Clinical Results of Arthroscopic Resection of Dorsal Wrist Ganglion with a Minimum of 3 Years Follow-up

Abstract

Introduction  Ganglion cysts are the most common benign tumors of the wrist. Their arthroscopic resection is becoming common. However, there are a limited number of studies comparing arthroscopic and open surgeries. This study evaluated the subjective and objective results of arthroscopy with a minimum of 3 years follow-up.

Patients and Methods  Patients with dorsal wrist ganglion who underwent arthroscopic ganglionectomy were evaluated regarding pain (using visual analog scale) and satisfaction as subjective results. We also evaluated their scar (with the Vancouver scar scale), range of motion, and recurrence as objective results.

Results  There were 20 patients in the study. Mean of follow-up time was 52.5 months. Recurrence rate was 5%, and visual analog scale of pain decreased from 3.7 to 0.5 at the final follow-up. Sixteen patients were completely satisfied, three patients were partially satisfied, and one patient was unsatisfied. The mean of Vancouver scar scale was 1.4 (range of 0–3). Improvement in range of flexion and extension of the wrist was significant without a significant complication.

Conclusion  Arthroscopic excision of dorsal wrist ganglion in the way described in this study is a safe and effective method that improves pain and range of motion of the wrist without major complications. The rate of recurrence was less than those reported for open surgery in long-term follow-up. The surgery scar has a promising score in Vancouver scar scale.

Dorsal and volar wrist ganglia are benign tumors. Most of them are asymptomatic and more than half of them can disappear spontaneously. Surgery is reserved for the rare painful ganglia, or more often for cosmetic concerns. Most ganglia are located dorsally around the scapholunate interval. It is more common in women. ¹

When nonoperative treatment fails, arthroscopic resection is a minimal invasive technique that is comparatively reliable. ² Although its published recurrence rate is 11%, and it is not significantly different from open surgery, ³ arthroscopic resection seems to skip pen excision's occasional complications especially unpleasant scarring and joint stiffness. It involves a short time away from work and faster functional recovery. Scapholunate instability can also be the underlying cause of dorsal wrist ganglion and should not be missed. It is possible to arthroscopically assess the scapholunate interval and perform arthroscopical ligament reconstruction and ganglion resection in the same surgery. ¹

Our study evaluated the clinical results and complications of patients who had undergone arthroscopic resection of their dorsal wrist ganglia with a minimum of 3 years follow-up. Furthermore, since ganglion excision is often done for esthetic purposes, we especially evaluated the surgery scar as an objective outcome to answer the question if patients are satisfied with the surgical scar.

Patients and Methods

All patients with pain or cosmetic concern about the dorsal wrist swelling due to a typical ganglion around the scapholunate interval were treated with arthroscopic resection. They had not responded to conservative treatment (activity modification and using wrist splint) for at least 6 months. Diagnosis was based on physical examination supplemented with ultrasound imaging (14 cases) or magnetic resonance imaging (MRI) (6 cases) of the wrist for evaluating dorsal wrist pain.

Children (since they more often respond to conservative treatment), patients with volar ganglion cyst, and those who had any pathological findings in the MRI as a potential underlying cause of the ganglion, including scapholunate injury, were excluded from the study. Also, patient whose ganglion had been operated more than 3 years before the study and those who could not attend for the final examination were excluded. Finally, 20 patients met our criteria, 14 women and 6 men. Their mean of age was 31 years (range of 16–53 years) ( Table 1 ).

Table 1. Demography of the patients.

	Frequency	%
Women	14	70
Men	6	30
Right handed	17	85
Left handed	3	15
Dominant	12	60
Student	8	40
Employee	2	10
Homemaker	6	30
Labor	2	10
No occupation	2	10
Total	20	100

The ethics committee of our university approved the study (IR.UMSHA.REC.1397.567). Before the surgery, we did the conventional radiography of the wrist for all patients. We did not perform a routine MRI unless for evaluating chronic wrist pain that resulted in diagnosis of dorsal wrist ganglion. Pain was evaluated with visual analog scale (0–10). We measured the range of motion of the wrist with a goniometer before the surgery.

