Efficacy of immobilization following aspiration of carpal and digital ganglions

Dorsal wrist ganglion: clinical and imaging correlation in symptomatic population based on high-field MRI

OBJECTIVES

To determine prevalence in the symptomatic population of dorsal mucoid cysts centered on dorsal capsuloscapholunate septum (DCSS) using high-field magnetic resonance imaging (MRI) for anatomoclinical and epidemiological correlations.

MATERIALS AND METHODS

This single-center retrospective study analyzed all 3-Tesla MRIs consecutively performed for painful wrists in 295 patients. Two blinded readers performed measurements. The protocol included T1 spin echo and 3D proton density sequences with fat saturation. Inter-observer reliability was assessed using kappa and intra-class correlation coefficients for cyst detection and volumetry, respectively. Disagreements concerning cyst detection were resolved by a consensus reading. Cyst size, relationship to extrinsic and scapholunate ligaments (SL), continuity of SL, minimum distance to the posterior interosseous nerve (PIN), cyst communication with joint, and anatomical classifications of cysts were analyzed. Correlation tests were performed to assess associations.

RESULTS

Two-hundred ninety-five patients (mean age 39.6 +/- 15.6 (standard deviation), 161 males) were evaluated for detection of dorsal wrist cysts identified in 150/295. In this subgroup, the mean age was 38.7 years (15-75), the sex ratio of 0.6 (59% women), and the median volume cyst of 8.7 mm3 (0.52-2555). Cyst detection, volume, and major axis measurements showed very high agreement between observers, respectively, 0.89, 0.96, and 0.91. 42 patients had dorsal SL pain. A weak negative correlation was found between distance to PIN and dorsal SL pain (r = -0.2415; p < 0.05) and a weak positive correlation between Guérini's classification and dorsal SL pain (r = 0.2466; p < 0.05).

CONCLUSION

High-field MRI is the modality of choice for the detection, anatomical, and volumetric assessment of dorsal cysts. Preoperative assessment will be aided by the proposed revised anatomical classification.

CLINICAL RELEVANCE STATEMENT

High-field MRI is the modality of choice for the anatomical study of dorsal ganglion cysts. It allows the radiologist to accurately describe the anatomical relationships, size, and visibility of the pedicle, essential information for the surgeon's preoperative assessment.

KEY POINTS

Dorsal mucoid wrist ganglion is a condition for which prevalence remains to be determined. High-field MRI is a reproducible imaging modality for the detection and assessment of dorsal wrist cysts. High-field MRI has a key role in the preoperative management of dorsal mucoid cysts.

Open Surgical Excision of Dorsal Wrist Ganglia: Puncturing the Dome Reduces Surgery Time

Background

The following study is retrospective and compared the operative time and complications using two techniques of surgical resection of primary dorsal wrist ganglia in adults.

Methods

Surgery was performed by the senior author (M.M.A.) through a transverse skin incision. The dome of the ganglion is dissected in both techniques. In the first technique (group A patients, n = 20 patients), dissection is continued to the base of the ganglion to reach the stalk near the scapho-lunate ligament. The stalk is transected and cauterized near the ligament. This surgical technique has been practiced by the senior author for 25 years. Over the last 5 years, the author has modified the technique (group B patients, n = 20 patients) by puncturing the dome of the ganglion following dome dissection. About two-thirds of the content of the ganglion is removed, and a mosquito is then used to close the puncture site. Dissection of the base of the ganglion to the stalk becomes easier and quicker, and the stalk is transected and cauterized near the scapho-lunate ligament.

Results

There was one recurrence in each group. Other complications were not seen in either group. The mean operative time (SD) was 30.75 (SD = 2.98) minutes for group A; and 20.75 (SD = 2.25) minutes for group B. An independent-samples t test was used to compare the operative time of both groups, which showed the difference was statistically significant (P < 0.001).

Conclusions

Our study showed that intentionally puncturing the dome of the ganglion makes the dissection of the base quicker, without increasing the risk of complications.

