Prognosis of wrist ganglion operations

A retrospective study was conducted to evaluate the results of treatment of 40 wrist ganglia operated under local anesthesia over four years. The mean follow-up period was 27 months (range 6-48 months). There were 24 dorsal and 16 volar ganglia. The mean complication rate was 56% for volar ganglia, 12.5% for dorsal ganglia, and the difference was significant (p < 0.05). The recurrence rates were 31.2% and 8.3%, respectively (mean 17.5%). There was evidence of nerve damage to the superficial branch of the radial nerve in one patient (dorsal cyst) and to the palmar cutaneous branch of the median nerve in two patients (volar cysts). The mean nerve injury rate was 7.5%. In two patients with volar ganglia, the palmar superficial branch of the radial artery was lace-rated and had to be ligated. The significantly higher complication rate after excision of volar ganglia in contrast to dorsal ones might indicate that the former should be approached more carefully in contrast to dorsal ones and preferably by a senior surgeon.     

Arthroscopic assessment of the volar region of the scapholunate interosseous ligament through a volar portal

PURPOSE: The volar region of the scapholunate interosseous ligament is one of the key structures that maintains scapholunate alignment. It is, however, difficult to evaluate this ligament using standard diagnostic procedures, including the arthroscopy through a dorsal portal. We have performed arthroscopic evaluation of this ligament through a volar portal. METHODS: Skin incision was made at just radial of the flexor carpi radialis tendon and the portal was opened through the tendon sheath. RESULTS: The volar approach enabled us to directly observe the extent of the tear of the volar region of scapholunate interosseous ligament. A shaver is inserted through the dorsal portal, and debridement can be performed by using the volar portal vein. We have not had any complications using volar portal. CONCLUSION: Volar approach is a feasible and safe procedure to evaluate and treat the volar region of the scapholunate interosseous ligament.     

Arthroscopic resection of volar wrist lipoma: a case report

We present the case of a patient who showed a volar radiocarpal mass confirmed to be a lipoma by the ultrasonographic examination. The whole procedure was done by arthroscopy, using portal 1-2 for the shaver and 3-4 for the arthroscope. The patient returned to daily activities within a few days, with a mobility of the operated wrist identical to that of the contralateral wrist, with no pain and only two little dorsal scars.     

Longitudinal observation of pediatric hand and wrist ganglia

The purpose of this study was to examine the behavior of ganglia of the hand and wrist in young children treated without surgery. Fourteen consecutive children, less than 10 years of age, who presented with cysts of the hand and wrist were followed up by a single surgeon. The average age of the patient at the time of diagnosis was 38 months (range, 2 months to 9 years 3 months). The masses included 7 retinacular cysts, 5 volar wrist ganglia, and 2 dorsal wrist ganglia. These cysts had been present for an average of 3.3 months (range, 1-12 months) before medical advice was sought. None of the cysts were painful. Follow-up averaged 33 months (range, 9-112 months), with 79% of all cysts spontaneously resolving, the majority within a year. We believe that a child presenting with a benign hand lesion characteristic of a ganglion cyst should initially be treated by observation.     

Arthroscopic Cystectomy for Popliteal Cysts Through the Posteromedial Cystic Portal

In the treatment of patients with popliteal cysts (Baker’s cysts), we generally need to address the intra-articular pathologies, most commonly, medial meniscal tears and concomitant connecting valvular mechanisms responsible for the formation and recurrence of the cyst. We introduce here an arthroscopic technique that can treat the associated intra-articular pathology and correct the valvular mechanism of the capsular fold. The most important step is to locate the opening connection between the joint cavity and the popliteal cyst at the posteromedial compartment. The opening is found at the posteromedial side of the medial head of the gastrocnemius after inferior displacement of the capsular fold, which overlies the opening. It is helpful to rotate the bevel of the arthroscope upward to the 11-, 12-, and 1-o’clock positions for most effective visualization of the capsular fold. After the opening connection of the cyst is found, the capsular fold is resected with basket forceps and a shaver inserted through the posteromedial portal to correct the valvular mechanism. Furthermore, we have developed an additional “posteromedial cystic portal,” which is located directly above the popliteal cyst and can be effectively used in cystectomy, especially in treatment of cysts that consist of septa and nodules. Arthroscopic popliteal cyst removal with use of an additional posteromedial cystic portal can be effective in treating a cyst with multiple fibrous septa or membranes.     

