Volume 26, Issue 5 , Pages 617-622, May 2010
Arthroscopic Ganglionectomy Through an Intrafocal Cystic Portal for Wrist Ganglia
Article Outline
Purpose
A retrospective study was conducted on arthroscopic ganglionectomy in wrists using a novel intrafocal cystic portal. The safety and efficacy of this technique were assessed by treatment of 15 wrists in 15 patients.
Methods
Arthroscopic ganglionectomy was performed by the same surgeon with the patient under general anesthesia or regional block. Preoperative complaints, intraoperative findings, and postoperative results of all the patients were reported. The mean follow-up was 15.3 months. Functional assessment by use of modified Mayo wrist scores, patient satisfaction, and recurrence were included in the follow-up evaluation.
Results
Two thirds of the patients acquired good to excellent results, whereas the results for the remaining third were fair. Complications included 1 recurrence and 1 case of transient paresthesia sensation. The most common arthroscopic findings were capsular and ligament lesions, rather than ganglionic stalks.
Conclusions
Arthroscopic ganglionectomy through an intrafocal cystic portal is a safe and efficacious option for the treatment of painful wrist ganglia.
Level of Evidence
Level IV, therapeutic case series.
The etiology of wrist ganglia remains obscure. Trauma to the wrist, synovial herniation, primary development of a tumor, and myxoid or mucoid degeneration of periarticular connective tissue have been implicated to play a role in the development of wrist ganglia. In addition, a common operative finding is the association of the dorsal wrist ganglion with the scapholunate (SL) ligament through a direct attachment.1, 2 A recent report from Povlsen and Peckett3 has concluded that a painful dorsal wrist ganglion is often a marker of an underlying joint abnormality, particularly of the SL ligament. Accordingly, traditional treatment methods, including simple aspiration,4 aspiration with instillation of steroid,5 forceful rupture or controlled rupture with multiple needle punctures,6 and surgical excision7 have frequently been found to provide inadequate evaluation of the associated intra-articular pathology. Although arthroscopic resection or decompression surgery of articular ganglion cysts with satisfactory results has been reported recently,8 concern remains regarding the adequacy in identification and management of the pathologic tissues, including capsule, synovium, and ganglion stalk, whenever present. The purpose of this study was to evaluate the results of arthroscopic ganglionectomy by use of a novel technique and report on the concomitant intra-articular pathology of wrist ganglia. Our hypothesis was that an additional arthroscopic portal through the focal cystic lesion is a feasible approach for visualizing the associated intra-articular lesions in the patients with symptomatic wrist ganglia.
Methods
We conducted a retrospective single-center study from September 2006 to June 2007 (Table 1). This study comprised 15 consecutive patients who underwent arthroscopic ganglionectomy in 15 wrists: 1 man and 14 women, 3 on the volar side and 12 on the dorsal side, and 4 recurrent cases and 11 primary cases. All participants received conservative treatment including observation and activity modification before surgery. However, neither aspiration nor injection was performed to treat the current lesion. The mean patient age was 35.7 ± 15.0 years (range, 20 to 81 years). Preoperatively, all patients presented with pain, a localized mass, and limited range of motion (ROM). The mean duration of these symptoms was 9.5 ± 9.0 months (range, 1 to 30 months). Patients with previous ipsilateral wrist fractures or pre-existing arthritis were excluded. The diagnosis was made based on the patients' history and physical examination. Plain radiographs were used to rule out pre-existing osseous lesions and carpal instability.
