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. 1. Introduction Ganglion cyst is the most common soft tissue swelling in hand and wrist. It occurs most commonly on the dorsal side of the wrist (70%), followed by volar side (20%) of wrist and tendon sheath of fingers. Most of the ganglion cysts are asymptomatic besides swelling. Most patients sought advice and treatment because of the cosmetic appearance or they were concerned that their ganglion was a malignant growth [1]. Treatment options include reassurance, nonsurgical means like aspiration with or without steroid injections or hyaluronidase and surgical excision. We review the treatment outcome of ganglion in the literature and compare their recurrence and complication rates. 2. Methods Electronic databases of Medline, PubMed, and the Cochrane libraries were searched with the key words “ganglion,” “conservative treatment,” “surgery” and “outcomes.” The inclusion criteria were (1) publication in English and (2) articles concerning the treatment of ganglion of hand and wrist. Recurrence rate, complications, and functional outcome were reviewed. References in review articles were screened for potentially relevant studies not yet identified. 3. Reassurance Majority of patients with ganglion do not have symptoms besides swelling, while others may present with pain, weakness, or paresthesia. Barnes et al. reported in their review that only 19.5% had symptoms other than a mass [2]. Westbrook et al. also reported majority of patients sought advice and treatment because of the cosmetic appearance or they were
References
[1]
A. P. Westbrook, A. B. Stephen, J. Oni, and T. R. C. Davis, “Ganglia: the patient's perception,” Journal of Hand Surgery, vol. 25, no. 6, pp. 566–567, 2000.
[2]
W. E. Barnes, R. D. Larsen, and J. L. Posch, “Review of ganglia of the hand and wrist with analysis of surgical treatment,” Plastic and Reconstructive Surgery, vol. 34, pp. 570–578, 1964.
[3]
P. J. Tomlinson and J. Field, “Morbidity of hand and wrist ganglia,” Hand Surgery, vol. 11, no. 1-2, pp. 5–8, 2006.
[4]
B. V. McEvedy, “Simple ganglia,” The British Journal of Surgery, vol. 49, no. 218, pp. 585–594, 1962.
[5]
L. Zachariae and H. Vibe-Hansen, “Ganglia. Recurrence rate elucidated by a follow up of 347 operated cases,” Acta Chirurgica Scandinavica, vol. 139, no. 7, pp. 625–628, 1973.
[6]
J. J. Dias and K. Buch, “Palmar wrist ganglion: does intervention improve outcome: a prospective study of the natural history and patient-reported treatment outcomes,” Journal of Hand Surgery, vol. 28, no. 2, pp. 172–176, 2003.
[7]
J. J. Dias, V. Dhukaram, and P. Kumar, “The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention,” Journal of Hand Surgery: European Volume, vol. 32, no. 5, pp. 502–508, 2007.
[8]
D. V. Nield and D. M. Evans, “Aspiration of ganglia,” Journal of Hand Surgery, vol. 11, no. 2, p. 264, 1986.
[9]
J. M. Esteban, Y. C. Oertel, M. Mendoza, and S. M. Knoll, “Fine needle aspiration in the treatment of ganglion cysts,” Southern Medical Journal, vol. 79, no. 6, pp. 691–693, 1986.
[10]
V. N. Zubowicz and C. H. Ishii, “Management of ganglion cysts of the hand by simple aspiration,” Journal of Hand Surgery, vol. 12, no. 4, pp. 618–620, 1987.
[11]
G. W. Varley, M. Needoff, T. R. C. Davis, and N. R. Clay, “Conservative management of wrist ganglia: aspiration versus steroid infiltration,” Journal of Hand Surgery: European Volume, vol. 22, no. 5, pp. 636–637, 1997.
[12]
A. B. Stephen, A. R. Lyons, and T. R. C. Davis, “A prospective study of two conservative treatments for ganglia of the wrist,” Journal of Hand Surgery: European Volume, vol. 24, no. 1, pp. 104–105, 1999.
[13]
T. W. Wright, W. P. Cooney, and D. M. Ilstrup, “Anterior wrist ganglion,” Journal of Hand Surgery, vol. 19, no. 6, pp. 954–958, 1994.
[14]
W. H. Breidahl and R. S. Adler, “Ultrasound-guided injection of ganglia with coricosteroids,” Skeletal Radiology, vol. 25, no. 7, pp. 635–638, 1996.