Volar Barton's fractures with concomitant dorsal fracture in older patients

PURPOSE: To describe a variant of Barton's volar articular shearing fracture of the distal radial articular surface with a subtle concomitant fracture of the dorsal metaphyseal cortex. METHODS: This fracture pattern was observed in 6 women and 2 men with an average age of 67 years (range, 58-76 years). All 8 patients were treated with a volar plate and screws. The dorsal metaphyseal fracture was not recognized in 5 patients and a volar buttress plating technique using an intentionally undercontoured volar plate was used. In 3 patients the dorsal fracture line was identified before surgery and the plate was contoured to fit the volar surface of the distal radius. RESULTS: All 5 patients treated with an undercontoured plate had loss of the normal palmar tilt of the distal radius (average,-9.4 degrees; range, 0 degrees to-22 degrees ) and dorsal translation of the distal radial articular fragments. For the entire group the palmar tilt averaged-5.9 degrees (range, 0.0 degrees to-22.0 degrees ), the ulnar inclination 19 degrees (range, 10 degrees -23 degrees ), and the ulnar variance-0.9 mm (range, 0.0 to-3.0 mm). All patients attained forearm supination of 80 degrees and the average pronation was 75 degrees (range, 45 degrees -80 degrees ). According to Sarmiento's modification of the system of Gartland and Werley there were 1 excellent, 6 good, and 1 fair results. The average Patient-Rated Wrist Evaluation score was 16 (range, 0-35). CONCLUSIONS: Some fractures with an oblique volar marginal articular fracture of the distal radius and volar radiocarpal subluxation (known as Barton's fracture) may also have a fracture through the dorsal metaphyseal cortex. Failure to identify this fracture line can lead to dorsal translation and angulation of the distal radius articular surface, particularly when an undercontoured volar plate is used for internal fixation.     

The role of total pericystectomy in hepatic hydatidosis

Between 1977 and 1995, 495 patients were operated on for hepatic hydatidosis. Total pericystectomy was performed in 26 patients (closed technique in 21 and open technique in 5). Twenty-one patients had single cysts and 5 had two cysts. The median cyst diameter was 8cm (range; 3–20cm). The requirements for total pericystectomy were: (1) the cyst(s) should be located away from the hepatic veins, large bile ducts, or major branches of the portal vein and hepatic artery and (2) the patient should be fit to undergo a major operation. There was no procedure-related morbidity. One patient developed a biliary fistula that closed after endoscopic sphincterotomy. The median hospital stay was 7 days (range; 3–22 days). The median follow up was 24 months (range; 9–114 months). There was disease recurrence in a non-adjacent segment in 1 patient at 4 years. Pericystectomy is a potentially dangerous operation, but it avoids problems with cavity management and has low rates of biliary fistula, spillage, and recurrence. Its success stems primarily from careful patient selection.     

Uncommon abdominal sites of hydatid disease. Our experience with the surgical treatment of 15 cases

The aim of this retrospective study is to report on a series of 15 patients with abdominal hydatid disease in uncommon sites submitted to surgery in our unit over the period 1974-2003. Eight women and 7 men (mean age: 48.4 years) were included in the study. The hydatid cysts were located in the peritoneum in 8 patients, in the spleen in 5, in the kidney in 1 and in the retroperitoneum in 1. In 4 cases the peritoneal cysts were solitary, while 4 patients in this subgroup presented multiple cysts and 2 had concomitant liver hydatidosis. The splenic cysts were solitary in 2 cases, associated with a hepatic cyst in 2 and with a lung cyst in 1. The renal and retroperitoneal cysts were both solitary. The diagnosis was made at operation in 3 cases, while in 12 patients it was made by serological tests, ultrasonography and/or CT. All patients were operated on: we performed a total cystectomy in 7 patients with peritoneal cysts and in the patient with a retroperitoneal location, splenectomy in the 5 splenic cysts and a partial cystectomy with external drainage of the residual cavity in 1 peritoneal cyst and in the renal location. The postoperative course was regular with no mortality and no major morbidity in 14 patients, while 1 patient submitted to splenectomy developed a subphrenic abscess that required surgical drainage. Two recurrences occurred in patients with peritoneal cysts 71 and 20 months, respectively, after the first operation and these were managed by total cystectomy. The diagnosis of uncommon abdominal sites of hydatid disease is more accurate today because of the new imaging techniques, which are often able to show specific radiological signs of hydatid disease. The treatment of choice is surgical and complete removal of the cyst is the gold standard, but its feasibility is related to the location of the cyst.     

