David J. Slutsky


Home
About
Publications
Procedures
Videos
Figures
Patient Forms
Office Directions

3475 Torrance Blvd., Ste F
Torrance, CA 90503


Appointments: 310.792.1809
Fax: 310.792.1811

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.
 


PROCEDURES

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.

Indications
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.

Contraindications
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.

Surgical Technique
Dorsal ganglionectomy

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)

Volar ganglionectomy
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.

Results
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.

Work Considerations
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.