Intra-articular Cystic Stalks

In the current literature, the exact roles of intra-articular cystic stalks are somewhat vague. Earlier reports implied, but did not specifically state, that identification and surgical excision of the stalk are paramount when standard arthroscopic techniques are used for ganglion excision. However, the presence of this important structure has been variably reported in the literature. Osterman and Raphael¹ identified a stalk in two thirds of their patients undergoing arthroscopic ganglion excision. Although one third of their patients had no identifiable stalk, ganglions were successfully excised with no recurrences. Other studies have reported a stalk incidence as low as 10%.^2–4 Despite vastly different reports on stalk identification, the importance of such pathology must be questioned. Rather than a cystic stalk, Edwards and Johansen⁴ described intra-articular cystic material and redundant capsular tissue in most of their patients with ganglion cysts. This finding, which was more consistently evident than the stalk, was the focus of their resection.

The intra-articular limitations of arthroscopic viewing may explain the paucity of stalk identification. The radiocarpal and midcarpal joints are separated by the extrinsic capsular ligaments. At this separation, the dorsal capsular reflection is adherent to the interosseous scapholunate ligament. It is possible for a ganglion stalk to travel toward the scapholunate ligament within the substance of the dorsal capsular reflection, rather than through the radiocarpal or midcarpal spaces, and the stalk may never be visualized by arthroscopy. Certain observations during arthroscopic resections may support this theory. On several occasions, extravasations of cystic fluid were observed during débridement of the dorsal capsular reflection between the radiocarpal and midcarpal joints when stalks had not been visualized in either compartment. In other words, the stalk might have been hidden within the dorsal capsular extrinsic ligaments.

Intra-articular Associations

The dorsal ganglion may be an overt sign of intra-articular pathology. Povlsen and Peckett⁵ found intra-articular abnormalities in 75% of patients with painful ganglia. They concluded that, like the popliteal cyst in the knee, the dorsal ganglion was a marker of joint abnormality. Osterman and Raphael¹ found abnormalities in 42% of their cases, predominately findings at the scapholunate ligament (24%), the triangular fibrocartilage (8%), and the lunatotriquetral ligament (3%) and significant chondromalacia. Despite the fact that only the ganglion was treated, wrist pain resolved in all cases. Edwards and Johansen⁴ elaborated on this notion by showing that most ganglia are associated with type II and III scapholunate and type III lunatotriquetral laxity (Table 23-1). Although it is reasonable to propose that increased intercarpal laxity may contribute to ganglion formation, the actual significance is unclear, given that the natural incidence of these ligamentous laxities in the general population is not known.

TABLE 23-1 Classification of Intracarpal Instability

Adapted from Geissler WB, Freeland AE, Savoie FH, et al. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am. 1996;78:357-365.

History and Physical Examination

The first question to answer when a patient presents with a mass is whether it is a cyst or a tumor. Many elements of the history and physical examination are not conclusive. Occurrence, progression, size, shape, texture, presence or absence of pain, and association with traumatic or repetitive activities provide little more than suggestions either way. One element of history, however, can be quite helpful in determining whether the lesion is cystic. Cysts and tumors get larger, but only cysts get smaller. There are rare exceptions to this rule, such as some vascular tumors that involute over a period of months to years, but cysts can decrease in size as quickly as overnight. On physical examination, transillumination can be helpful to differentiate a cyst from a tumor. This is performed by holding a penlight up against the lesion. A cystic lesion allows the light to transmit through its fluid medium, whereas the solid tissue of a tumor prevents any propagation of light.

Occasionally, cysts may herald a more dubious underlying pathology, such as a scapholunate ligament injury. The history and physical examination should focus on any recent or remote trauma. Often, patients have incompetent scapholunate ligaments that remain clinically unapparent until the manifestation of an associated ganglion cyst. Palpation of the dorsal portion of the scapholunate ligament, a positive Watson scaphoid shift test, or a positive straight finger resistance test may suggest scapholunate ligament pathology. Cysts may resemble other pathologies, such as gouty tophus, tenosynovitis, and rheumatoid pannus. A careful history and physical examination should suffice to differentiate these conditions.