Recurrence after laparoscopic excision of nonparasitic splenic cysts

Background

Minimally invasive treatments for nonparasitic splenic cysts are well described. Recent evidence suggests that laparoscopic splenic cystectomy is associated with high recurrence rates in children. Because these cysts are uncommon, no large series is available. We reviewed our clinical data focusing on cyst recurrences and their management.

Methods

All children who underwent laparoscopic excision of a nonparasitic splenic cyst from January 2002 to December 2006 were identified. Medical and surgical records were reviewed for perioperative details, hospital course, and outcome.

Results

Eight children (median age, 13 years; range, 7-16 years) who underwent laparoscopic splenic cystectomy were identified. The most common presenting complaint was left upper quadrant pain or mass (n = 6; 75%). Median cyst size was 13 cm (range, 4-20 cm). There were no conversions to an open technique, completion splenectomies, or perioperative complications. Cysts were identified pathologically as epidermoid (n = 6) or posttraumatic (n = 2). Median hospital stay was 1.5 days. One child required partial splenectomy because of cyst anatomy and remains recurrence-free at 12 months. Cyst recurrence occurred in 7 patients (88%) at a median of 9.4 months (range, 3-18 months) after initial surgery. Median recurrent cyst size was 5.6 cm (range, 3-11 cm). Of 7 recurrences, 4 (57%) were symptomatic. Percutaneous ultrasound-guided cyst drainage and sclerosis were performed in 2 children with symptomatic recurrences, one of whom required 4 separate interventions. There were no complications during management of cyst recurrences. Five children with recurrence (71%) have been followed conservatively and are free of morbidity at a median of 23 months (range, 8-55 months).

Conclusions

Laparoscopic excision of nonparasitic splenic cysts in children is associated with a high recurrence rate and may be insufficient treatment. Partial splenectomy may decrease recurrence rates. Conservative management of splenic cyst recurrence after laparoscopic excision is associated with good short-term outcomes. If necessary, image-guided management of symptomatic recurrences can be performed safely.     

Minimal access surgery for hydatid cyst disease: laparoscopic,thoracoscopic, and retroperitoneoscopic approach

Surgery has remained the mainstay for the treatment of hydatid cyst. The rapid development of laparoscopic techniques has encouraged surgeons to replicate principles of conventional hydatid surgery using a minimally invasive approach. Several reports have confirmed the feasibility of laparoscopic hepatic hydatid surgery. We report the use of a laparoscopic approach for cysts located in the liver, lung, and retroperitoneum. Fifteen patients with hydatid cysts, including one patient with a recurrent cyst, of various organs, including the liver, lung, and retroperitoneum, were operated on laparoscopically. Sixteen hydatid cysts were drained in a total of 15 patients. The mean operative time was 84 +/- 6 minutes (60-125 minutes). The mean duration of the hospital stay was 2.3 days (1-6 days). The mean cyst diameter was 9.2 cm (6.4-13.5 cm). No conversions to open surgery were required. One complication, a trocar-induced bowel perforation, occurred, and there was no mortality. During 3 to 44 months (mean, 27 months) of follow-up, no recurrences developed. Minimal access surgery is a safe, effective, and viable option for the management of selected patients with hydatid cysts in various locations, such as the liver, lung, and retroperitoneum.     