Effect of Mitomycin C on Recurrence of Ganglion Cysts in the Foot and Ankle

Ganglion cysts are among the most common benign soft tissue masses. Although surgery has been shown to be effective, ∼12% to 42% of cases with long-term follow-up have been reported to recur. The purpose of this study was to determine the impact of the topical application of mitomycin C used as an adjuvant to surgery on recurrence rate of ganglion cysts. A retrospective analysis was done on all patients surgically treated by 1 surgeon for ganglion cysts. The primary end point was local recurrence after the procedure, determined clinically and by ultrasound. Secondary outcomes included wound complication rate, adverse effects, and overall patient satisfaction. A total of 98 consecutive patients were included in this study and assigned to a study group in a nonrandomized manner. The control group (n = 52) consisted of patients who underwent surgical resection only. The study group (n = 46) consisted of patients who underwent surgical resection with application of topical mitomycin C. No patients were lost to follow-up. Of the 52 patients in the control group, 13 (25.0%) had recurrence of the ganglion cyst. In contrast, in the experimental study group, 2 patients (4.3%) had a recurrence. There was no difference in superficial wound infections between the 2 groups. In this study, we found that the use of topical mitomycin C as an adjuvant to surgical resection significantly reduced the recurrence rate. Wound infection and overall nonrecurrence complication rates were similar to those of other studies.

Surgical Treatment of Dorsal Carpal Ganglions: A Retrospective Clinical Trial

Objectives

Our primary goal in this study was to investigate whether the surgical treatment we performed on the patients with dorsal carpal ganglion was effective rather than evaluating preoperative and postoperative functional results.

Methods

The retrospective study included patients who were operated with open technique due to dorsal wrist ganglion at a single center between March 1, 2015, and December 1, 2017, and were followed for at least six months. Thirty-three wrists of 32 patients (31 unilateral and 1 bilateral) were operated. During follow-ups, complication rates, patient satisfaction, and recurrence rates were evaluated.

Results

Of the 32 patients, 19 were females and 13 were males. Mean age of the patients was 38.6 ± 13.0 years (min-max = 19-60 years). Excision was performed on 28 right and 5 left wrists. The follow-up period of patients varied between 6 months and 38 months (mean = 21.7 ± 9.4 months). Recurrence was detected in four (12.5%) patients during the postoperative period. Complex regional pain syndrome occurred in two (6.25%) patients. Joint stiffness developed in six (18.75%) patients during the postoperative period. When recurrent cases were excluded from our cases, the satisfaction rate was 87.5%.

Conclusions

Open surgical excision has satisfactory results that cannot be achieved with conservative treatment in the treatment of symptomatic dorsal ganglia. In order to keep the recurrence rate at the minimum level after surgery, it is critical to excise the ganglion and pedicle without leaving any residual tissue. Proper surgical technique improves patient satisfaction by eliminating pain and cosmetic discomfort.

Wrist Ganglia in Children: Nonsurgical Versus Surgical Treatment

PURPOSE

To compare the outcomes of nonsurgical and surgical treatment of children with wrist ganglia.

METHODS

We performed a retrospective review of children with wrist ganglia treated at 2 separate institutions. In one, a clinic setting, children were treated with observation. In the other, a hospital referral center, children had surgical excision. Information obtained included persistent or recurrent cyst, and Quick-Disabilities of the Arm, Shoulder, and Hand measure. Patients aged 17 years or less at the time of cyst appearance with at least 1 year of follow-up were included.

RESULTS

We successfully contacted 90 patients: 50 in the nonsurgical and 40 in the surgical group. Average follow-up was 4.6 years. The persistence rate in the nonsurgical group was 52%. The recurrence rate in the surgical group was 15%. In the nonsurgical group, if a ganglion resolved, it did so within 18 months in 94% of patients. Dorsal ganglions persisted more often than volar ones (63% vs 33%). Older children had a higher rate of persistence than did younger children (58% vs 31%). For children aged 10 or less, surgery was associated with a recurrence rate of 17%, compared with 31% persistence in the nonsurgical group. For children aged 11 and more, surgery was associated with a recurrence rate of 15%, compared with 58% persistence in the nonsurgical group. There was no significant difference between Quick-Disabilities of the Arm, Shoulder, and Hand scores in any group.

CONCLUSIONS

In a child with a wrist ganglion, if the cyst ultimately resolved, it usually did so within 18 months. Dorsal ganglion cysts and ganglion cysts in older children have a higher chance of persisting. In children treated with surgical excision, we found a 15% recurrence rate.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The Outcome of Treatment of Flexor Sheath (seed) Ganglia by a Percutaneous Partial Pulley Release

BACKGROUND

The aims of this study were to assess the safety and efficacy of a technique of partial percutaneous pulley release.

