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Treatment of Ganglion Cysts

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Abstract

Ganglion cysts are soft tissue swellings occurring most commonly in the hand or wrist. Apart from swelling, most cysts are asymptomatic. Other symptoms include pain, weakness, or paraesthesia. The two main concerns patients have are the cosmetic appearance of the cysts and the fear of future malignant growth. It has been shown that 58% of cysts will resolve spontaneously over time. Treatment can be either conservative or through surgical excision. This review concluded that nonsurgical treatment is largely ineffective in treating ganglion cysts. However, it advised to patients who do not surgical treatment but would like symptomatic relief. Compared to surgery, which has a lower recurrence rate but have a higher complication rate with longer recovery period. It has been shown that surgical interventions do not provide better symptomatic relief compared to conservative treatment. If symptomatic relief is the patient’s primary concern, a conservative approach is preferred, whilst surgical intervention will decrease the likelihood of recurrence.
Hindawi Publishing Corporation
ISRN Orthopedics
Volume , Article ID , pages
http://dx.doi.org/.//
Review Article
Treatment of Ganglion Cysts
Matthew Suen, B. Fung, and C. P. Lung
Department of Orthopaedics and Traumatology, University of Hong Kong Medical Centre, Queen Mary Hospital,
Pokfulam Road, Hong Kong
Correspondence should be addressed to Matthew Suen; msuen@student.unimelb.edu.au
Received  March ; Accepted  April 
Academic Editors: B. V. Darden and C. Mathoulin
Copyright ©  Matthew Suen et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Ganglion cysts are so tissue swellings occurring most commonly in the hand or wrist. Apart from swelling, most cysts are
asymptomatic. Other symptoms include pain, weakness, or paraesthesia. e two main concerns patients have are the cosmetic
appearance of the cysts and the fear of future malignant growth. It has been shown that % of cysts will resolve spontaneously over
time. Treatment can be either conservative or through surgical excision. is review concluded that nonsurgical treatment is largely
ineective in treating ganglion cysts. However, it advised to patients who do not surgical treatment but would like symptomatic
relief. Compared to surgery, which has a lower recurrence rate but have a higher complication rate with longer recovery period.
It has been shown that surgical interventions do not provide better symptomatic relief compared to conservative treatment. If
symptomatic relief is the patient’s primary concern, a conservative approach is preferred, whilst surgical intervention will decrease
the likelihood of recurrence.
1. Introduction
Ganglion cyst is the most common so tissue swelling in
handandwrist.Itoccursmostcommonlyonthedorsalside
of the wrist (%), followed by volar side (%) of wrist
and tendon sheath of ngers. Most of the ganglion cysts
are asymptomatic besides swelling. Most patients sought
advice and treatment because of the cosmetic appearance
or they were concerned that their ganglion was a malignant
growth []. Treatment options include reassurance, nonsurgi-
cal means like aspiration with or without steroid injections or
hyaluronidase and surgical excision. We review the treatment
outcomeofganglionintheliteratureandcomparetheir
recurrence and complication rates.
2. Methods
Electronic databases of Medline, PubMed, and the Cochrane
librariesweresearchedwiththekeywords“ganglion,”“con-
servative treatment,” “surgery” and “outcomes.” e inclusion
criteria were () publication in English and () articles
concerning the treatment of ganglion of hand and wrist.
Recurrence rate, complications, and functional outcome were
reviewed. References in review articles were screened for
potentially relevant studies not yet identied.
3. Reassurance
Majority of patients with ganglion do not have symptoms
besides swelling, while others may present with pain, weak-
ness, or paresthesia. Barnes et al. reported in their review that
only .% had symptoms other than a mass []. Westbrook
et al. also reported majority of patients sought advice and
treatment because of the cosmetic appearance or they were
concerned that their ganglion was a malignant growth, while
only % consulted because of pain and % consulted altered
sensation or restricted hand function [].
Many may not opt for any treatment if they are reassured
of the benign nature of the disease. Also, even for painful
ganglions, they cause less pain compared to other common
orthopaedic problems, like carpal tunnel syndrome and
osteoarthritis, in terms of Mean Visual Analogue Pain Scores
[].
e spontaneous resolution rate of untreated ganglion
ranged –% (Table )[]. erefore reassurance can be
the option if the patients do not want any intervention.
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FU Resolution rate
Carp and Stout   years / (%)
McEvedy  []  years / (%)
Zachariae and Vibe-Hansen  []  years / (%)
Dias and Buch  []months/(%)
Dias et al.  []  months / (%)
4. Conservative Treatment
4.1. Aspiration. Aspiration alone is one of the simplest ways
to treat ganglion. However, it has high recurrence rates. Most
of the studies showed more than half of ganglion treated with
aspiration alone will recur (Table )[]. Many methods
have been tried in order to increase the ecacy. Zubowicz and
Ishii reported a recurrence rate of % by repeated aspiration
up to three times. However, they also noticed the successful
rate decreased with those who needed repeated aspiration
[]. Multiple puncture of ganglion wall has not shown to
improve the result of simple ganglion aspiration [].
4.2. Steroid. Becker suggested the use of steroid injection
in treating ganglion, with % resolution rate, based on the
initial theory that chronic inammatory may take part in
the pathogenesis of ganglion. Subsequent studies showed
variable successful rate. Varley et al. conducted a randomized
controlled trial to aspiration with or without steroid and
concluded that additional injection of steroid is of no benet
and subcutaneous fat atrophy and skin depigmentation can
be the potential complications [].