Table 1. Demographic Data of 15 Patients
| Case No. | Sex | Age (yr) | Ganglion Location | Recurrent Lesion | Duration (mo) | Lesion Size (mm) |
|---|---|---|---|---|---|---|
| 1 | F | 30 | Volar | No | 6 | 15 |
| 2 | M | 27 | Dorsal | Yes | 3 | 15 |
| 3 | F | 48 | Dorsal | No | 24 | 15 |
| 4 | F | 81 | Dorsal | No | 12 | 10 |
| 5 | F | 41 | Volar | No | 24 | 20 |
| 6 | F | 35 | Dorsal | No | 1 | 20 |
| 7 | F | 34 | Dorsal | Yes | 4 | 25 |
| 8 | F | 50 | Dorsal | No | 6 | 20 |
| 9 | F | 27 | Dorsal | No | 6 | 10 |
| 10 | F | 34 | Dorsal | No | 6 | 15 |
| 11 | F | 29 | Dorsal | Yes | 6 | 15 |
| 12 | F | 20 | Volar | No | 6 | 15 |
| 13 | F | 27 | Dorsal | No | 1 | 15 |
| 14 | F | 26 | Dorsal | Yes | 8 | 15 |
| 15 | F | 27 | Dorsal | No | 30 | 15 |
All operations were performed by the same surgeon. Most patients underwent outpatient surgery; an overnight stay postoperatively was allowed for patients who lived far from the hospital. Standard wrist arthroscopy techniques were conducted by use of a 2.5-mm 30° angulated arthroscope under finger traction of 10 to 12 lb (Video 1, available at www.arthroscopyjournal.org). Standard arthroscopic portals were used, whereas skin incisions near the region of the ganglion cysts were intentionally avoided to prevent uncontrolled decompression of the ganglion cysts. Most commonly, 1-2 and 3-4 portals were used for volar ganglia and 1-2 and 4-5 portals for dorsal ganglia. Midcarpal portals were added in cases of radio-dorsal lesions and all recurrent cases. Initially, the ganglionic lesion was identified from the articular side by identifying the capsular bulging lesion with focal hyperplasic tissue. This finding could be confirmed during arthroscopic examination by palpating the mass outside the skin or by transillumination of the cyst by use of an arthroscopic light source from the inside (Fig 1). We then thoroughly examined the wrist joint arthroscopically, focusing particularly on the integrity of the SL ligament, the radiocarpal ligament, the lunotriquetral ligament, the triangular fibrocartilage complex (TFCC), and the joint capsule. We used the definitions suggested by Stanley and Saffar9 to detect any abnormal synovitis, capsular or ligament tear, or avulsion from osseous origins. The entire dorsal portion of the SL ligament was thoroughly examined and traced upward to detect any significant tear and any visible stalk connecting to the joint capsule or the ganglion cyst. After assessment of the intra-articular pathology, arthroscopic shaving and ganglion resection were performed with a 2.5-mm oscillating shaver (Fig 2). The shaver was also used for trimming partial tear of the carpal ligament and TFCC.
Figure 1.
The location of the intra-articular ganglionic tissue is confirmed by transillumination of the cyst with an arthroscopic light source from inside out.
Figure 2.
Arthroscopy showed a ganglion cyst (arrows) on the SL ligament, as well as a connecting stalk between the dorsal capsular lesion and the distal part of the SL ligament. As shown in right lower panel, all the ganglionic tissue and the stalk were excised after shaving.
An additional tiny puncture wound was then made on the surface skin over the ganglion cyst, followed by a gentle introduction of the oscillating shaver through the ganglion cyst all the way to the wrist joint. In cases of volar ganglia, the puncture wound was created with guidance from the light source of the arthroscope, which was introduced through the 3-4 portal. Arthroscopically guided shaving through this intrafocal cystic portal was then performed to remove all the residual ganglionic tissue, as well as the connecting stalk. However, it was limited to visible peritendinous tissue and joint capsule. Finally, the arthroscope was introduced into the intrafocal cystic portal to ensure the accomplishment of complete ganglionectomy and removal of residual stalk or remnant ganglionic tissue (Fig 3). The entire surgery was conducted under pneumatic tourniquet control. The pressure of the tourniquet ranged from 200 to 250 mm Hg. The mean duration of surgery was 65.2 minutes (range, 55 to 95 minutes).
Figure 3.
Arthroscopic viewing inside the ganglion cyst was performed by introducing the arthroscope into the cyst from the articular side (A) (top row) and from the outside through the cystic portal (bottom row). (C, cystic side.)
Gentle motion exercise was started 1 week postoperatively. Simple actions such as writing and operation calculations were allowed, but vigorous activity and excessive wrist motion were prohibited until 6 weeks after surgery. Regular follow-up at the outpatient clinic was arranged 1 week postoperatively and at 3-month intervals thereafter. The modified Mayo wrist scores consisting of pain, functional status, ROM, and grip strength were used for the postoperative assessment at 6 months and 1 year. The incidence of ganglion recurrence and patient satisfaction were also evaluated. The mean follow-up was 15.3 months (range, 12 to 26 months).