METHODS

A retrospective cohort study was undertaken treating adults with seed ganglia with a percutaneous pulley release. The patients were reviewed independently after a mean of 6 (range 6-36) months.

RESULTS

We treated 24 patients over a 3 year period. There were 14 women and ten men. The mean age was 39 (range 17-65) years. We were able to assess 21 patients with long term follow up. There was complete resolution in 14 (2/3) and partial resolution in four. The remaining three patients had persisting symptoms and requested open surgical excision. Apart from local tenderness and failure of resolution there were no complications of percutaneous pulley release.

CONCLUSIONS

Bursting or aspiration of flexor sheath ganglia appears to be the best primary treatment. If the ganglion recurs, this study suggests a percutaneous release is safe and will resolve the symptoms in most patients.

Ultrasound-Guided Therapy for Knee and Foot Ganglion Cysts

The present study evaluated the effectiveness of ultrasound-guided aspiration/injection of ganglion cysts in the lower extremities (knee and foot) that required referral to the radiology department for precise localization. The present study is the first series to describe such results. The study population consisted of 15 patients who had undergone treatment from April 2012 to January 2015. Follow-up was by telephone survey, which was performed at a mean of 15 ± 6 months after treatment. Almost 90% of patients experienced immediate improvement in symptoms (mostly pain), and 77% of these patients had not experienced a recurrence of symptoms at a mean follow-up time of 14 ± 6 months. In conclusion, ultrasound-guided therapy is a safe and potentially effective treatment for most cases of symptomatic lower extremity ganglion cysts.

Wrist ganglion treatment: systematic review and meta-analysis

PURPOSE

To review the clinical outcomes of treatment for adult wrist ganglions and to conduct a meta-analysis comparing the 2 most common options: open surgical excision and aspiration.

METHODS

The review methodology was registered with PROSPERO. We performed a systematic search of MEDLINE and EMBASE for articles published between 1990 and 2013. Included studies reported treatment outcomes of adult wrist ganglions. Two independent reviewers performed screening and data extraction. We evaluated the methodological quality of randomized controlled trials (RCT) and cohort studies using the Cochrane Handbook for Systematic Reviews and the Newcastle-Ottawa Scale, respectively; Grading of Recommendations, Assessment, Development, and Evaluation was used to evaluate the quality of evidence.

RESULTS

A total of 753 abstracts were identified and screened; 112 full-text articles were reviewed and 35 studies (including 2,239 ganglions) met inclusion criteria for data extraction and qualitative synthesis. Six studies met criteria for meta-analysis, including 2 RCTs and 4 cohort studies. In RCTs surgical excision was associated with a 76% reduction in recurrence compared with aspiration. Randomized controlled trial quality was moderate. In cohort studies surgical excision was associated with a 58% reduction in recurrence compared with aspiration. Cohort study quality was very low. In cohort studies aspiration was not associated with a significant reduction in recurrence compared with reassurance. Across all studies mean recurrence for arthroscopic surgical excision (studies, 11; ganglions, 512), open surgical excision (studies, 14; ganglions, 809), and aspiration (studies, 12; ganglions, 489) was 6%, 21%, and 59%, respectively. Mean complication rate for arthroscopic surgical excision (studies, 6; ganglions, 221), open surgical excision (studies, 6; ganglions, 341), and aspiration (studies, 3; ganglions, 134) was 4%, 14%, and 3%, respectively.

CONCLUSIONS

Open surgical excision offers significantly lower chance of recurrence compared with aspiration in the treatment of wrist ganglions. Arthroscopic excision has yielded promising outcomes but data from comparative trials are limited and have not demonstrated its superiority. Further RCTs are needed to increase confidence in the estimate of effect and to compare complications and recovery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Dorsal wrist ganglion: Current review of literature

Ganglion cyst is the most common soft tissue tumour of hand. Sixty to seventy percent of ganglion cysts are found in the dorsal aspect of the wrist. They may affect any age group; however they are more common in the twenties to forties. Its origin and pathogenesis remains enigmatic. Non-surgical treatment is unreliable with a high recurrence rates. Open surgical excision leads to unsightly scar and poor outcome. Arthroscopy excision has shown very promising result with very low recurrence rate. We reviewed the current literature available on dorsal wrist ganglion.

