Reconstructive Surgery

Ganglions are soft-tissue swellings and usually arise from the underlying joint capsule or tendon covering/sheath. They contain tick, gelatinous fluid, most commonly occur in women and present in young/middle age. The cause is unknown, but various theories hint towards a breach in the joint capsule with out-pouching of the joint capsule and its contents. They do not always precede trauma although are more common after repetitive activity. The most common sites are the back of the wrist, under the nail-folds and on the palmar surface of the fingers.

Due to their benign nature, the majority can be left alone unless they cause symptoms, restriction of movement or progressively increase in size. They can sometimes disappear spontaneously without any active treatment.

The dorsal (ba of the wrist) wrist ganglions can be occasionally associated with an underlying weakness in the wrist joint (scapho-lunate joint) and therefore need careful clinical examination and an MRI. If superficial and not involving the joint, they can be left alone or aspirated. Surgery if indicated ( especially if they recur after aspiration), involves meticulous removal of the whole swelling together with repair of the underlying wrist ligament if necessary.

The volar ganglions ( front of the wrist) can either be left alone or removed in their entirety with careful, microscopic dissection to free them from the adjacent radial artery and branches of the radial nerve.

Ganglions under the nail folds ( mucous cysts) are indicative of underlying joint arthritis and again need careful removal with a limited synovectomy to free the joint of active, inflammatory, synovial tissue.

Flexor sheath ganglions can again be left alone if trouble-free or removed under microscopic control to ensure complete excision and careful preservation of the adjacent neuro-vascular structures.

In all of the above, post-operative hand therapy and massage with splintage for a short period is mandatory in order to minimise swelling and facilitate early, safe and comfortable return to activity.

Dupuytren’s Disease (DD) is a thickening of the deep tissues of the palm and digits and commonly affects the ring and little fingers. Thickening and tightening of these bands produces cord-like structures which tighten the palm and also pull the digits into flexion and inwards, into the palm. The cause is multi-factorial, primarily involving a genetic predisposition with contributory factors including trauma, certain occupations, excessive alcohol intake, anti-epileptic medication. The condition is progressive and treatment involves splintage, injections for early, localised disease and surgery for advanced disease.

Early assessment, intervention and close follow-up is recommended for a particular group of patients with high susceptibility. These include patients with the following features:

• Positive family history
• Onset of disease in young adulthood
• Disease involving both hands, especially if the disease involves the thumb and index finger
• Rapid progression of the contracture and hence functional compromise
• Presence of disease outside the palmar aspect of hand i.e. on the soles of the feet, on the genitals and also on the knuckles of the digits

At the initial consultation, a detailed examination to establish extent is carried out together with a comprehensive functional assessment of the degree of functional compromise. Treatment is tailored to stage of disease, symptoms and level of functional deficit and ranges from injection with steroids and local anaesthetic for pain-relief, enzymatic degradation of specific single cords in selected cases to surgical removal of the diseased cords using contemporary, minimally-invasive techniques to minimise discomfort, swelling and encourage early return to activity and work.

Follow-up clinics are scheduled to suit patient’s time and work commitments and hand exercises, splintage, ultrasound massage and lymphatic drainage e are carried out by expert, accredited therapists to ensure a comfortable and speedy recovery.