4.3. Sclerotherapy. Sclerotherapy has been proposed to treat
ganglion. Sclerosant was injected into ganglion sac to damage
theintimalliningandcausebrosistoreducetherecurrence
rate. Initial study showed high successful rate ranging –
%.Mackieetal.,however,conrmedganglionhadno
intimal lining by histological studies and reported a failure
rate as high as %. Since there is communication between
ganglion and synovial joint, sclerosant might pass from gan-
glion to the joint and tendon and cause damage to them [].
Since the publication of these reports, the use of sclerotherapy
had declined. New technique had been developed with the
aim of causing ganglion sclerosis without the risk of damage
to the joints. G¨
um¨
us¸ used electrocautery to cause ganglion
sclerosis and showed favorite results. is technique had not
been widely adopted [].
4.4. Hyaluronidase. econtentofganglionmaybetoo
vigorous to be drawn, and thus aspiration may not be
complete. Some advocated the use of hyaluronidase, which
depolymerizes the hyaluronic acid present in ganglion con-
tent. Otu reported a % cure rate aer a follow-up period
of  months []. Paul and Sochart also showed that the
use of hyaluronidase in conjunction with steroid has resulted
in signicantly higher resolution rate compared to the use
of steroid alone, but only % of their patients treated by
hyaluronidase and steroid had complete resolution, com-
pared to % in those treated with steroid []. Akkerhuis et
al., however, reported a recurrence rate of %, for treatment
of ganglion with hyaluronidase []. us, the successful
rate had been variable, and hyaluronidase may cause allergic
reaction.
4.5. Immobilization. Immobilization following aspiration
had showed conicting results. Richman et al. showed that -
week immobilization aer aspiration and multiple puncture
had a signicantly higher successful rate for dorsal carpal
ganglion, but the result for palmar ganglion was inconclusive
[]. On the other hand, Korman et al. concluded that
immobilization did not signicantly improve the successful
treatment of ganglions over perforation and aspiration alone
and had the potential adverse eects of inconvenience,
economic repercussions, and stiness [].
4.6. reat Technique. Gang and Makhlouf introduce the
thread technique, by which two sutures were passed through
the ganglion at right angles to each other, and each was tied
in a loop. e contents of ganglion were expelled by massage
at interval. ey reported a recurrence rate of .%. However,
% of the patients had positive culture swabs []. Singhal et
al. described a similar technique, but the complete resolution
rate was only % [].
Takingintoaccountthatnearlyhalfoftheganglion
would resolve spontaneously, with such a high failure rate,
nonsurgical treatment of ganglion was generally ineective.
However, the complications were considered less (Table )
[]. Some reported zero percent of complication rates,
while others reported minor complications like transient
pain and swelling. erefore, nonsurgical treatment can be
considered to be an alternative way for symptomatic relief if
the patients do not want surgery.
Another advantage of conservative treatment is that
aspiration of ganglion contents conrms a benign diagnosis
and allays the patients’ fear and desire for further treatment.
5. Surgery
In , Angelides and Wallace []introducedthetech-
niques of excising the whole ganglion including the cyst, its
attachments to the scapholunate ligament, and the involved
segmentofjointcapsule,toreducetherecurrencerate.Itis
now considered to be the most eective technique.
5.1. Recurrence. According to the study conducted by Ange-
lides and Wallace, the recurrence rate can be as low as %.
However, subsequent recurrence rate of surgical excision
reported by the literatures was variable (Table )[,,,,
,,], with the range of –.%. ere were only
tworandomizedcontrolledtrialscomparingtherecurrence
rate of conservative treatment to surgery. Limpaphayom
and Wilairatana compared aspiration, steroid injection, and
immobilization with surgery, while Akkerhuis et al. com-
pared hyaluronidase with surgery. Both of them reported
surgery had a lower recurrence rate [,].
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FU Failure rate
Aspiration
Nield and Evans  []  year / (%)
Esteban et al.  []months()/(%)
Zubowicz and Ishii  []  year– months / (%)
Varley e t a l .   [ ]  months (–) / (%)
Stephen et al.  []  year / (%)
Aspiration with or without steroid
Dias and Buch  []years/(%)
Dias et al.  []  months / (%)
Steroid
Wrightetal.[]  years (– years) / (%)
Breidahl and Adler  []  months / (%)
Paul and Sochart  []  years / (%)
Varley e t a l .   [ ]  months (–) / (%)
Sclerotherapy
Mackie et al.  []  months / (%) Sclerosant (sodium tetradecyl disulphate)
Dogo et al.  [] – months / (.%) Sclerosant (hypertonic saline)
G¨
um¨
us¸[]  months (–) / (.%) Transcutaneous electrocauterization
Hyaluronidase
Otu  []months/(%)
Paul and Sochart  []  years / (%)
Akkerhuis et al.  []year/(%)
Aspiration + multiple puncture
Richman et al.  []  months / (%)
Korman et al.  []  year / (%)
Stephen et al.  []  year / (%)
Aspiration + multiple puncture + immobilization
Richman et al.  []  months / (%)
Korman et al.  []  year / (%)
Aspiration + steroid + immobilization
Limpaphayom and Wilairatana  []  months / (%)
read technique
Gang and Makhlouf  [] Min.  months / (.%)
Singhal et al.  []  years / (%)
Failure rate = recurrence + in complete resolution.
5.2. Complications. Complications for surgical excision in-
cluded wound infection, neuroma formation, hypertrophic
scar, median nerve, and radial artery damage, with complica-
tion rate ranging –% (Table )[,,,,,,
]. In Dias and Buch’s cohort study, surgery (%) had a
higher complication rate compared with aspiration (%) or
reassurance [].