Results
The diameter of the ganglion cysts was measured during surgery by measuring the maximal width on palpation. It ranged between 10 and 25 mm (mean, 16.0 ± 3.9 mm). The arthroscopic findings for the 15 patients' wrists are summarized in Table 2. The most common arthroscopic finding was a capsular bulging lesion with local tissue hyperplasia (11 wrists [73%]) that was detected from the articular side of the ganglion cyst. A carpal ligament lesion was noted in 5 wrists (33%). A partial tear of the lunotriquetral ligament was found in 1 wrist, whereas a partial tear of the SL ligament was noted in 3 wrists. All 3 of these wrists had a partial SL ligament tear over the dorsal-inferior region. Of the 3 wrists with a volar ganglion cyst, 1 had a partial tear of the volar radioscaphocapitate ligament near the sulcus adjacent to the long radiolunate ligament; the other 2 wrists exhibited no remarkable intra-articular lesion throughout the arthroscopic examination. One wrist had a 4-mm TFCC tear near the radial attachment. Among all 15 wrists, only 2 stalks (13%) were noted; both of these were recurrent cases after previous open excision surgery.
Table 2. Arthroscopic Findings
| Case No. | Intra-articular Lesions | ||||||
|---|---|---|---|---|---|---|---|
| SL Tear | LT Tear | RSC Tear | TFCC Tear | Capsular Lesion | Ganglion on SL | Ganglion Stalk⁎ | |
| 1 | 0 | 0 | 0 | 0 | 1 | 0 | 0 |
| 2 | 0 | 0 | 0 | 0 | 0 | 0 | 1 |
| 3 | 0 | 0 | 0 | 0 | 1 | 0 | 0 |
| 4 | 1 | 0 | 0 | 0 | 0 | 0 | 0 |
| 5 | 0 | 0 | 0 | 1† | 1 | 0 | 0 |
| 6 | 1 | 0 | 0 | 0 | 0 | 1 | 0 |
| 7 | 0 | 1 | 0 | 0 | 1 | 0 | 0 |
| 8 | 1 | 0 | 0 | 0 | 1 | 0 | 0 |
| 9 | 0 | 0 | 0 | 0 | 1 | 0 | 0 |
| 10 | 0 | 0 | 0 | 0 | 1 | 0 | 0 |
| 11 | 0 | 0 | 0 | 0 | 0 | 1 | 1 |
| 12 | 0 | 0 | 1 | 0 | 1 | 0 | 0 |
| 13 | 0 | 0 | 0 | 0 | 1 | 0 | 0 |
| 14 | 0 | 0 | 0 | 0 | 1 | 0 | 0 |
| 15 | 0 | 0 | 0 | 0 | 1 | 0 | 0 |
| Total | 3 (20%) | 1(7%) | 1(7%) | 1(7%) | 11(73%) | 2(13%) | 2(13%) |
⁎Both were recurrent cases. These underwent open surgery previously. |
†Four-millimeter radial-sided peripheral tear. |
The postoperative modified Mayo wrist scores at 6 months and 1 year are summarized in Table 3. Among the 15 patients, 12 (80%) had no or mild residual wrist pain and 3 (20%) had moderate wrist pain after vigorous activity 6 months postoperatively. With regard to the resumption of employment, all resumed work within 6 months without Workers' Compensation. Of the patients, 11 (73%) returned to regular employment and 4 (21%) returned to restricted employment. Regarding ROM recovery, 11 patients (73%) had equal to or greater than 90% recovery and 1 patient (7%) had less than 70% recovery. With respect to grip strength, 6 patients (40%) had full recovery, defined as 90% or more of the normal side; 8 patients (53%) had more than half of normal strength; and 1 patient (7%) regained less than half of normal strength. In total, 5 patients (33%) were graded as having excellent results; 5 patients (33%), good; and 5 patients (33%), fair. At 1 year postoperatively, the results in 13 patients (87%) were ranked as good to excellent; the results remained fair in only 2 patients (13%). There were no other immediate complications except for 1 case of transient paresthesia along the radial side, which resolved within 1 month. Recurrent lesion after the index surgery was noted in 1 patient (7%), who was originally a recurrent case after previous open surgery. The ganglion cyst recurred 8 months after arthroscopic surgery but exhibited no continuous growth or remarkable symptoms. No revision surgery was performed. All patients (100%) reported that they were satisfied or very satisfied with the outcome of the operation.
