Hyaluronidase versus surgical excision of ganglia: a prospective, randomized clinical trial

Treatment of Primary Dorsal Wrist Ganglion-A Systematic Review

Purpose  The aim of this study was to compare the rates of recurrence and wound infection in patients with primary dorsal wrist ganglion treated with aspiration (with or without an injection of an additive), open excision, or arthroscopic resection. Methods  This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and registered on PROSPERO. Systematic electronic searches in PubMed (MEDLINE), EMBASE, Web of Science, and the Cochrane Library of Controlled Trials were performed on May 5, 2020, and June 1, 2021, respectively. All clinical studies written in English determining the recurrence and wound infection rates after treatment of primary dorsal wrist ganglion with aspiration, open excision, or arthroscopic resection in patients over the age of 16 years were eligible for inclusion. Quality assessment was guided by the Cochrane Collaboration's tool for randomized controlled trials (RCTs) and the methodological index for nonrandomized studies (MINORS) tool for observational studies. Results  The literature searches resulted in 1,691 studies. After screening, five RCTs, enrolling 233 patients, and six observational studies, enrolling 316 patients with primary dorsal wrist ganglions were included. Quality assessment of the included RCTs and observational studies determined the existing level of evidence pertaining to primary dorsal wrist ganglion treatment to be low. About 11 studies reported on recurrence rate, which ranged between 7 and 72% for patients initially treated with aspiration (with or without an injection of an additive). In comparison, the recurrence rate for the open excision and arthroscopic resection groups ranged between 6 to 41% and 0 to 16%, respectively. Four studies investigated wound-related complications, for which zero infections were reported, irrespective of treatment. Conclusion  The evidence summarized in this systematic review demonstrates a considerable variability in recurrence rate following aspiration and open or arthroscopic resection of a primary dorsal wrist ganglion. The greatest variability in recurrence was displayed among studies on aspiration. The overall infection rate after treatment of dorsal wrist ganglions seems to be low regardless of the treatment type. However, the divergent results of individual studies highlight a pressing need for prospective controlled trials assessing outcomes following dorsal wrist ganglion treatment. Level of Evidence  Systematic review on level 1 to 4 clinical therapeutic studies.

Immobilization of the Wrist After Dorsal Wrist Ganglion Excision: A Systematic Review and Survey of Current Practice

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).

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.

Treatment of Wrist Dorsal Synovial Cyst with Percutaneous Sclerotherapy Using Hypertonic Saline Solution

Objective  To evaluate the efficacy of hypertonic saline infiltration as a sclerosing agent in the dorsal synovial cyst of the wrist. Method  Patients of both genders, aged 18 years or older, with clinical and ultrasound diagnosis of synovial cyst, and without any previous treatment were selected. Case series in which 50 patients underwent aspiration of the contents of the cyst and infiltration of the hypertonic saline solution (2 ml sodium chloride solution 20% and 1 ml of lidocaine 2%). The patients were followed up for 24 weeks, when the parameters pain, strength, range of motion, function (quickDASH and Brief Michigan question), recurrence, and complications were evaluated. Results  A total of 46 patients were evaluated for 24 weeks, 18 (39.1%) cysts evolved to resolution, and 28 (60.9%) presented recurrence. There was no statistically significant difference in the effect force or in the range of motion. There was no clinically significant difference in the scores of the questionnaires. The most frequent complications were pain and edema. Conclusion  Infiltration with hypertonic saline solution for the treatment of dorsal synovial cyst of the wrist showed a recurrence rate of 60.9%.

Successful Outcome of Transfixation Technique with Linen in Dorsal Wrist Ganglion: A Descriptive Cross-sectional Study

INTRODUCTION

Ganglion is a commonly encountered soft tissue tumor. Most commonly patients seek treatment for cosmetic issues. There are a variety of treatment options available but very few are effective and cosmetically acceptable. Common treatment techniques have either high recurrence rates or have complications. Treatment by transfixation with linen suture under local anaesthesia on an outpatient basis is an upcoming treatment. The objective of the study is to find out the prevalence of successful outcome of transfixation techniques in treatment of dorsal wrist ganglion.