Diagnostic Imaging

MRI and ultrasonography remain the imaging modalities most commonly used to differentiate fluid-filled cysts from solid tumors. Although both perform this task with equal reliability, MRI may suggest an etiology of a solid tumor, whereas ultrasonography cannot. Nevertheless, there has been a shift toward ultrasonography as the preferred technique, given its lesser comparable cost. Very small ganglions, although clinically significant, can be readily overlooked by both types of imaging. Surgeons should keep a high index of suspicion for these lesions even if the face of a negative reading.

Nonoperative Management

Although there is no consensus about the best nonoperative treatment for ganglion cysts, restriction of wrist activity seems to be well accepted. The efficacy of anti-inflammatory medications is more controversial. Some believe that reducing inflammation is helpful for patients with painful cysts, whereas others believe that these medications may make the cystic fluid less viscous and possibly more likely to spontaneously decompress. Neither belief has been substantiated in the literature. Needle aspiration seems to be relatively safe for dorsal ganglion cysts, but volar ganglions place neurovascular structures at particular risk with blind aspiration. Patients need to understand that recurrences after aspiration can be high. In summary, nonoperative treatments for dorsal ganglion cysts are unpredictable, and the evidence to support such measures is largely anecdotal. However, most surgeons attempt a trial of nonoperative treatment before committing the patient to surgical excision.

Indications and Contraindications

Indications and contraindications for arthroscopic dorsal wrist ganglion resection are still evolving. Ho and colleagues² reported two recurrences after resection of ganglia originating from the midcarpal joint. They concluded that arthroscopic resection was not indicated for cysts originating from the midcarpal joint. Many would agree that most dorsal wrist ganglia originate from the scapholunate interval. Given the capsular limitation in the wrist, this interval is only partially visualized from the radiocarpal joint. One study⁴ observed that cysts communicated with the midcarpal joint in 75% of cases. In the same report, 25% of cysts were accessed exclusively through the midcarpal joint, which suggests that evaluation of the midcarpal joint is mandatory for successful resection. Whereas most cysts may be resected successfully through an isolated radiocarpal portal, some require supplemental débridement from the midcarpal joint.

Regarding recurrent cysts, one group of investigators suggested that recurrent cysts after previous open surgical excision should be considered a contraindication for arthroscopic resection.⁶ Appropriate concerns are the risk of injury to the extensor tendons because of their potential displacement by the scar from the previous surgery. For this reason, most studies have identified recurrence as an exclusion criterion. One significant exception was a series in which 15% of the patients had recurrent ganglia, and outcomes were comparable to those of primary cyst resections. Based on this experience, the authors stated that arthroscopic resection of recurrent cysts is not contraindicated. In fact, it may be helpful in identifying a potential cause of the recurrence. Studies have identified intra-articular abnormalities such as ligament tears, excessive intercarpal laxities, chondromalacia, and triangular fibrocartilage tears as being associated with ganglion cysts.^1,4 It is unclear whether such findings contribute to cystic development, but, to the degree that they have a role, arthroscopy is more effective than open excision at identifying and addressing these abnormalities. Given a recurrent cyst, an arthroscopic evaluation may identify a partial scapholunate ligament tear that could be débrided, thereby lowering the probability of further recurrence. An open technique may not identify the cause as easily and therefore may doom the recurrent excision to another recurrence.

Cosmetic reasons sometime drive decisions to pursue any endoscopic technique. Although an open incision across the dorsum of the wrist may not seem excessive to a surgeon, the patient may have another perspective. One study reported a very high postoperative satisfaction rate, despite the fact that 17% of the patients were asymptomatic preoperatively and opted surgery for cosmetic reasons.⁴ There has been no similar report for open resections. The implication is that it would be reasonable to offer arthroscopic ganglion resections for patients who are primarily interested in the cosmetic appearance of their hands.

