglion is an acceptable alternative to open excision.6,8-11 However, previous wrist arthroscopy experience is recommended before undertaking this endeavor. Part of the difficulty of performing arthroscopic ganglion excision is related to the difficulty of identifying the ganglion stalk as it originates off the SLIL. In a study by Osterman and Raphael,10 the ganglion stalk was identified in 79% of cases. Kang et al.9 found that the stalk was visible in 41 of 41 arthroscopic resections; however, the clarity of visualization was not reported. In contrast, Edwards and Johansen8 found a discrete stalk visible in only 4 of 45 cases, and diffuse cystic material and redundant capsular thickening were present in 38 of 45 cases. Similarly, Rizzo et al.6 found a discrete stalk visible in 12 of 41 cases of arthroscopic resection. These results suggest that the rate of stalk visualization in arthroscopic resection of wrist ganglia inconsistently ranges from 10% to 100% depending on the series and criteria. If the stalk is not adequately visualized and complete excision of the stalk and cyst may not be verified arthroscopically, it is often necessary to convert to open ganglion resection. Recurrence rates after open surgery vary, but the recurrence rate is approximately 20%.4-6,12,13 Early reports suggested that rates are lower with arthroscopic resection. For example, Osterman and Raphael10 did not report any recurrences in 18 cases of arthroscopic ganglionectomy. In a study by Luchetti et al.,14 30 patients with dorsal wrist ganglia and 4 with recurrent dorsal ganglia underwent arthroscopic resection. The mean follow-up was 16 months, and no complications were observed. Of note, 2 recurrences were seen after arthroscopic resection of primary ganglia. Whether the recurrences were due to incomplete resection or an anatomic predilection to recurrence remains unknown. Rizzo et al.6 reported increased grip strength and range of motion with only 2 recurrences after a mean follow-up of 4 years. Kang et al.9 performed a randomized trial of open versus arthroscopic ganglion
excision in 72 patients and found recurrence in 3 of 28 patients in the arthroscopic group and 2 of 23 patients in the open resection group at a minimum follow-up of 1 year. Gallego and Mathoulin12 reported on their 2-year follow-up of arthroscopic ganglionectomy and found that although their recurrence rate was 12.3%, their patients exhibited significantly better wrist flexion/extension arc and grip strength, with a complication rate of 5%. Chen et al.13 described an intrafocal portal used for the resection of ganglia arthroscopically and reported a 7% recurrence rate after 15 months and only 1 complication (transient neurapraxia). Notably, the stalk was seen in only 13% of their patients. Complications after ganglion excision are rare but include scaphoid subluxation, chronic scapholunate instability due to ligament injury, hypertrophic scarring, painful neuroma, and infection.15,16 These are likely decreased with arthroscopic excision, but this fact is yet to be proven in the literature. In addition, arthroscopic ganglion excision has the added benefit of being able to concurrently treat associated lesions of the wrist including, but not limited to, triangular fibrocartilage complex tears, cartilage injuries, and ligamentous derangement.17 We hypothesize that our technique will allow visualization of the stalk in all cases. This will provide 2 benefits. First, extensive capsule debridement may be eliminated if an increased number of stalks are seen. Second, the conversion rate to open excision will be decreased, and the risk of subsequent complication from open excision would be eliminated. In addition, earlier return to function and decreased postoperative pain will be appreciated in our patients. To date, using this technique, we have had no ganglion recurrences and complications, and we attribute this success to improved stalk visualization. Ongoing studies will show whether decreased recurrence rates and complications will consistently be observed. Regardless of the final outcome, our method provides a reliable method for stalk visualization and is a useful additional tool to any surgeon considering arthroscopic ganglion resection.
REFERENCES 1. Janzon L, Niechajev IA. Wrist ganglia. Incidence and recurrence rate after operation. Scand J Plast Reconstr Surg 1981; 15:53-56. 2. Zachariae L, Vibe-Hansen H. Ganglia. Recurrence rate elucidated by a follow-up of 347 operated cases. Acta Chir Scand 1973;139:625-628.
