Dorsal ganglion of the wrist: results of treatment by arthroscopic resection

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.

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.

Arthroscopic resection of recurrent wrist ganglions - A retrospective study of 17 patients

BACKGROUND

Arthroscopic resection has become a favorable alternative for wrist ganglions. However, for recurrent wrist ganglions, arthroscopic resection is relatively contraindicated. The purpose of this study was to evaluate the clinical outcomes of arthroscopic resection for recurrent wrist ganglions and to identify their safety and efficacy.

METHODS

From June 2011 to February 2017, 17 patients with recurrent wrist ganglion were treated with arthroscopic resection. We evaluated the visual analog scale, modified Mayo wrist score, and Disabilities of Arm, Shoulder and Hand Outcome Measure preoperatively and at the final follow-up. Patients were questioned for pain reduction, pain during pushups, and any difficulty in returning to work. Recurrence and complications were also assessed at each follow-up visit.

RESULTS

We enrolled 17 patients and median follow-up was 58 months. The reduction in pain was significant. Only 2 of the 17 patients had residual pain after arthroscopic resection. One female patient showed recurrences 3 years later. Although 2 cases of stiffness were noted after the operation, no significant complication was present 3 months postoperatively. Most patients had good recovery and could resume work; however, 2 patients reported fair recovery.

CONCLUSION

The results of this study confirmed that arthroscopic excision could be an effective and safe treatment for recurrent ganglions; therefore, should not be contraindicated for treating recurrent wrist ganglions. Nevertheless, further prospective studies with larger patient numbers are needed to establish a stronger evidence for arthroscopic resection of recurrent wrist ganglions.

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 resection of occult dorsal wrist ganglia

INTRODUCTION

Arthroscopic resection of dorsal wrist ganglia has become a well-accepted practice. However, there is a paucity of results on occult ganglia in the literature. The purpose of this study is to evaluate the subjective outcomes of occult dorsal wrist ganglion cysts resected arthroscopically, and to identify and examine intraarticular findings and relate them to pre-operative MRI findings and histologies.

MATERIALS AND METHODS

In 39 patients, 40 wrists were treated with arthroscopic resection of an occult dorsal wrist ganglion. Radio-carpal arthroscopy and mid-carpal arthroscopy were performed, and a capsular window overlying both compartments at the level of the scapholunate interval was created. The motivation to undergo operation for all patients was pain at rest and on load. In a retrospective study by telephone interview, patients were asked for pain reduction and satisfaction with the operation. 30 patients could be reached after 28.5 months on average.

RESULTS

29 of the 30 patients were content with the operation. Reduction of pain at rest and on load was significant. MRI was performed pre-operatively in all the cases and could confirm the presence of a ganglion in 31 cases. Intraoperatively, ganglion structures were identified in 25 cases. Histology showed ganglion tissue or myxoid degeneration in 12 of 26 taken samples. Histology was positive in the cases without intraoperative visualization of typical ganglion structures and without confirmation by MRI.

CONCLUSION

The results of this study confirm that a high patient satisfaction can be achieved for arthroscopic treatment of occult dorsal wrist ganglia, which seem especially amenable for arthroscopic treatment. Furthermore, the results suggest that arthroscopic resection of a dorsal capsular window can be indicated if the complaints and the clinical findings are typical for dorsal wrist ganglion, even though MRI findings may be negative.

Considerations in performing open surgical excision of dorsal wrist ganglion cysts

PURPOSE

To investigate which conditions should be considered to make a successful resection of the entire ganglion complex during open excision.

METHODS

We reviewed 52 patients who underwent open surgical excision of dorsal wrist ganglions. The inclusion criterion was a symptomatic ganglion causing pain, weakness and limitation of range of motion. The mean follow-up was 26 (range 12-45) months. We recorded operative details including whether or not the stalk was identified, how the ganglia were resected, and where the stalk originated. Intentional rupture of cyst was performed when the stalk was not easily identified with dissection. Pain score was measured using a visual analog scale system pre-operatively and post-operatively. Recurrence was also described.