METHODS

This study is a descriptive cross-sectional study undertaken at a tertiary care center from November 2018 to May 2020. Ethical approval was taken from the same institution. Convenient sampling method was used. Patients presenting with dorsal wrist ganglion and consenting for the transfixation underwent the procedure. All the patients were operated under local anesthesia. Statistical analysis was done using Statistical Package for Social Sciences version 24.0. Point estimate was done at 95% Confidence Interval and frequency and percentage were calculated.

RESULTS

Out of 30 cases, 29 (96.66%) have got successful outcomes with transfixation techniques. Among 30 patients, recurrences were seen in 2 (6.66%) cases. Patient satisfaction was high in 27 (90 %) cases. No complication was encountered.

CONCLUSIONS

Transfixation technique had good results in terms of low recurrence rate, percentage resolution in size and high patient satisfaction.\ Keywords: ganglion cyst; treatment; minimally invasive.

Current updates in image-guided musculoskeletal interventions

Image-guided musculoskeletal interventions are frequently done in clinical practice. Even then, the literature regarding their effectiveness is relatively scarce. Image guidance adds value over the conventional landmark-based approach and should be preferred. We hereby try to list the commonly performed procedures along with the current practice guidelines regarding their clinical indications and periprocedural care.

Bedside ultrasound-guided aspiration and corticosteroid injection of a baker's cyst in a patient with osteoarthritis and recurrent knee pain

Baker's cyst accompanying knee osteoarthritis represents a common cause of knee pain presenting to the emergency department. In this case report, a 56-year-old male presented with atraumatic left knee pain and swelling. Radiographically, he had tricompartmental osteoarthritis and was found to have a baker's cyst on duplex ultrasound. Using point-of-care ultrasound, the cyst was aspirated and corticosteroids were injected. The patient tolerated the procedure well and was discharged with a compression wrap and orthopedic follow-up. Baker's cyst aspiration with corticosteroid injection represents a safe alternative treatment option for patients. In some cases, this treatment may be definitive. Orthopedists currently use this procedure to reduce pain and improve function for patients with chronic knee ailments related to baker's cysts. As demonstrated in this case report, implementing this bedside procedure in the emergency department with orthopedic follow-up expands non-surgical, non-narcotic treatment options for patients with chronic knee pain secondary to Baker's cysts with osteoarthritis.

Epidemiology of Symptomatic Dorsal Wrist Ganglia in Active Duty Military and Civilian Populations

Purpose

The epidemiology of dorsal wrist ganglia (DWG) has been poorly studied. The purpose of this study was to determine the epidemiology of DWG in the US military and civilian populations. We hypothesized that military service would be associated with an increased risk for developing a DWG.

Methods

The US Department of Defense Management Analysis and Reporting Tool, a database of health care encounters by military personnel and dependents, was queried for encounters with an International Classification of Diseases, Ninth Revision diagnosis of 727.41 (ganglion of a joint) or 727.43 (ganglion, unspecified location) between 2009 and 2014. There is no specific code for DWG, so a random sample of 1,000 patients was selected from both the military and civilian cohorts. These 2,000 electronic medical records were examined to identify patients with a DWG. This estimate was used to determine the unadjusted incidence of DWG with a 95% confidence interval and a 5% margin of error in the entire military and civilian dependent population. Adjusted incidence rates and incidence rate ratios (IRR) were determined using Poisson regression, controlling for demographic covariates.

Results

The incidence of DWG in the military population is 14.25/10,000 person-years compared with 7.01/10,000 person-years in the civilian population. Female sex was a significant risk factor in both the military (IRR, 2.59) and civilian populations (IRR, 2.26). Younger age group (age 25–34 years) was a significant risk factor for DWG compared with an older age group (age 45–64 years) in both the military (IRR, 1.74) and civilian populations (IRR, 2.56). Senior rank (both officer and enlisted) was a significant risk factor for DWG compared with junior rank (IRR, 1.95).

Conclusions

The incidence of DWG was higher in the military compared with the civilian population. There is a higher incidence of a DWG in females and in the senior ranks (both officer and enlisted).

Type of study/level of evidence

Prognostic III.

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.