Treatment of ganglion cysts

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.

Surgery for ganglia of the flexor tendon sheath

There are very few reports in the literature on the results of surgery for ganglia of the flexor tendon sheaths of the digits. We reviewed 24 patients operated for flexor tendon sheath ganglia 8 (3-11) years previously. Two operations were for recurrences and one of these recurred again. There was one permanent digital nerve injury and one patient complained of cold sensibility. VAS (0=best; 100=worst) for mean general complaints from the hand was remembered as 51 before surgery and was 5 at review. Mean pain at review was reported as VAS 4 and general satisfaction with the operation as VAS 3. All stated that they would have consented to surgery if they had known the outcome in advance. We conclude that the results of surgery are good, although complications do occur.

PREDICTING SUCCESSFUL OUTCOMES OF WRIST AND FINGER GANGLIA

Introduction: Ganglia are the commonest cause of swellings of the hand and wrist; the documented success of outcomes varies considerably. There is little published data to help predict patients likely to benefit from each treatment modality. We sought to identify factors predicting success of each intervention to provide an evidence basis to inform referral criteria and treatment decisions. Materials and Methods: A retrospective series of 140 serial patients referred with confirmed hand and wrist ganglia between June 2005 and January 2011 was studied to a minimum of 12-month follow-up to determine predictors of successful treatment. Treatment was deemed to be successful if the patient did not develop recurrence. Analysis was completed for predictors of successful treatment at presentation; examining gender, presence of pain, duration of symptoms, anatomic location and treatment modality. Results: Treatment success rate following aspiration was 34% for wrist and 58% for finger ganglia and for surgical excision 7% for wrist and 4% for finger ganglia. Surgical excision was significantly more successful than aspiration (p < 0.01). Duration of symptoms greater than one year was significantly associated with increased recurrence rates (relative risk 2.33, p < 0.05) and male sex was associated with lower recurrence (relative risk: 0.54, p = 0.14). Subgroup analysis of different varieties of soft tissue ganglia did not show any statistically significant factors predictive of recurrence, although both painless presentation and male sex were of borderline significance. Discussion and Conclusions: Duration of symptoms less than one year and male sex can be used to identify patients likely to benefit from interventional treatments and guide treatment decisions. Surgical excision was significantly more successful than aspiration (p < 0.01).

Methylene blue-enhanced arthroscopic resection of dorsal wrist ganglions

The ganglion is the most common soft tissue mass of the hand and wrist. Over the past 10 to 15 years, there has been a growing interest in arthroscopic treatment of dorsal wrist ganglions. Proposed advantages of arthroscopy include greater motion (particularly wrist flexion), improved cosmesis, and potential to identify/treat other intra-articular pathology. Despite the documented clinical success of arthroscopic ganglion excision, limitations include inconsistent identification of the ganglion stalk. Our described technique offers a means by which to improve visualization of the ganglion stalk intra-articularly to produce a more effective and efficient arthroscopic ganglion excision. During the procedure, a small volume of methylene blue solution is injected into the cyst. Its communication with the joint is apparent arthroscopically, thus identifying the location of the stalk. With the ability to precisely identify the ganglion stalk using an injection of methylene blue, the surgeon can direct the arthroscopic debridement toward the appropriate pathologic tissue. Unnecessary debridement of uninvolved tissue can be avoided with the technique. This also allows for optimal portal placement and, in particular, indicates whether a midcarpal portal should be employed. This should result in fewer recurrences, decreased operative time, and less iatrogenic injury.

FLEXOR TENDON SHEATH GANGLION: ANALYSIS OF 128 CASES

A 30-year analysis of 128 patients with flexor tendon sheath ganglion was investigated. The majority of patients were females with sex ratio of 2.6 : 1. Most of the patients are in their third to fifth decade of life. Hand dominance, previous trauma as well as other illnesses involving the hand did not show any correlation to the formation of ganglion. The middle finger was most commonly affected and 69% of the ganglion were located on A1 and A2 pulley. Recurrence was high (89%) after multiple percutaneous puncture and treatment was successful with no cases of recurrence after surgical excision.

