SRPS PS - Plastic Surgery Internal

SRPS Volume 10, Issue 25, 2009
complex probably accounts for the high recurrence
rate. 163 Prevention of recurrence depends on
identification and excision of the involved segment of
joint capsule and deep attachments of the cyst pedicle
to the scapholunate ligament but only minimal
resection of the ligament itself to prevent future
scapholunate dissociation (Fig. 10). 164 Clay and
Clement 150 noted only 3.2% recurrence when using
that protocol. More radical procedures pose a greater
risk of subsequent stiffness, hypertrophic scar, wound
infection, and nerve damage.
Figure 10. Ganglion with pedicle attached to scapholunate
ligament. (Reprinted with permission from Minotti and Taras. 164 )
Filan and Herbert 165 think that symptomatic dorsal
wrist ganglia are the result of scaphoid instability that,
if present at the preoperative clinical examination, is
treated by a dorsal capsulorrhaphy of the wrist
combined with ganglion excision. Of seven patients
who underwent surgery for recurrent ganglia in whom
capsulorrhaphy was performed, none had experienced
recurrence of ganglia at 12 months.
The treatment of wrist ganglia is indicated only in
the event of significant discomfort or deformity.
Although surgery is the mainstay of treatment,
various nonoperative techniques have been
advocated. Aspiration 166,167 or injection of enzymes, 168
sclerosing agents, or cortisone have been suggested,
but all are associated with a significant recurrence
rate. Arthroscopic resection of the ganglion might be
associated with a lower recurrence rate. 169–171 It can also
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identify the exact origin of the ganglion and other
intra-articular pathological conditions.
Giant Cell Tumors of Tendon Sheath
Giant cell tumors are the second most frequent type of
hand tumor. They typically occur in the fingers of 20to
40-year-old patients and are slightly more common
in women. Giant cell tumors of the tendon sheath are
also known as pigmented villonodular synovitis when
they arise from the volar joint recess. 172,173 No evidence
has shown that repeated hemorrhage, friction, or
cholesterol imbalance contributes significantly to the
development of giant cell tumors, and only
approximately one-third of patients provide histories
of previous trauma or surgery to the region. Pain and
tenderness are not prominent features, but prolonged
unchecked tumor growth interferes with mechanical
function of the hand.
The clinical presentation of a giant cell tumor of
the tendon sheath is that of a lobulated, mottled,
yellow subcutaneous mass. Although the diagnosis
usually is evident clinically, magnetic resonance
imaging (MRI) has been described as an adjunct in the
preoperative assessment of extensive tumors. 174 The
characteristic lobulation is seen microscopically, and a
relatively noncellular, collagenous connective tissue
often divides and partially envelops the lesion. 175
Histological examination reveals the basic polyhedral
cells of a fibrous xanthoma. In the more cellular areas,
mitotic figures are seen, but never in large numbers.
Also present are spindle cells, multinucleated giant
cells, foam cells, and reticulin. 175,176 The tumor can erode
bone by pressure 177 and/or infiltrate the overlying
dermis. 178 Frank bony invasion has been documented. 179
Treatment is complete local excision, ensuring
total clearance of the volar joint recess. Recurrences
unfortunately are common, especially in the fingers,
and are the result of inadequate resection, for which
repeat excision is recommended. 180 Extensive
recurrences often necessitate arthrodesis of the
affected joint in that resection of violated ligaments
and joint capsule might be required. Very occasionally,
amputation is necessary. Despite infiltrative growth
patterns, rapid recurrence, and a frequently confusing
histological appearance, giant cell tumors are
considered benign. 181