Scapholunate instability has been reported aer dorsal
wrist ganglion excision. Some suggested periscaphoid liga-
mentous injury was a cause of ganglion rather than a com-
plication of surgery [,]. Kivett et al. examined 
postganglionectomy patients by physical examination and
radiography and concluded that ganglion excision did not de-
stabilise the wrist [].
5.3. Mobility and Other Outcomes. Surgery may not result
in favourable outcomes. Angelides et al. reported .% of
patients had – degree loss of volar exion aer surgery,
although this had no functional signicant []. Sanders
studied nine patients with occult dorsal ganglion. One out of
eight who attended followup had residual pain aer surgery,
whilethreeoutofeighthadlimitedmotion[]. Clay and
Clement reported that while surgery resulted in improvement
of pain in %, it worsen the pain in % of patients. %
of patients complained of weakened grip with % demon-
strating loss of grip strength of more than % compared
with opposite hand []. Residual pain, limited range of
motion, and weaken grip were also reported in other studies
(Table ).
ISRN Orthopedics
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Method Complication rate Complications
Esteban et al.  [] Aspiration 
Dias and Buch  [] Aspiration/steroid % Scar tender
Dias et al.  [] Aspiration/steroid / (.%)
Paul and Sochart  [] Steroid / (%) Supercial infection, mild localized
rash, and small area of depigmentation
Dogo et al.  [] Hypertonic saline % swelling, / severe pain
G¨
um¨
us¸[] Transcutaneous electrocauterization  cases of transient swelling and pain
Paul and Sochart  [] Hyaluronidase / (.%) Supercial infection
Richman et al.  [] Multiple puncture
Richman et al.  [] Immobilization 
Limpaphayom and Wilairatana  [] Immobilization
Gang and Makhlouf  [] read technique / (%) Positive culture swab
Singhal et al.  [] read technique / (%) Localized rash, mild restriction
T 
FU Recurrence rate
Open excision
Angelides and Wallace  [] Dorsal  months– years / (.%)
Janzon and Niechajev  []  years / (%)
Clay and Clement  [] Dorsal  months (– months) / (.%)
Wat son et al.  [ ,] Dorsal and palmar  years / (%)
Jacobs and Govaers  [] Palmar  months (–) / (%)
Wrightetal.[] Palmar  years (– years) / (%)
Filan and Herbert  [] Recurrent dorsal  months (–) / (%)
Hwang et al.  [] Dorsal / (.%)
Faithfull and Seeto  [] Dorsal and palmar  months (–) / (%)
G¨
undes¸ et al.  [] dorsal  months (–) .%
 volar .%
Akkerhuis et al.  [] Wrist and foot  months / (%)
Limpaphayom and Wilairatana  [] Dorsal  months / (%)
Kang et al.  [] Dorsal  months / (.%)
Rocchi et al.  [] Palmar  months / (%)
Arthroscopy + open
Dias and Buch  [] Palmar  years / (%)
Dias et al.  [] Dorsal  months / (%)
Arthroscopic resection
Osterman and Raphael  [] Dorsal / (%)
Luchetti et al.  [] Dorsal  months / (.%)
Ho et al.  []Dorsal  months (–) / (%)
Palmar . months (–) / (%)
Nishikawa et al.  [] Dorsal  months / (.%)
Shih et al.  [] Dorsal . months (–) / (%)
Rizzo et al.  [] Dorsal . months (–) / (.%)
Mathoulin et al.  []Dorsal  months (–) / (.%)
Palmar  months (–) / (%)
Rocchi et al.  [] Dorsal and palmar  months (–) / (.%)
Kang et al.  [] Dorsal  months / (.%)
Rocchi et al.  []Palmarmonths/(%)
Edwards and Johansen  [] Dorsal Min.  months / (%)
Chen et al.  [] Dorsal and palmar . months / (.%)
ISRN Orthopedics
T 
Complication rate
Open excision
Angelides and Wallace  [] Dorsal / (%) .% had – degree loss of volar exion
Janzon and Niechajev  []Notreported
Clay and Clement  [] Dorsal / (%)  had evidence of scapholunate dissociation
Wat son et al.  [ ,]DorsalandpalmarNotreported
Jacobs and Govaers  [] Palmar / (%)  had unsatisfactory scar ( had evidence of neuroma),
 had evidence of median nerve damage
Wrightetal.[] Palmar / (.) supercial infection, tendinitis, and pain dystrophy
Filan and Herbert  [] Recurrent dorsal Not reported
Hwang et al.  [] Dorsal / (%)  suture abscess,  loss of wrist exion of  degree, and
 transient neuropraxia
Faithfull and Seeto  []DorsalandpalmarNotreported
G¨
undes¸ et al.  [] dorsal .%  had evidence of radial nerve injuries
 volar %  had evidence of median nerve injuries,  had radial
artery injuries
Akkerhuis et al.  []WristandfootNotreported
Limpaphayom and Wilairatana  [] Dorsal / (%)
Kang et al.  [] Dorsal / (%)
Rocchi et al.  [] Palmar / (%)  radial artery injuries,  partial stiness of the wrist,
and  neuropraxia
Arthroscopy + open
Dias and Buch  []Palmar%
Dias et al.  [] Dorsal / (.%)  numbness,  scar tender, and  keloid
Arthroscopic resection
Osterman and Raphael  [] Dorsal / (%)
Luchetti et al.  [] Dorsal / (%)
Ho et al.  []Dorsal / (%)
Palmar / (%)
Nishikawa et al.  [] Dorsal / (%)
Shih et al.  []DorsalNotreported
