Arthroscopic Treatment of Intraosseous Ganglion Cyst of the Lunate Bone Alexandre Cerlier Jr., M.S., André-Mathieu Gay, M.D., Ph.D., and Michel Levadoux, M.D., Ph.D.
Abstract: Intraosseous ganglion cysts are rare causes of wrist pain. Surgical treatment of this pathologic condition yields good results and a low recurrence rate. The main complications are joint stiffness and vascular disturbances of the lunate bone. Wrist arthroscopy is a surgical technique that reduces the intra-articular operative area and therefore minimizes postoperative stiffness. This article describes an arthroscopic technique used for lunate intraosseous cyst resection associated with an autologous bone graft in a series of cases to prevent joint stiffness while respecting the scapholunate ligament. This study was based on a series of 4 patients, all of whom had wrist pain because of intraosseous ganglion cysts. Arthrosynovial cyst resection, ganglion curettage, and bone grafting were performed arthroscopically. Pain had totally disappeared within 2 months after the operation in 100% of patients. The average hand grip strength was estimated at 100% compared with the opposite side, and articular ranges of motion were the same on both sides in 100% of cases. No complications were reported after surgery. On the basis of these results, arthroscopic treatment of intraosseous synovial ganglion cysts seems to be more efficient and helpful in overcoming the limitations of classic open surgery in terms of complications.
W
rist intraosseous ganglion cysts are rare tumors in adults, and they are asymptomatic and idiopathic most of the time; however, but they represent one of the few causes of wrist pain.1 Classic cases include lytic bone tumors found through radiologic diagnosis, with a scapholunate ligament origin. Diagnoses of symptomatic cystic lesions of the lunate bone (Kienböck disease, trauma, scaphoid pseudarthrosis) must be eliminated before stating that the wrist pain is due to an intraosseous bone ganglion cyst. Surgical treatment of this pathologic condition yields good results and a low recurrence rate.2 It consists of curettage of the cyst associated with a bone graft, mostly autologous graft, performed by an open surgical approach. The main complications are joint stiffness3 and vascular disturbances of the very fragile vascular system of the lunate bone.4
From the Department of Hand Surgery (A.C., A.-M.G.), Timone Hospital, Marseille, France; and Department of Hand Surgery, (M.L.) Clinique Saint Roch, Toulon, France. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received February 16, 2015; accepted May 20, 2015. Address correspondence to Alexandre Cerlier Jr, Department of Hand Surgery, Timone Hospital, 264 Rue Saint Pierre, Marseille 13006, France. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 2212-6287/15161/$36.00 http://dx.doi.org/10.1016/j.eats.2015.05.011
Wrist arthroscopy is a recent, up-and-coming surgical technique, usually performed with the patient under local or regional anesthesia and performed either with saline irrigation or as a dry procedure. The wrist arthroscopy setup includes a small fiberoptic camera with a diameter of 2.4 or 2.7 mm, a shaver without a suction pump and with or without an electrocautery, and basic arthroscopy instruments (palpation rod, basket forceps). There are more and more wrist arthroscopy indications, including scapholunate ligament repair, treatment of fractures of the distal radius, intercarpal arthrodesis, and intra-articular cyst resection, but the use of wrist arthroscopy in such cases needs to be qualified. The main advantage of this technique is that it reduces the intra-articular operative area and therefore minimizes postoperative joint stiffness. However, it is a difficult technique with a significant learning process. This article describes an arthroscopic technique used for lunate intraosseous cyst resection associated with an autologous bone graft in a series of cases to prevent joint stiffness while respecting the scapholunate ligament (Figs 1-3). Our hypothesis was that arthroscopic treatment provides good results regarding cyst resorption with fewer complications.