Ganglion cysts of the wrist: pathophysiology, clinical picture, and management

This article reviews what is known about ganglion cyst formation, natural history (50% of cysts will spontaneously resolve), diagnosis, and management of this common malady. Although the exact mechanism of cyst formation is unknown, most current theories hold that extra-articular mucin “droplets” coalesce to form the main body of the tumor. Only subsequently are the “cyst wall” and pedicle (connecting the cyst to a nearby synovial joint) formed. Treatment options include watchful waiting, nonoperative aspiration/injection, and surgical removal. Although treatment is often unnecessary, many patients seeking consultation desire some form of definitive treatment. Cyst aspiration/injection is fraught with a high incidence of recurrence. Surgery generally results in lower rates of recurrence, but a higher incidence of complications. All current treatment options are suboptimal.

The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention

We have evaluated the long-term outcome of excision, aspiration and no treatment of dorsal wrist ganglia prospectively in 236 (83%) of 283 patients who responded to a postal questionnaire at a mean of 70 months. The resolution of symptoms was similar between the treatment groups (p>0.3). Pain and unsightliness improved in all three treatment groups. The prevalence of weakness and stiffness altered only slightly in all three treatment groups. More patients with a recurrent, or persistent ganglion complained of pain, stiffness and unsightliness (p<0.0001). Patient satisfaction was higher after surgical excision (p<0.0001), even if the ganglion recurred. Twenty-three of 55 (58%) untreated ganglia resolved spontaneously. The recurrence rate was 58% (45/78) and 39% (40/103) following aspiration and excision, respectively. Eight out of 103 patients had complications following surgery. In this study, neither excision nor aspiration provided significant long-term benefit over no treatment.

Flexor tendon sheath ganglions: results of surgical excision

The purpose of our study was to review the clinical features and determine the results following surgical excision of a flexor tendon sheath ganglion. A retrospective analysis of 24 consecutive patients (25 ganglions) who underwent excision of a painful flexor tendon sheath ganglion by the same surgeon was performed. The patient's medical and operative records were reviewed. Each patient was invited to return for an evaluation, which consisted of a clinical interview, completion of a questionnaire, and physical examination. Those patients that were unable to return underwent a detailed telephone interview. Sixteen patients returned for a clinical evaluation, while eight patients underwent a telephone interview. There were 15 women and nine men, with an average age of 43 years (range, 21-68 years). The dominant hand was involved in 15 patients. The long finger was most commonly involved (11 cases). The ganglion arose from the A1 pulley in 13 cases, between the A1 and A2 pulleys in three cases, and from the A2 pulley in nine cases. At an average follow-up of 18.5 months (range, 5-38 months), all of the patients were satisfied with their final result. No patient developed a recurrence and all returned to their previous functional level. There were two minor complications that resolved uneventfully; one patient experienced mild incisional tenderness, while an additional patient experienced transient digital nerve paresthesias. We conclude that surgical excision is a simple, safe, and effective method for treating a painful ganglion of the digital flexor tendon sheath.

Ganglion cysts and other tumor related conditions of the hand and wrist

Most regard ganglion, giant cell tumor of tendon sheath and epidermal inclusion cysts as tumor-like conditions as opposed to true neoplasms. Ganglion cysts are the most common lesion of the hand and wrist, accounting for 50% to 70% of all masses identified. The majority of ganglion cysts can be treated nonoperatively but when surgery is performed a low recurrence rate can be anticipated. Giant cell tumor of the tendon sheath hand epidermoid cysts are also common hand lesions that require surgical excision in most instances. Of the three, giant cell tumor of tendon sheath have the most notable recurrence rates. This article reviews the clinical presentations of these lesions as well as their proposed pathophysiology.

Ganglion-associated ulnar tunnel syndrome treated by ultrasonographically assisted aspiration and splinting

We describe a case of ulnar nerve compression at the wrist due to a ganglion. This was treated by aspiration of the ganglion under ultrasonography and splinting because the patient was pregnant. The ulnar nerve palsy resolved completely and the ganglion disappeared. A follow-up ultrasonographic examination after 2 years showed no recurrence of the ganglion.

