|3475 Torrance Blvd., Ste F
Torrance, CA 90503
Office hours: M-F, 9am
– 5 pm
Worker’s compensation, Medicare
and most insurance plans accepted.
In September 2008, we will be moving to a beautiful new 4,400 sq ft,
state of the art dedicated hand center located at 2808 Columbia Ave
in Torrance, CA., which will feature onsite nerve conduction studies,
occupational hand therapy and digital x-ray.
ARTHROSCOPIC WRIST GANGLIONECTOMY
Osterman et al pioneered the arthroscopic resection of dorsal wrist ganglia
and reported on 150 procedures with only 1 recurrence. Volar wrist ganglia
that originate from the radiocarpal joint are amenable to arthroscopic
resection, but those that arise from the STT joint are not.
The indication for arthroscopic removal of a dorsal ganglion is similar
to the those for an open method. An ideal indication is when patients
have concomitant wrist pain and a positive scaphoid shift test where evaluation
of any associated SLIL instability is desirable. The occult ganglion that
is entirely intracapsular and cannot be visualized during open surgery
is another good indication. Preoperative x-rays should be performed to
rule out intraosseous communication or other carpal pathology. It is important
to ensure the lesion is in fact a ganglion either with transillumination,
an MRI or needle aspiration. An Allen’s test should be performed
with volar ganglia to ensure adequate hand perfusion from the ulnar artery
in the event of radial artery perforation, and to rule out an aneurysm
masquerading as a cyst.
Previous scarring in the area due to previous injury or surgery for recurrence
may distort the anatomy and make it difficult to establish the portals.
Since the ganglion overlies the 3-/,4 portal, it is the author’s
preference to view the ganglion through the VR portal, which provides
a direct line of sight and allows one to rule out a tear of the DRCL.
The ganglion appears like a reddish mass of tissue without fluid but takes
on a wavy, filmy appearance under fluid irrigation (link to ganglion 1,2).
Alternatively, the 1-/,2 or 6-R portal can be used. A shaver is then introduced
into the ganglion through the 3-/,4 portal to perforate the ganglion and
resect the stalk. The intra articular ganglion is completely debrided
along with a 1 cm area of surrounding dorsal capsule (link to ganglion
1,2. The extensor tendons may be visible through the defect. Midcarpal
arthroscopy should be performed to debride any midcarpal extension of
the ganglion and to assess the status of the SL and LT joints. Occasionally
one sees an area of cartilage erosion from longstanding ganglia, which
can be a source of persistent wrist pain (link to ganglion 5,6)
The ganglion is amenable to arthroscopic resection only if it arises from
the radiocarpal joint which can be determined by injecting the cyst with
dye intraoperatively under fluoroscopy.42 The joint is surveyed in the
standard fashion starting with the 3-/,4 portal. When a volar ganglion
is present, there may be an out-pouching in the sulcus between the RSC
and LRL. Volar pressure on the cyst can deliver it in to the joint space.
A resector is placed through the VR portal, 1-/2 or 4-/,5 portal to resect
the ganglion and 1 cm of surrounding capsule until the FCR tendon is seen.
Postoperatively the wrist is splinted for 1 week for comfort followed
by protected range of motion. Loss of wrist flexion following dorsal ganglia
excision or loss of wrist extension with volar ganglia can be treated
with dynamic splinting at 6-8 weeks.
Rizzo and coauthors performed an arthroscopic resection of 41 dorsal ganglia.
At 2 years, patients demonstrated improved wrist motion and grip strength,
excellent pain relief and only 2 recurrences. Mathoulin et al performed
an arthroscopic resection on 32 patients with volar ganglia using a 1-,2
portal, with no recurrences at the 26 month follow up. Good results are
not invariable in patients with associated intracarpal pathology however.
Povlsen and Peckett noted an abnormal scapholunate joint in 10/16 patients
and an abnormal lunotriquetral joint in 2/16 patients. At a 5 year follow-up
only 1 patient remained pain free.
Most people can perform one-handed work activity by the 2nd week followed by light duty including clerical work at 4-6 weeks. Heavy manual labor can often be resumed by 8 -12 weeks.