Tables 5.

4 “D″of ganglion cyst management.

	Technique	Pitfall
Dissection	1.Under tourniquet With loupe magnification of microscope20 2.The integrity of the cyst should be maintained. 3.Proper dissection involving the whole extent of the cyst is a must 4.If the cyst has neuronal involvement, then the following three branches of the nerve need to be identified and mobilized: the articular branch, the DPN, and the SPN.	1.The most common surgical error is the failure to identify the joint connection, even though sometimes it's not possible to find, a genuine attempt to look for it is a must.
Decompression (Only for intra-neural types)	1.A longitudinal epineural incision is made away from the fascicles of the nerve, usually centered over a cystic bleb. 3.Epineurotomy by fenestration is preferred as it prevents neural tissue injuries and can be applied to the larger extension of the intraneural ganglion	1.Overzealous attempts at resecting the entire cyst may lead to the entire peroneal nerve resection followed by nerve grafting 2.A less invasive technique minimizes the need for intraneural dissection and decreases the risk of iatrogenic neural injury.
Disconnection	1.For intra-neural cysts, a Small recurrent articular branch is ligated and transected, preserving the branch to the anterior tibialis muscle, and ligate the proximal and distal stumps as a “belt and suspenders” method. 2.For other cysts, connecting stalk to the PTFJ should be excised	1.RJ Spinner et al.30 have claimed that there is no intra-neural recurrence once an articular branch is resected, if not, recurrence is inevitable.
Disarticulation	1.Resection of PTFJ is necessary to prevent recurrence for all the cysts. 2.Simple cyst with connecting stalk to the PTFJ should be managed with resection of PTFJ. 3.Care must be taken to prevent injury to surrounding anatomical structures such as LCL, Biceps tendon, CPN and its branch, and Anterior Tibial vessels	1.No long-term sequelae associated with resection of the superior tibiofibular joint for the treatment of peroneal and tibial intraneural ganglia. But the same should not be followed in other joints such as the wrist or ankle. 2.Although fusion of the superior tibiofibular joint is also an option, resection is technically easier to perform than fusion, which can be complicated by nonunion, and joint resection does not require a period of immobilization postoperatively.
Closure	1.Release the tourniquet and achieve the proper hemostasis	1.Failure to obtain hemostasis intraoperatively can lead to wound hematoma. Later, the risks of extrinsic nerve compression or secondary fibrosis around the nerve increase.