Current treatment of ganglion of the wrist

Ganglion of the wrist is one of the the most common lesions of the hand. The cause of pain in an occult dorsal wrist ganglion has been linked to compression of the posterior interosseous nerve at the wrist. A case is presented in this paper and the pathoanatomy discussed. Ultrasound-guided aspiration after hyaluronidase instillation provided a useful alternative to surgery with a high success rate. Arthroscopic decompression for dorsal and palmar wrist ganglia offered the patient the benefit of smaller surgical scars and a high success rate. A description of the surgical techniques, pathoanatomy, and early results of the authors and a review of the literature is presented.

Ganglions of the hand and wrist

Ganglions of the hand and wrist are common benign lesions. They most frequently arise adjacent to joints and tendons, but may also be intratendinous or intraosseous. Treatment options include observation, aspiration, and surgical excision. Observation is acceptable in most instances. Indications for more aggressive treatment include pain, interference with activity, nerve compression, and imminent ulceration (in the case of some mucous cysts). The recurrence rate after puncture and aspiration is greater than 50% for cysts in most locations, but is less than 30% for cysts in the flexor tendon sheath. Surgical excision is effective, with a recurrence rate of only 5% if care is taken to completely excise the stalk of the cyst along with a small portion of joint capsule. Surgical treatment of occult ganglions is successful with accurate assessment of the source of the pain. Arthroscopic treatment of dorsal wrist ganglions is still experimental, but early results are encouraging. Ganglion surgery requires a formal operative environment and careful technique in order to minimize injury to adjacent structures and minimize the likelihood of recurrence.

Treatment of Carpal and Digital Ganglions by Simple Aspiration, or Aspiration and Injection of Corticosteroid And/Or Hyaluronidase

This retrospective study examined the treatment outcome of 178 carpal and digital ganglion cysts by simple aspiration or aspiration and injection of corticosteroid (triamcinolone acetonide 40 mg/mL) and/or hyaluronidase in 174 patients between 1987 and 1995. A total of 106 ganglions were treated with aspiration and triamcinolone acetonide injection; the cumulative cure rates were 45.3%, 50.0% and 53.8% following one, two or three treatments, respectively. The cure rates were similar in 23 ganglions in the hyaluronidase group: 43.5%, 52.2% and 56.5%, respectively. Seventeen of the 23 ganglions treated with a combination of triamcinolone acetonide and hyaluronidase recurred, yielding success rates of 17.4% and 26.1% following two or three treatments, respectively. Twenty-six ganglions were treated with simple aspiration. Of these, 23 were volar digital ganglions. The success rates were 61.5% and 69.2% following one or two treatments, respectively. The overall success rate was 94 of 178 (52.8%) after a maximum of three treatments, regardless of the type of treatment and the anatomical location of the ganglions. This study provided baseline data following nonoperative management of ganglions; the data can be compared with those from a planned prospective randomized clinical trial involving the use of rolitetracycline as a sclerosing agent, which is currently under review by the Ethics Committee at the authors’ institution.

Treatment of flexor tendon sheath ganglions using ultrasound imaging

Forty-one patients with a symptomatic digital mass or swelling of suspected ganglionic origin were examined by ultrasound. Findings were classified into 4 groups: group 1, solitary cyst appearing as a well-defined solitary oval anechoic mass (27 digits); group 2, multiple cysts having multiple oval anechoic masses (3 digits); group 3, solid tumor indicating a heterogeneous hypoechoic mass (6 digits); and group 4, tenosynovitis with no abnormal echoic mass (5 digits). Treatment was determined by lesion classification. In group 1, 26 of the 27 solitary cysts were punctured, and a jellylike material was aspirated from 24 cysts. Postaspiration ultrasound examination revealed that a cyst was still present in 2 cases, and these were excised surgically. In group 2, all the cysts were surgically removed. A ganglion with multiple cysts was confirmed on pathological examination. In group 3, the lesions were removed surgically; among the diagnoses were tendon sheath ganglion, giant-cell tumor of tendon sheath, neurilemmoma, and hemangioma. In group 4, no abnormal masses had appeared at follow-up examination. The 24 patients whose ganglions were treated by aspiration, as well as the 8 patients whose ganglions were excised, were monitored for more than 12 months. None of these 32 patients experienced residual pain or lesion recurrence. These results indicate that ultrasound is useful, in cases in which flexor tendon sheath ganglion are suspected, for assisting in diagnosis and determining whether patients should undergo aspiration or surgical excision.