66: Arthroscopic Ganglionectomy

Published on 19/04/2015 by admin

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Last modified 19/04/2015

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Procedure 66 Arthroscopic Ganglionectomy

William B. Geissler, Daniel C.M. Williams

Indications

Ideal indication

• Symptomatic single dorsal wrist ganglion located between the third and fourth dorsal compartments with at least one failed aspiration

Additional indications

• Patient desiring rapid return to motion after surgery and early return to work and function

• Suspicion of additional intra-articular pathology that needs evaluation

Examination/Imaging

Clinical Examination

Ganglions are the most common tumors of the hand and represent about 50% to 70% of all soft-tissue hand tumors. Ganglions are more prevalent in females and usually appear between the second and fifth decades of life. Dorsal wrist ganglions are by far the most common cyst and account for 60% to 70% of all hand and wrist ganglions. The origin of the dorsal ganglion, with rare exception, arises over the junction of the dorsal capsule with the scapholunate intraosseous ligament. Angelides and Wallace stated that the transition between the dorsal capsule and the scapholunate interosseous ligament can serve as a duct with a one-way valve mechanism. The main cyst is usually located directly over the scapholunate ligament. However, the cyst may occur anywhere between the extensor tendons and can be connected to the ligament through a long pedicle. Palpation of the mass usually reveals the extent of the cyst in the direction of the pedicle. Transillumination or aspiration confirms the diagnosis preoperatively.

Open excision of the dorsal ganglion is a time-proven procedure with a low recurrence rate. However, open excision of an occult ganglion frequently requires blunt dissection to identify the ganglion, which may lead to increased scarring and decreased range of motion. Arthroscopic excision allows precise identification of the stock and excision with potentially less scarring.

Imaging

Radiographs of the involved region are usually unremarkable. Although plain radiographs are usually unremarkable, they may be helpful in evaluating additional pathologic changes to the wrist, including static wrist instability.

Arthrograms may show communication of the wrist joint with the cyst via a one-way valve mechanism.

Magnetic resonance imaging (MRI) may be helpful in detection of an occult dorsal ganglion. MRI evaluation is potentially helpful when additional intra-articular pathologic changes are suspected.

Surgical Anatomy

Typically, the cyst appears between the extensor pollicis longus and the extensor digitorum communis tendons. Arthroscopically, the pearl or the origin of the ganglion stalk from the distal portion of the scapholunate interosseous ligament is identified with the arthroscope in the 4-5 or 6R portals. (Fig. 66-1 shows an arthroscopic view of the scapholunate ligament.) The cyst is seen about two thirds of the time.

Attenuation or laxity of the scapholunate interosseous ligament may be seen with the arthroscope in the 3-4 portal and radiocarpal space, or widening of the scapholunate may be seen with the arthroscope in the radial midcarpal portal.

FIGURE 66-1

Positioning

The patient is positioned in the traction tower with about 10 pounds of traction.

The wrist is slightly flexed to make it easier to insert the arthroscope and arthroscopic instrumentation.

Small joint instrumentation with a 2.7-mm or smaller arthroscope is used.

Small joint shavers are used as well. Large joint instrumentation is not recommended for the wrist.

A wrist traction tower helps provide traction to the wrist and stabilizes the forearm. If this is not available, the wrist can be suspended in a shoulder traction tower, although the forearm is not stabilized, and the wrist will be at neutral position.

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Operative Techniques Hand and Wrist Surgery