Ganglionectomy without repairing the bursal defect: long-term results in a series of 124 wrist ganglia

Surgical and Patient-Centered Outcomes of Open versus Arthroscopic Ganglion Cyst Excision: A Systematic Review

Introduction  As the popularity of wrist arthroscopy grows, it continues to prove useful in the treatment of ganglion cysts. Previous studies comparing an arthroscopic technique to traditional open excision have demonstrated generally equivalent results regarding complications and cyst recurrence. However, this systematic review compares the two treatment methods not only regarding cyst recurrence but also regarding patient-centered outcomes. Additionally, new studies in the available literature may allow for further analysis. Methods  This systematic review identified 23 articles published between 2000 and 2021 that met inclusion criteria. Articles were assessed for quality, and reported cyst recurrence rates, patient satisfaction, patients' preoperative and postoperative pain, and complications associated with either open or arthroscopic excisions were pooled into open excision and arthroscopic excision groups for analysis. Results  In total, 23 studies accounted for 1,670 cases. Pooled data for patient-centered outcomes indicated a significantly higher patient satisfaction rate (89.2 vs 85.6%, p  < 0.001) and higher reported pain relief (69.5 vs. 66.7%, p  = 0.011) associated with arthroscopic excision versus open excision. Recurrence rates were also significantly lower for the arthroscopic excision group (9.4 vs. 11.2%, p  < 0.001). Overall, the complication rate was significantly lower for arthroscopic excision (7.5 vs. 10.7%, p  < 0.001), but the complication profile distinctly differed between the two methods. Conclusions  Both arthroscopic and open excision of dorsal wrist ganglions are viable treatment options. However, the results of this meta-analysis suggest benefits associated with the arthroscopic technique in both patient-centered outcomes and in traditional, surgical outcomes. This may prove advantageous as wrist arthroscopy becomes more common.

Minimizing Costs for Dorsal Wrist Ganglion Treatment: A Cost-Minimization Analysis

PURPOSE

Dorsal wrist ganglions are treated commonly with aspiration, or open or arthroscopic excision in operating room (OR) or procedure room (PR) settings. As it remains unclear which treatment strategy is most cost-effective in yielding cyst resolution, our purpose was to perform a formal cost-minimization analysis from the societal perspective in this context.

METHODS

A microsimulation decision analytic model evaluating 5 treatment strategies for dorsal wrist ganglions was developed, ending in either resolution or a single failed open revision surgical excision. Strategies included immediate open excision in the OR, immediate open excision in the PR, immediate arthroscopic excision in the OR, or 1 or 2 aspirations before each of the surgical options. Recurrence and complications rates were pooled from the literature for each treatment type. One-way sensitivity and threshold analyses were performed.

RESULTS

The most cost-minimal strategy was 2 aspiration attempts before open surgical excision in the PR setting ($1,603 ± 1,595 per resolved case), followed by 2 aspirations before open excision in the OR ($1,969 ± 2,165 per resolved case). Immediate arthroscopic excision was the costliest strategy ($6,539 ± 264 per resolved case). Single aspiration preoperatively was more cost-minimal than any form of immediate surgery ($2,918 ± 306 and $4,188 ± 306 per resolved case performed in the PR and OR, respectively).

CONCLUSIONS

From the societal perspective, performing 2 aspirations before surgical excision in the PR setting was the most cost-minimal treatment strategy, although in reference to surgeons who do not perform this procedure in the PR setting, open excision in the OR was nearly as cost-effective. As patient preferences may preclude routinely performing 2 aspirations, performing at least 1 aspiration before surgical excision improves the cost-effectiveness of dorsal wrist ganglions treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic Decision Analysis II.

Volar Ganglion Cyst and Echo-Guided Assistance for the Arthroscopic Removal

The ganglion of the wrist is very common but with uncertain prognosis. The arthroscopic resection seems to improve the result compared with open procedure, in decreasing recurrence and morbidity. Volar ganglions are close to the radial artery, the flexor pollicis longus tendon, and even the median nerve. Ultrasonography combined with arthroscopy offers incomparable safety for the resection of volar ganglions. The technical steps of this combined procedure are described, and the first published series are discussed.

The Effect of Tourniquet Usage and Anesthesia Method on Prognosis in the Treatment of Dorsal Wrist Ganglion Cysts by Open Surgery

Introduction

Ganglion cysts are the most common soft tissue masses seen on the wrist, which often cause pain or cosmetic complaints. The treatment of these masses includes intra-cystic injections or surgery. Recurrence rates are very high in surgical or non-surgical treatment. Inadequate excision for recurrence after surgery is blamed; however, the reasons for the recurrence still remain mysterious.

Objectives

In this study, the effect of anesthesia selection and tourniquet use on the dorsal wrist ganglion cysts in open surgery was investigated.

Materials and methods

Patients with dorsal wrist ganglion cysts, who were operated with open surgery between 2015 and 2018 and who had at least six months after the surgery, were examined. The patients were divided into two groups: patients who underwent surgery without tourniquet with local anesthesia and patients operated with tourniquet with general or regional anesthesia. Age, sex, cause of operation, visual analog scale (VAS) scores before and after surgery, limitation of movement, postoperative complications, and recurrence were compared.