[15]
A. S. Paul and D. H. Sochart, “Improving the results of ganglion aspiration by the use of hyaluronidase,” Journal of Hand Surgery: European Volume, vol. 22, no. 2, pp. 219–221, 1997.
[16]
I. G. Mackie, C. B. Howard, and P. Wilkins, “The dangers of sclerotherapy in the treatment of ganglia,” Journal of Hand Surgery, vol. 9, no. 2, pp. 181–184, 1984.
[17]
D. Dogo, A. W. Hassan, and U. Babayo, “Treatment of ganglion using hypertonic saline as sclerosant,” West African Journal of Medicine, vol. 22, no. 1, pp. 13–14, 2003.
[18]
N. Gümü？, “A new sclerotherapy technique for the wrist ganglion: transcutaneous electrocauterization,” Annals of Plastic Surgery, vol. 63, no. 1, pp. 42–44, 2009.
[19]
A. A. Otu, “Wrist and hand ganglion treatment with hyaluronidase injection and fine needle aspiration: a tropical African perspective,” Journal of the Royal College of Surgeons of Edinburgh, vol. 37, no. 6, pp. 405–407, 1992.
[20]
M. J. O. Akkerhuis, M. van der Heijden, and P. R. G. Brink, “Hyaluronidase versus surgical excision of ganglia: a prospective, randomized clinical trial,” Journal of Hand Surgery, vol. 27, no. 3, pp. 256–258, 2002.
[21]
J. A. Richman, R. H. Gelberman, W. D. Engber, P. B. Salamon, and D. J. Bean, “Ganglions of the wrist and digits: results of treatment by aspiration and cyst wall puncture,” Journal of Hand Surgery, vol. 12, no. 6, pp. 1041–1043, 1987.
[22]
J. Korman, R. Pearl, and V. R. Hentz, “Efficacy of immobilization following aspiration of carpal and digital ganglions,” Journal of Hand Surgery, vol. 17, no. 6, pp. 1097–1099, 1992.
[23]
N. Limpaphayom and V. Wilairatana, “Randomized controlled trial between surgery and aspiration combined with methylprednisolone acetate injection plus wrist immobilization in the treatment of dorsal carpal ganglion,” Journal of the Medical Association of Thailand, vol. 87, no. 12, pp. 1513–1517, 2004.
[24]
R. K. Gang and S. Makhlouf, “Treatment of ganglia by a thread technique,” Journal of Hand Surgery, vol. 13, no. 2, pp. 184–186, 1988.
[25]
R. Singhal, N. Angmo, S. Gupta, V. Kumar, and A. Mehtani, “Ganglion cysts of the wrist: a prospective study of a simple outpatient management,” Acta Orthopaedica Belgica, vol. 71, no. 5, pp. 528–534, 2005.
[26]
A. C. Angelides and P. F. Wallace, “The dorsal ganglion of the wrist: Its pathogenesis gross and microscopic anatomy, and surgical treatment,” Journal of Hand Surgery, vol. 1, no. 3, pp. 228–235, 1976.
[27]
L. Janzon and I. A. Niechajev, “Wrist ganglia. Incidence and recurrence rate after operation,” Scandinavian Journal of Plastic and Reconstructive Surgery, vol. 15, no. 1, pp. 53–56, 1981.
[28]
N. R. Clay and D. A. Clement, “The treatment of dorsal wrist ganglia by radical excision,” Journal of Hand Surgery, vol. 13, no. 2, pp. 187–191, 1988.
[29]
H. K. Watson, W. D. Rogers, and D. Ashmead IV, “Reevaluation of the cause of the wrist ganglion,” Journal of Hand Surgery, vol. 14, no. 5, pp. 812–817, 1989.
[30]
H. K. Watson, W. D. Rogers, and D. Ashmead IV, “Reevaluation of the cause of the wrist ganglion,” Journal of Hand Surgery, vol. 14, no. 5, pp. 812–817, 1989.
[31]
L. G. H. Jacobs and K. J. M. Govaers, “The volar wrist ganglion: just a simple cyst?” Journal of Hand Surgery, vol. 15, no. 3, pp. 342–346, 1990.
[32]
S. L. Filan and T. J. Herbert, “Recurrent dorsal wrist ganglion: aetiology and treatment,” Hand Surgery, vol. 1, no. 1, pp. 7–9, 1996.