Technique The operations were performed using regional anesthesia and were same-day surgical procedures. The
Arthroscopy Techniques, Vol 4, No 5 (October), 2015: pp e513-e518
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Fig 1. (A) Frontal radiographic view of the wrist of a 48-yearold woman with an intraosseous ganglion cyst of the lunate bone. (B) Close-up view of cyst.
patient was placed in a dorsal position, with a pneumatic tourniquet placed on the base of the arm (cuff pressure of up to 250 mm Hg), and the shoulder was abducted 90 and counterbraced on the arm. The elbow was flexed to 90 so that the wrist, hand, and forearm were in a vertical position. A traction system (AR-1611S; Arthrex, Naples, FL) was used, and 6 kg of
Fig 2. Computed tomography scans of the wrist of a 63-yearold man with an intraosseous ganglion cyst of the lunate bone. (A) Frontal view showing that the cyst is on the scaphoid side of the lunate and is communicating with the articulation. (B) Frontal view showing the cyst on the triquetral side. (C) On the sagittal view, the cyst is shown to represent more than 50% of the height of the lunate. (D) On the transverse view, the cyst is shown to represent one-third of the lunate length.
traction was applied with a Chinese finger trap. The arthroscope had a 2.7-mm-diameter lens at an oblique angle of 30 (Stryker, Kalamazoo, MI). After infiltration of the radiocarpal joint with 10 mL of saline solution, the arthroscope was inserted through the 3-4 portal (for the lens) and 6R or 4-5 portal (for insertion of instruments). Before performing any treatment, we
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Fig 3. Magnetic resonance images, frontal view. (A) T2 image showing no sclerosis of the lunate bone, permitting exclusion of Kienböck disease. (B) T1 image showing a cyst with hypersignal in the lunate bone.
verified that there were no lesions in the mediocarpal joint (Fig 4). The first step of treatment was to locate the lunate bone. Then, resection of the arthrosynovial cyst was performed using a 2.5-mm shaver (2.5-mm arthroscopic shaver blade; Stryker Formula Aggressive Cutter) (Fig 5). On the basis of the computed tomography (CT) scan information, we were able to locate the intraosseous ganglion cyst of the lunate bone. Under arthroscopic control and by use of a 2.5-mm-diameter wick or an awl (Fig 6A, Video 1), corticotomy of the lunate bone was performed (Fig 6B). The aforementioned CT scan was necessary to avoid a false way and
allow a direct transosseous approach. The original hole was slowly enlarged with a small curette. Yellowish cystic liquid/tissue was extracted. The space was filled using the 2.5-mm shaver, which was used to resect the inside of the cyst (Video 1). The resection was completed using a small curette to scrape off any remaining wall of the cyst (Fig 7, Video 1). The best method of disposal was to use a large number of small, differently angled curettes to help the surgeon to remove all the remaining cystic parts.
Fig 4. Arthroscopic view from radiocarpal showing scapho lunate space and capitate on the top (arthroscope in 3-4 portal and instruments in 4-5 portal).
Fig 5. Arthrosynovial cyst resection with shaver from radiocarpal position (arthroscope in 3-4 portal and instruments in 4-5 portal).
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Fig 7. Arthroscopic view: cyst resection is completed with a small curette (arthroscope in 3-4 portal and instruments in 45 portal).
Fig 6. Arthroscopic views (A) with awl in radiocarpal joint and (B) after corticotomy (arthroscope in 3-4 portal and instruments in 4-5 portal).
Finally, an anterior surgical cast was used for pain reduction. Patients left the clinic in the evening on the same day with simple analgesic treatment (moderate to severe pain treatment). The primary criterion for success was pain relief. Disappearance of lytic lesions, another criterion for success, was evaluated by CT scans. Postoperative complications were recorded (infection, algodystrophy, compartment syndrome, need for open surgery). Patients were initially seen 3 to 4 days after the operation to avoid early complications. They were then seen 2 to 3 months later, with imaging examinations obtained (standard radiographs or CT scans), and again 8 to 9 months later, with more imaging examinations obtained (standard radiographs or CT scans). They were finally assessed 1 year later to eliminate recurrence.
The next step was to take a sample for the bone graft either on the distal part of the radius or on the iliac crest. The trabecular bone was put on a gauze compress and split into small fragments. Returning to the wrist arthroscopy, the surgeon placed the trabecular bone graft using either a soft-tissue protector with 2.5- or 3.5-diameter screws (Fig 8, Video 1) or a large-core needle used for osteomedullary biopsy. The cystic cavity was filled with the autologous bone graft (Fig 9, Video 1). We found it very useful to work under dry arthroscopy conditions at that time to keep the graft in the right position and avoid intra-articular bone dispersion. We did not use surgical glue to secure the graft. However, it was necessary to compress the graft into the bone. The iliac crest surgical site was closed, and an occlusive dressing with Steri-Strips (3M, St Paul, MN) was applied at the arthroscopic orifices.