DORSAL WRIST GANGLION STALKS 3. Holm PC, Pandey SD. Treatment of ganglia of the hand and wrist with aspiration and injection of hydrocortisone. Hand 1973;5:63-68. 4. McEvedy BV. Cystic ganglia; their pathology, natural history and treatment. Med Illus 1955;9:425-428. 5. McEvedy BV. The simple ganglion: A review of modes of treatment and an explanation of the frequent failures of surgery. Lancet 1954;16:135-136. 6. Rizzo M, Berger RA, Steinmann SP, Bishop AT. Arthroscopic resection in the management of dorsal wrist ganglions: Results with a minimum 2-year follow-up period. J Hand Surg Am 2004;29:59-62. 7. Angelides AC, Wallace PF. The dorsal ganglion of the wrist: Its pathogenesis, gross and microscopic anatomy, and surgical treatment. J Hand Surg Am 1976;1:228-235. 8. Edwards SG, Johansen JA. Prospective outcomes and associations of wrist ganglion cysts resected arthroscopically. J Hand Surg Am 2009;34:395-400. 9. Kang L, Akelman E, Weiss AP. Arthroscopic versus open dorsal ganglion excision: A prospective, randomized comparison of rates of recurrence and of residual pain. J Hand Surg Am 2008;33:471-475.
429
10. Osterman AL, Raphael J. Arthroscopic resection of dorsal ganglion of the wrist. Hand Clin 1995;11:7-12. 11. Geissler WB. Arthroscopic excision of dorsal wrist ganglia. Tech Hand Up Extrem Surg 1998;2:196-201. 12. Gallego S, Mathoulin C. Arthroscopic resection of dorsal wrist ganglia: 114 cases with minimum follow-up of 2 years. Arthroscopy 2010;26:1675-1682. 13. Chen ACY, Lee WC, Hsu KY, Chan YS, Yuan LJ, Chang CH. Arthroscopic ganglionectomy through an intrafocal cystic portal for wrist ganglia. Arthroscopy 2010;26:617-622. 14. Luchetti R, Badia A, Alfarano M, Orbay J, Indriago I, Mustapha B. Arthroscopic resection of dorsal wrist ganglia and treatment of recurrences. J Hand Surg Br 2000;25:38-40. 15. Crawford GP, Taleisnik J. Rotatory subluxation of the scaphoid after excision of dorsal carpal ganglion and wrist manipulation—A case report. J Hand Surg Am 1983;8:921925. 16. Duncan KH, Lewis RC Jr. Scapholunate instability following ganglion cyst excision. A case report. Clin Orthop Relat Res 1988;228:250-253. 17. Chloros GD, Wiesler ER, Poehling GG. Current concepts in wrist arthroscopy. Arthroscopy 2008;24:343-354.
Color-Aided Visualization of Dorsal Wrist Ganglion Stalks Aids in Complete Arthroscopic Excision Jeffrey Yao, M.D., and Michael C. D. Trindade, M.D., M.S.
Abstract: Dorsal wrist ganglia are the most common mass of the upper extremity. Treatment modalities include benign neglect, aspiration, and surgical excision. Arthroscopic excision is a less invasive surgical alternative to open resection with the benefit of visualizing and treating other intra-articular pathology, fewer potential complications, earlier return to activities, and possibly, a more complete resection. This may lead to a lower rate of recurrence, although this has not been proven in the literature. Recurrence depends in part on adequate ganglion stalk visualization and resection. This is often difficult in open and arthroscopic ganglionectomy. This work describes a new technique with improved arthroscopic stalk visualization and ganglion resection using intralesional injection of an inert dye.
H
ippocrates described ganglia as containing “mucoid flesh.” Throughout time, these masses have been considered to be tumors, synovial outpouchings, or myxoid degenerative change of connective tissue. Ganglia are the most common mass of the upper extremity. The annual incidence of ganglia of the wrist and hand is approximately 34 per 100,000 persons.1 The dorsum of the wrist is the most common location of these ganglia, with the female-male ratio being approximately 2:1.1 When conservative treatment is elected, 40% of these masses disappear on their own.2 Aspiration of the cyst may lead to resolution; however, the proce-
From the Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, California, U.S.A. Received September 9, 2010; accepted October 29, 2010. Address correspondence and reprint requests to Jeffrey Yao, M.D., Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway St, Ste C-442, Redwood City, CA 94063, U.S.A. E-mail: [email protected] © 2011 by the Arthroscopy Association of North America 0749-8063/10537/$36.00 doi:10.1016/j.arthro.2010.10.017 Note: To access the video accompanying this report, visit the March issue of Arthroscopy at www.arthroscopyjournal.org.