Rizzo et al.  [] Dorsal / (%)  postoperative stiness
Mathoulin et al.  []Dorsal / (%)
Palmar / (.%) hematoma
Rocchi et al.  [] Dorsal and palmar / (.%)  radial artery injury,  haematoma, and  axonotmesis
Kang et al.  []Dorsal/(.%)
 neuropraxia
Rocchi et al.  [] Palmar / (%)  neuropraxia,  injury to a branch of the radial artery
Edwards and Johansen  [] Dorsal / (.%)  extensor tenosynovitis
Chen et al.  [] Dorsal and palmar / (.%)  case of transient paresthesia
T 
Residual pain Limited ROM Reduced grip power Loss of function
Sanders  []%%
Clay and Clement  [] Improved in %, worsen in % %
Wrightetal.[] .% .% %
Faithfull and Seeto  []%  %
Dias and Buch  []% %%
Dias et al.  []%%%
ISRN Orthopedics
T 
Mean
recovery time Time o work
Open
Janzon and Niechajev  []Majority –
days
Jacobs and Govaers  []
Majority –
days (median
. weeks)
Rocchi et al.  [] days  days
Open + arthroscopy
Dias and Buch  []. days
Dias et al.  []. days
Arthroscopy
Luchetti et al.  [] days
Nishikawa et al.  [] days
(–)
Rocchi et al.  [] days  days
Dias conducted two prospective cohort comparing the
outcomes of dorsal and palmar ganglions, respectively,
treatedbysurgerywiththosetreatedbyreassuranceand
aspiration. No signicant dierence was found in persistent
symptoms and symptom relief among three groups. However,
those treated with surgery had signicantly higher recov-
ery times, with averaged . days and . days o work
for palmar and dorsal wrist ganglion excision, respectively,
compared to averaged . days and . days for aspiration of
palmar and dorsal wrist ganglion [,](Table).
5.4. Arthroscopic Excision. In , Osterman and Raphael
described a technique of arthroscopic excision of dorsal wrist
ganglia. Arthroscopic resection has the potential advantages
of minimizing the surgical scar and permits evaluation of any
intra-articular pathologic condition of either midcarpal or
radiocarpal joints [].
Majority of initial reports on recurrence rate look more
favourable than open excision (Tables and ). However,
a prospective, randomized study in  showed rates of
recurrence with arthroscopic dorsal ganglion excision (/)
are comparable with and not superior to those of open
excision (/). Additional long-term comparative studies are
needed to accurately dierentiate the ecacy of open and
arthroscopic techniques [].
6. Conclusion
Majority of patients with ganglion do not have symptoms.
Given that the spontaneous resolution rate of ganglion can
be as high as %. Reassurance and observation can be the
option if the patients are asymptomatic or do not want any
intervention. Nonsurgical treatments of ganglion including
aspiration, steroid injection sclerotherapy, and hyaluronidase
were generally ineective. However, since they had lower
complication rates, they can be used for symptomatic relief
if the patients do not want surgery. Surgery had a lower
recurrence rate than conservative treatment. However it has
higher rates of complication and longer recovery period, and
therateofsymptomaticreliefmaynotbehigherthanother
treatments.
References
[] A. P. Westbrook, A. B. Stephen, J. Oni, and T. R. C. Davis, “Gan-
glia: the patient’s perception,JournalofHandSurgery,vol.,
no. , pp. –, .
[] W. E. Barnes, R. D. Larsen, and J. L. Posch, “Review of ganglia of
thehandandwristwithanalysisofsurgicaltreatment,Plastic
and Reconstructive Surgery,vol.,pp.,.
[] P. J. Tomlinson and J. Field, “Morbidity of hand and wrist gan-
glia,Hand Surgery, vol. , no. -, pp. –, .
[] B. V. McEvedy, “Simple ganglia,e British Journal of Surgery,
vol.,no.,pp.,.
[] L. Zachariae and H. Vibe-Hansen, “Ganglia. Recurrence rate
elucidated by a follow up of  operated cases,Acta Chirurgica
Scandinavica,vol.,no.,pp.,.
[] J. J. Diasand K. Buch, “Palmar wrist ganglion: does intervention
improve outcome: a prospective study of the natural histor y and
patient-reported treatment outcomes,Journal of Hand Surgery,
vol.,no.,pp.,.
[] J. J. Dias, V. Dhukaram, and P. Kumar, “e natural history of
untreated dorsal wrist ganglia and patient reported outcome
 years aer intervention,JournalofHandSurgery:European
Volume,vol.,no.,pp.,.
[] D.V.NieldandD.M.Evans,“Aspirationofganglia,Journal of
Hand Surger y,vol.,no.,p.,.
[] J.M.Esteban,Y.C.Oertel,M.Mendoza,andS.M.Knoll,“Fine
needle aspiration in the treatment of ganglion cysts,” Southern
Medical Journal,vol.,no.,pp.,.
[] V.N.ZubowiczandC.H.Ishii,“Managementofganglioncysts
of the hand by simple aspiration,Journal of Hand Surgery,vol.
,no.,pp.,.
[] G. W. Varley, M. Needo, T. R. C. Davis, and N. R. Clay, “Con-
servative management of wrist ganglia: aspiration versus steroid
inltration,Journal of Hand Surgery: European Volume,vol.,
no.,pp.,.