Fig 8. Placement of bone graft in lunate with a 2.7-mm softtissue protector (arthroscope in 3-4 portal and instruments in 4-5 portal).
INTRAOSSEOUS GANGLION CYST OF LUNATE BONE
Fig 9. Bone graft impaction.
Discussion From February 2011 to March 2012, we performed the described technique in 4 patients. Pain had totally disappeared within 2 months after the operation in 100% of patients. The average hand grip strength was estimated at 100% compared with the opposite side, and articular ranges of motion were the same on both sides in 100% of cases. One patient complained of moderate pain after starting tennis lessons after 6 months, which faded in time. Fracture healing with disappearance of lytic imaging findings was obtained in 100% of cases 9 months after surgery (Fig 10). There were no infections during follow-up. The mean duration of the operation was 1 hour 2 minutes. Intraosseous ganglion cysts and intraosseous mucous cysts are included in the same nosologic category as intraosseous synovial cysts. They are benign lytic tumors, generally lobular, and frequently located on the subchondral part of the long bone’s epiphysis.1 They can sometimes be found on the carpal bones (lunate, scaphoid bones) either by accidental discovery or during a medical checkup for carpal pain. The origins of such cysts remain uncertain. Standard radiographic photography can easily diagnose this pathologic condition and must be completed with a CT scan or magnetic resonance imaging to eliminate the differential diagnoses (enchondroma, chondroblastoma, simple osseous ganglion cyst, aneurysmal bone cyst, Kienböck disease, ulnocarpal impingement syndrome, arthrosis, or punched-out lesions). In our study, persistent pain while under medical treatment led to the indication for surgery. In case of accidental discovery, an asymptomatic patient would be supervised with standard radiographs.
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Technically speaking, the arthroscopic method has many advantages (Table 1). First, it prevents deterioration caused by the classic surgical approach, which is most of the time performed by a posterior approach because of the smaller risk of causing damage to the median nerve than by an anterior approach. On the vascular side, the lunate bone has a double perfusion system. On the palmar surface of the hand, it is hard to identify the pedicles, but on the dorsal surface of the hand, 2 to 3 recurrent arteries coming from the dorsal radiocarpal arches irrigate the lunate bone and other close bones.4 Anastomoses between those 2 irrigation systems are not always respected, and in some cases, an exclusive palmar or dorsal vascular system exists. Classic surgery therefore exposes the patient to a more important risk of devascularization. Some authors think that the origin of the ganglion cysts could be a consequence of repeated microtraumas leading to intraosseous vascularization trouble, creating bone aseptic necrosis, followed by mucoid degeneration.5,6 Classic surgery would be an additional risk of lesion on the vascular system of a bone already weakened by the
Fig 10. CT scan showing cyst resorption.
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Table 1. Advantages and Risks/Limitations Advantages Efficiency No stiffness No disorder of lunate vascularization Better cosmetic results Risks/limitations Significant learning curve No histologic analysis
ganglion cyst. The aim of this treatment is not only to remove the ganglion cyst but also to fill the cavity to boost osteogenesis, so the vascular system of the lunate bone needs to be preserved. The second advantage of the arthroscopic approach is the reduction of joint stiffness. In this study no modification of joint range of motion was observed during the preoperative and postoperative periods. Calcagnotto et al.3 showed a decrease in wrist range of motion of 20 to 30 in patients undergoing classic surgical procedures. The third advantage of our approach is very few scar complications. Finally, the arthroscopic approach allows a complete view of the joint. In case of a concomitant extraosseous synovial cyst, this approach allows an additional simultaneous treatment, with minimum risk of iatrogenic rupture of the scapholunate ligament. It can help to confirm the diagnosis of Kienböck disease if radiolunate chondral injury or lunocapitate injury is found, as well as in the case of lunate cartilage showing a depression when being pressed on; arthroscopy therefore helps guide therapeutic indications.7,8 On the other hand, the learning process is long and precise knowledge of anatomy is needed to lower the risks of vascular and nervous complications (e.g.,
complications involving the dorsal carpal branch of the radial artery or the superficial branch of the radial nerve), cartilaginous complications (e.g., recurrent inconvenient penetration or incorrect orientation of instruments), or tendinous complications. Moreover, the arthroscopic approach does not allow either a histologic diagnosis or security that the whole cystic cavity has been emptied (this, in fact, requires large curettes with different orientations). However, arthroscopic treatment of intraosseous synovial ganglion cysts seems to be more efficient and helpful in overcoming the limitations of classic open surgery in terms of complications.
