Abstract
Ganglions are common soft tissue masses of the hand. High recurrence rates are associated with nonsurgical treatment; thus, excision is often indicated. Arthroscopic excision and open excision have similar recurrence rates; however, the latter is associated with prolonged healing time and increased scarring. Recently, dry wrist arthroscopic techniques have been used. This technique allows easier confirmation of complete ganglion removal, easier conversion to open surgery, earlier return of motion, and stitch-less closure when compared with traditional “wet” arthroscopic excision.
Ganglions are common soft tissue masses of the hand with most located on the dorsal wrist. High recurrence rates are associated with nonsurgical treatment.1 Surgical excision is indicated when the ganglion causes pain or affects range of motion and can be performed open or arthroscopically. The arthroscopic approach can decrease healing time and reduce scarring compared with the open approach.2 Rates of recurrence with arthroscopic dorsal ganglionectomy are comparable with those of open excision.3 Recently dry wrist arthroscopic techniques have been described.4, 5 This technique may be employed to remove ganglions. Dry wrist arthroscopy has several advantages over standard the “wet” technique due to avoidance of fluid extravasation and associated swelling: (1) easier visualization and palpation of the ganglion during surgical removal allowing for more accurate confirmation of complete removal, (2) easier conversion to open surgery if arthroscopic removal fails, (3) faster rehabilitation and return of motion, and (4) stitchless closure (steri strips are adequate) allowing for reduced scarring and improved cosmesis. We present our technique for dry arthroscopic wrist ganglionectomy.
Surgical Technique
In regard to preoperative planning and the operating room setup, it is the primary surgeon's (R.S.) preference to use the equipment listed in Table 1.
Table 1.
Primary Surgeon's Preferred Equipment
| Accumed Wrist Traction tower |
| Arthrex SynergyHD3 Imaging platform |
| Arthrex conical obturator for 2.7-mm arthroscope with handle |
| Arthrex sheath 2 stopcocks for 2.7-mm arthroscope |
| Arthrex 2.7 mm × 72 mm arthroscope |
| Arthrex DualWave pump |
| Arthrex outflow tubing |
| Arthrex shaver 2.0-mm Sabre small hub |
| Arthrex Distal Extremity Synergy shaver handpiece |
| Arthrex Synergy resection shaver system |
The patient is brought to the operating suite and placed in the supine position. General anesthesia is performed, and the table is rotated such that anesthesia is positioned on the contralateral side of the operative extremity. The arthroscopic monitor is placed near the patient's feet and the surgeon positions himself cephalad to the patient's extremity (Fig 1). The patient's wrist is suspended with 5 kg (approximately 10-12 lbs) of traction in a traction tower. Initially, the 6R portal is identified with 22-gauge finder needle localization (Video 1; Fig 2). Skin incision is then made with a No. 15 blade and mosquitos are used to spread soft tissue in a longitudinal direction parallel to the extensor tendons (Fig 3). A blunt trochar is placed intra-articular (Fig 4) and the arthroscope is introduced into the 6R portal (Video 1). No fluid is injected into the joint given that this is a dry technique. The arthroscope eye is turned radially and the scaphoid, lunate, and scapholunate interval are identified. The stalk will be seen inserting on to the dorsal aspect of the scapholunate ligament (Fig 5). An 18- or 22-gauge needle is now passed through the cyst into the joint at the level of the stalk; this typically will be at the 3-4 interval (Fig 6). Once correct needle localization is confirmed, the 3-4 portal is established through the ganglion using the standard tissue spread technique. Typically egress of mucin and partial decompression of the ganglion is noted at this time. The shaver is placed into the joint through this portal (Fig 7). Ensure that the valve of the arthroscope sheath is open allowing for free circulation of air and preventing capsular collapse and loss of visualization (Table 2). Synovectomy and stalk resection is completed with the shaver in oscillation mode up to 3,000 rpm at this time. Complete resection of the stalk is confirmed when the dorsal aspect of the scapholunate interval is free of any aberrant tissue (Fig 8).
Fig 1.
Appreciate the surgeon's and anesthesiologist's positioning relative to the patient. The patient (yellow star) is supine and once intubated the bed is turned 90° with the anesthesiologist (black star) and equipment on the nonoperative side. The surgeon (red star) stands on the operative side, in this case right, with direct access to the dorsal aspect of the wrist. The right arm is abducted 90°, and the elbow flexed to 90° with the hand in axial traction. The monitor (not pictured) is placed at the foot of the bed in the surgeon's direct line of sight.
Fig 2.
With the patient lying supine, the right wrist is suspended with 5 kg (approximately 10-12 lbs) of traction in a traction tower (black star). Initially, the 6R portal is identified with 22-gauge finder needle localization, identified by the red arrow. Note the dorsal ganglion (black arrow).
Fig 3.
With the patient lying supine and the right wrist suspended, a skin incision is made with a No. 15 blade at the site of the 6R portal identified in Figure 1. Mosquitoes are used to spread soft tissue in a longitudinal direction parallel to the extensor tendons, identified by the red arrow. Note the dorsal ganglion (black arrow).
Fig 4.
With the patient lying supine and the right wrist suspended, a blunt trochar is introduced to the wrist joint via the 6R portal, identified by the red arrow. Note the dorsal ganglion (black arrow).
Fig 5.
An intra-articular view of the right wrist joint. The ganglion stalk, denoted by the red arrow, will be seen via the 6R viewing portal inserting on to the dorsal aspect of the scapholunate ligament. The carpus is denoted by the black star and the distal radius by the red star.
