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Falcochio DF, Brunelli JPF, Oliveira RKD, Ruggiero GM. Arthroscopy-assisted Procedures in Hand and Wrist Surgery: An Update. Where Are We So Far? Rev Bras Ortop 2024; 59:e349-e357. [PMID: 38911879 PMCID: PMC11193588 DOI: 10.1055/s-0044-1779336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/10/2023] [Indexed: 06/25/2024] Open
Abstract
Wrist and hand arthroscopy, despite being an old tool, has gained popularity and advanced in assisting in the treatment of various injuries and conditions in the region in recent years. Dorsal, volar, ulnar, and radial accessory portals are used to reach all points of the carpal and hand joints. The minimal tissue damage, lesser injury to the capsule and its mechanoreceptors, the assessment of injuries associated with the reason for surgery, and aesthetically more favorable scars have attracted many doctors and their patients. As a result, there has been an increase in publications and diversifications of arthroscopic techniques. The aim of this update article is to present the advances and the evidence available in the literature to assist readers in their decision on which technique to use in the treatment of wrist and hand conditions.
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Wong CR, Karpinski M, Hatchell AC, McRae MH, Murphy J, McRae MC. Immobilization of the Wrist After Dorsal Wrist Ganglion Excision: A Systematic Review and Survey of Current Practice. Hand (N Y) 2023; 18:254-263. [PMID: 34096351 PMCID: PMC10035098 DOI: 10.1177/15589447211014631] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Postoperative care after dorsal wrist ganglion (DWG) excision is highly varied. The effect of immobilization of the wrist on patient outcomes has not yet been examined. METHODS A systematic review of the literature was performed to determine whether wrist immobilization after DWG surgical excision is beneficial. A survey of hand surgeons in Canada was performed to sample existing practice variations in current immobilization protocols after DWG excision. RESULTS A systematic review yielded 11 studies that rigidly immobilized the wrist (n = 5 open excision, n = 5 arthroscopic excision, n = 1 open or arthroscopic excision), 10 studies that used dressings to partially limit wrist motion (n = 5 open, n = 5 arthroscopic), 1 study (open) that did either of the above, and 2 studies (arthroscopic) that did not restrict wrist motion postoperatively. This ranged from 48 hours to 2 weeks in open DWG excision and 5 days to 3 weeks in arthroscopic DWG excision. The survey of Canadian hand surgeons had a similarly divided result of those who chose to immobilize the wrist fully (41%), partially (14%), or not at all (55%). Most surgeons surveyed who immobilized the wrist postoperatively did so for 1 to 2 weeks. CONCLUSION The systematic review and survey of Canadian hand surgeons reveal that hand surgeons are divided regarding the need to immobilize the wrist after DWG excision. In terms of functional outcome, there is no compelling data to suggest 1 strategy is superior. The time frame for immobilization when undertaken was short at 2 weeks or less.The systematic review is registered in the PROSPERO database (PROSPERO 2016:CRD42016050877).
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Affiliation(s)
| | | | | | | | | | - Matthew C McRae
- McMaster University, Hamilton, ON, Canada
- St. Joseph's Healthcare Hamilton, ON, Canada
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Clark DM, Nelson SY, O'Hara M, Putko RM, Bedrin MD, Daniels CM. Surgical and Patient-Centered Outcomes of Open versus Arthroscopic Ganglion Cyst Excision: A Systematic Review. J Wrist Surg 2023; 12:32-39. [PMID: 36644727 PMCID: PMC9836780 DOI: 10.1055/s-0042-1749678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/20/2022] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- DesRaj M. Clark
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Sarah Y. Nelson
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Matthew O'Hara
- University of California Riverside, School of Medicine, Riverside, California
| | - Robert M. Putko
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Michael D. Bedrin
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
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Saremi H, bolbanabad MM, Abdollahian AR, Mohammadi Y. Clinical Results of Arthroscopic Resection of Dorsal Wrist Ganglion with a Minimum of 3 Years Follow-up. J Wrist Surg 2023; 12:52-55. [PMID: 36644718 PMCID: PMC9836768 DOI: 10.1055/s-0042-1756673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/22/2022] [Indexed: 11/11/2022]
Abstract
Introduction Ganglion cysts are the most common benign tumors of the wrist. Their arthroscopic resection is becoming common. However, there are a limited number of studies comparing arthroscopic and open surgeries. This study evaluated the subjective and objective results of arthroscopy with a minimum of 3 years follow-up. Patients and Methods Patients with dorsal wrist ganglion who underwent arthroscopic ganglionectomy were evaluated regarding pain (using visual analog scale) and satisfaction as subjective results. We also evaluated their scar (with the Vancouver scar scale), range of motion, and recurrence as objective results. Results There were 20 patients in the study. Mean of follow-up time was 52.5 months. Recurrence rate was 5%, and visual analog scale of pain decreased from 3.7 to 0.5 at the final follow-up. Sixteen patients were completely satisfied, three patients were partially satisfied, and one patient was unsatisfied. The mean of Vancouver scar scale was 1.4 (range of 0-3). Improvement in range of flexion and extension of the wrist was significant without a significant complication. Conclusion Arthroscopic excision of dorsal wrist ganglion in the way described in this study is a safe and effective method that improves pain and range of motion of the wrist without major complications. The rate of recurrence was less than those reported for open surgery in long-term follow-up. The surgery scar has a promising score in Vancouver scar scale.