Table 3. Functional Assessment and Outcome in 15 Patients
| Case No. | Preoperative Modified Mayo Wrist Score⁎ | Modified Mayo Wrist Score at 6 mo⁎ | Modified Mayo Wrist Score at 1 yr⁎ | Recurrence | Satisfaction† | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Pain | Function | ROM | Grip Strength | Total | Pain | Function | ROM | Grip Strength | Total | Pain | Function | ROM | Grip Strength | Total | |||
| 1 | 15 | 20 | 25 | 5 | 65 | 20 | 20 | 25 | 10 | 75 | 25 | 20 | 25 | 15 | 85 | No | 10 |
| 2 | 15 | 20 | 25 | 10 | 70 | 20 | 25 | 25 | 25 | 95 | 20 | 25 | 25 | 25 | 95 | No | 10 |
| 3 | 15 | 15 | 25 | 5 | 60 | 15 | 25 | 25 | 10 | 75 | 20 | 25 | 25 | 15 | 85 | No | 10 |
| 4 | 15 | 20 | 25 | 15 | 75 | 15 | 25 | 25 | 25 | 90 | 20 | 25 | 25 | 25 | 95 | No | 8 |
| 5 | 15 | 20 | 10 | 10 | 55 | 25 | 25 | 10 | 10 | 70 | 25 | 25 | 10 | 10 | 70 | No | 8 |
| 6 | 15 | 20 | 25 | 15 | 75 | 25 | 25 | 25 | 25 | 100 | 25 | 25 | 25 | 25 | 100 | No | 10 |
| 7 | 15 | 20 | 25 | 10 | 70 | 20 | 20 | 25 | 15 | 80 | 25 | 20 | 25 | 15 | 85 | Yes‡ | 8 |
| 8 | 15 | 20 | 25 | 10 | 70 | 25 | 25 | 25 | 25 | 100 | 25 | 25 | 25 | 25 | 100 | No | 10 |
| 9 | 15 | 20 | 25 | 15 | 75 | 25 | 25 | 25 | 25 | 100 | 25 | 25 | 25 | 25 | 100 | No | 10 |
| 10 | 15 | 20 | 25 | 10 | 70 | 20 | 25 | 25 | 10 | 80 | 25 | 25 | 25 | 10 | 85 | No | 8 |
| 11 | 15 | 20 | 25 | 10 | 70 | 20 | 20 | 25 | 10 | 75 | 20 | 20 | 25 | 15 | 80 | No | 10 |
| 12 | 15 | 20 | 25 | 5 | 65 | 25 | 25 | 25 | 25 | 100 | 25 | 25 | 25 | 25 | 100 | No | 9 |
| 13 | 15 | 20 | 15 | 5 | 55 | 15 | 20 | 15 | 5 | 55 | 20 | 20 | 15 | 10 | 75 | No | 10 |
| 14 | 15 | 20 | 10 | 5 | 50 | 20 | 25 | 20 | 10 | 75 | 20 | 25 | 20 | 15 | 80 | No | 9 |
| 15 | 15 | 20 | 10 | 10 | 55 | 20 | 25 | 20 | 15 | 80 | 20 | 25 | 20 | 15 | 80 | No | 8 |
⁎The modified Mayo wrist scores contain 4 items with 25 points in each (excellent, 91 to 100 points; good, 80 to 90 points; fair, 65 to 79 points; poor, <65 points). It was measured preoperatively and at 6 months and 1 year postoperatively. |
†Very satisfied, 9 to 10; satisfied, 7 to 8; even (neither satisfied nor dissatisfied), 5 to 6; dissatisfied, 3 to 4; very dissatisfied, 1 to 2. |
‡Recurrence 8 months after operation. |
Discussion
Current publications reported similar complication rates for both open and arthroscopic ganglion excision.10 Given that the recurrence rate is similar to that with open excision, arthroscopic ganglionectomy, which possesses the inherent advantage of superior recognition of intra-articular pathology, has become an increasingly acceptable surgical option for wrist ganglia.8, 9, 10, 11, 12 However, concerns still remain regarding the effectiveness in identifying and excising pathognomonic lesions through arthroscopy.13, 14 On the basis of our arthroscopic findings and the data obtained from a literature review, we fully agree with the opinion of Clay and Clement7 that wrist ganglia may also arise from a variety of additional sites other than the SL ligament. Therefore arthroscopic assessment is necessary before any decompression or excision surgery is undertaken. We believe that this is particularly essential for painful, symptomatic wrist ganglia because intra-articular lesions other than ganglion stalks were a relatively common finding in our series. Accordingly, arthroscopy can be used feasibly to uncover the associated articular lesions, in addition to ganglionectomy procedures.
