Patient-Related Outcomes of Arthroscopic Resection of Ganglion Cysts of the Wrist

Abstract

Background  Ganglion cysts of the wrist can cause pain and loss of functionality. No consensus exist on optimal treatment. Arthroscopic resection shows promising results but is poorly studied. Furthermore, only few studies have used patient-related outcomes to evaluate arthroscopic treatment.

Purpose  The purpose of this study was to assess patient-related outcomes following arthroscopic resection of wrist ganglion cysts.

Patients and Methods  This was a retrospective study of all consecutive patients that underwent arthroscopic resection of a dorsal or volar wrist ganglion. Minimum follow-up was 6 months. The primary outcome was the patient-rated wrist evaluation (PRWE). Secondary outcomes were recurrence rate and complications.

Results  A total of 53 patients were included with a mean follow-up of 13 months (interquartile range: 6–23 months). Twenty-six patients (49%) presented with a recurrence following prior treatment. Mean PRWE was 13 (standard deviation [SD] = 1.8), with no difference between patients with dorsal or volar ganglion cysts. There were five recurrences (9%), of which three occurred in the first five patients who were operated. There were three patients with complications (6%), consisting of neuropraxia, extensor carpi ulnaris tendinitis, and painful scar tissue.

Conclusion  Arthroscopic resection results in good patient-related outcome and low complication and recurrence rates when performed by an experienced surgeon. Recurrence and complication rates are similar to arthroscopic resections described in literature and superior to open resection and needle aspiration. Well-designed randomized clinical trials will be necessary to confirm these findings.

Level of Evidence  This is a level IV, retrospective study.

Ganglion cysts of the wrist are the most common benign tumors of the wrist. ^{1 2} Symptoms include pain, impaired mobility, and esthetical dissatisfaction due to swelling. Management primarily consists of reassurance and education, as spontaneous regression of ganglion cysts can be as high as 58%. ³ If symptoms persist, treatment options consist of needle aspiration, corticosteroid injection, and open or arthroscopic resection. Because recurrence occurs in approximately half of the patients, needle aspiration with or without corticosteroid injection is only used for patients who are not suitable for surgery. ^{4 5} Open resection of ganglion cysts results in recurrence in 21% of the cases and complications in 14%. ^{3 4} Possible complications include hematoma formation, wound infection, painful scar tissue, neuroma, and neuropraxia. Arthroscopic resection is a less invasive alternative to open resection. A study reviewing various treatment options showed that arthroscopic resection had lower recurrence rates (6 vs. 21%) and lower complication rates (4 vs. 14%) compared with open excision. ⁴ Despite promising results, overall data on arthroscopic resections are limited. Furthermore, only one study evaluated patient-related outcomes of arthroscopic ganglion cyst resection, with good patient-rated wrist evaluation (PRWE) scores. ⁶ Therefore, the purpose of this study was to assess patient-related outcomes following arthroscopic resection of ganglion cysts of the wrist, measured with the PRWE.

Patients and Methods

Patients

This single-center study retrospectively reviewed all consecutive patients who underwent arthroscopic treatment of a wrist ganglion cysts between June 2015 and December 2018. Patients were included if they had a symptomatic ganglion cyst on the dorsal or volar side of the wrist treated with arthroscopic resection. No age limit was applied. Diagnosis of the ganglion cysts was based on clinical findings. In clinically uncertain cases, the diagnosis and origin of the ganglion cyst were confirmed by magnetic resonance imaging (MRI) or ultrasound before arthroscopy. Patients were excluded if they had a follow-up time of less than 6 months (determined as the time between the arthroscopic treatment and contact by telephone) or if contact details were missing.

Outcome Measures

The primary outcome was postoperative wrist function, measured using the PRWE questionnaire at a minimum follow-up of 6 months. This is a validated 15-item questionnaire containing 5 questions regarding wrist pain and 10 questions regarding wrist function. The score ranges from 0 to 100. A high score indicates worse outcome. ⁷ Patients were contacted by telephone to assess the postoperative outcome and to obtain the questionnaire. The hospital's clinical records were used to collect patient characteristics, contact information, imaging records, perioperative details, and complications. Relevant intraoperative findings were documented. Patients gave verbal informed consent for the use of patient data and questionnaires. Secondary outcomes were recurrence of ganglion cysts measured from time of surgery until contact by telephone and perioperative or postoperative complications. Subsequent treatment was documented if patients had recurrence of the ganglion cyst. Preoperative treatment and postoperative interventions were specified as needle aspiration, corticosteroid injections, wrist denervation, open resection, and arthroscopic resection.

