Journal of Hand Surgery (European Volume) http://jhs.sagepub.com/
Commentary on Lee et al. Osteophyte excision without cyst excision for a mucous cyst of the finger R. Page J Hand Surg Eur Vol 2014 39: 262 DOI: 10.1177/1753193413510663 The online version of this article can be found at: http://jhs.sagepub.com/content/39/3/262
Published by: http://www.sagepublications.com
On behalf of: British Society for Surgery of the Hand
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>> Version of Record - Feb 23, 2014 What is This?
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10663
JHS39310.1177/1753193413510663The Journal of Hand Surgery
JHS(E)
Commentary
The Journal of Hand Surgery (European Volume) 2014, Vol. 39E(3) 262 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1753193413510663 jhs.sagepub.com
Commentary on Lee et al. Osteophyte excision without cyst excision for a mucous cyst of the finger Most surgeons accept that mucous cysts arise because of degenerative changes in the distal interphalangeal or thumb interphalangeal (IP) joints. The size of the cyst and the extent of the arthritic changes in the joint are not directly related. There can be a wide range of presentations; a small cyst associated with gross joint changes at one end of the scale and a large thin-walled cyst with no obvious radiographic changes at the other. This situation has led to the suggestion of many surgical treatments for the condition; most involve removal of the cyst and some include attention to the degenerative joint. This article is unusual because it suggests that the cyst can be left and all attention is focussed on the distal interphalangeal joint osteophytes. In a consecutive series of mucous cysts, 80% will show osteophytes radiologically (Jamnadas-Khoda et al., 2009) and 20% have minimal changes. This procedure would probably be inappropriate in 20% of cases. In addition, if the cyst is small and can easily be excised with primary closure, it seems a little perverse to leave it in position. Most patients will complain about cosmetic disfigurement as well as discomfort, discharge and infection; all symptoms related to the cyst. No doubt an important step in this operation, although it is not emphasized by the authors, is that the cyst should be
drained at the point where it communicates with the distal interphalangeal joint capsule. If the cyst is not adequately drained, which could occur in the larger multilocular lesions, and reveals itself at the first dressing, some patients will be eager to seek an explanation. Perhaps ‘quilting’ sutures through the skin and cyst would inhibit a tendency to refill. Ganglia can decompress spontaneously with resolution of visible swelling, but what happens to the underlying tissues is uncertain. The authors obviously feel that the cyst follows the same process. Their technique does not result in a specimen for pathology to confirm the diagnosis beyond doubt. Even allowing for the short follow-up period, the article shows that osteophyte removal results in a low cyst recurrence rate, indicating that it should be undertaken regardless of the surgeon’s plan for the soft tissues. The proposed technique will find its place in the surgical options available for the treatment of this variable condition and will appeal to some because reconstruction on the dorsum of the distal phalanx, occasionally difficult, can be avoided. Reference Jamnadas-Khoda B, Agarwal R, Harper R, Page RE. Use of Wolfe graft for the treatment of mucous cysts. J Hand Surg Eur. 2009, 3(4): 519–21.
Downloaded from jhs.sagepub.com at UNIV OF GUELPH on November 18, 2014
R. Page Hand Surgeon, Sheffield, UK Email: [email protected]
Commentary on Lee et al. Osteophyte excision without cyst excision for a mucous cyst of the finger R. Page J Hand Surg Eur Vol 2014 39: 262 DOI: 10.1177/1753193413510663 The online version of this article can be found at: http://jhs.sagepub.com/content/39/3/262
Published by: http://www.sagepublications.com
On behalf of: British Society for Surgery of the Hand
Additional services and information for Journal of Hand Surgery (European Volume) can be found at: Email Alerts: http://jhs.sagepub.com/cgi/alerts Subscriptions: http://jhs.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Feb 23, 2014 What is This?
Downloaded from jhs.sagepub.com at UNIV OF GUELPH on November 18, 2014
10663
JHS39310.1177/1753193413510663The Journal of Hand Surgery
JHS(E)
Commentary
The Journal of Hand Surgery (European Volume) 2014, Vol. 39E(3) 262 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1753193413510663 jhs.sagepub.com
Commentary on Lee et al. Osteophyte excision without cyst excision for a mucous cyst of the finger Most surgeons accept that mucous cysts arise because of degenerative changes in the distal interphalangeal or thumb interphalangeal (IP) joints. The size of the cyst and the extent of the arthritic changes in the joint are not directly related. There can be a wide range of presentations; a small cyst associated with gross joint changes at one end of the scale and a large thin-walled cyst with no obvious radiographic changes at the other. This situation has led to the suggestion of many surgical treatments for the condition; most involve removal of the cyst and some include attention to the degenerative joint. This article is unusual because it suggests that the cyst can be left and all attention is focussed on the distal interphalangeal joint osteophytes. In a consecutive series of mucous cysts, 80% will show osteophytes radiologically (Jamnadas-Khoda et al., 2009) and 20% have minimal changes. This procedure would probably be inappropriate in 20% of cases. In addition, if the cyst is small and can easily be excised with primary closure, it seems a little perverse to leave it in position. Most patients will complain about cosmetic disfigurement as well as discomfort, discharge and infection; all symptoms related to the cyst. No doubt an important step in this operation, although it is not emphasized by the authors, is that the cyst should be
drained at the point where it communicates with the distal interphalangeal joint capsule. If the cyst is not adequately drained, which could occur in the larger multilocular lesions, and reveals itself at the first dressing, some patients will be eager to seek an explanation. Perhaps ‘quilting’ sutures through the skin and cyst would inhibit a tendency to refill. Ganglia can decompress spontaneously with resolution of visible swelling, but what happens to the underlying tissues is uncertain. The authors obviously feel that the cyst follows the same process. Their technique does not result in a specimen for pathology to confirm the diagnosis beyond doubt. Even allowing for the short follow-up period, the article shows that osteophyte removal results in a low cyst recurrence rate, indicating that it should be undertaken regardless of the surgeon’s plan for the soft tissues. The proposed technique will find its place in the surgical options available for the treatment of this variable condition and will appeal to some because reconstruction on the dorsum of the distal phalanx, occasionally difficult, can be avoided. Reference Jamnadas-Khoda B, Agarwal R, Harper R, Page RE. Use of Wolfe graft for the treatment of mucous cysts. J Hand Surg Eur. 2009, 3(4): 519–21.
Downloaded from jhs.sagepub.com at UNIV OF GUELPH on November 18, 2014
R. Page Hand Surgeon, Sheffield, UK Email: [email protected]