Results of modified thread technique for the treatment of wrist ganglion

BACKGROUND

Ganglion cyst is the commonest swelling around the wrist. It usually presents as a painless swelling. There is no consensus as to the exact cause and the ideal modality of its treatment. Surgical excision has the best cure rates but has its share of complications. The aim of this study was to evaluate whether a modified thread technique can give reasonably good results with a low complication rate in patients with wrist ganglion.

MATERIAL AND METHODS

One hundred and sixteen patients with wrist ganglion underwent a modified thread technique in which a sterile silk suture was passed through the ganglion, the contents of the ganglion were expressed out completely by firm pressure and the thread was tied over a sterile gauze piece forming a single loop. The thread was removed once serosanginous discharge was seen at entry point of the thread into the cyst.

RESULTS

One hundred and eight patients were available for final analysis with minimum six months follow up. There was no recurrence in ninety eight patients giving success rate of ninety one percent. Recurrence was only seen in patients where complete evacuation of the contents of ganglion could not be achieved. Nine patients had minor complications in the form of superficial infection in two patients and mild pain around thread entry point in seven patients.

CONCLUSION

Modified thread technique for the treatment of wrist ganglion is a minimally invasive, low cost, day care procedure which can give reasonably good results with a very low complication rate.

A Prospective Randomized Controlled Trial of Aspiration and Fibrin Sealant Use Versus Aspiration Alone in the Treatment of Dorsal Wrist Ganglia

Purpose

Multiple treatments for dorsal wrist ganglia (DWG) exist but have high recurrence rates. We investigated whether aspiration followed by injection of Tisseel is more effective at reducing the DWG recurrence rate than aspiration alone.

Methods

Adults with untreated DWG were randomly assigned to aspiration alone (A) or aspiration followed by Tisseel injection (AT). Patients were measured at baseline, 1, 6, and 12 months. Primary outcome was the rate of recurrence. Secondary outcomes included recurrent ganglion size and maximum pain experienced from the ganglion. Continuous data were compared with Student t tests and Mann-Whitney U tests. Categorical data were compared with χ² tests and Fisher exact tests. Treatment effect was reported as relative risk or mean differences (MD) with 95% confidence intervals.

Results

Seventy-nine patients were randomized to the A (n = 39) or AT (n = 40) group. Twenty-five patients were lost to follow-up. There were no differences in recurrence risk between groups at 1, 6, or 12 months (P > .05). Ganglia were significantly smaller for both groups at 1 month versus baseline (P < .001). The A group demonstrated a significantly larger decrease in size at 1 month versus the AT group (MD = 0.75 cm², 95% confidence interval: 0.07-1.43, P = .03). Both groups experienced significantly less pain at 1, 6, and 12 months (P < .03), but this was not significantly different between groups.

Conclusion

Aspiration and Tisseel injection does not decrease DWG recurrence versus aspiration alone. Both interventions produced a significant decrease in pain. Although aspiration alone carries a high recurrence risk, it may provide sufficient symptomatic relief for patients with DWG.

Arthroscopic versus open excision of dorsal ganglion cysts: a systematic review

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.

Arthroscopic Management of Dorsal and Volar Wrist Ganglion

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.

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.

Treatment of Popliteal (Baker) Cysts With Ultrasound-Guided Aspiration, Fenestration, and Injection: Long-term Follow-up

Background:

The purpose of this study was to determine the efficacy of ultrasound-guided aspiration, fenestration, and injection as a treatment in patients with symptomatic popliteal cysts.

Hypothesis:

Ultrasound-guided aspiration, fenestration, and injection (UGAFI) is an effective and safe treatment option for symptomatic popliteal cysts.

Study Design:

Retrospective cohort study.

Level of Evidence:

Level 3.

Methods:

Patients who received a UGAFI of popliteal cysts from 2008 to 2011 were identified. Preaspiration (PA) and follow-up Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, cyst recurrence, complications, cyst complexity, and size were obtained and compared for statistical significance. UGAFI involved aspiration of fluid through a spinal needle, fenestration of the cyst walls and septations, and injection of 1 mL (40 mg) triamcinolone (Kenalog) and 2 mL 0.5% bupivacaine (Sensorcaine) into the decompressed remnant.