References 1. Paparo F, Fabbro E, Piccazzo R, et al. Multimodality imaging of intraosseous ganglia of the wrist and their differential diagnosis. Radiol Med 2012;117:1355-1373. 2. Kligman M, Roffman M. Bilateral intraosseous ganglia of the scaphoid and lunate bones. J Hand Surg Br 1997;22: 820-821. 3. Calcagnotto G, Sokolow C, Saffar P. Intraosseus synovial cysts of the lunate bone: Diagnostic problems. Chir Main 2004;23:17-23 [in French]. 4. Fontaine C, Wavreille G, Aumar A, Bry R, Demondion X. Osseous vascular anatomy in the hand and wrist. Chir Main 2010;29:S11-S20 (suppl) [in French]. 5. Uriburu IJF, Levy VD. Intraosseous ganglia of the scaphoid and lunate bones: Report of 15 cases in 13 patients. J Hand Surg Am 1999;24:508-515. 6. Waizenegger M. Intraosseous ganglia of carpal bones. J Hand Surg Br 1993;18:350-355. 7. Bain I, Munt J, Turner PC. New advances in wrist arthroscopy. Arthroscopy 2008;24:355-367. 8. Rizzo M, Berger RA, Steinmann SP, Bishop AT. Arthroscopic resection in the management of dorsal wrist ganglions: Results with a minimum 2-year follow-up period. J Hand Surg Am 2004;29:59-62.
Abstract: Intraosseous ganglion cysts are rare causes of wrist pain. Surgical treatment of this pathologic condition yields good results and a low recurrence rate. The main complications are joint stiffness and vascular disturbances of the lunate bone. Wrist arthroscopy is a surgical technique that reduces the intra-articular operative area and therefore minimizes postoperative stiffness. This article describes an arthroscopic technique used for lunate intraosseous cyst resection associated with an autologous bone graft in a series of cases to prevent joint stiffness while respecting the scapholunate ligament. This study was based on a series of 4 patients, all of whom had wrist pain because of intraosseous ganglion cysts. Arthrosynovial cyst resection, ganglion curettage, and bone grafting were performed arthroscopically. Pain had totally disappeared within 2 months after the operation in 100% of patients. The average hand grip strength was estimated at 100% compared with the opposite side, and articular ranges of motion were the same on both sides in 100% of cases. No complications were reported after surgery. On the basis of these results, arthroscopic treatment of intraosseous synovial ganglion cysts seems to be more efficient and helpful in overcoming the limitations of classic open surgery in terms of complications.