Most theories consider residual stalks to be the common cause for the recurrence after open excision. However, the diverse occurrence of ganglion stalks in the primary as well as the recurrent cases may arouse the reasonable suspicion of other residual lesions after arthroscopic ganglionectomy. One critical concern is that the resection of only the ganglion stalk without removal of the sac may yield slightly higher recurrence rates than formal open resection of the sac and stalk. This may be attributed to cases in which the capsular attachment to the SL ligament is debrided without identification and removal of the true stalk.15 We recommend the use of an intrafocal cystic portal for both arthroscopic examination and shaving. Arthroscopy-guided shaving inside the ganglion can be safely performed under direct supervision on a magnified monitor. Similar concepts and techniques have been successfully applied for the arthroscopic resection of popliteal cysts.16 However, 1 patient in our series had transient postoperative paresthesia, which was considered to be related to repetitive instrumentation in the 1-2 portal. Because of the close proximity to the dorsal sensory branch of radial nerve, many surgeons may use it sparingly. A meticulous approach and protection of sensory nerve branches are thus emphasized when using this portal, as well as the other portals around the dorsal-radial side of the wrist joint.
It has been postulated that acute trauma or chronic stress in the SL region may be of etiologic significance.1, 2, 17, 18 We identified carpal ligament tears in approximately one third of patients in this study. These patients, however, did not report any associated trauma history, nor did preoperative radiographs show any evidence of carpal instability. Therefore the concurrent carpal instability should be meticulously addressed during arthroscopic surgery on painful wrist ganglia. The use of midcarpal arthroscopy may yield additional information for the diagnosis and may alter the potential subsequent treatment.19 It is hereby recommended to be added based on the clinical impression and at the surgeon's discretion.10
Previous publications on arthroscopic ganglionectomy have shown recurrence rates ranging from 0% to 7%.8, 9, 10, 11, 12 Despite a similar recurrence rate in our series, none of our primary cases exhibited any recurrence at the time of the latest follow-up. We had 1 recurrent case, which was originally a recurrent ganglion after previous open surgery. An arthroscopic survey failed to show any residual stalk or connection between the intra-articular structures and the ganglion per se. The ganglion cyst recurred at 8 months after arthroscopic surgery, and examination at the most recent clinical visit at 1 year postoperatively did not show increasing growth and symptomatic flare-up. No second-look arthroscopy or revision surgery was performed.
This study had certain limitations. One limitation concerns the case selection for enrollment. On the basis of our study hypothesis, we only included patients with symptomatic wrist ganglia and thus had limited total case numbers. The other limitation was lack of a control group. However, this study has yielded findings that have both diagnostic and therapeutic implications and thus encourages us to keep using the surgical technique. Future investigation and follow-up are necessary to clarify the relation between pathogenicity and clinical relevance.
Conclusions
Arthroscopic ganglionectomy through an intrafocal cystic portal is a safe and efficacious option for the treatment of painful wrist ganglia.
Supplementary data
Video 1. Surgical technique.
Supplementary data.
References
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- . Arthroscopic cystectomy for popliteal cysts through the posteromedial cystic portal. Arthroscopy. 2007;23:559.e1–559.e4www.arthroscopyjournal.org
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The authors report no conflict of interest.
Note: To access the video accompanying this report, visit the May issue of Arthroscopy at www.arthroscopyjournal.org.
PII: S0749-8063(09)00780-4
doi:10.1016/j.arthro.2009.08.021
© 2010 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
Volume 26, Issue 5 , Pages 617-622, May 2010