ARTHROSCOPIC TREATMENT OF PERIARTICULAR GANGLION CYSTS WITH MARSUPIALIZATION

Arthroscopic Treatment of Periarticular Ganglion Cysts with Marsupialization

Mark Pinto and Stephen J. Snyder

Compression of the suprascapular nerve by a ganglion cyst has traditionally been treated with open excision. Previous studies have shown that debridement or repair of the glenoid labrum was required in the majority of patients with a spinoglenoid notch ganglion cyst. Due to the association of ganglion cysts with capsulolabral pathology and morbidity of open procedures, arthroscopic excision is a logical intervention to address ganglion cysts and other intraarticular pathology at the same time.

Indications

1. EMG and clinical findings consistent with compression neuropathy

2. Magnetic resonance imaging (MRI) demonstrating a ganglion cyst at the level of compression

3. Symptomatic labral tear

Contraindications

1. Ganglion cyst not amenable to arthroscopic excision due to location

2. Suprascapular nerve coursing over a ganglion cyst

Mechanism of Injury

The pathogenesis of ganglion cysts has not been clearly identified. Ganglion cysts are characteristically found juxtaposed to joints throughout the body. The suprascapular nerve is particularly vulnerable at the spinoglenoid notch. Some authors have suggested that ganglions are caused by joint fluid leaking through a weak area of the capsule in a one-way valve mechanism. Authors have described the association of ganglion cysts with glenoid labral tears (Fig. 21–1).

Physical Examination

1. Findings are nonspecific.

2. Vague dull shoulder pain, which is poorly localized.

3. Weakness to resisted external rotation may be noted alone or in combination with abduction.

4. Patients may present with painless infraspinatus wasting.

5. Cross-body adduction localizes pain to the posterior shoulder.

6. Direct palpation over the spinoglenoid and suprascapular notch may reproduce sharp pain.

7. Labral signs may or may not be present.

Diagnostic Tests

1. Plain radiographs should be obtained including an anteroposterior, axillary, and supraspinatus outlet to rule out bony lesions or erosion of bone by the cyst and degenerative arthritis.

2. MRI should be ordered to rule out a ganglion cyst. MRI accurately shows the size and location of ganglion cysts, which is critical in planning surgical intervention. MRI also shows associated intraarticular pathology such as labral or rotator cuff tears.

3. EMG/NCS to confirm the diagnosis and confirm the level of compression.

Preoperative Planning and Timing of Surgery

1. EMG to determine the site of compression

2. Careful review of the MRI to determine and plan the location of the arthroscopic capsulotomy

3. Early intervention if compression neuropathy confirmed

Special Instruments

1. Electrosurgical device

2. 4.0-mm shaver

3. 30-degree arthroscope

4. STaR® sleeve (Arthrex Incorporated, Naples, FL)

5. Labral repair equipment

6. Revo® anchor and tools (Linvatec Corporation, Largo, FL)