Results

There was no significant difference between the groups in terms of causes of surgery, recurrence rates, preoperative and postoperative limitations of movement, and complications. In terms of age, the group operated with local anesthesia and without tourniquet was significantly larger. There was also no significant difference between the groups in terms of preoperative pain. Postoperative pain was significantly less in the group operated by tourniquet with general-regional anesthesia.

Conclusion

There is no significant difference in the recurrence and complications between patients operated under local anesthesia without tourniquets and patients operated with tourniquets under general or regional anesthesia during the open excision of the dorsal wrist ganglion cysts. However, it should be kept in mind that postoperative pain does not diminish in later ages, especially in cases of ganglion cysts, and other pathologies may also potentially cause pain in the wrist.

Outcomes of Open Dorsal Wrist Ganglion Excision in Active-Duty Military Personnel

PURPOSE

To examine the most common presenting complaints of active-duty service members with isolated dorsal wrist ganglions and to determine the rate of return to unrestricted duty after open excision.

METHODS

Surgical records at 2 military facilities were screened to identify male and female active duty service members undergoing isolated open excision of dorsal wrist ganglions from January 1, 2006 to January 1, 2014. Electronic medical records and service disability databases were searched to identify the most common presenting symptoms and to determine whether patients returned to unrestricted active duty after surgery. Postoperative outcomes examined were pain persisting greater than 4 weeks after surgery, stiffness requiring formal occupational therapy treatment, surgical wound complications, and recurrence.

RESULTS

A total of 125 active duty military personnel (Army, 54; Navy, 43; and Marine Corps, 28) met criteria for inclusion. Mean follow-up was 45 months. Fifteen percent (8 of 54) of the Army personnel were given permanent waivers from performing push-ups owing to persistent pain and stiffness. Pain persisting greater than 4 weeks after surgery was an independent predictor of eventual need for a permanent push-up waiver. The overall recurrence incidence was 9%. No demographic or perioperative factors were associated with recurrence.

CONCLUSIONS

Patients whose occupation or activities require forceful wrist extension should be counseled on the considerable risk of residual pain and functional limitations that may occur after open dorsal wrist ganglion excision.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Surgery for wrist Ganglia: one-hundred and twenty-two patients reviewed 8 years after operation

Wrist ganglia give few symptoms, but are a common reason for referral to a hand surgeon. We studied patient long-term satisfaction after operation. We reviewed 122 patients, who were operated for dorsal (n=82) and volar (n=40) wrist ganglia 8 years before (range 3-11). Three radial arteries were injured during surgery for volar a ganglion. By the time of review 33 patients (27%) had a recurrence or had been re-operated. Radical surgery did not reduce the recurrence rate significantly. Reported general complaints from the wrist improved from a mean visual analogue scores (VAS, 0=best; 100= worst) of 56 before surgery to VAS 14 at review and unsightliness from VAS 50 to VAS 14. Patients were equally happy with transverse and longitudinal scars. Ten patients (8%) stated that they would not have consented to surgery if they had known the outcome in advance. We conclude that, in spite of a high recurrence rate, most patients are happy with the results of surgery.

Inflammatory mediators in posttraumatic radiocarpal osteoarthritis

PURPOSE

To identify the mediator profile in healthy, pre-osteoarthritis (OA) and end-stage OA radiocarpal joints. We hypothesized that there would be an increase in soluble mediators in posttraumatic wrist OA.

METHODS

We obtained radiocarpal synovial fluid samples from 3 groups of patients: healthy control (n = 12) samples were collected during wrist ganglion resection; pre-osteoarthritic (n = 16) samples, during a 3-ligament tenodesis procedure for complete scapholunate dissociation; and end-stage OA (n = 20) samples in patients with proven radiological OA changes. Using a multiplex enzyme-linked immunosorbent assay, we measured 12 mediators: interleukin (IL)-1β, tumor necrosis factor-α, oncostatin-M, interferon-γ, IL-4, IL-6, IL-7, IL-8, IL-10, IL-13, IL-1RA, and osteoprotegerin. Statistical analysis was performed using analysis of variance and Bonferroni-corrected post hoc tests.

RESULTS

Mediators IL-6, IL-10, and interferon-γ were increased in OA wrists compared to healthy and pre-OA samples. Tumor necrosis factor-α, oncostatin-M, osteoprotegerin, IL-8, and IL-1RA were detected but not at increased levels in OA wrists. We found no differences between healthy and pre-OA joints in all 12 mediators. Mediators IL-4, IL-7, IL-13, and IL-1β were not detected in either healthy, pre-OA or end-stage OA samples.

CONCLUSIONS

We identified no differences between healthy and pre-OA samples, suggesting no alteration in inflammatory status at the time of the 3-ligament tenodesis procedure. Consequently, mechanical disturbance seems to be the driving force toward OA and OA-associated inflammation in this stage of scapholunate dissociation. Increased levels of interferon-γ, IL-6, and IL-10 confirm inflammatory changes in the mechanically disturbed posttraumatic radiocarpal joint.