Statistical Methods

The distribution of the data was checked for normality by visually inspecting the histograms and box plots. Normally distributed data were reported as mean and standard deviation (SD) and nonnormally distributed data were reported as median with interquartile range (IQR). Categorical data were presented as the absolute frequency and the percentage. PRWE scores between groups were compared using the unpaired t -test. Recurrence rates between groups were compared using the Fisher's exact test. A p -value of less than 0.05 was considered statistically significant. The cumulative number of recurrences and complications was calculated for all consecutive patients to examine the presence of a learning curve in performing arthroscopic resection of ganglion cysts.

Surgical Technique

All surgeries were performed by one surgeon (N.W.L.S.) with a high level of experience in wrist arthroscopy, based on the scale introduced by Tang and Giddins. ⁸ Patients underwent general anesthesia or brachial plexus block. All interventions were performed under tourniquet exsanguination and 5 kg of vertical arm traction. The radiocarpal joint was initially visualized using a 2.4-mm arthroscope with 30-degree angulation through the dorsal 3–4 portal. The 6R portal was created under visual control. Next the camera was introduced through the 6R portal. Dorsal ganglion cysts were removed using a shaver through the 3–4 portal. During surgery, the surgeon inspected the dorsal capsule, scapholunate interval, and dorsal capsuloscapholunate septum (DCSS). Mucoid dysplasia, if present, was removed using a shaver. The dorsal capsule was opened until the extensor tendons were visible proximal to the DCSS. Next, an ulnar midcarpal portal was used to introduce the shaver. The stalk of the ganglion, herniating into the midcarpal joint, was resected together with the corresponding dorsal capsule.

For resection of volar ganglion cysts, the camera was initially placed in the 3–4 portal. In most instances, the surgeon could identify the stalk of the ganglion between the radioscaphocapitate ligament (RSC) and long radiolunate ligament (LRL) by manually pressing on the volar ganglion. A shaver was introduced through a dorsal 6R portal. If necessary the camera and shaver were switched. The cyst and stalk were resected with the shaver while applying continuous pressure on the ganglion with the thumb or index finger. All portals were closed with single nylon sutures or sterile adhesive tape. A soft pressure dressing was applied for 48 hours. Patients were instructed to mobilize their wrist immediately.

Results

Patient Characteristics

In total, 53 patients were included in the study. Mean age at time of surgery was 32 years (SD = 12.6), ranging from 10 to 70 years ( Table 1 ). The ganglion cyst was located on the volar aspect of the wrist in 20 patients and dorsal in 33 patients. For confirmation of the diagnosis, 39 patients underwent an MRI scan and two underwent an ultrasound preoperatively. Indications for arthroscopic treatment were pain ( n  = 47), reduced range of motion ( n  = 1) or both ( n  = 5). Twenty-six of the 53 patients (49%) were presented with a recurrence following prior treatment that included needle aspiration ( n  = 4) and open resection ( n  = 22). Two patients had open resection twice and one three times before arthroscopic treatment.

Table 1. Patient characteristics at baseline.

Characteristic	All participants ( n  = 53)
Age in years, mean (SD)	32 (13)
Female sex, n (%)	44 (83)
Ganglion cyst on dorsal wrist, n (%)	33 (62)
Dominant side treated, n (%)	23 (43)
Recurrence of ganglion cyst at baseline, n (%)	26 (49)
Occupation, n (%)
Unemployed	4 (8)
Light manual labor	26 (49)
Moderate manual labor	12 (23)
Heavy manual labor	11 (21)
Previous treatment, n (%)
None	27 (51)
Aspiration	4 (8)
Open resection	18 (34)
Open resection and aspiration	4 (8)

Abbreviation: SD, standard deviation.