腕关节镜掌侧入路的实验与临床研究

目的 报告腕关节镜掌侧入路的设计及初步应用结果.方法 腕关节镜掌桡侧入路定位在桡侧腕屈肌腱桡侧与舟骨结节交界处,掌尺侧入路定位在尺侧腕屈肌腱的尺侧缘、豌豆骨近侧0.5 cm处.对20具防腐腕关节以上离断标本进行解剖学研究,5具新鲜腕关节以上离断标本进行模拟镜下手术.2004年4月至2008年1月,共进行腕关节镜掌侧入路手术20例.男8例,女12例;年龄21～64岁,平均35.6岁.结果 掌侧入路与其周围的血管、神经等结构均有一定的安全距离.掌侧入路镜检可以清晰显示背侧关节囊、舟月骨间韧带的掌侧部分和月三角骨间韧带的掌侧部分.通过掌侧入路置入关节镜,背侧入路置入手术器械,可以更方便地处理腕关节腔背侧部分的病变.20例临床病例均未发生并发症,平均随访23.4(12～37)个月.末次随访时,腕关节背伸-掌屈活动度为134°±16°,桡尺偏活动度为39°±8°,旋前-旋后活动度为139°±18°.术前有2例疼痛为Ⅱ级,18例疼痛为Ⅲ级;末次随访时,11例疼痛为Ⅰ级,8例为Ⅱ级,1例为Ⅲ级;疼痛缓解显著(Z=31.2,P＜0.01).改良Garland和Werley评分为:优10例,良6例,可4例,优良率为80%.结论 腕关节镜掌侧入路是传统背侧入路的重要补充,具有安全性高、操作方便的优点.     

Alcohol sclerotherapy of non-parasitic cysts of the liver

Between 1980 and 1987, nine patients with non-parasitic cysts of the liver were treated with computed tomography-guided percutaneous puncture and evacuation of the cyst contents followed by injection of absolute alcohol as a sclerosing agent. During the same period only one patient was treated with surgery. The patients included seven women and two men with a mean age of 62 years. Three patients had a single cyst and six patients had multiple cysts. The size of the largest cysts varied between 5 and 20 cm (mean 10 cm). Patients with multiple liver cysts had repeated punctures and sclerosing procedures (up to eight times); 50-3100 ml of cyst fluid (mean 650 ml) was drained per procedure. One patient had symptoms of moderate alcohol intoxication; otherwise no complications were noted. Follow-up was performed with computed tomography or ultrasonography for 8-54 months (median 18 months). The results have been considered successful in eight out of nine patients who had cyst regression and reduced symptoms. Two patients, however, required additional surgical treatment due to residual and multiple cysts. Computed tomography-guided alcohol sclerotherapy of non-parasitic liver cysts appears to be a safe and effective initial therapy.     

Prolonged ICP monitoring in Sylvian arachnoid cysts

BACKGROUND: The decision making process for patients with Sylvian fissure arachnoid cysts still represents a challenge for the neurosurgeon. A high percentage of patients are indeed asymptomatic, despite neuroimaging signs of apparently increased intracranial pressure (ICP). The present study was conducted to evaluate the usefulness of prolonged ICP recording in the preoperative work-up. METHODS: Eleven children (10 M/1 F) harboring temporal arachnoid cysts were investigated (mean age: 5.9 years). According to Galassi classification they were subdivided in three groups. Group I was made up of three patients with Type I cysts; Group II comprised six children with Type II cysts; Group III consisted of two children with Type III cysts. An extensible silicone microprocessor (Codman), developed for continuous ICP recording, was implanted intraparenchymally, adjacent to the major extension of the cyst. The collected information was cable unloaded to a PC and stored. All the patients underwent a minimum of 48 hours to a maximum of 72 hours of ICP continuous check. In resting conditions, 10 mm Hg was arbitrarily chosen as the upper normal limit of ICP, and the patients were classified according to the percentile distribution of their ICP daily and nightly pressure values. RESULTS: ICP recordings were in the normal range in all the three children with Type I cysts (49-86%< 10 mm Hg during the entire recording), despite the fact that two of them were apparently symptomatic. Three of the six children with a Type II temporal cyst had elevated ICP values (69-99%> 10 mm Hg), even though they had an incidental (1 case) or prenatal (2 cases) diagnosis. The remaining three patients had normal ICP values for more than 70% of the recording time period. The two patients with type III temporal arachnoid cysts had almost constantly abnormal ICP values (95-99%> 10 mm Hg). Five patients were operated; in four of them the surgical indication was based on ICP recordings (two of the three children with a Type II cyst and increased ICP and the two patients with a Type III cyst). The last child, harboring a Type I cyst, was operated upon parents' request, as a preventive measure. At a mean follow-up of 9.3 months all the patients operated on are in excellent clinical condition; one of them (Type II cyst) initially undergoing a craniotomy and cystic membrane excision required a subduro-peritoneal shunt implant 3 months after surgery for a symptomatic subdural hygroma on the side of the cyst. Postoperative computed tomography showed signs of brain expansion in the two patients operated on for a Type III cyst, and in the patient operated on for a Type I cyst. CONCLUSIONS: With the limit of the relatively small series presented here, prolonged ICP recording appeared to be an important preoperative tool to rule out the necessity of operating on children with Type I cysts. Furthermore, the study confirmed that an increase of the ICP is almost constantly present in children with Type III cysts. In cases of Type II lesions, the study results were less discriminating, though the ICP monitoring contributed in identifying those patients in whom surgery was indicated despite the absence of symptoms.     