RESULTS

A stalk was identified in eight cases using dissection and in 43 cases by rupturing the cyst. The entire ganglion complex was resected in 50 cases. The stalk originated most commonly in the radio-lunate joint. The average pain score improved from 3.9 to 1.8 after ganglion removal. The ganglion recurred in two cases where incomplete resection of the ganglion was made.

CONCLUSIONS

In the majority of ganglions, it is difficult to identify the stalk and its capsular attachment due to a large cyst with severe adhesion to adjacent soft tissues including joint capsule. Rupturing a cyst on purpose helps to identify the stalk and minimize capsular loss. A ganglion over the radiolunate joint was most commonly found and excision of joint capsule over scapholunate joint without identification of the stalk and its capsular attachment might result in recurrence. Recurrence was definitely related to incomplete resection which was more commonly made in ganglions over uncommon sites.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the guidelines online for a complete description of level of evidence.

[Arthroscopic resection of dorsal wrist ganglion cysts]

OBJECTIVE

Pain relief and improvement of hand function by ganglion cyst resection and/or creation of a dorsal capsular window with partial synovectomy. In the case of visible ganglion cysts consideration of aesthetic aspects.

INDICATIONS

Visible and occult persisting dorsal wrist ganglion cysts, recurrent ganglion cyst after open or arthroscopic resection and intraosseous ganglion cyst with an extraosseous portion.

CONTRAINDICATIONS

Recent skin lesion of the wrist.

SURGICAL TECHNIQUE

Standard setting for wrist arthroscopy. Portals: radiocarpal 3‑4 and 6R, midcarpal radial (RMC) and midcarpal ulnar (UMC) portals. Start with arthroscopy in 3‑4 portal. If there is insufficient visualization of the dorsal capsular fold, change the arthroscope to the 6R portal. From here a tangential view onto the dorsal capsule at the level of the scapholunate (SL) ligament can be obtained. If a large ganglion overlying the 3‑4 portal or the RMC portal is present, UMC portals are primarily used. Intra-articular visualization of ganglion structures should always be attempted, especially for occult ganglion cysts. If the radiocarpal findings are inconspicuous, midcarpal arthroscopy from the UMC portal is performed to visualize the dorsal capsule at the SL ligament. Depending on the main localization of the visible alterations, ganglion or thickening of the capsule, a dorsal capsular window is created at the level of the SL ligament either radiocarpal or midcarpal or overlying both joints. Complete resection of the ganglion is controlled by palpation. Use of a 2.4 mm arthroscope with 30° angle of vision and 2.5 mm shaver (aggressive cutter). Low-suction drainage and soft padded dressing. An arthroscope with 70° angle of vision enables an even better view onto the dorsal capsule.

POSTOPERATIVE MANAGEMENT

Immediate wrist mobilization, avoidance of excessive loading for 3 weeks. Physiotherapy is necessary if wrist flexion is not regained 3  weeks postoperatively.

RESULTS

From 2007 to 2010 a total of 92 wrists from 88 patients were treated by arthroscopic ganglion cyst resection, 44 % for occult and 17 % for recurrent ganglia. At a mean follow-up of 78 % after 29.5 months a high patient satisfaction of 90 % was achieved. The only complication was a complex regional pain syndrome (CRPS) in one patient. The recurrence rate was 12.5 %.

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.

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.

Arthroscopic dorsal wrist ganglion excision with color-aided visualization of the stalk: minimum 1-year follow-up

BACKGROUND

Dorsal wrist ganglia (DWG) are a common, benign soft-tissue mass of the wrist. Excision of DWG is a common procedure performed by hand surgeons and may be performed using either open or arthroscopic techniques. This study aims to evaluate the frequency of stalk visualization with intralesional injection of inert dye in the course of arthroscopic excision along with incidence of recurrence with a minimum of 1-year follow-up.

METHODS

Upon IRB approval, a retrospective chart review was performed identifying 27 patients who had consecutively undergone arthroscopic excision of a DWG with the color-aided technique at our institution with a minimum follow-up duration of 12 months. Intraoperative findings were reviewed. Patients were contacted to investigate for incidence of recurrence.