W
rist intraosseous ganglion cysts are rare tumors in adults, and they are asymptomatic and idiopathic most of the time; however, but they represent one of the few causes of wrist pain.1 Classic cases include lytic bone tumors found through radiologic diagnosis, with a scapholunate ligament origin. Diagnoses of symptomatic cystic lesions of the lunate bone (Kienböck disease, trauma, scaphoid pseudarthrosis) must be eliminated before stating that the wrist pain is due to an intraosseous bone ganglion cyst. Surgical treatment of this pathologic condition yields good results and a low recurrence rate.2 It consists of curettage of the cyst associated with a bone graft, mostly autologous graft, performed by an open surgical approach. The main complications are joint stiffness3 and vascular disturbances of the very fragile vascular system of the lunate bone.4
From the Department of Hand Surgery (A.C., A.-M.G.), Timone Hospital, Marseille, France; and Department of Hand Surgery, (M.L.) Clinique Saint Roch, Toulon, France. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received February 16, 2015; accepted May 20, 2015. Address correspondence to Alexandre Cerlier Jr, Department of Hand Surgery, Timone Hospital, 264 Rue Saint Pierre, Marseille 13006, France. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 2212-6287/15161/$36.00 http://dx.doi.org/10.1016/j.eats.2015.05.011
Wrist arthroscopy is a recent, up-and-coming surgical technique, usually performed with the patient under local or regional anesthesia and performed either with saline irrigation or as a dry procedure. The wrist arthroscopy setup includes a small fiberoptic camera with a diameter of 2.4 or 2.7 mm, a shaver without a suction pump and with or without an electrocautery, and basic arthroscopy instruments (palpation rod, basket forceps). There are more and more wrist arthroscopy indications, including scapholunate ligament repair, treatment of fractures of the distal radius, intercarpal arthrodesis, and intra-articular cyst resection, but the use of wrist arthroscopy in such cases needs to be qualified. The main advantage of this technique is that it reduces the intra-articular operative area and therefore minimizes postoperative joint stiffness. However, it is a difficult technique with a significant learning process. This article describes an arthroscopic technique used for lunate intraosseous cyst resection associated with an autologous bone graft in a series of cases to prevent joint stiffness while respecting the scapholunate ligament (Figs 1-3). Our hypothesis was that arthroscopic treatment provides good results regarding cyst resorption with fewer complications.
Technique The operations were performed using regional anesthesia and were same-day surgical procedures. The
Arthroscopy Techniques, Vol 4, No 5 (October), 2015: pp e513-e518
e513
e514
A. CERLIER ET AL.
Fig 1. (A) Frontal radiographic view of the wrist of a 48-yearold woman with an intraosseous ganglion cyst of the lunate bone. (B) Close-up view of cyst.
patient was placed in a dorsal position, with a pneumatic tourniquet placed on the base of the arm (cuff pressure of up to 250 mm Hg), and the shoulder was abducted 90 and counterbraced on the arm. The elbow was flexed to 90 so that the wrist, hand, and forearm were in a vertical position. A traction system (AR-1611S; Arthrex, Naples, FL) was used, and 6 kg of
Fig 2. Computed tomography scans of the wrist of a 63-yearold man with an intraosseous ganglion cyst of the lunate bone. (A) Frontal view showing that the cyst is on the scaphoid side of the lunate and is communicating with the articulation. (B) Frontal view showing the cyst on the triquetral side. (C) On the sagittal view, the cyst is shown to represent more than 50% of the height of the lunate. (D) On the transverse view, the cyst is shown to represent one-third of the lunate length.
traction was applied with a Chinese finger trap. The arthroscope had a 2.7-mm-diameter lens at an oblique angle of 30 (Stryker, Kalamazoo, MI). After infiltration of the radiocarpal joint with 10 mL of saline solution, the arthroscope was inserted through the 3-4 portal (for the lens) and 6R or 4-5 portal (for insertion of instruments). Before performing any treatment, we
INTRAOSSEOUS GANGLION CYST OF LUNATE BONE
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Fig 3. Magnetic resonance images, frontal view. (A) T2 image showing no sclerosis of the lunate bone, permitting exclusion of Kienböck disease. (B) T1 image showing a cyst with hypersignal in the lunate bone.
verified that there were no lesions in the mediocarpal joint (Fig 4). The first step of treatment was to locate the lunate bone. Then, resection of the arthrosynovial cyst was performed using a 2.5-mm shaver (2.5-mm arthroscopic shaver blade; Stryker Formula Aggressive Cutter) (Fig 5). On the basis of the computed tomography (CT) scan information, we were able to locate the intraosseous ganglion cyst of the lunate bone. Under arthroscopic control and by use of a 2.5-mm-diameter wick or an awl (Fig 6A, Video 1), corticotomy of the lunate bone was performed (Fig 6B). The aforementioned CT scan was necessary to avoid a false way and
allow a direct transosseous approach. The original hole was slowly enlarged with a small curette. Yellowish cystic liquid/tissue was extracted. The space was filled using the 2.5-mm shaver, which was used to resect the inside of the cyst (Video 1). The resection was completed using a small curette to scrape off any remaining wall of the cyst (Fig 7, Video 1). The best method of disposal was to use a large number of small, differently angled curettes to help the surgeon to remove all the remaining cystic parts.