Clinical evaluation and treatment of spinoglenoid notch ganglion cysts

Spinoglenoid notch cysts were identified by magnetic resonance imaging in 73 patients. Posterosuperior labral tears were identified in 65 patients who had spinoglenoid notch cysts. Patient follow-up was available on 88% of patients at a mean of 20.5 months after treatment. There were 52 men and 11 women, with a mean age of 39 years (range, 19-76 years). All patients reported shoulder pain. Infraspinatus atrophy occurred in 25 patients, weakness with external rotation in 43, and posterior shoulder tenderness in 30. Nineteen patients underwent nonoperative management of the cyst (group I). Eleven underwent attempted needle aspiration of the cyst (group II). Six had isolated arthroscopic treatment of a labral defect with no cyst excision (group III). Twenty-seven were treated with surgical cyst excision with the cyst and superior labral tear fixed arthroscopically or with an open approach in various combinations (group IV). Of the patients, 53% were satisfied in group I, 64% in group II, 67% in group III, and 97% in group IV.     

Lumbar synovial cysts: experience with nine cases

Nine patients treated surgically for lumbar spinal synovial cyst were reviewed. Four patients had synovial, two had ganglion, one had posterior longitudinal ligament, and two had ligamentum flavum cyst. Synovial cysts had a single layer of epithelial cells in the inner layer of the cyst with continuity with the facet joint. Ganglion cyst had no continuity with the facet joint and epithelial lining was present in one and absent in one case. Posterior longitudinal ligament and ligamentum flavum cysts had no continuity with the facet joint and no epithelial lining. Magnetic resonance imaging showed the cysts better than computed tomography. All patients treated for nerve root compression or lumbar spinal canal narrowing. One patient suffered recurrence 1 year later and was reoperated. Operative results were excellent in six and good in three patients. Lumbar spinal synovial cysts should be considered in differential diagnosis of lumbar radiculopathy/neurogenic claudication and is surgically treatable.     

Superior eyelid incision: an alternative approach for frontozygomatic dermoid cyst excision

Sixty-five children presenting with frontozygomatic (lateral brow) dermoid cysts were operated using an upper eyelid crease incision. There were 38 girls and 27 boys age 3 months to 13 years (mean age, 15 months). The lesions were left sided in 32 patients and right sided in 33 patients. Preoperative radiograph or computed tomographic scan performed for 25 children failed to demonstrate a bony defect in the area of the cyst. At surgery, 14% of the cysts were adherent to the periosteum and 5% were subperiosteal. One cyst extended through the bone into the orbit. All cysts were removed completely, and this was accomplished without rupture in 54 patients. The average operating time was 21 minutes. All children were seen within 1 month of surgery. The postoperative course was uneventful except for early swelling and erythema in 2 children. Thirty-six patients (55%) could be reached for long-term follow-up (range, 1-7.1 years) postoperatively. The authors found no lid or ocular dysfunction and excellent scar camouflage in all patients.     