RESULTS

Of the 27-patient cohort, the ganglion stalk was identified in 100 % of the color-aided arthroscopic DWG excisions. Ganglion recurrence was identified in one patient, an incidence of 3.7 %.

CONCLUSIONS

The color-aided technique for arthroscopic DWG visualization was found to be a safe and valuable tool for surgeons performing arthroscopic DWG resection. The intraarticular ganglion stalk was identified in 100 % of cases and patients responded well with a low incidence of recurrence.

Arthroscopic excision of dorsal wrist ganglion: factors related to recurrence and postoperative residual pain

PURPOSE

The purpose of this study was to assess the recurrence rate and postoperative residual pain rate after arthroscopic excision of dorsal wrist ganglia and the risk factors for recurrence and residual pain.

METHODS

A total of 115 wrists (111 patients: 57 men, 54 women; average age 34 years; range, 9 to 72 years) treated with arthroscopic excision for wrist dorsal ganglia between April 2005 and December 2009 were enrolled. The follow-up averaged 32 months (range, 12 to 67 months). Demographic data and operative details, including the presence of a ganglion stalk, were retrospectively reviewed and tested against recurrence and residual pain at final follow-up.

RESULTS

The recurrence rate of dorsal wrist ganglia after arthroscopic excision was 11% (13 of 115 wrists). Recurrence was on the dominant side in 12 of 13 (91%) patients, which was the most important risk factor for recurrence (odds ratio [OR], 8.0; 95% confidence interval [CI], 0.94 to 68.49), followed by female sex (OR, 4.9; 95% CI, 0.84 to 28.39) and age 24 years or younger (OR, 3.1; 95% CI, 0.75 to 12.74). Twenty-seven wrists (23%) had postoperative residual pain at final follow-up. The results of logistic regression showed that pain before surgery was the most important risk factor for residual pain after surgery (OR, 4.9; 95% CI, 1.36 to 18.3), followed by female sex (OR, 3.2; 95% CI, 1.22 to 8.53).

CONCLUSIONS

Dominant side, female sex, and age of 24 years or younger are considered to be the most influential risk factors for recurrence after arthroscopic excision of dorsal wrist ganglia. However, the presence or absence of the cyst stalk was not a significant factor for recurrence. Female patients who have preoperative pain around the dorsal wrist ganglia were most likely to experience residual pain after surgery.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

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.

Prospective outcomes of arthroscopic treatment of dorsal wrist ganglia

The purpose of this study was to assess the results of arthroscopic resection of dorsal wrist ganglia. Between November 2002 and September 2007, all patients with dorsal wrist ganglia underwent arthroscopic resection in our institution. Average follow-up was 39.2 months (range, 24-71 months). Fifty-two patients (40 women and 12 men; mean age, 29.8 years) were treated with our operative technique. Symptoms at presentation were unpleasant appearance in 15 patients (28.8 %), pain in 30 (57.6%), and unpleasant appearance and pain in 7 (13.5%). The ganglion cyst site was in front of the midcarpal joint in 41 patients (78.8%), in front of the radiocarpal joint in 6 patients (11.5%), and in front of the radiocarpal and midcarpal joints in 5 patients (9.6%). Our surgical technique resulted in a significant improvement in flexion, extension, and grip strength (P≤.005). In patients with painful ganglia, treatment also had a significant effect. Nine (17.3%) recurrences were observed. Mean time off work was 14 days, but 19 patients returned to work immediately. According to the results of this study, we recommend the use of arthroscopy as the primary treatment method for dorsal wrist ganglion excision.