Patient-Rated Wrist Evaluation Questionnaire

Of the 53 patients, 52 (98%) patients completed the PRWE questionnaire. One patient was lost to follow-up. Median time between arthroscopy and completion of the PRWE was 13 months (IQR: 6–23 months), ranging from 6 to 42 months. Mean PRWE score was 13 (SD = 1.8). There was no difference in PRWE scores between volar and dorsal ganglion cysts (13 and 14 respectively, p  = 0.751). No correlation was found between PRWE score and follow-up time ( p  = 0.604).

Complications and Recurrences

Recurrence of the wrist ganglion cyst occurred in five patients (9%). They were located dorsally in three patients and volarly in two patients. Three patients had received prior open resection and one patient had undergone prior needle aspiration. PRWE scores were significantly higher in patients with a recurrence (30 vs. 12, p  = 0.002). Patients initially presenting with a new ganglion cyst had fewer recurrences at final follow-up compared with patients initially presenting with recurrence (4 vs. 15%, respectively). Two of the recurrences were symptomatic, which were treated with rearthroscopy. Asymptomatic ganglion cysts were left untreated. One patient experienced another recurrence following rearthroscopy, which was successfully treated with a third arthroscopy. Three of the 53 patients (6%) had a complication. One patient experienced neuropraxia of the radial superficial nerve, which resolved spontaneously. One patient developed extensor carpi ulnaris (ECU) tendinitis which was successfully treated with splinting. One patient experienced painful scar tissue, which was successfully removed surgically. Three of the five recurrences occurred among the first five patients operated on, whereas two recurrences occurred in the consecutive 48 patients (4%; Fig. 1 ). Complications were more evenly distributed.

Fig. 1.

Cumulative number of recurrences and complications following arthroscopic ganglion cyst resection displayed in consecutive order.

Intraoperative Findings

Intraoperative visualization of the stalk of the ganglion cyst was successful in all cases ( Fig. 2 ). All 33 dorsal ganglion cysts originated at the scapholunate (SL) interval. Of the 20 volar ganglion cysts, 16 originated radiocarpally and four midcarpally. In six patients with a large dorsal ganglion cyst, an additional small incision was required to remove the remaining ganglion cyst wall. Three patients had ganglion cysts on both the dorsal and volar side of the wrist. Additional findings were scar tissue in one previously operated patient, tears in the triangular fibrocartilage complex (TFCC) in two patients and disruption of the scapholunate ligament (European Wrist Arthroscopy Society classification 3B) in one patient.

Fig. 2.

( A – F ) All images are from a dorsal ganglion cysts of a single patient's right wrist. ( A and B ) The ganglion cyst is outlined together with the location of the arthroscopy portals. ( C ) Radiocarpal image of a dorsal ganglion cyst (seen from the 6R portal). ( D ) Radiocarpal image. A shaver is used to remove the ganglion stalk. ( E ) Midcarpal image (seen from the MCU portal). ( F ) Midcarpal image (seen from the MCU portal with the camera turned). The dorsal capsule is removed until the extensor tendons are visible. 3–4, portal between the third and fourth extensor tendon compartment; 6R, portal radial of the sixth extensor tendon compartment; C: capitate; DC, dorsal capsule; DCSS, dorsal capsuloscapholunate septum; ET, extensor tendons of the hand; GS, ganglion stalk; L, lunate; LF, lunate fossa of the radius; MCU, midcarpal ulnar portal; R, radius; S, scaphoid; SF, scaphoid fossa of the radius.

Discussion

Adequate treatment of ganglion cysts of the wrist remains challenging. Different interventions have shown varying recurrence and complication rates as demonstrated by Head and colleagues. ⁴ More importantly, patient-related outcomes have been poorly investigated. Patient-related outcomes are, however, an important tool for determining functionality after surgery to the hand and wrist. This study assessed patient-related outcome after arthroscopic ganglion cyst resection in a large patient cohort.

