Direct “Cystoscopic” Approach for Arthroscopic Decompression of an Intraosseous Ganglion of the Lunate  Deepak N. Bhatia, M.S.(Orth), D.N.B.(Orth)  Arthroscopy Techniques  Volume 4, Issue 3, Pages e223-e229 (June 2015) DOI: 10.1016/j.eats.2015.01.010 Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 1 Magnetic resonance images of the right wrist in a 26-year-old male patient show mild degeneration of the scapholunate ligament with resultant ganglion cyst formation that extends into the lunate and dorsal soft tissues. (Arrows, intraosseous ganglion; S, scaphoid; L, lunate; T, triquetrum; C, capitate; H, hamate; R, radius; U, ulna, D, dorsal; V, volar.) Arthroscopy Techniques 2015 4, e223-e229DOI: (10.1016/j.eats.2015.01.010) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 2 (A) Standard wrist arthroscopy portals (X). Both dorsal (left) and volar (right) portals are marked: 3-4 portal (1), 4-5 portal (2), 6R portal (3), 6U portal (4), volar radial portal (VR), and volar ulnar portal (VU). (B) Dry arthroscopic view of the lunate (L) via the 3-4 portal. The scapholunate ligament (SL) is intact. The dorsal radiocarpal capsular fold (cp) is seen attaching to the non-articular dorsal lunate surface (black arrow). The entry point for the guidewire (asterisk) is placed 2 to 4 mm away from the articular surface of the lunate (white arrow). (R, radius articular surface.) Arthroscopy Techniques 2015 4, e223-e229DOI: (10.1016/j.eats.2015.01.010) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 3 Arthroscopic drilling of lunate (right wrist). The arthroscope (A) is placed in the 3-4 portal (1), and a drill guide (S) is inserted through the 4-5 portal (2). The wrist is held in a slight dorsiflexion position by the assistant. The inset shows placement of the guide (S) on the non-articular dorsal lunate surface (arrow), with the drill bit (D) drilling a pilot hole into the lunate (L). (R, radius articular surface.) Arthroscopy Techniques 2015 4, e223-e229DOI: (10.1016/j.eats.2015.01.010) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 4 (A) A guidewire (GW) is passed into the pilot hole (black arrow) and drilled into the cyst. Approximately 20° to 30° of upward angulation is necessary to achieve this through the 4-5 radiocarpal portal (2). The white arrow indicates the lunate articular surface. (Cp, dorsal capsule; L, lunate; R, radius articular surface; X, 3-4 portal.) (B) The image intensifier (IM) is positioned orthogonal to the suspended wrist, and biplanar views are obtained. (GW, guidewire.) The left inset shows an anteroposterior view, and the guidewire (GW, 4-5 portal) appears to be within the lunate cyst (L). The right inset shows a lateral view and confirms the correct intralunate position and depth. (C, capitate; H, hamate; P, pisiform; R, radius; S, scaphoid; T, triquetrum; Tr, trapezium; U, ulna.) Arthroscopy Techniques 2015 4, e223-e229DOI: (10.1016/j.eats.2015.01.010) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 5 A 3.2-mm cannulated drill bit (Db, 4-5 portal) is used to create a 10-mm-long tunnel into the lunate cyst (L). Entry of the drill bit into the intraosseous ganglion cyst is indicated by extrusion of viscous fluid (not shown) from the lunate. (Cp, capsule; R, radius articular surface.) Arthroscopy Techniques 2015 4, e223-e229DOI: (10.1016/j.eats.2015.01.010) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 6 A radiofrequency probe (RF) is used through the 4-5 portal (2) to clear the soft-tissue debris around the lunate drill hole (H) and around the 4-5 portal (Cp). The arthroscope (A) is in the 3-4 portal (1), and an assistant maintains the slightly dorsiflexed position of the wrist. (Cp, capsule; L, lunate; R, radius articular surface.) Arthroscopy Techniques 2015 4, e223-e229DOI: (10.1016/j.eats.2015.01.010) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 7 (A) A direct cystoscopic view of the lunate ganglion (L), through the 4-5 portal, provides an excellent view of the cyst walls (C), and the soft-tissue lining (S) is seen along the radial wall of the cyst. (B) A direct cystoscopic view of the lunate ganglion, through the 3-4 portal, is obtained from the edge of the lunate tunnel (L), and a 1.25-mm probe (W, 4-5 portal) is passed simultaneously into the cyst. Under direct vision, the cyst walls (C) and the lining (S) are probed and scraped. Arthroscopy Techniques 2015 4, e223-e229DOI: (10.1016/j.eats.2015.01.010) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 8 A direct cystoscopic view of the lunate ganglion, through the 3-4 portal, is obtained from the edge of the lunate tunnel (L), and a 1.9-mm grasper (B, 4-5 portal) is passed simultaneously into the cyst. Under direct vision, the cyst walls (C) and the lining (S) are grasped and excised for histopathologic confirmation. Arthroscopy Techniques 2015 4, e223-e229DOI: (10.1016/j.eats.2015.01.010) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 9 Debridement of the intraosseous ganglion cyst is performed with a 3-mm shaver (SH, left inset) and a 3-mm burr (BR, right inset) inserted into the lunate hole (H) through the 4-5 portal (2). The arthroscope (A) is in the 3-4 portal (1), and an assistant maintains the slightly dorsiflexed position of the wrist. (L, lunate; R, radius articular surface.) Arthroscopy Techniques 2015 4, e223-e229DOI: (10.1016/j.eats.2015.01.010) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

Fig 10 (A) A postoperative oblique radiograph clearly shows the position of the lunate drill hole (arrow) in relation to the larger cyst surrounding it. (C, capitate; L, lunate; P, pisiform; R, radius; S, scaphoid; T, triquetrum; U, ulna). (B) A postoperative lateral radiograph clearly shows the length and orientation of the lunate tunnel (arrows) along the anteroposterior axis of the lunate (L). (M1, first metacarpal; M2, second metacarpal; R, radius; S, scaphoid; Tr, trapezium; U, ulna.) (C) Early initiation of range-of-motion exercises results in full range within 3 to 6 weeks of surgery. Arthroscopy Techniques 2015 4, e223-e229DOI: (10.1016/j.eats.2015.01.010) Copyright © 2015 Arthroscopy Association of North America Terms and Conditions