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Affiliation(s)
- Hossein Saremi
- Department of Orthopedics, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | | | | | - Younes Mohammadi
- Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
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Cost Implications of Varying the Surgical Setting and Anesthesia Type for Dorsal Wrist Ganglion Cyst Excision Surgery. Plast Reconstr Surg 2022; 149:240e-247e. [PMID: 35077419 PMCID: PMC8797019 DOI: 10.1097/prs.0000000000008725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Minimizing expenses attributed to dorsal wrist ganglion cyst excisions, a common minor surgical procedure, presents potential for health care cost savings. Varying the surgical setting (operating room versus procedure room) and type of anesthesia (local-only, monitored anesthesia care, or monitored with regional or general anesthesia) may affect total operative costs. METHODS Patients who underwent an isolated unilateral dorsal wrist ganglion cyst excision between January of 2014 and October of 2019 at a single academic medical center were identified by CPT code. The total direct costs for each surgical encounter that met inclusion criteria were calculated. The relative total direct costs were compared between surgical setting and anesthesia type groups. Univariate and multivariable gamma regression models were used to identify factors associated with surgical costs. RESULTS A total of 192 patients were included; 26 cases (14 percent) were performed in the procedure room and 166 cases (86 percent) were performed in the operating room. No significant differences in demographic factors were identified between groups. Univariate analysis demonstrated that use of operating room/monitored anesthesia care, operating room/monitored anesthesia care with regional anesthesia, and operating room/general anesthesia groups, as compared to procedure room/local-only, yielded significantly greater median costs (1.76-, 2.34-, and 2.44-fold greater, respectively). Multivariable analysis demonstrated 1.80-, 2.10-, and 2.31-fold greater costs with use of operating room/monitored anesthesia care, operating room/monitored anesthesia care with regional anesthesia, and operating room/general anesthesia relative to procedure room/local-only, respectively. CONCLUSION Performing dorsal wrist ganglion cyst excisions in a procedure room with local-only anesthesia minimizes operative direct costs relative to use of the operating room and other anesthetic types.
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Fernandes CH, Meirelles LM, Raduan Neto J, Fernandes M, dos Santos JBG, Faloppa F. Arthroscopic Resection of Dorsal Wrist Ganglion: Results and Rate of Recurrence Over a Minimum Follow-up of 4 Years. Hand (N Y) 2019; 14:236-241. [PMID: 29185350 PMCID: PMC6436138 DOI: 10.1177/1558944717743601] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Dorsal wrist ganglia are the most common soft tissue tumor type of the upper limb. Surgical resection, open or arthroscopic, is one of the most frequent procedures performed by hand surgeons. This study sought to perform an objective evaluation of the outcomes of arthroscopic resection of dorsal wrist ganglia and their recurrence rates over 4 years. Patients treated with arthroscopic resection were expected to have favorable outcomes and low complication rates after 4 years of follow-up. METHODS We evaluated 34 cases of dorsal wrist ganglia in patients who underwent arthroscopic resection. The patients were evaluated using the Quick-Disabilities of the Arm, Shoulder and Hand (QuickDASH) outcome measure, visual analog scale (VAS) for pain, range of motion of the wrist, palmar grip strength, rates of recurrence, and complications. RESULTS During the postoperative period, the QuickDASH score averaged 2.3 points, the mean residual pain by VAS was 0.54, full range of wrist movement was recovered by all patients, and the mean palmar grip strength was 29.4 kgf; there was 1 case with recurrence. There were no severe postoperative complications throughout the follow-up period. CONCLUSIONS The outcomes, recurrence, and complications rates after 4 years of follow-up presented in this study support the use of arthroscopy as a treatment for dorsal wrist ganglion.