[] A. B. Stephen, A. R. Lyons, and T. R. C. Davis, “A prospective
study of two conservative treatments for ganglia of the wrist,
Journal of Hand Surgery: European Volume,vol.,no.,pp.
–, .
[] T. W. Wright, W. P. Cooney, and D. M. Ilstrup, “Anterior wrist
ganglion,Journal of Hand Surgery,vol.,no.,pp.,
.
[] W. H. Breidahl and R. S. Adler, “Ultrasound-guided injection of
ganglia with coricosteroids,Skeletal Radiology,vol.,no.,pp.
–, .
[] A.S.PaulandD.H.Sochart,“Improvingtheresultsofganglion
aspiration by the use of hyaluronidase,” JournalofHandSurgery:
European Volume,vol.,no.,pp.,.
[] I. G. Mackie, C. B. Howard, and P. Wilkins, “e dangers of scle-
rotherapy in the treatment of ganglia,JournalofHandSurgery,
vol. , no. , pp. –, .
[] D.Dogo,A.W.Hassan,andU.Babayo,“Treatmentofganglion
using hypertonic saline as sclerosant,West African Journal of
Medicine,vol.,no.,pp.,.
ISRN Orthopedics
[] N. G¨
um¨
us¸, “A new sclerotherapy technique for the wrist gan-
glion: transcutaneous electrocauterization,Annals of Plastic
Surgery,vol.,no.,pp.,.
[] A. A. Otu, “Wrist and hand ganglion treatment with hyaluroni-
dase injection and ne needle aspiration: a tropical African per-
spective,” JournaloftheRoyalCollegeofSurgeonsofEdinburgh,
vol. , no. , pp. –, .
[] M. J. O. Akkerhuis, M. van der Heijden, and P. R. G. Brink,
“Hyaluronidase versus surgical excision of ganglia: a prospec-
tive, randomized clinical trial,JournalofHandSurgery,vol.,
no. , pp. –, .
[] J. A. Richman, R. H. Gelberman, W. D. Engber, P. B. Salamon,
and D. J. Bean, “Ganglions of the wrist and digits: results of
treatmentby aspiration and cyst wall puncture,Journal of Hand
Surgery,vol.,no.,pp.,.
[] J. Korman,R . Pearl, and V. R. Hentz, “Ecacy of immobilization
following aspiration of carpal and digital ganglions,Journal of
Hand Surger y,vol.,no.,pp.,.
[] N. Limpaphayom and V. Wilairatana, “Randomized controlled
trial between surgery and aspiration combined with methyl-
prednisolone acetate injection plus wrist immobilization in the
treatment of dorsal carpal ganglion,JournaloftheMedical
Association of ailand,vol.,no.,pp.,.
[] R. K. Gang and S. Makhlouf, “Treatment of ganglia by a thread
technique,JournalofHandSurgery,vol.,no.,pp.,
.
[] R. Singhal, N. Angmo, S. Gupta, V. Kumar, and A. Mehtani,
“Ganglion cysts of the wrist: a prospective study of a simple out-
patient management,Acta Orthopaedica Belgica,vol.,no.,
pp. –, .
[] A. C. Angelides and P. F. Wallace, “e dorsal ganglion of the
wrist: Its pathogenesis gross and microscopic anatomy, and
surgical treatment,JournalofHandSurgery,vol.,no.,pp.
–, .
[] L. Janzon and I. A. Niechajev, “Wrist ganglia. Incidence and
recurrence rate aer operation,Scandinavian Journal of Plastic
and Reconstructive Surgery,vol.,no.,pp.,.
[] N.R.ClayandD.A.Clement,“etreatmentofdorsalwrist
ganglia by radical excision,Journal of Hand Surgery,vol.,no.
, pp. –, .
[] H.K.Watson,W.D.Rogers,andD.AshmeadIV,“Reevaluation
of the cause of the wrist ganglion,Journal of Hand Surgery,vol.
,no.,pp.,.
[] H.K.Watson,W.D.Rogers,andD.AshmeadIV,“Reevaluation
of the cause of the wrist ganglion,Journal of Hand Surgery,vol.
,no.,pp.,.
[] L. G. H. Jacobs and K. J. M. Govaers, “e volar wrist ganglion:
justasimplecyst?Journal of Hand Surgery,vol.,no.,pp.
–, .
[] S. L. Filan and T. J. Herbert, “Recurrent dorsal wrist ganglion:
aetiology and treatment,Hand Surgery,vol.,no.,pp.,
.
[] J.J.Hwang,C.A.Goldfarb,R.H.Gelberman,andM.I.Boyer,
“e eect of dorsal carpal ganglion excision on the scaphoid
shi test,Journal of Hand Surgery: European Volume,vol.,
no. , pp. –, .
[] D. K. Faithfull and B. G. Seeto, “e simple wrist ganglion—
more than a minor surgical procedure?” Hand Surgery,vol.,
no. , pp. –, .
[] H. G¨
undes¸, Y. Cirpici, A. Sarlak, and S. M¨
uezzinoglu, “Progno-
sis of wrist ganglion operations,” Acta Orthopaedica Belgica,vol.
, no. , pp. –, .
[] L. Kang, E. Akelman, and A. P. C. Weiss, “Arthroscopic versus
open dorsal ganglion excision: a prospective, randomized com-
parison of rates of recurrence and of residual pain,Journal of
Hand Surger y,vol.,no.,pp.,.
[] L.Rocchi,A.Canal,F.Fanfani,andF.Catalano,“Articulargan-
glia of the volar aspect of the wrist: arthroscopic resection com-
pared with open excision. A prospective randomised study,
Scandinavian Journal of Plastic and Reconstructive Surgery and
Hand Surger y,vol.,no.,pp.,.