RESULTS AND COMPLICATIONS IN DORSAL AND VOLAR WRIST GANGLIA ARTHROSCOPIC RESECTION

The authors present the procedure and results of five years of arthroscopic treatment of wrist radiocarpal and midcarpal ganglia. Thirty cases of dorsal ganglia and seventeen cases of volar ganglia were operated on arthroscopically. The technique was easy to perform in all the radiocarpal ganglia, not easy in midcarpal dorsal ganglia and very difficult in midcarpal volar ganglia. The results were recorded with a mean follow-up of 15 months. Twenty-seven cases of dorsal ganglia and twelve cases of volar ganglia had excellent results with active motion recovery, no complications, absence of scars and no recurrence. Two cases had a recurrence. There were four complications: a case of injury of a radial artery branch, a case of extensive haematoma, and two cases of neuropraxia. In three cases the procedure was converted into open surgery: they had a longer time of healing and a residual scar. The arthroscopic resection has been in our experience effective and safe for the treatment of all radiocarpal ganglia. Good results have been obtained also in the treatment of dorsal midcarpal ganglia. Concerning the uncommon cases of volar midcarpal (STT) ganglia, an open approach seems still indicated.

Prospective outcomes and associations of wrist ganglion cysts resected arthroscopically

PURPOSE

To prospectively evaluate objective and subjective outcomes of arthroscopic dorsal wrist ganglion cyst resection, and to identify and examine intra-articular pathologies associated with ganglion cysts.

METHODS

We prospectively evaluated 55 patients with dorsal wrist ganglion cysts who underwent arthroscopic resection with a minimum follow-up of 24 months. Ten had recurrent ganglion cysts previously treated with open resection. Grip strength, wrist motion, and Disabilities of the Arm, Shoulder, and Hand questionnaire scores were evaluated preoperatively and at 6 weeks, 6 months, and 2 years postoperatively. Intraoperative findings were reviewed.

RESULTS

In primary ganglion cysts a discrete stalk was present in 4 of 45 cases and diffuse cystic material and redundant capsular thickening were present in 38 of 45 cases. Cystic material appeared to arise from the radiocarpal joint exclusively in 11 of 42 cases, extended into the midcarpal joint in 29 of 42 cases, and arose exclusively from the midcarpal joint in 2 of 42 cases. The scapholunate joint demonstrated instability types I (2 of 45 cases), II (22 of 45 cases), III (20 of 45 cases), and IV (1 of 45 cases). The lunatotriquetral joint demonstrated instability types II (6 of 45 cases) and III (39 of 45 cases). At 6 weeks, average grip strengths increased by 5.9 kg and wrist flexion decreased 13 degrees . Preoperative Disabilities of the Arm, Shoulder, and Hand scores improved from 14.2 to 1.7 at 6 weeks and remained stable at 2 years. At 2 years, all patients demonstrated motion to within 5 degrees of preoperative measurements, and there were no recurrences.

CONCLUSIONS

Patients experienced significant increases in function and decreases in pain within 6 weeks after arthroscopic ganglion cyst resection, and the recurrence and complication rates appear to be comparable to open resections. Ganglion cysts also have a high association with certain interosseous laxities, and recurrent ganglion cysts originating from the midcarpal joint are not contraindications for arthroscopic resection. Assessment of the midcarpal joint is necessary for complete resection of most ganglion cysts, and identification of a discrete stalk is an uncommon finding and not necessary for successful resection.

Arthroscopic management of dorsal wrist impingement

Dorsal wrist impingement (DWI) occurs when the dorsal wrist capsule becomes trapped and pinched between the extensor carpi radialis brevis (ECRB) and the dorsal ridge of the scaphoid. The diagnosis is purely clinical and depends on accurate localization by history and during examination as well as carefully ruling out alternative etiologies for dorsal wrist pain. Nonsurgical treatment is based on corticosteroid injection and activity modification. In resistant cases, arthroscopic resection of the involved segment of dorsal capsule offers a reliable solution for the problem.

Arthroscopic versus open dorsal ganglion excision: a prospective, randomized comparison of rates of recurrence and of residual pain

PURPOSE

The purpose of this study was to compare the postoperative rates of ganglion recurrence between arthroscopic and open techniques of dorsal ganglion (DG) excision.

METHODS

A total of 72 patients had either arthroscopic or open excision of a primary, simple DG by 1 of 2 senior hand surgeons. Three prospective postoperative assessments were performed. The first examination was performed at 5 to 7 days, the second at 4 to 8 weeks, and the third assessment was performed at a minimum of 1 year after surgery. Percentages of ganglion recurrence at the second and third assessments were recorded.