Results:

The mean PA WOMAC score (48.55) improved significantly at final follow-up (FFU) to 17.15 (P < 0.0001) for 47 patients. Within the WOMAC subcategories, there was also a significant difference in pain (PA, 10.68; FFU, 3.94; P < 0.0001), stiffness (PA, 4.51; FFU, 1.77; P < 0.0001), and physical function (PA, 31.34; FFU, 12.17; P < 0.0001). There were 6 reaspirations for recurrence (12.7%), and 1 patient underwent unicompartmental knee arthroplasty. There were no infections or other complications.

Conclusion:

Significant clinical improvement in patients with symptomatic popliteal cysts can be achieved via UGAFI as the sole treatment.

Clinical Relevance:

UGAFI is a safe and effective option as the sole treatment modality for symptomatic popliteal 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.

Ligamentous hyperlaxity and dorsal wrist ganglions

PURPOSE

To determine whether symptomatic dorsal wrist ganglions are associated with generalized ligamentous hyperlaxity.

METHODS

Ninety-six patients (61 females) presenting to hand surgeons for a symptomatic dorsal wrist ganglions were prospectively enrolled in this case-control investigation. Beighton scores were calculated to quantify generalized ligamentous laxity in each patient, and a scaphoid shift test (scapholunate capsuloligamentous laxity evaluation) was performed. A positive scaphoid shift test was defined by both pain and a palpable clunk. Ninety-six individuals without ganglions were then enrolled to form an age and sex frequency-matched control cohort. The control group was similarly assessed for Beighton score and scaphoid shift test. Binary logistical regression was performed to assess the association of ganglions with generalized ligamentous hyperlaxity (Beighton score ≥ 4) while accounting for effects of age and sex.

RESULTS

Patients with symptomatic dorsal wrist ganglions demonstrated significantly increased rates of generalized ligamentous hyperlaxity. Among those with ganglions, 27 of 96 (28%) patients exhibited generalized ligamentous hyperlaxity, compared with 12 of the 96 (13%) age- and sex-matched individuals in the control group. Patients with symptomatic dorsal wrist ganglions were also significantly more likely to demonstrate localized scapholunate hyperlaxity with a positive scaphoid shift test (25% positive scaphoid shift test with ganglions vs 1% in controls). In logistical modeling, patients with dorsal wrist ganglions had 2.9 (95% confidence interval [CI] 1.3-6.2) times greater odds of generalized ligamentous hyperlaxity compared with patients without a dorsal wrist ganglion after accounting for patient age and sex.

CONCLUSIONS

Symptomatic dorsal wrist ganglions were associated with both generalized ligamentous hyperlaxity and a positive scaphoid shift test. Although an association between wrist ganglions and ligamentous hyperlaxity does not prove causation, the possibility of the same underlying pathological entity causing both can be envisioned (ie, abnormal formation or organization of dense regular connective tissue).

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

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.

Peripheral neuropathy caused by joint-related cysts: a review of 17 cases

BACKGROUND

Clinical compression neuropathy caused by para-articular cysts is rare. Only recently, the unifying articular theory was proposed to clarify its true etiologic nature. The authors attribute 17 cases to this theory in order to illustrate the shift in the diagnostic and treatment protocol, and the possible impact on patient outcome.

METHODS

Eight intraneural and nine extraneural cysts were included. The proposed diagnostic protocol includes electromyography and ultrasound, followed by magnetic resonance imaging to characterize the cyst. The proposed treatment protocol consists of (1) ligation of the pedicle connecting the cyst with the afflicted joint, (2) decompression of the nerve and, when needed and (3) disarticulation of the superior tibiofibular joint (in case of peroneal nerve involvement).

RESULTS

Outcome was good to excellent in all patients, with recovery of sensory and motor function. Cyst recurrence was observed in three intraneural cases (18 %). Analysis of our own diagnostic protocol showed that atypical compression neuropathies should follow a strict diagnostic protocol to exclude missing the presence of a cyst. Ultrasound needs to play a crucial role, with MRI for cyst characterization and pedicle identification.