[] A. L. Osterman and J. Raphael, “Arthroscopic resection of dorsal
ganglion of the wrist,” Hand Clinics,vol.,no.,pp.,.
[] R. Luchetti, A. Badia, M. Alfarano, J. Orbay, I. Indriago, and B.
Mustapha, “Arthroscopic resection of dorsal wrist ganglia and
treatment of recurrences,Journal of Hand Surgery,vol.,no.
,pp.,.
[] P.C.Ho,J.Griths,W.N.Lo,C.H.Yen,andL.K.Hung,“Cur-
rent treatment of ganglion of the wrist,Hand Surgery,vol.,
no. , pp. –, .
[] S. Nishikawa, S. Toh, H. Miura, K. Arai, and T. Irie, “Arthro-
scopic diagnosis and treatment of dorsal wrist ganglion,Journal
of Hand Surgery,vol.,no.,pp.,.
[] J.T.Shih,S.T.Hung,H.M.Lee,andC.M.Tan,“Dorsalganglion
of the wrist: results of treatment by arthroscopic resection,
Hand Surger y,vol.,no.,pp.,.
[] M. Rizzo, R. A. Berger, S. P. Steinmann, and A. T. Bishop,
Arthroscopic resection in the management of dorsal wrist
ganglions: results with a minimum -year follow-up period,
Journal of Hand Surgery,vol.,no.,pp.,.
[] C. Mathoulin, A. Hoyos, and J. Pelaez, “Arthroscopic resection
of wrist ganglia,Hand Surgery,vol.,no.,pp.,.
[]L.Rocchi,A.Canal,J.Pelaez,F.Fanfani,andF.Catalano,
“Results and complications in dorsal and volar wrist ganglia
arthroscopic resection,Hand Surgery,vol.,no.-,pp.,
.
[] S. G. Edwards and J. A. Johansen, “Prospective outcomes and
associations of wrist ganglion cysts resected arthroscopically,
Journal of Hand Surgery,vol.,no.,pp.,.
[] A.C.Y.Chen,W.C.Lee,K.Y.Hsu,Y.S.Chan,L.J.Yuan,andC.
H. Chang, “Arthroscopic ganglionectomy through an intrafocal
cystic portal for wrist ganglia,Ar throscopy,vol.,no.,pp.
–, .
[] W. E. Sanders, “e occult dorsal carpal ganglion,Journal of
Hand Surger y,vol.,no.,pp.,.
[] K. H. Duncan and R. C. Lewis, “Scapholunate instability follow-
ing ganglion cyst excision. A case report,Clinical Orthopaedics
and Related Research, no. , pp. –, .
[] W.F.Kivett,F.M.Wood,G.E.Rauscher,andN.A.Taschler,
“Does ganglionectomy destabilize the wrist over the long term?”
Annals of Plastic Surgery, vol. , no. , pp. –, .
... The most common soft tissue bulge in the hand and wrist is a ganglion cyst [1]. The dorsal side of the wrist (70%) and the volar side (20%) of the wrist most usually been affected, as well as the tendon sheath of the fingers. ...
... The majority of patients sought guidance and therapy because they felt self-conscious about their ganglion's appearance or were frightened that it was a cancerous growth [3]. Reassurance, nonsurgical therapies such as aspiration, steroid injections or hyaluronidase, and surgical removal are all possible options [1]. In this article, we aim to review the management options that were presented in the published literature. ...
... Most ganglion patients have no symptoms other than swelling, but some may have pain, weakness, or paresthesia [1]. In Barnes et al. study,only 19.5% showed symptoms other than a mass [12]. ...
... Nonsurgical treatments of ganglion, including aspiration, steroid injection sclerotherapy, and hyaluronidase, are generally ineffective, although they do have lower complication rates. Open surgical excursions have a lower recurrence rate, but they have higher complication rates and longer recovery periods [7,8]. The recurrence rate can be reduced when the pedicle of the ganglion is completely removed during surgery [8]. ...
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... Injection of hyaluronidase prior to aspiration leads to the breakdown of mucinous intracystic contents leading to more complete aspiration and fewer chances of recurrence. Aspiration followed by steroid injection is also considered useful as it disrupts the chronic inflammatory process leading to the formation of ganglion cysts (66). Cyst aspiration followed by cyst wall fenestration and subsequent injection of steroid using a large bore needle (14-18G) has also shown good efficacy (42). ...