[33]
J. J. Hwang, C. A. Goldfarb, R. H. Gelberman, and M. I. Boyer, “The effect of dorsal carpal ganglion excision on the scaphoid shift test,” Journal of Hand Surgery: European Volume, vol. 24, no. 1, pp. 106–108, 1999.
[34]
D. K. Faithfull and B. G. Seeto, “The simple wrist ganglion—more than a minor surgical procedure?” Hand Surgery, vol. 5, no. 2, pp. 139–143, 2000.
[35]
H. Günde？, Y. Cirpici, A. Sarlak, and S. Müezzinoglu, “Prognosis of wrist ganglion operations,” Acta Orthopaedica Belgica, vol. 66, no. 4, pp. 363–367, 2000.
[36]
L. Kang, E. Akelman, and A. P. C. Weiss, “Arthroscopic versus open dorsal ganglion excision: a prospective, randomized comparison of rates of recurrence and of residual pain,” Journal of Hand Surgery, vol. 33, no. 4, pp. 471–475, 2008.
[37]
L. Rocchi, A. Canal, F. Fanfani, and F. Catalano, “Articular ganglia of the volar aspect of the wrist: arthroscopic resection compared with open excision. A prospective randomised study,” Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, vol. 42, no. 5, pp. 253–259, 2008.
[38]
A. L. Osterman and J. Raphael, “Arthroscopic resection of dorsal ganglion of the wrist,” Hand Clinics, vol. 11, no. 1, pp. 7–12, 1995.
[39]
R. Luchetti, A. Badia, M. Alfarano, J. Orbay, I. Indriago, and B. Mustapha, “Arthroscopic resection of dorsal wrist ganglia and treatment of recurrences,” Journal of Hand Surgery, vol. 25, no. 1, pp. 38–40, 2000.
[40]
P. C. Ho, J. Griffiths, W. N. Lo, C. H. Yen, and L. K. Hung, “Current treatment of ganglion of the wrist,” Hand Surgery, vol. 6, no. 1, pp. 49–58, 2001.
[41]
S. Nishikawa, S. Toh, H. Miura, K. Arai, and T. Irie, “Arthroscopic diagnosis and treatment of dorsal wrist ganglion,” Journal of Hand Surgery, vol. 26, no. 6, pp. 547–549, 2001.
[42]
J. T. Shih, S. T. Hung, H. M. Lee, and C. M. Tan, “Dorsal ganglion of the wrist: results of treatment by arthroscopic resection,” Hand Surgery, vol. 7, no. 1, pp. 1–5, 2002.
[43]
M. Rizzo, R. A. Berger, S. P. Steinmann, and A. T. Bishop, “Arthroscopic resection in the management of dorsal wrist ganglions: results with a minimum 2-year follow-up period,” Journal of Hand Surgery, vol. 29, no. 1, pp. 59–62, 2004.
[44]
C. Mathoulin, A. Hoyos, and J. Pelaez, “Arthroscopic resection of wrist ganglia,” Hand Surgery, vol. 9, no. 2, pp. 159–164, 2004.
[45]
L. Rocchi, A. Canal, J. Pelaez, F. Fanfani, and F. Catalano, “Results and complications in dorsal and volar wrist ganglia arthroscopic resection,” Hand Surgery, vol. 11, no. 1-2, pp. 21–26, 2006.
[46]
S. G. Edwards and J. A. Johansen, “Prospective outcomes and associations of wrist ganglion cysts resected arthroscopically,” Journal of Hand Surgery, vol. 34, no. 3, pp. 395–400, 2009.
[47]
A. C. Y. Chen, W. C. Lee, K. Y. Hsu, Y. S. Chan, L. J. Yuan, and C. H. Chang, “Arthroscopic ganglionectomy through an intrafocal cystic portal for wrist ganglia,” Arthroscopy, vol. 26, no. 5, pp. 617–622, 2010.
[48]
W. E. Sanders, “The occult dorsal carpal ganglion,” Journal of Hand Surgery, vol. 10, no. 2, pp. 257–260, 1985.
[49]
K. H. Duncan and R. C. Lewis, “Scapholunate instability following ganglion cyst excision. A case report,” Clinical Orthopaedics and Related Research, no. 228, pp. 250–253, 1988.
[50]
W. F. Kivett, F. M. Wood, G. E. Rauscher, and N. A. Taschler, “Does ganglionectomy destabilize the wrist over the long term?” Annals of Plastic Surgery, vol. 36, no. 5, pp. 466–468, 1996.