RESULTS

Forty-one patients had arthroscopic excision, and 31 patients had open excision. Baseline patient age, gender, and surgical side were similar between the 2 groups. Recurrence of the DG at the second postoperative assessment was 1 of 41 patients in the arthroscopic group and none in the open excision group, and, after a minimum of 12 months after excision, recurrence was 3 of 28 in the arthroscopic group and 2 of 23 in the open group.

CONCLUSIONS

This study compares the rates of ganglion recurrence between arthroscopic and open DG excision. Our results demonstrate that at 12 months follow-up, the rates of recurrence with arthroscopic DG excision are comparable with and not superior to those of open excision. Our results suggest that additional long-term comparative studies are needed to accurately differentiate the efficacy of open and arthroscopic techniques.

Current concepts in wrist arthroscopy

The purpose of this article is to review the recent literature on arthroscopic treatment of distal radius fractures (DRFs), triangular fibrocartilage complex injuries, intercarpal ligament injuries, and ganglion cysts, including the use of electrothermal devices. A major advantage of arthroscopy in the treatment of DRFs is the accurate assessment of the status of the articular surfaces and the detection of concomitant injuries. Nonrandomized studies of arthroscopically assisted reduction of DRFs show satisfactory results, but there is only 1 prospective randomized study showing the benefits of arthroscopy compared with open reduction-internal fixation. Wrist arthroscopy plays an important role as part of the treatment for DRFs; however, the treatment for each practitioner and each patient needs to be individualized. Wrist arthroscopy is the gold standard in the diagnosis and treatment of triangular fibrocartilage complex injuries. Type 1A injuries may be successfully treated with debridement, whereas the repair of type 1B, 1C, and 1D injuries gives satisfactory results. For type 2 injuries, the arthroscopic wafer procedure is equally effective as ulnar shortening osteotomy but is associated with fewer complications in the ulnar positive wrist. With interosseous ligament injuries, arthroscopic visualization provides critical diagnostic value. Debridement and pinning in the acute setting of complete ligament tears are promising and proven. In the chronic patient, arthroscopy can guide reconstructive options based on cartilage integrity. The preliminary results of wrist arthroscopy using electrothermal devices are encouraging; however, complications have been reported, and therefore, their use is controversial. In dorsal wrist ganglia, arthroscopy has shown excellent results, a lower rate of recurrence, and no incidence of scapholunate interosseous ligament instability compared with open ganglionectomy. Arthroscopy in the treatment of volar wrist ganglia has yielded encouraging preliminary results; however, further studies are warranted to evaluate the safety and efficacy of arthroscopy.

Electroacupuncture in the treatment of a ganglion of the wrist--a case report

A ganglion is a cystic swelling that occurs most commonly in women. Recurrence is possible after conservative or surgical treatment. A novel method of therapy, electroacupuncture stimulation, was performed in a 53 year old woman with a large, recurrent dorsal wrist ganglion. After treatment it rapidly disappeared and there was no recurrence during the one year follow-up period. Although the mechanism is obscure, it is our impression that electroacupuncture may have a local action on such cysts in addition to needle drainage.

Uses and abuses of wrist arthroscopy

PURPOSE OF REVIEW

The use of wrist arthroscopy in the diagnosis and treatment of carpal pathology continues to expand. The purpose of this paper is to summarize recent advances in the utility of this diagnostic, therapeutic, and research tool.

RECENT FINDINGS

The indications for wrist arthroscopy are growing with the description of volar portals for the radiocarpal and scaphotrapezial trapezoid joint. Arthroscopic assistance in the treatment of distal radius and scaphoid fractures is also becoming more feasible. Arthroscopic excision of dorsal carpal ganglions has met with considerable success. In addition, the application of electrothermal collagen shrinkage is an exciting new frontier in arthroscopic wrist procedures.

SUMMARY

Wrist arthroscopy has evolved to be an essential diagnostic and therapeutic tool in the armamentarium of every surgeon treating disorders of the wrist.