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BACKGROUND: The occurrence of ganglion cysts around the elbow is rare, and the occurrence of these lesions without any symptoms of compression to the nearby structures is even rarer. Most published cases of elbow ganglions have reported patients with symptoms relating to compression of the radial nerve, or branches thereof secondary to anteriorly located cysts. We present two cases of ganglions occurring on the posterolateral aspect of the elbow with no pressure symptoms to the radial nerveCASE SERIES: The first case is a 33-year-old male, with a seven-month history of a spontaneous, slow-growing mass on the posterolateral aspect of his left elbow. The second case is a 38-year-old female, with a 12-month history of a spontaneous mass on the posterolateral aspect of her left elbow. In both cases, the reason for presentation was the unsightly elbow with an enlarging mass. The lesions were painless and both patients were neurologically intact with no restriction on range of motion of the joint. Both patients underwent excision of the mass for aesthetic reasonsDISCUSSION: Patients with elbow ganglions usually have cysts located anterior to the radiocapitellar joint and almost invariably present with an associated motor, or less commonly, a sensory deficit of the radial nerve. Various treatment modalities have been reported; however, the vast majority undergo open surgical excision due to their association with progressive neurological symptoms. This usually leads to resolution of symptoms, and recurrence is rareCONCLUSION: The clinical presentation of the two patients reported in this case series seems to be far less frequent than patients presenting with a neuropathy of the radial nerve due to an anteriorly located elbow ganglion. It cannot, however, be excluded that there is an underreporting of asymptomatic elbow ganglions. According to our review of the English literature, this is only the third report of an asymptomatic elbow ganglion in the lateral compartment of the elbowLevel of evidence: Level 5
Article
Purpose The treatment of ganglion cysts of the wrist remains understudied in the pediatric population, with the literature showing variable recurrence rates following different interventions. This study sought to determine whether surgical and nonsurgical management of pediatric ganglion cysts was associated with improved resolution rates when compared to observation alone. Methods We identified 654 cases of pediatric ganglion cysts treated across 5 institutions between 2012 and 2017. The mean age at presentation was 11.6 ± 5.2 years. Of the patients, 315 had >2 years (mean, 50.0 months) of follow-up, either via chart review or telephone callbacks. There were 4 different treatment groups: (1) observation, (2) cyst aspiration, (3) removable orthosis, and (4) surgical excision. Results For patients followed >2 years, the cyst resolved in 44% (72/163) of those observed. Only 18% (9/49) of those treated with aspiration resolved, and 55% (12/22) of those treated with an orthosis resolved. Surgical excision was associated with resolution of the cyst in 73% (59/81) of patients. Observation had higher rates of resolution compared to aspiration. Orthosis fabrication and observation had similar rates of cyst resolution. Surgery had the highest rates of resolution when compared to observation and aspiration. Patients older than 10 years were less likely to have the cyst resolve with observation (35%; 28/80) than those younger than 10 years (53%; 44/83) at >2 years of follow-up. Conclusions This study did not find evidence that nonsurgical treatments were associated with improved rates of cyst resolution compared to observation alone in a large pediatric sample. Surgical excision had the overall highest rate of resolution. Despite the costs and increased clinic time of orthosis fabrication and aspiration, these treatments were not associated with improved rates of cyst resolution in pediatric ganglion cysts compared to observation, with aspiration having higher rates of recurrence compared to observation. Type of study/level of evidence Therapeutic IV.
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Ganglion cysts of the psoas tendon are uncommon and rarely reported in the literature. Often they remain asymptomatic and are found incidentally or can be a cause of atypical groin/hip pain. We present a rare case of ganglion cyst in a child arising from the psoas tendon, causing symptomatic hip pain, which failed non-surgical treatment and eventually successfully treated with surgical excision.
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A retrospective study was conducted on arthroscopic ganglionectomy in wrists using a novel intrafocal cystic portal. The safety and efficacy of this technique were assessed by treatment of 15 wrists in 15 patients. Arthroscopic ganglionectomy was performed by the same surgeon with the patient under general anesthesia or regional block. Preoperative complaints, intraoperative findings, and postoperative results of all the patients were reported. The mean follow-up was 15.3 months. Functional assessment by use of modified Mayo wrist scores, patient satisfaction, and recurrence were included in the follow-up evaluation. Two thirds of the patients acquired good to excellent results, whereas the results for the remaining third were fair. Complications included 1 recurrence and 1 case of transient paresthesia sensation. The most common arthroscopic findings were capsular and ligament lesions, rather than ganglionic stalks. Arthroscopic ganglionectomy through an intrafocal cystic portal is a safe and efficacious option for the treatment of painful wrist ganglia. Level IV, therapeutic case series.
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Seven patients with symptomatic recurrent dorsal wrist ganglia were treated by excision of the origin of the ganglion from the scapholunate ligament combined with dorsal capsulorrhaphy. All patients presented with radial wrist pain associated with recurrent dorsal wrist ganglia. Examination revealed localised tenderness over the scapholunate joint with clinical signs of scaphoid instability in every case. Postoperatively, all patients reported pain relief and improved wrist function. There have been no recurrences, with an average follow-up of 14 months (range 12–22 months). Dorsal capsulorrhaphy appears to be a successful method of relieving symptoms, improving wrist function and preventing ganglion recurrence.
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Ganglion, a cystic benign mass, most common soft tissue tumor of the hand, usually occurs in hand, wrist, and foot. In this study, we discuss a new sclerotherapy technique through which 17 patients with wrist ganglion were treated by using short bursts of high-frequency low voltage electrodessication delivered through a fine electrode that was inserted into the sac. Their ages varied from 28 to 52 with an average of 32.7 years. Two patients had volar wrist and 15 others had dorsal ganglia. In all patients, an ultrasound imaging was done for the discrimination of the other hand tumors. Under aseptic conditions, first ganglion was aspirated by using a large needle, which was commonly used for peripheric venous catheterization, and 0.5 mL of 1% xylocaine was injected into the cystic cavity, then electrocauterization was done. In the postoperative follow-up ranging from 6 to 29 months, 1 recurrence developed 3 months after the intervention, requiring the same procedure to overcome it. No complication occurred and all complaints of the patients resolved with this approach. The present technique is simple, safe, effective, and inexpensive for ganglion sclerotherapy, resulting in hopeful outcomes to become as an acceptable alternative to the open surgery.