Arthroscopic Technique

Before excision of a dorsal wrist ganglion, a tourniquet is placed as a precaution, and it is inflated in the event that intra-articular bleeding obscures visualization. While the patient’s arm is suspended in a traction tower with 5 to 10 pounds of traction applied, a 6-R or 6-U portal is created as a visualization portal. The more radial 3-4 or 4-5 portal is avoided at this time, to prevent inadvertent decompression of the cyst. After the 2.7-mm arthroscopic camera is directed toward the dorsal compartment of the wrist, the capsule adjacent to the scapholunate ligament can be visualized. Occasionally, a sessile or pedunculated protrusion into the joint can be seen in the area where the extrinsic capsule joins the distal portion of the dorsal scapholunate ligament. This capsular reflection serves as part of the barrier between the radiocarpal and midcarpal joints, and the protrusion located here has been termed the cystic stalk (Fig. 23-1). More often, the surgeon may be impressed with the amount of synovitis and redundant capsule in this area instead of an actual stalk.

FIGURE 23-1 Cystic stalks. A, Pedunculated. B, Sessile. C, cyst; L, lunate; SLL, scapholunate ligament.

A common technique for arthroscopic ganglionectomy is to place the shaver through the cystic sac, because it often resides directly over the usual 3-4 portal. This action decompresses the cyst and may obscure any presence of an intra-articular stalk. Some think that this has some therapeutic benefit, whereas critics of the procedure argue that arthroscopic excisions are nothing more than glorified aspirations. We recommend a method that attempts to avoid decompressing the cyst with the shaver before excision, so as to observe the possibility of an undisturbed cystic stalk and its path elsewhere outside the radiocarpal joint. The working portal is created adjacent to the immediate area of the cyst, rather than directly over the 3-4 portal. This modified working portal is usually just distal and sometimes slightly radial to the actual 3-4 portal. A 2.9-mm, full-radius shaver is introduced through this portal, and every effort is made to avoid decompressing the cyst with simple introduction of the shaver.

Although the procedure implies that the cyst is removed by the arthroscope, this is often not the case. The arthroscopy procedure disrupts the communication between the cyst and the joint, leaving behind a deflated sac that cannot re-inflate. Eventually, the empty sac is resorbed. Recurrences can happen only if another cyst is generated.

The focus of the resection begins at the site of the ganglion stalk or redundant capsular material, if identified. This billowing, redundant material appears different from typical reactive synovitis. Although its exact significance is unclear, it seems to be continuous with the capsule that lies adjacent to the cyst. With this landmark, surgeons may confidently begin the capsulotomy. If neither structure is identified, the débridement begins adjacent to the dorsal scapholunate ligament and distal capsular reflection. Commonly, the cyst travels within the capsular reflection as it communicates with the scapholunate joint. Care should be taken to keep the blade of the shaver away from the scapholunate ligament at all times. On initial débridement of the capsular reflection, occasionally a flash of viscous cystic fluid may be visualized escaping into the joint. Débridement continues until approximately 1 cm of capsule has been removed.

A common mistake is to make the capsulotomy too small, which is easy to do under magnification. The 2.9-mm shaver is helpful as a reference in gauging the size of the capsulotomy. Another common mistake is to create an incomplete capsulotomy that fails to communicate with the extra-articular space. We advise direct visualization of the extensor tendons to verify that a complete capsulotomy has been performed (Fig. 23-2). Removal of the cystic sac is not necessary, because it often resorbs over time after it is detached from its origin at the joint. If the cyst is particularly large, resorption may take some time, and patients may complain about residual prominence on the dorsum of the hand. Removal of the truncated sac may be performed by pulling it out of the 3-4 portal with a hemostat. Because this is a blind maneuver and the risk of neuroma formation is relatively high, we think that, if removal of the cystic sac is elected, it should be done arthroscopically from inside the joint, provided that the surgeon is comfortable with the technique. Careful extensor tenosynovectomy may be performed at the same time with the shaver, if desired.

