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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
ineective 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 identied.
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.
ISRN Orthopedics
T
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 ecacy. 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 inammatory 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 benet
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
theintimalliningandcausebrosistoreducetherecurrence
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 aer a follow-up period
of months []. Paul and Sochart also showed that the
use of hyaluronidase in conjunction with steroid has resulted
in signicantly 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 conicting results. Richman et al. showed that -
week immobilization aer aspiration and multiple puncture
had a signicantly 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 signicantly improve the successful
treatment of ganglions over perforation and aspiration alone
and had the potential adverse eects of inconvenience,
economic repercussions, and stiness [].
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 ineective.
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 conrms 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 eective 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 [,].
ISRN Orthopedics
T
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 aer 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 aer surgery,
although this had no functional signicant []. Sanders
studied nine patients with occult dorsal ganglion. One out of
eight who attended followup had residual pain aer 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
T
Method Complication rate Complications
Esteban et al. [] Aspiration
Dias and Buch [] Aspiration/steroid % Scar tender
Dias et al. [] Aspiration/steroid / (.%)
Paul and Sochart [] Steroid / (%) Supercial 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 / (.%) Supercial 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 / (.) supercial 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 stiness 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 stiness
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 signicant dierence was found in persistent
symptoms and symptom relief among three groups. However,
those treated with surgery had signicantly 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 dierentiate the ecacy 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 ineective. 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.
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