The mean PRWE score in our study was 13. This is in line with findings of a retrospective study with an average follow-up 4.6 years, which showed a mean PRWE score of 8 among 30 patients who underwent arthroscopic resection of symptomatic wrist ganglion cysts. ⁶ In comparison, a cross-sectional study among the general population found a mean PRWE score of 7.7 (SD = 15). ⁹ This suggests that pain and wrist function following arthroscopic ganglion cyst resection are comparable to that of the general population.

The recurrence rate was 9% among our patients. Similar results were found by a meta-analysis that compared various types of ganglion cysts treatment in 35 studies with a total of 2,239 ganglion cysts. ⁴ Treatment included needle aspiration, open excision, and arthroscopic resection. Recurrence rates of arthroscopic resection, open excision, and aspiration were 6, 21, and 59%, respectively. In the current study, three recurrences occurred among the first five patients operated on, whereas only two recurrences occurred in the following 48 patients (4%). These numbers indicate that even for surgeons with a high level of experience in wrist arthroscopy, arthroscopic resection of ganglion cysts requires a learning process to minimize the incidence of recurrence.

Reason for this improvement could be the less extensive removal of ganglion stalk in the first series of patients. Moreover, in later surgeries, the dorsal capsule surrounding the stalk was opened to the point where the extensor tendons were visible proximal to the DCSS.

An interesting finding in the current study is that four of five patients with recurrence had presented with recurrence at baseline. Three of these patients had received prior open resection and one patient had undergone needle aspiration. Compared with patients with a primary ganglion cyst, recurrence at final follow-up was four times higher in patients presenting with a recurrence (4 vs. 15%). This suggests that prior recurrence might negatively influence treatment outcomes of arthroscopy, which should be discussed with the patient. In contrast, a study of Kim and colleagues evaluated the risk factors for recurrence in 115 patients who underwent arthroscopic resection and they found no difference in recurrence rate between patients with or without prior open excision (6 and 12%, respectively). ¹⁰ Clearly, more data are needed to determine recurrence rates after secondary treatment. In this study, no difference was found between recurrence rates in volar and dorsal ganglion cysts. This confirms the results from two systematic reviews that found recurrence following arthroscopic resection in 9% of 587 dorsal ganglion cysts and 6% of 232 volar ganglion cysts. ^{11 12}

We reported a total of three complications in our patient group (6%), which is similar to complication rates described in other studies on arthroscopic ganglion cysts resection, although numbers vary widely (0–56%). ^{4 12} Noticeably, these rates are lower than those of open resection (4 vs. 14%), according to the meta-analyses by Head and colleagues. ⁴ Similar to this study, complications in other studies include hematoma, infection, neuroma, painful scar tissue, and neuropraxia. ^{1 4} Neuropraxia of the radial superficial nerve has been associated with placement of the 1–2 portal due to its proximity to the nerve. ¹³ In our study, the 1–2 portal, however, was not used and it remains unclear what exactly caused the transient neuropraxia in our patient.

Limitations

The results of this study should be interpreted with some limitations. First, due to its retrospective nature, no preoperative data could be obtained. Therefore, pre- and postoperative PRWE scores could not be compared. Second, the recurrence rate in our study could be an underestimation of true recurrence rates following arthroscopic resection of ganglion cysts. A study on 115 ganglia patients who received arthroscopic resection demonstrated recurrence typically occurred at a mean of 18 months postoperatively, whereas median follow-up duration in our study was 13 months (IQR: 6–23 months). ¹⁰ And third, the heterogeneity of the population influences the study outcome due to confounders. However, a heterogeneous study population more adequately represents patient diversity in clinical practice.

Conclusion

This study demonstrated that arthroscopic resection is a good method for treating ganglion cysts of the wrist. It showed acceptable functional outcomes, when measured with the PRWE questionnaire, and lower complication and recurrence rates compared with needle aspiration and open resection. Therefore, we believe wrist arthroscopy will play an important role in the future of ganglion cyst treatment. However, as our study shows, surgeon expertise is essential for good results, which emphasizes the need for expert centers for wrist arthroscopy. Future research should further explore the recurrence and complications of open and arthroscopic surgery for the treatment of ganglion cysts of the wrist, preferably in a prospective randomized setting. Above all, studies should include patient-related outcomes to offer insight in the perception of symptoms and functionality of the wrist.