FIGURE 23-2 Complete capsulotomy communicating with the extra-articular space. Notice the visualization of the extensor tendons.

To remedy this situation, the arthroscopic camera is introduced through an ulnar midcarpal portal, and a similar capsulotomy is performed adjacent to the scapholunate interval through the radial midcarpal portal. Often, during débridement from the midcarpal joint, a fenestration is created between the midcarpal and radiocarpal joint through the capsular reflection. On removal of the arthroscopic equipment, the wrist is palpated again to ensure that the cyst has been completely excised. This can be difficult, especially if there is fluid extravasation, if substantial amounts of adipose tissue obscure the cyst, or if a very small cyst is present before resection.

Some surgeons close each arthroscopic portal with one simple nonabsorbable suture, but others leave them open with no cosmetic detriment. Open arthroscopic wounds can rarely form sinus tracts, as reported in other joints, so we prefer to close these wounds. A sterile wrist dressing is used in all cases. Splinting for 1 week has been advocated by some, but others believe splinting to be unnecessary.

PEARLS& PITFALLS

• If the cyst is decompressed prematurely by introduction of the instruments, the surgeon cannot confirm by palpation whether the cyst was adequately resected or simply decompressed with a “glorified aspiration.”

• A cystic stalk seems to be present variably, and its presence appears to have no effect on the outcomes of the resection. Redundant capsular material (Fig. 23-3) has been described and is reported to serve as a more reliable landmark for resection.

• Know what the shaver is cutting. It takes some pressure to cut into the extrinsic ligaments of the wrist, which is necessary for a complete capsulotomy, and that same pressure may easily cut inadvertently into an extensor tendon lying on the other side of the capsule. Even the most experienced arthroscopists should stop frequently and reassess the terrain.

• After the capsulotomy and cyst excision have been completed from the radiocarpal joint, the camera is removed and the dorsal wrist is palpated to determine the efficacy of the débridement. If a portion of the cyst remains, there is some degree of communication between the cyst and the midcarpal joint that has not yet been addressed.

FIGURE 23-3 Redundant capsule and diffuse cystic material. There is no defined cystic stalk. C, cyst; L, lunate, SLL, scapholunate ligament.

Postoperative Rehabilitation

Immediately postoperatively, digital motion is encouraged; sutures are removed in 7 to 10 days. Very seldom is any supervised therapy required. If there is residual fullness over the ganglion or its portal, the use of an elastomer as a pressure scar modulator may be helpful. Activity is resumed as tolerated, and the patient is advised against forceful loading of the wrist for 4 weeks. The theoretical advantages of a minimally invasive procedure to reliably remove wrist ganglion cysts seem intuitive but have not been validated until recently. Reduced recovery times, less postoperative pain, and quicker returns to work and athletics have been reported.^4,6

Patients can expect decreased pain and increased function within 6 weeks after surgery. Outcome surveys, often regarded as the most important assessment of patients, have documented considerable improvements in the short and the long term.⁴ However, positive short-term outcomes cannot be referenced to open excisions, because there have not been comparable reports dealing with these procedures.

Although an increasing number of studies have demonstrated that arthroscopic ganglion resection is a safe and effective technique with a predictable and easy recovery, there has been only one prospective, randomized study comparing arthroscopic resection with more traditional open techniques.⁷ This study evaluated patients at 4 to 8 weeks and again at 1 year postoperatively and could find no difference in outcomes. Most would agree, however, that the true benefits of a minimally invasive arthroscopy would be most profound within the first 4 weeks. No study has compared the two techniques and specifically assessed patient outcome during this defining time. Until this is done, it is difficult to make any meaningful comparisons between arthroscopic and open resections.