dure may need to be repeated multiple times, and recurrence rates are up to 70%.3 Some patients do not tolerate office aspiration or find the high incidence of recurrence unacceptable. Therefore operative excision remains the preferred option in the definitive treatment of ganglion cysts of the wrist. In the early history of surgical excision of ganglia, recurrence rates were up to 40%.4-6 Subsequent attention focused on delineating the deep attachments and stalk of the cyst, and complete resection may now be performed safely with lower recurrence rates and minimal morbidity.2,7 More recently, arthroscopic resection of dorsal wrist ganglia has become a popular procedure producing reliable relief of symptoms and low recurrence.8-10 The potential benefit of arthroscopic ganglion excisions includes shorter recovery time and the ability to evaluate the joint for other potential pathology. The success of arthroscopic excision of ganglia hinges on the adequate resection of the cyst, as well as the cyst stalk, because it typically arises from the scapholunate ligament. However, the results of previous studies suggest that the rate of stalk visualization in arthroscopic resection of wrist ganglia inconsistently ranges from 10% to 100% depending on the series and criteria.6,8-10 If the stalk is not adequately visualized
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 27, No 3 (March), 2011: pp 425-429
425
426
J. YAO AND M. C. D. TRINDADE
and complete excision of the stalk and cyst may not be verified arthroscopically, it is often necessary to convert to open ganglion resection. Given these inconsistent data, we hypothesized that visualization of dorsal wrist ganglia, as well as their stalks, could be improved during arthroscopy with intralesional injection of dye. This improvement in stalk visualization may assist in the complete excision of these ganglia and stalks and thereby reduce recurrence rates. To our knowledge, intralesional injection of dye has not been previously reported. SURGICAL TECHNIQUE The ganglion is marked with a skin marker before the procedure because the mass is often difficult to visualize and palpate once the surgery has begun (Table 1, and Video 1 [available at www.arthroscopyjournal .org]). The surgery is performed with the patient under a supraclavicular regional block. A standard wrist arthroscopy tower is used with 10 to 15 lb of longitudinal traction placed on the index and long fingers (Fig 1). An upper arm tourniquet is inflated to 250 mm Hg. Once the radiocarpal joint is insufflated with normal saline solution, the standard 6R portal is made directly radial to the extensor carpi ulnaris tendon. A 2.7-mm arthroscope is inserted into the ulnocarpal joint through this portal, and diagnostic arthroscopy is performed to evaluate for other potential causes of
TABLE 1. Improved Visualization for Arthroscopic Ganglion Excision: Pearls and Pitfalls Place wrist in standard wrist arthroscopy tower with 10 to 15 lb of traction on the index and long fingers. Draw out the ganglion after the wrist is in the tower and before arthroscopy so that it is not lost during the procedure. Use of a tourniquet may aid in visualization. Start with the arthroscope in the 6R portal. Identify the SLIL and follow it dorsally to try to identify the stalk. Inject the indigo carmine in an intralesional manner while watching with the arthroscope. The stalk and cyst should become colored blue and be readily visible. Introduce a motorized shaver through a distal 3-4 portal and excise the cyst and stalk from its origin. Follow the cyst distally to the midcarpal joint if necessary by following all areas colored blue to confirm complete excision. Beware of the extensor tendons and avoid injury with the shaver. Consider open excision if complete arthroscopic excision is not confirmed. A soft dressing with no splint is applied and range of motion is begun immediately postoperatively.
FIGURE 1. Setup for arthroscopic wrist ganglionectomy. The standard wrist arthroscopy tower is used with 10 to 15 lb of longitudinal traction placed on the index and long fingers. Marking of the ganglion on the skin before surgery is useful, because it is often difficult to visualize and palpate once the surgery has begun.
wrist pain. The arthroscope is advanced radially and dorsally toward the dorsal portion of the scapholunate interosseous ligament (SLIL). At this point, visualization of the stalk of the cyst is attempted because it most commonly arises from the SLIL. If the stalk is not fully visualized, a 1:10,000 solution of indigo carmine (American Reagent, Shirley, NY) (Fig 2) is injected in an intralesional manner into the ganglion. This provides excellent visualization of the ganglion and stalk (Fig 3). Indigo carmine is inert and safe when used intra-articularly. At this point, a distal 3-4
FIGURE 2. Visualization of the ganglion stalk as the arthroscope, which is in the 6R portal, is advanced radially and dorsally toward the dorsal portion of the SLIL. The 1:10,000 solution of indigo carmine is being injected in an intralesional manner.