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Affiliation(s)
- Carlos H. Fernandes
- Universidade Federal de São Paulo, Brazil,Carlos H. Fernandes, Hand Surgery Unit, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Borges Lagoa 786, São Paulo, São Paulo 04038-032, Brazil.
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Crawford C, Keswani A, Lovy AJ, Levy I, Lutz K, Kim J, Hausman M. Arthroscopic versus open excision of dorsal ganglion cysts: a systematic review. J Hand Surg Eur Vol 2018; 43:659-664. [PMID: 29022775 DOI: 10.1177/1753193417734428] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED We conducted a systematic review comparing recurrence and complication rate following open versus arthroscopic excision of ganglion cysts. Sixteen full-text articles were included. The pooled recurrence rate of open excision was 20% (range: 5.6-40.7%) with Q value of 27 and I2 of 82%. The pooled recurrence rate of arthroscopic excision was 9% (range: 0-17%) with Q value of 10 and I2 of 2%. Eleven of 16 studies were low quality or had a high risk of bias; however, excluding low quality studies or those with high risk of bias produced similar recurrence rates in arthroscopic and open excision (7.9% versus 9.8%). For the subset of studies with complete reporting of complications, rates were similar in open and arthroscopic excision (6% versus 4%). Our review suggests that arthroscopic and open approaches have comparable outcome profiles. Nevertheless, standardized study methods with adequate powering are required to collect high quality data, allowing for greater confidence in conclusions regarding these two approaches for existing ganglion cysts. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Catherine Crawford
- Mount Sinai Hospital, Department of Orthopaedic Surgery, New York, NY, USA
| | - Aakash Keswani
- Mount Sinai Hospital, Department of Orthopaedic Surgery, New York, NY, USA
| | - Andrew J Lovy
- Mount Sinai Hospital, Department of Orthopaedic Surgery, New York, NY, USA
| | - Isaiah Levy
- Mount Sinai Hospital, Department of Orthopaedic Surgery, New York, NY, USA
| | - Kristina Lutz
- Mount Sinai Hospital, Department of Orthopaedic Surgery, New York, NY, USA
| | - Jaehon Kim
- Mount Sinai Hospital, Department of Orthopaedic Surgery, New York, NY, USA
| | - Michael Hausman
- Mount Sinai Hospital, Department of Orthopaedic Surgery, New York, NY, USA
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Abstract
Dorsal and volar wrist ganglions are benign tumors; most of them are asymptomatic. They can disappear spontaneously. Arthroscopic resection can be performed for pain or cosmetic concern. Dorsal ganglion is more common (70%). The hypothesis of the origin is the result of mucoid dysplasia in association with intracapsular and extrasynovial ganglia that occur at the level of the dorsal scapholunate complex. Volar wrist ganglia are less common (20%) and occur mainly in the radiocarpal joint. They are due to capsular destruction at the volar insertion of the SL ligament and arise from the interval between radio scaphocapitate and long radiolunate ligament.
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Balazs GC, Dworak TC, Tropf J, Nanos GP, Tintle SM. Incidence and Risk Factors for Volar Wrist Ganglia in the U.S. Military and Civilian Populations. J Hand Surg Am 2016; 41:1064-1070. [PMID: 27663053 DOI: 10.1016/j.jhsa.2016.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 07/20/2016] [Accepted: 08/10/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To identify the incidence and demographic factors associated with volar wrist ganglia in both military and civilian beneficiary populations. METHODS The U.S. Department of Defense Management Analysis and Reporting Tool (M2) accesses a comprehensive database of all health care visits by military personnel and their dependents. Because there is no specific code for ganglions of the wrist, the database was searched for all military personnel and civilian beneficiaries with an International Classification of Diseases, 9th Revision, diagnosis of 727.41 (ganglion of a joint) or 727.43 (ganglion, unspecified location) between 2009 and 2014. Two random samples of 1000 patients were selected from both the military and the civilian beneficiary cohorts, and their electronic medical records were examined to identify those with volar wrist ganglia. The proportion of volar wrist ganglia was then applied to the overall population data to estimate the total incidence with a 95% confidence interval and 5% margin of error. Unadjusted incidence rates and adjusted incidence rate ratios were determined using Poisson regression, controlling for age, sex, branch of military service, and military seniority. RESULTS The unadjusted incidence of volar wrist ganglia is 3.72 per 10,000 person-years (0.04%/y) in female civilian beneficiaries, 1.04 per 10,000 person-years (0.01%/y) in male civilian beneficiaries, 7.98 per 10,000 person-years (0.08%/y) in female military personnel, and 3.73 per 10,000 person-years (0.04%/y) in male military personnel. When controlled for age, military personnel have a 2.5-times increased rate of volar wrist ganglia, and women have a 2.3-times increased rate. In the military cohort, female sex, branch of service, and seniority were significantly associated with the diagnosis of a volar wrist ganglion when controlled for age. In the civilian beneficiary cohort, only female sex was significant. CONCLUSIONS Military service members have higher rates of volar wrist ganglia diagnoses than their age- and sex-matched civilian counterparts. Women are significantly more likely to be diagnosed with a volar wrist ganglion, regardless of age or military status. CLINICAL RELEVANCE The epidemiology of volar wrist ganglia is poorly defined, and few studies have firmly defined demographic factors associated with the diagnosis. We provide the overall incidence rate of the diagnosis and report a significant association with female sex even when controlled for age.