Minimal invasive surgery for unicameral bone cyst using demineralized bone matrix: a case series

ABSTRACT: BACKGROUND: Various treatments for unicameral bone cyst have been proposed. Recent concern focuses on the effectiveness of closed methods. This study evaluated the effectiveness of demineralized bone matrix as a graft material after intramedullary decompression for the treatment of unicameral bone cysts. METHODS: Between October 2008 and June 2010, twenty-five patients with a unicameral bone cyst were treated with intramedullary decompression followed by grafting of demineralized bone matrix. There were 21 males and 4 female patients with mean age of 11.1 years (range, 3-19 years). The proximal metaphysis of the humerus was affected in 12 patients, the proximal femur in five, the calcaneum in three, the distal femur in two, the tibia in two, and the radius in one. There were 17 active cysts and 8 latent cysts. Radiologic change was evaluated according to a modified Neer classification. Time to healing was defined as the period required achieving cortical thickening on the anteroposterior and lateral plain radiographs, as well as consolidation of the cyst. The patients were followed up for mean period of 23.9 months (range, 15-36 months). RESULTS: Nineteen of 25 cysts had completely consolidated after a single procedure. The mean time to healing was 6.6 months (range, 3-12 months). Four had incomplete healing radiographically but had no clinical symptom with enough cortical thickness to prevent fracture. None of these four cysts needed a second intervention until the last follow-up. Two of 25 patients required a second intervention because of cyst.     

腹腔镜下胆总管囊肿切除、肝管空肠吻合、腹腔外空肠吻合术50例报告

目的探讨腹腔镜下胆总管囊肿根治切除、肝管空肠吻合、腹腔外空肠吻合术的技巧和中期疗效。方法对大的囊肿,于囊肿中部切开前壁,再用电钩横断囊肿后壁;对小的囊肿,围绕囊肿周围游离,完整切除扩张胆管。对反复发生胆管炎症的患儿,采用Lilly’s方法游离囊肿。脐部切口扩大至1.5 cm,将空肠提出腹壁外,行空肠Roux-Y吻合。腹腔镜监视下肝管空肠端侧吻合。结果16例患儿行囊肿全部切除,34例患儿行Lilly’s囊肿切除。1例早期手术患儿术前反复发作胆管炎症,囊肿周围紧密粘连,分离中渗血明显中转开腹完成手术。手术时间190-450 min,平均226 min。8例患儿需要输血。术后住院时间6-16 d,平均8 d。49例术后随访3-39个月,平均26个月。术后并发症4例：1例发生胆漏,经腹腔引流后自愈;急性胰腺炎1例,保守治疗治愈;肠粘连肠梗阻1例,保守治疗;肠坏死1例,开腹探查见空肠肝支肠管梗阻坏死,行肠切除和再次胆肠吻合手术。余45例无腹痛、发热、黄疸等症状。无胆管狭窄和反流性胃炎病例,无手术死亡。结论分离囊肿后壁,避免门静脉损伤是最关键的腹腔镜操作;胆肠吻合是腹腔镜最难的技术。腹腔镜下胆总管囊肿根治术疗效满意。     

耻骨上辅助经脐微双孔腹腔镜技术治疗肾囊肿

目的探讨耻骨上辅助经脐微双孔腹腔镜技术（SAU—LEMDS）治疗。肾囊肿的安全性、可行性和有效性。方法本组26例,男16例,女10例。年龄18～70岁,平均年龄（48．5±2．5）岁。均为单发肾囊肿,其中左侧18例,右侧8例;囊肿位于肾上极背侧3例、肾上极腹侧3例、肾中部背侧2例、肾中部腹侧3例、肾下极背侧6例、。肾下极腹侧9例。囊肿最大径5．8～12．0cm,平均（7．5±2．0）cm。全麻,健侧70。卧位,脐缘置人两个5mm Trocar及操作器械,自耻骨联合患侧阴毛覆盖区置入-5mm Trocar及腹腔镜。手术方法同普通腹腔镜肾囊肿去顶减压术,标本自脐部任一Trocar取出,无需延长切口。结果全部手术均成功。手术时间20～65min,平均（30±5．6）min。失血量5-20ml,平均（10±2．5）ml。住院时间3-6d,平均（4±0．5）d。术后随访1-3个月,平均（2±0．5）个月,囊肿无复发,术后切口愈合良好,手术瘢痕隐蔽,美容效果佳。结论SAU—LEMDS技术治疗肾囊肿安全可行,可降低经脐单孔腹腔镜技术（U-LESS）手术难度,且具有良好的美容效果;可作为现阶段U—LESS的过渡手术,值得临床推广应用。