CONCLUSIONS

Retrospective proof in favor of the articular theory was found in all cases. An explanation for the cyst recurrences was formed based on the articular theory. In addition, a diagnostic and therapeutic protocol is proposed for all atypical peripheral compression neuropathies with the ultimate goal to achieve optimal patient outcome.

Comparative Study of Recurrence and Complications Using Various Sclerosants by Single Dart Technique in Treatment of Ganglion Cysts

Ganglion cysts are tense,smooth,fluctuant,cystic and transilluminant swellings. They are commonly found on the dorsum of the wrist, at the scapholunate articulation and may involve volar wrist, tendon sheaths and even inter phalangeal joints. This study aims to compare the efficacy and the recurrence rates with triamcinolone, hyaluronidase and sodium tetradecyl sulphate,using the single dart technique. This prospective observational study was conducted on patients who presented to the general surgery outpatient department of our institute with ganglion cysts of wrist between January 2010 and August 2011 (20 months). A total of 180 patients were included in this study. The difference in the recurrence rates after sclerotherapy for ganglion cysts is statistically not significant between triamcinolone and hyaluronidase regimens as Z (P1-P2) = 1.70, p > 0.05 but the difference in the recurrence rates after sclerotherapy for ganglion cysts is statistically significant between triamcinolone and sodium tetradecyl sulphate regimens as Z (P1-P2) = 3.34, p < 0.05 . Chi-square value -10.33 (2 ° of freedom), p = 0.00571987 (significant at 5 % level). Intralesional injection of triamcinolone by single dart technique, therefore, may be considered as a simple, safe, cost effective, convenient, less invasive alternative to surgical excision of wrist ganglion cysts.

Double dart technique of instillation of triamcinolone in ganglion over the wrist

Background:

Ganglia are the most common benign cystic swellings found over both the dorsal and volar aspects of the wrist. In spite of technical advancement, both operative and non-operative interventions achieve more or less similar results. Complete evacuation of gelatinous fluid followed with intra cystic instillation of triamcinolone has given encouraging results.

Aims:

To assess the efficacy and safety of drainage of cyst and instillation of triamcinolone in wrist ganglion.

Materials and Methods:

A prospective study was conducted on patients with simple ganglion cysts on the wrist. Total of 219 patients underwent this study. Out of this, 105 patients underwent the aspiration of the cyst fluid followed by intracystic instillation of triamcinolone, and 114 patients underwent surgical excision of wrist ganglia. Two years follow up was done for recurrence.

Results:

Most ganglia of wrist occurred in the extensor aspect. Complications noted among the surgically excised group were post operative pain and restricted mobility of wrist with a recurrence rate of 21.5%. Instillation of Triamcinolone into the ganglion yielded early resolution with a low recurrence of 8.4%.

Conclusions:

Intracystic instillation of triamcinolone after complete evacuation of cyst fluid is a simple and effective technique for treatment of ganglion.

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.

Experimental pseudocyst model resembling human ganglion

There is no animal model of ganglion. We describe a simple and reproducible animal model of pseudocystic diseases. First, we experimented to establish a pseudocystic model. We used cylindrical glass implants (6 mm diameter, 30 mm long) to create fibrous capsules in rats. The implants were inserted in the subcutaneous tissue in the dorsum of rats. Sixty implants were carried out (two implants per rat). Twelve weeks after implantation, the glass implants were removed and 0.5 mL sodium hyaluronate solution was injected into each cavity. Next, we tested the model by histological examination after OK-432 administration. Microscopic examination revealed that the wall was composed of a layer of collagenous fibers similar to those noted in ganglia; the lumen was retained for 3 weeks. Histopathological changes after OK-432 administration showed nonspecific inflammatory response induced by OK-432, resulting in in vivo activation of many inflammatory cells and then fast and reliable closure of cavities. No harmful reactions to OK-432 were observed histopathologically. These data suggest that our experimental cyst is a suitable model for studying pseudocystic diseases. This model can be used for research evaluating safe drug doses, conducting therapeutic comparison of several agents, and histopathological time course studies of the affected tissues. OK-432 administration on this model showed the potential of one of the ideal agents to treat pseudocystic lesions like ganglion.

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.