Fig 4. Arthroscopic view from radiocarpal showing scapho lunate space and capitate on the top (arthroscope in 3-4 portal and instruments in 4-5 portal).
Fig 5. Arthrosynovial cyst resection with shaver from radiocarpal position (arthroscope in 3-4 portal and instruments in 4-5 portal).
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Fig 7. Arthroscopic view: cyst resection is completed with a small curette (arthroscope in 3-4 portal and instruments in 45 portal).
Fig 6. Arthroscopic views (A) with awl in radiocarpal joint and (B) after corticotomy (arthroscope in 3-4 portal and instruments in 4-5 portal).
Finally, an anterior surgical cast was used for pain reduction. Patients left the clinic in the evening on the same day with simple analgesic treatment (moderate to severe pain treatment). The primary criterion for success was pain relief. Disappearance of lytic lesions, another criterion for success, was evaluated by CT scans. Postoperative complications were recorded (infection, algodystrophy, compartment syndrome, need for open surgery). Patients were initially seen 3 to 4 days after the operation to avoid early complications. They were then seen 2 to 3 months later, with imaging examinations obtained (standard radiographs or CT scans), and again 8 to 9 months later, with more imaging examinations obtained (standard radiographs or CT scans). They were finally assessed 1 year later to eliminate recurrence.
The next step was to take a sample for the bone graft either on the distal part of the radius or on the iliac crest. The trabecular bone was put on a gauze compress and split into small fragments. Returning to the wrist arthroscopy, the surgeon placed the trabecular bone graft using either a soft-tissue protector with 2.5- or 3.5-diameter screws (Fig 8, Video 1) or a large-core needle used for osteomedullary biopsy. The cystic cavity was filled with the autologous bone graft (Fig 9, Video 1). We found it very useful to work under dry arthroscopy conditions at that time to keep the graft in the right position and avoid intra-articular bone dispersion. We did not use surgical glue to secure the graft. However, it was necessary to compress the graft into the bone. The iliac crest surgical site was closed, and an occlusive dressing with Steri-Strips (3M, St Paul, MN) was applied at the arthroscopic orifices.
Fig 8. Placement of bone graft in lunate with a 2.7-mm softtissue protector (arthroscope in 3-4 portal and instruments in 4-5 portal).
INTRAOSSEOUS GANGLION CYST OF LUNATE BONE
Fig 9. Bone graft impaction.
Discussion From February 2011 to March 2012, we performed the described technique in 4 patients. Pain had totally disappeared within 2 months after the operation in 100% of patients. The average hand grip strength was estimated at 100% compared with the opposite side, and articular ranges of motion were the same on both sides in 100% of cases. One patient complained of moderate pain after starting tennis lessons after 6 months, which faded in time. Fracture healing with disappearance of lytic imaging findings was obtained in 100% of cases 9 months after surgery (Fig 10). There were no infections during follow-up. The mean duration of the operation was 1 hour 2 minutes. Intraosseous ganglion cysts and intraosseous mucous cysts are included in the same nosologic category as intraosseous synovial cysts. They are benign lytic tumors, generally lobular, and frequently located on the subchondral part of the long bone’s epiphysis.1 They can sometimes be found on the carpal bones (lunate, scaphoid bones) either by accidental discovery or during a medical checkup for carpal pain. The origins of such cysts remain uncertain. Standard radiographic photography can easily diagnose this pathologic condition and must be completed with a CT scan or magnetic resonance imaging to eliminate the differential diagnoses (enchondroma, chondroblastoma, simple osseous ganglion cyst, aneurysmal bone cyst, Kienböck disease, ulnocarpal impingement syndrome, arthrosis, or punched-out lesions). In our study, persistent pain while under medical treatment led to the indication for surgery. In case of accidental discovery, an asymptomatic patient would be supervised with standard radiographs.