Article
To prospectively evaluate objective and subjective outcomes of arthroscopic dorsal wrist ganglion cyst resection, and to identify and examine intra-articular pathologies associated with ganglion cysts. We prospectively evaluated 55 patients with dorsal wrist ganglion cysts who underwent arthroscopic resection with a minimum follow-up of 24 months. Ten had recurrent ganglion cysts previously treated with open resection. Grip strength, wrist motion, and Disabilities of the Arm, Shoulder, and Hand questionnaire scores were evaluated preoperatively and at 6 weeks, 6 months, and 2 years postoperatively. Intraoperative findings were reviewed. In primary ganglion cysts a discrete stalk was present in 4 of 45 cases and diffuse cystic material and redundant capsular thickening were present in 38 of 45 cases. Cystic material appeared to arise from the radiocarpal joint exclusively in 11 of 42 cases, extended into the midcarpal joint in 29 of 42 cases, and arose exclusively from the midcarpal joint in 2 of 42 cases. The scapholunate joint demonstrated instability types I (2 of 45 cases), II (22 of 45 cases), III (20 of 45 cases), and IV (1 of 45 cases). The lunatotriquetral joint demonstrated instability types II (6 of 45 cases) and III (39 of 45 cases). At 6 weeks, average grip strengths increased by 5.9 kg and wrist flexion decreased 13 degrees . Preoperative Disabilities of the Arm, Shoulder, and Hand scores improved from 14.2 to 1.7 at 6 weeks and remained stable at 2 years. At 2 years, all patients demonstrated motion to within 5 degrees of preoperative measurements, and there were no recurrences. Patients experienced significant increases in function and decreases in pain within 6 weeks after arthroscopic ganglion cyst resection, and the recurrence and complication rates appear to be comparable to open resections. Ganglion cysts also have a high association with certain interosseous laxities, and recurrent ganglion cysts originating from the midcarpal joint are not contraindications for arthroscopic resection. Assessment of the midcarpal joint is necessary for complete resection of most ganglion cysts, and identification of a discrete stalk is an uncommon finding and not necessary for successful resection.
Article
Our aim was to compare two methods of treatment of ganglia on the volar aspect of the wrist (the open excision done through a longitudinal volar skin incision and the arthroscopic resection through two or three dorsal ports), to see if arthroscopy could reduce the risks of operating in this area and the time to healing. Twenty radiocarpal and five midcarpal volar ganglia were operated on by open approach and an equivalent group was treated by arthroscopy. Fifteen radiocarpal and five midcarpal ganglia were treated with good results in the open group and 18 radiocarpal and one midcarpal ganglia in the arthroscopic group (no visible or palpable ganglion, a full range of active wrist movement, grip strength equal to preoperatively, no pain, and a cosmetically acceptable scar). In the open group there were four injuries to a branch of the radial artery, two cases of partial stiffness of the wrist associated with a painful scar, one case of neuropraxia, and one recurrence (all of which were among the 20 radiocarpal ganglia). In the arthroscopic group there was one case of neuropraxia, one injury to a branch of the radial artery, and three recurrences (three of the complications were among the five midcarpal ganglia). The mean functional recovery time was equal to 15 (6) days in the open group and 6 (2) days in the arthroscopic group. The mean time lost from work was equal to 23 (11) days in the open group and 10 (5) days in the arthroscopic group. Our results suggest that arthroscopic resection is a reasonable alternative to open excision in treating radiocarpal volar ganglia because it has less postoperative morbidity and a better cosmetic result. Midcarpal volar ganglia, however, should still be treated by open operation.
Article
During a period of 25 years, 500 dorsal ganglions of the wrist were treated surgically. Three hundred and forty-six were followed for a minimum of 9 months; there were three recurrences. Dissection of the cysts under magnification of six to 25 times and serial microscopic studies showed evidence of a one way, valvelike system between the scapholunate joint and the ganglion. Stress, as a cause of ganglions, is suggested. Operative treatment involved excising all attachments to the scapholunate ligament.
Article
In a prospective study 69 carpal and digital ganglions were aspirated, multiply punctured, and digitally ruptured. Fifty percent of the wrists and digits were immobilized for 3 weeks and 50% were mobilized early. Follow-up was 1 year. Immobilization in our study did not significantly improve the results of treatment. During the course of the study, 51% of all ganglions did not recur. The outcome was successful in 52% of the wrists and digits that were immobilized and in 50% of those that were not. Forty-six percent of the dorsal carpal ganglions did not recur. Treatment was successful in 48% of dorsal carpal ganglions in which the wrists were immobilized and in 45% of those that were not. Similar percentages were found for palmar and digital ganglions. From our results, we conclude that immobilization does not significantly improve the successful treatment of ganglions over perforation and aspiration alone.
Article
In an attempt to provide an alternative non-invasive treatment to surgical excision of ganglion cysts of the hand, and as part of the departmental audit resulting from the prevailing economic depression, 340 consecutive patients with 349 ganglia were treated in a prospective investigation by intralesional injection of hyaluronidase (up to 150 units in 1 ml) followed by fine needle aspiration (FNA) of the cyst to dryness. Pressure was applied over a piece of gauze and maintained with a crepe bandage for 24 h. Of the 340 patients treated in this way, the vast majority (323 or 95.0%) were considered to be cured on clinical examination at 6-month follow-up; only 17 patients (5.0%) exhibited recurrence during this period and these were successfully treated by re-aspiration. To the knowledge of this author, this is the first report of the use of the enzyme hyaluronidase as an adjunct to FNA in the treatment of ganglion cysts of the hand. The results clearly show that this method of treatment is a safe, fast, well accepted and cost-effective alternative to surgical excision, which is relatively expensive and is known to be associated with certain complications, including hypertrophic scars and cheloids.