Fig 6.
With the patient lying supine, the right wrist suspended, and the arthroscope inserted in the 6R portal, an 18- or 22-gauge needle, denoted by the red arrow, is passed through the cyst into the joint at the level of the stalk.
Fig 7.
With the patient lying supine, the right wrist suspended, and the arthroscope inserted in the 6R portal, the shaver, denoted by the red arrow, is inserted intra-articularly directly through the cyst and stalk.
Table 2.
Operative Pearls
| Portals | Viewing portal is 6R; working portal is through the ganglion, typically 3-4 |
| Tips | Ensure that the valve of the arthroscope sheath is open allowing for free circulation of air and preventing capsular collapse and loss of visualization |
| Pitfalls | Avoid fluid injection in the joint, excessive use of suction, and iatrogenic injury of the extensor tendons |
| Indications | Ganglion cyst over the 3-4 interval |
| Contraindications | Recurrent or organized cyst with scar tissue not amendable to treatment with the shaver |
Fig 8.
An intra-articular view of the right wrist joint. Visual confirmation of dorsal stalk resection, red arrow, is viewed through the 6R portal. The carpus is denoted by the black star and the distal radius by the red star.
Once resection is visually and clinically confirmed (Fig 9), the deep dermal fascia is approximated with a single inverted interrupted 4-0 monocryl suture. Mastisol and steri strip closure is then adequate given lack of swelling and fluid extravasation. The patient's wrist is placed into a volar splint for 2 weeks with unrestricted activities postoperatively. Finger range of motion is encouraged immediately. One follow-up at 10 to 14 days for steri strip removal and finger range of motion check is completed.
Fig 9.
With the patient lying supine and the right wrist suspended, clinical confirmation of cyst excision is appreciated, denoted by the red arrow. Compare to Fig 1, Fig 2, Fig 3, in which the ganglion was denoted by black arrows. In addition, note the absence of generalized swelling about the wrist due to lack of fluid extravasation.
Discussion
Dorsal wrist ganglions are believed to communicate with the joint via a stalk that serves as a one-way valve, allowing joint fluid to leave the joint, but limiting return. The fluid becomes organized as mucin creating the ganglion. Most commonly the stalk originates from the scapholunate ligament.6 The pathogenesis of ganglions remains unknown; however, intra-articular pathology and repetitive activities are believed to play a role.
Expectant management of ganglions may result in spontaneous resolution 49% of the time.7 Nonsurgical management includes observation and aspiration. Success with aspiration is variable and the reported recurrence rate is 47%.8 One may also perform aspiration followed by steroid injection, which may have equivalent results to aspiration alone.1
Surgical excision is the gold standard for treatment of ganglions. This can be accomplished via an open approach or arthroscopically. Success has been found with excision of the entire ganglion complex, including cyst and stalk with or without a cuff of the adjacent joint capsule.1 Open excision of dorsal wrist ganglions has a recurrence rate of 1% to 14%.6, 9, 10 Risks of open excision include infection, neuroma, scarring, and keloid formation. Postoperative stiffness, grip weakness, decreased range of motion, and pain may also occur.1
Arthroscopic excision has been used with success.11, 12, 13 One study found a recurrence rate similar to open excision.3 Advantages of arthroscopic excision include decreased pain, loss of motion, and scarring and a quicker return of motion.11 Intralesional injection of inert dye has also been used to help identify the stalk and aid in excision.14, 15, 16, 17
The described technique, dry wrist arthroscopy, is advantageous over the standard “wet” technique because it avoids fluid extravasation and swelling. Benefits include easier visualization and palpation of the ganglion during excision, easier conversion to open surgery, faster rehabilitation and return of motion, and stitchless closure allowing for reduced scarring. Risks include incomplete cyst excision, extensor tendon injury, scapholunate ligament injury, infection, stiffness, and a theoretical synovial-cutaneous fistula (Table 3).4, 5 To date no case series have been published with regard to this technique. Our early experience suggests that recurrence rates are likely similar to open and other arthroscopic techniques.
Table 3.
Advantages, Risks, and Limitations
| Advantages | Risks | Limitations |
|---|---|---|
| Avoid fluid extravasation and swelling | Incomplete cyst excision | Ganglion cysts isolated to the 3-4 interval not previously operated on |
| Direct visualization of the stalk | Extensor tendon injury | |
| Easier intraoperative palpation of the ganglion | Scapholunate ligament injury | |
| Easier conversion to open surgery | Infection | |
| Faster rehabilitation and return of motion | Stiffness | |
| Stitchless closure allowing for reduced scarring | Synovial-cutaneous fistula (theoretical) |
Footnotes
The authors report that they have no conflicts of interest in the authorship and publication of this article.
Supplementary Data
Dry arthroscopic excision of dorsal ganglion. Shown are selected clips from an actual surgery performed on a right wrist with the use of equipment listed in Table 1 using the stepwise approach listed in the “Surgical Technique” section. Throughout the video, regarding the intra-articular views, the carpus is at the top of the screen, the distal radius at bottom, and the dorsal wrist capsule/ganglion are to the left.
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Associated Data
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Supplementary Materials
Dry arthroscopic excision of dorsal ganglion. Shown are selected clips from an actual surgery performed on a right wrist with the use of equipment listed in Table 1 using the stepwise approach listed in the “Surgical Technique” section. Throughout the video, regarding the intra-articular views, the carpus is at the top of the screen, the distal radius at bottom, and the dorsal wrist capsule/ganglion are to the left.