e517
Technically speaking, the arthroscopic method has many advantages (Table 1). First, it prevents deterioration caused by the classic surgical approach, which is most of the time performed by a posterior approach because of the smaller risk of causing damage to the median nerve than by an anterior approach. On the vascular side, the lunate bone has a double perfusion system. On the palmar surface of the hand, it is hard to identify the pedicles, but on the dorsal surface of the hand, 2 to 3 recurrent arteries coming from the dorsal radiocarpal arches irrigate the lunate bone and other close bones.4 Anastomoses between those 2 irrigation systems are not always respected, and in some cases, an exclusive palmar or dorsal vascular system exists. Classic surgery therefore exposes the patient to a more important risk of devascularization. Some authors think that the origin of the ganglion cysts could be a consequence of repeated microtraumas leading to intraosseous vascularization trouble, creating bone aseptic necrosis, followed by mucoid degeneration.5,6 Classic surgery would be an additional risk of lesion on the vascular system of a bone already weakened by the
Fig 10. CT scan showing cyst resorption.
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Table 1. Advantages and Risks/Limitations Advantages Efficiency No stiffness No disorder of lunate vascularization Better cosmetic results Risks/limitations Significant learning curve No histologic analysis
ganglion cyst. The aim of this treatment is not only to remove the ganglion cyst but also to fill the cavity to boost osteogenesis, so the vascular system of the lunate bone needs to be preserved. The second advantage of the arthroscopic approach is the reduction of joint stiffness. In this study no modification of joint range of motion was observed during the preoperative and postoperative periods. Calcagnotto et al.3 showed a decrease in wrist range of motion of 20 to 30 in patients undergoing classic surgical procedures. The third advantage of our approach is very few scar complications. Finally, the arthroscopic approach allows a complete view of the joint. In case of a concomitant extraosseous synovial cyst, this approach allows an additional simultaneous treatment, with minimum risk of iatrogenic rupture of the scapholunate ligament. It can help to confirm the diagnosis of Kienböck disease if radiolunate chondral injury or lunocapitate injury is found, as well as in the case of lunate cartilage showing a depression when being pressed on; arthroscopy therefore helps guide therapeutic indications.7,8 On the other hand, the learning process is long and precise knowledge of anatomy is needed to lower the risks of vascular and nervous complications (e.g.,
complications involving the dorsal carpal branch of the radial artery or the superficial branch of the radial nerve), cartilaginous complications (e.g., recurrent inconvenient penetration or incorrect orientation of instruments), or tendinous complications. Moreover, the arthroscopic approach does not allow either a histologic diagnosis or security that the whole cystic cavity has been emptied (this, in fact, requires large curettes with different orientations). However, arthroscopic treatment of intraosseous synovial ganglion cysts seems to be more efficient and helpful in overcoming the limitations of classic open surgery in terms of complications.
References 1. Paparo F, Fabbro E, Piccazzo R, et al. Multimodality imaging of intraosseous ganglia of the wrist and their differential diagnosis. Radiol Med 2012;117:1355-1373. 2. Kligman M, Roffman M. Bilateral intraosseous ganglia of the scaphoid and lunate bones. J Hand Surg Br 1997;22: 820-821. 3. Calcagnotto G, Sokolow C, Saffar P. Intraosseus synovial cysts of the lunate bone: Diagnostic problems. Chir Main 2004;23:17-23 [in French]. 4. Fontaine C, Wavreille G, Aumar A, Bry R, Demondion X. Osseous vascular anatomy in the hand and wrist. Chir Main 2010;29:S11-S20 (suppl) [in French]. 5. Uriburu IJF, Levy VD. Intraosseous ganglia of the scaphoid and lunate bones: Report of 15 cases in 13 patients. J Hand Surg Am 1999;24:508-515. 6. Waizenegger M. Intraosseous ganglia of carpal bones. J Hand Surg Br 1993;18:350-355. 7. Bain I, Munt J, Turner PC. New advances in wrist arthroscopy. Arthroscopy 2008;24:355-367. 8. Rizzo M, Berger RA, Steinmann SP, Bishop AT. Arthroscopic resection in the management of dorsal wrist ganglions: Results with a minimum 2-year follow-up period. J Hand Surg Am 2004;29:59-62.