DORSAL WRIST GANGLION STALKS
427
portal is made under direct vision, and following the areas colored blue by the dye, a 3.5-mm full-radius arthroscopic shaver is then used to debride the ganglion down to the level of the scapholunate ligament including the stalk and its attachment to the capsule. Once the stalk is amputated at the level of the SLIL,
FIGURE 4. Arthroscopic visualization of the inside of the ganglion cyst with the smooth cyst wall stained blue. The dorsal SLIL is to the left. One of the extensor digitorum communis tendons is seen and protected during the cyst excision.
the dye may be followed along the stalk to view the entire cyst (often into the midcarpal joint) and ensure its complete excision (Figs 4 and 5). The portals are closed with No. 4-0 nylon suture in an interrupted
FIGURE 3. Visualization of the ganglion stalk as the arthroscope, which is in the 6R portal, is advanced radially and dorsally toward the dorsal portion of the SLIL. The ganglion stalk is faintly visible arising from the SLIL before intralesional injection of indigo carmine (A) and more clearly visible after injection (B). The dorsal SLIL is to the left. The dorsal wrist capsule is to the right.
FIGURE 5. Complete excision of the cyst with the stalk is verified arthroscopically. The dorsal SLIL is to the left and protected. The remnant of the cyst stalk is in the center. The site of capsulectomy is seen to the right, at the 2- to 3-o’clock position.
428
J. YAO AND M. C. D. TRINDADE
fashion, and a soft dressing without a splint is applied. The sutures are removed 14 days postoperatively. Although we have only been using this technique for 16 months, to date, we have had no ganglion recurrences using this technique, and we attribute this success to the improved visualization of the ganglion stalks to guide us toward complete excision. DISCUSSION It is well accepted in the literature that arthroscopic treatment of a dorsal wrist ganglion is an acceptable alternative to open excision.6,8-11 However, previous wrist arthroscopy experience is recommended before undertaking this endeavor. Part of the difficulty of performing arthroscopic ganglion excision is related to the difficulty of identifying the ganglion stalk as it originates off the SLIL. In a study by Osterman and Raphael,10 the ganglion stalk was identified in 79% of cases. Kang et al.9 found that the stalk was visible in 41 of 41 arthroscopic resections; however, the clarity of visualization was not reported. In contrast, Edwards and Johansen8 found a discrete stalk visible in only 4 of 45 cases, and diffuse cystic material and redundant capsular thickening were present in 38 of 45 cases. Similarly, Rizzo et al.6 found a discrete stalk visible in 12 of 41 cases of arthroscopic resection. These results suggest that the rate of stalk visualization in arthroscopic resection of wrist ganglia inconsistently ranges from 10% to 100% depending on the series and criteria. If the stalk is not adequately visualized and complete excision of the stalk and cyst may not be verified arthroscopically, it is often necessary to convert to open ganglion resection. Recurrence rates after open surgery vary, but the recurrence rate is approximately 20%.4-6,12,13 Early reports suggested that rates are lower with arthroscopic resection. For example, Osterman and Raphael10 did not report any recurrences in 18 cases of arthroscopic ganglionectomy. In a study by Luchetti et al.,14 30 patients with dorsal wrist ganglia and 4 with recurrent dorsal ganglia underwent arthroscopic resection. The mean follow-up was 16 months, and no complications were observed. Of note, 2 recurrences were seen after arthroscopic resection of primary ganglia. Whether the recurrences were due to incomplete resection or an anatomic predilection to recurrence remains unknown. Rizzo et al.6 reported increased grip strength and range of motion with only 2 recurrences after a mean follow-up of 4 years. Kang et al.9 performed a randomized trial of open versus arthroscopic ganglion
excision in 72 patients and found recurrence in 3 of 28 patients in the arthroscopic group and 2 of 23 patients in the open resection group at a minimum follow-up of 1 year. Gallego and Mathoulin12 reported on their 2-year follow-up of arthroscopic ganglionectomy and found that although their recurrence rate was 12.3%, their patients exhibited significantly better wrist flexion/extension arc and grip strength, with a complication rate of 5%. Chen et al.13 described an intrafocal portal used for the resection of ganglia arthroscopically and reported a 7% recurrence rate after 15 months and only 1 complication (transient neurapraxia). Notably, the stalk was seen in only 13% of their patients. Complications after ganglion excision are rare but include scaphoid subluxation, chronic scapholunate instability due to ligament injury, hypertrophic scarring, painful neuroma, and infection.15,16 These are likely decreased with arthroscopic excision, but this fact is yet to be proven in the literature. In addition, arthroscopic ganglion excision has the added benefit of being able to concurrently treat associated lesions of the wrist including, but not limited to, triangular fibrocartilage complex tears, cartilage injuries, and ligamentous derangement.17 We hypothesize that our technique will allow visualization of the stalk in all cases. This will provide 2 benefits. First, extensive capsule debridement may be eliminated if an increased number of stalks are seen. Second, the conversion rate to open excision will be decreased, and the risk of subsequent complication from open excision would be eliminated. In addition, earlier return to function and decreased postoperative pain will be appreciated in our patients. To date, using this technique, we have had no ganglion recurrences and complications, and we attribute this success to improved stalk visualization. Ongoing studies will show whether decreased recurrence rates and complications will consistently be observed. Regardless of the final outcome, our method provides a reliable method for stalk visualization and is a useful additional tool to any surgeon considering arthroscopic ganglion resection.
