Available via license: CC BY-NC-ND 4.0
Content may be subject to copyright.
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.
Wrist intraosseous ganglion cysts are rare tumors
in adults, and they are asymptomatic and idio-
pathic 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. Di-
agnoses of symptomatic cystic lesions of the lunate
bone (Kienböck disease, trauma, scaphoid pseudarth-
rosis) 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 stiffness
3
and vascular disturbances of the very fragile vascular
system of the lunate bone.
4
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, bas-
ket forceps). There are more and more wrist arthros-
copy indications, including scapholunate ligament
repair, treatment of fractures of the distal radius,
intercarpal arthrodesis, and intra-articular cyst resec-
tion, 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 stiff-
ness. However, it is a difficult technique with a signif-
icant 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 liga-
ment (Figs 1-3). Our hypothesis was that arthroscopic
treatment provides good results regarding cyst resorp-
tion with fewer complications.
Technique
The operations were performed using regional anes-
thesia and were same-day surgical procedures. The
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: alexandre.cerlier@gmail.com
Ó2015 by the Arthroscopy Association of North America
2212-6287/15161/$36.00
http://dx.doi.org/10.1016/j.eats.2015.05.011
Arthroscopy Techniques, Vol 4, No 5 (October), 2015: pp e513-e518 e513
patient was placed in a dorsal position, with a pneu-
matic tourniquet placed on the base of the arm (cuff
pressure of up to 250 mm Hg), and the shoulder was
abducted 90and counterbraced on the arm. The elbow
was flexed to 90so 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
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 in-
struments). Before performing any treatment, we
Fig 1. (A) Frontal radiographic
view of the wrist of a 48-year-
old woman with an intraosseous
ganglion cyst of the lunate bone.
(B) Close-up view of cyst.
Fig 2. Computed tomography
scans of the wrist of a 63-year-
old 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 communi-
cating 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.
e514 A. CERLIER ET AL.
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 arthro-
scopic shaver blade; Stryker Formula Aggressive Cutter)
(Fig 5). On the basis of the computed tomography (CT)
scan information, we were able to locate the intra-
osseous 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 aforemen-
tioned 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 3. Magnetic resonance im-
ages, frontal view. (A) T2 image
showing no sclerosis of the
lunate bone, permitting exclu-
sion of Kienböck disease. (B) T1
image showing a cyst with
hypersignal in the lunate bone.
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 radio-
carpal position (arthroscope in 3-4 portal and instruments in
4-5 portal).
INTRAOSSEOUS GANGLION CYST OF LUNATE BONE e515
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 cav-
ity 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.
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). Pa-
tients 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 ob-
tained (standard radiographs or CT scans). They were
finally assessed 1 year later to eliminate recurrence.
Fig 6. Arthroscopic views (A) with awl in radiocarpal joint
and (B) after corticotomy (arthroscope in 3-4 portal and in-
struments in 4-5 portal).
Fig 7. Arthroscopic view: cyst resection is completed with a
small curette (arthroscope in 3-4 portal and instruments in 4-
5 portal).
Fig 8. Placement of bone graft in lunate with a 2.7-mm soft-
tissue protector (arthroscope in 3-4 portal and instruments in
4-5 portal).
e516 A. CERLIER ET AL.
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 tu-
mors, 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 dur-
ing a medical checkup for carpal pain. The origins of
such cysts remain uncertain.
Standard radiographic photography can easily di-
agnose this pathologic condition and must be completed
with a CT scan or magnetic resonance imaging to elim-
inate the differential diagnoses (enchondroma, chon-
droblastoma, 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 dis-
covery, an asymptomatic patient would be supervised
with standard radiographs.
Technically speaking, the arthroscopic method has
many advantages (Table 1). First, it prevents deterio-
ration 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 conse-
quence of repeated microtraumas leading to intra-
osseous 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 9. Bone graft impaction.
Fig 10. CT scan showing cyst resorption.
INTRAOSSEOUS GANGLION CYST OF LUNATE BONE e517
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 modi-
fication of joint range of motion was observed during
the preoperative and postoperative periods. Calcag-
notto et al.
3
showed a decrease in wrist range of motion
of 20to 30in patients undergoing classic surgical
procedures.
The third advantage of our approach is very few scar
complications. Finally, the arthroscopic approach al-
lows 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 Kien-
böck disease if radiolunate chondral injury or lunoca-
pitate injury is found, as well as in the case of lunate
cartilage showing a depression when being pressed on;
arthroscopy therefore helps guide therapeutic in-
dications.
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 his-
tologic 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 lim-
itations 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. Arthro-
scopic 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.
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
e518 A. CERLIER ET AL.