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Affiliation(s)
- George C Balazs
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
| | - Theodora C Dworak
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
| | - Jordan Tropf
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - George P Nanos
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
| | - Scott M Tintle
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD.
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Kang HJ, Chun YM, Oh WT, Koh IH, Lee SY, Choi YR. The Effect of Debridement of Coexisting Partial Ligament Injuries on Outcomes Following Arthroscopic Osteosynthesis for Minimally Displaced Scaphoid Nonunions. J Hand Surg Am 2016; 41:e135-42. [PMID: 27137080 DOI: 10.1016/j.jhsa.2016.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 03/06/2016] [Accepted: 04/06/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE Partial intercarpal ligament injuries can coexist with scaphoid nonunions. However, whether these injuries should be debrided simultaneously when scaphoid nonunions are treated is unclear. The purpose of this study was to compare union rates and clinical outcomes after arthroscopic management of scaphoid nonunions, in which coexisting partial ligament injuries were, or were not, simultaneously debrided. METHODS This retrospective study included 46 patients with scaphoid nonunions and coexisting partial intercarpal ligament injuries who underwent arthroscopy-guided bone grafting and fixation (K-wires or headless screws) between March 2008 and May 2014 with a minimum follow-up of 1 year. None of the cases had necrosis of the proximal fragment (determined by contrast-enhanced magnetic resonance imaging), severe deformities, or advanced arthritis. The partial intercarpal ligament injuries were either simultaneously debrided (25 patients; group D) or not debrided (21 patients; group ND). Visual analog scale pain scores, grip strength, flexion-extension arc of the wrist, Mayo Wrist Scores, and Disabilities of Arm, Shoulder, and Hand scores were used to compare clinical outcomes between the 2 groups. RESULTS The nonunions united in 93% (43 of 46) of the patients. There were no differences between the 2 groups with regard to patient demographics, preoperative outcome measures, location of scaphoid nonunion, and degree of ligament injury. The overall union rate was similar between group D (92%; 23 of 25) and group ND (95%; 20 of 21). At a median follow-up of 24 months for group D and group ND, the visual analog scale pain score, grip strength, Mayo Wrist Scores, and Disabilities of the Arm, Shoulder, and Hand scores were significantly improved in both groups, compared with preoperative scores. Flexion-extension arc showed no change in both groups compared with preoperative angles. All of the follow-up measurements were similar in the 2 groups. CONCLUSIONS In patients who underwent arthroscopic bone grafting and fixation of scaphoid nonunions, simultaneous debridement of incidentally found partial intercarpal ligament injuries did not result in a better union rate or clinical outcomes than not debriding the partial ligament injuries. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.
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Affiliation(s)
- Ho-Jung Kang
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong-Min Chun
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Won-Taek Oh
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Il-Hyun Koh
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Sang-Yun Lee
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yun-Rak Choi
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
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Balazs GC, Donohue MA, Drake ML, Ipsen D, Nanos GP, Tintle SM. Outcomes of Open Dorsal Wrist Ganglion Excision in Active-Duty Military Personnel. J Hand Surg Am 2015; 40:1739-47. [PMID: 26228481 DOI: 10.1016/j.jhsa.2015.05.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 05/28/2015] [Accepted: 05/29/2015] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- George C Balazs
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Michael A Donohue
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Matthew L Drake
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Derek Ipsen
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - George P Nanos
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Scott M Tintle
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD.
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