REFERENCES 1. Janzon L, Niechajev IA. Wrist ganglia. Incidence and recurrence rate after operation. Scand J Plast Reconstr Surg 1981; 15:53-56. 2. Zachariae L, Vibe-Hansen H. Ganglia. Recurrence rate elucidated by a follow-up of 347 operated cases. Acta Chir Scand 1973;139:625-628.
DORSAL WRIST GANGLION STALKS 3. Holm PC, Pandey SD. Treatment of ganglia of the hand and wrist with aspiration and injection of hydrocortisone. Hand 1973;5:63-68. 4. McEvedy BV. Cystic ganglia; their pathology, natural history and treatment. Med Illus 1955;9:425-428. 5. McEvedy BV. The simple ganglion: A review of modes of treatment and an explanation of the frequent failures of surgery. Lancet 1954;16:135-136. 6. Rizzo M, Berger RA, Steinmann SP, Bishop AT. Arthroscopic resection in the management of dorsal wrist ganglions: Results with a minimum 2-year follow-up period. J Hand Surg Am 2004;29:59-62. 7. Angelides AC, Wallace PF. The dorsal ganglion of the wrist: Its pathogenesis, gross and microscopic anatomy, and surgical treatment. J Hand Surg Am 1976;1:228-235. 8. Edwards SG, Johansen JA. Prospective outcomes and associations of wrist ganglion cysts resected arthroscopically. J Hand Surg Am 2009;34:395-400. 9. Kang L, Akelman E, Weiss AP. Arthroscopic versus open dorsal ganglion excision: A prospective, randomized comparison of rates of recurrence and of residual pain. J Hand Surg Am 2008;33:471-475.
429
10. Osterman AL, Raphael J. Arthroscopic resection of dorsal ganglion of the wrist. Hand Clin 1995;11:7-12. 11. Geissler WB. Arthroscopic excision of dorsal wrist ganglia. Tech Hand Up Extrem Surg 1998;2:196-201. 12. Gallego S, Mathoulin C. Arthroscopic resection of dorsal wrist ganglia: 114 cases with minimum follow-up of 2 years. Arthroscopy 2010;26:1675-1682. 13. Chen ACY, Lee WC, Hsu KY, Chan YS, Yuan LJ, Chang CH. Arthroscopic ganglionectomy through an intrafocal cystic portal for wrist ganglia. Arthroscopy 2010;26:617-622. 14. Luchetti R, Badia A, Alfarano M, Orbay J, Indriago I, Mustapha B. Arthroscopic resection of dorsal wrist ganglia and treatment of recurrences. J Hand Surg Br 2000;25:38-40. 15. Crawford GP, Taleisnik J. Rotatory subluxation of the scaphoid after excision of dorsal carpal ganglion and wrist manipulation—A case report. J Hand Surg Am 1983;8:921925. 16. Duncan KH, Lewis RC Jr. Scapholunate instability following ganglion cyst excision. A case report. Clin Orthop Relat Res 1988;228:250-253. 17. Chloros GD, Wiesler ER, Poehling GG. Current concepts in wrist arthroscopy. Arthroscopy 2008;24:343-354.