**8. Arthroscopic treatment of ganglion cysts**

Ganglion cysts are the most common benign soft-tissue tumors of the wrist. Dorsal cysts are more common than volar and surgical treatment is indicated for painful ganglions or large ones for cosmetic purposes. These ganglions usually appear in the dorsal scapholunate region which consists of three anatomical structures – the dorsal segment of scapholunate (SL) ligament, the dorsal intercarpal ligament (DICL) and the dorsal capsuloscapholunate septum (DCSS) [31]. The extra-articular part of the cyst can vary in size and location as well as in

relation to dorsal ligaments. Surgical treatment of the so called "occult" ganglion cysts, who are small, intracapsular and can be very painful, is challenging by conventional methods. Arthroscopic treatment of such ganglion cysts is a method of a choice.

There are two different arthroscopical techniques for resection of the dorsal ganglia. The one is an access via radiocarpal joint and the other is through the ganglion and via the midcarpal joint [32, 33]. Some authors describe the necessity to combine radiocarpal and midcarpal portals, thus enabling a complete resection [34].

In the 2nd edition of Wrist Arthroscopy Techniques by C. Mathoulin different techniques of the dorsal ganglion artrhroscopic resections using only midcarpal portals are described and well-illustrated [35]. In our hands the midcarpal approach works perfect in most cases, except if ganglions are located very proximally (**Figure 20**). It provides also a good cosmetic result with only two almost invisible scars on the dorsal aspect of the wrist, which is important especially in younger females.

Aftertreatment – patients have to be encouraged to start early movements. In some cases, if patients have low pain malaise, short arm cast or wrist splint is recommended for first week after surgery. Recurrence rate for dorsal wrist ganglions treated arthroscopically is from 3 to 12% [34, 36–38]. Complications are rare and they are less common than in open surgeries. Most common complications reported are some stiffness (less than with open surgery), neurapraxia, extensor tenosynovitis and complex regional pain syndrom [39]. In meta-analysis presented by Head et al. in 2015, mean complication rate for arthroscopic surgical excision was 4%, and recurrence rate 6% [40]. Complication rate reported for open surgeries was 14% and recurrence rate 21%.

Volar wrist ganglions are less common than dorsal ganglions (about 20%) and they mainly occur in the radiocarpal joint, especially in the radial corner of the volar aspect. Volar ganglions in the midcarpal joint are very rare ant mostly they occur as a result of STT arthritis. The most common appearance is below FCR and FPL tendons. The technique of the arthroscopic volar ganglion resection was first described by P.C. Ho et al. in 2003 [41]. The origin and stalk of the ganglion usually locates between radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments. It becomes visible

**Figure 20.**

*Dorsal ganglion, view from MCU portal, a – visualization of ganglion cyst after synovectomy, b – ganglion removed, clean extensor tendons visible.*

#### **Figure 21.**

*Volar ganglion of the wrist, a – ganglion detected in volar radial corner of the wrist, b – ganglion removed.*

by gently pushing with finger on the ganglion while scope is positioned in 3-4 portal. Shaver is inserted in the 1-2 portal and ganglion has to be removed gently to avoid injuries of the neurovascular structures and flexor tendons (**Figure 21**) [39, 42].

Aftertreatment is similar to that one for dorsal ganglions. In a systemic review presented by Fernandes et al. in 2014 mean complication rate for arthroscopic volar ganglion surgeries was 6% and recurrence rate 6.9% [43]. Reported complications are increased cyst site volume during the immediate postoperative period, radial artery injuries, neuropraxia of the dorsal radial nerve, partial lesions of the median nerve [39, 43, 44].