Surgical Technique

A highly experienced surgeon who has number 4 level of expertise (the first author who has more than 10 years' experience of wrist arthroscopy) did all the surgeries. The patients were under general anesthesia and in supine position. A tourniquet was placed on the arm near the elbow and counter traction was applied to it. Traction was applied by a traction tower. The required traction of 30 to 50 N was applied using the Chinese finger traps ( Fig. 1A ). The surgeon was standing beside the patient's head, and the assistant stood at the palmar side of the wrist.

Fig. 1.

( A ) Position of the hand under traction; ( B ) introducing a needle through the ganglion into the mid-carpal joint; ( C ) introducing a shaver through the ganglion into the joint; and ( D ) resection of cyst wall while protecting extensor tendons.

We started all the wrist arthroscopy procedures with radiocarpal assessment using 3–4 and 6R portals, even if we did the main procedure from the mid-carpal portals. After doing the radiocarpal diagnostic arthroscopy, we inserted the scope through the ulnar mid-carpal portal to visualize the stem of the ganglion and navigate its resection from the mid-carpal portal. ¹ As described by Mathoulin and Gras, mid-carpal exploration usually reveals a dorsal synovial bulge at the scapholunate interval corresponding to the intra-articular portion of the ganglion. ¹ We also evaluated scapholunate instability using a probe before resecting the ganglion.

Then, we did a transcystic mid-carpal portal approach by introducing a needle through the ganglion into the mid-carpal joint by the radial mid-carpal portal ( Fig. 1B ). A shaver was introduced through a transcystic, radial mid-carpal portal. The stem of the ganglion (its capsular extension) was resected carefully to preserving the dorsal capsuloscapholunate septum (DCSS) and for the continuity of the dorsal intercarpal ligament ( Fig. 1C ).

The ganglionic part of the capsule was resected by gradually pulling back the shaver under direct arthroscopic control. Care was taken not to damage the extensor carpi radialis tendons ( Fig. 1D ).

After finishing the cyst wall excision, we switched the scope to the 6R portal to evaluate the integrity of the scapholunate ligament and the DCSS. An occasional capsuloligamentous repair was accomplished through the 3–4 portal. ¹ The patients removed the splint and started active range of motion of the wrist the day after surgery unless they had undergone capsuloligamentous repair, requiring them to keep the splint for 6 weeks.

We evaluated all patients at least 3 years after surgery. They filled the visual analog scale and satisfaction questionnaires. First, we asked the patients to express their satisfaction as completely satisfied, partially satisfied, or unsatisfied. Then, we asked them to rate their satisfaction from 0 (completely unsatisfied) to 10 (completely satisfied). Finally, we asked them if they would choose this operation on their other wrist if it had a similar cyst.

We examined the patients for recurrence of the ganglion cyst. Since esthetics is a major reason for ganglion excision, we evaluated the scar using the Vancouver scar scale. ⁴ Vancouver scar scale scores the scar from 0 (as normal) to 13 based on vascularity, pigmentation, pliability, and scar height ( Table 2 ).

Table 2. The Vancouver scar scale.

	Scar characteristic	Score
Vascularity	Normal	0
	Pink	1
	Red	2
	Purple	3
Pigmentation	Normal	0
	Hypopigmentation	1
	Hyperpigmentation	2
Pliability	Normal	0
	Supple	1
	Yielding	2
	Firm	3
	Ropes	4
	Contracture	5
Height	Flat	0
	<2 mm	1
	2–5 mm	2
	>5 mm	3
	Total score	13

Results

Twenty patients who had undergone arthroscopical excision of a dorsal wrist ganglion from October 2014 to November 2017 and met our inclusion criteria were included in the study. Mean of follow-up time was 52.5 months (38–71 months). The ganglion cyst was in the dominant hand in 12 patients (60%) and in the nondominant hand in 8 patients (40%). The indication for treatment was pain in 12 patients (60%), cosmetics in 3 patients (15%), and both pain and cosmetics in 5 patients (25%).

One patient (5%) had a history of open surgery, and two patients (10%) had a history of puncture for treating the ganglion, both more than 3 years before the arthroscopic excision of this study. Mean time of symptoms' presentation until arthroscopic surgery was 27 months (6–48 months). In the follow-up (minimum of 3 years), one right-handed woman (5%) suffered from painless ganglion recurrence.

Pain, which was evaluated with visual analog scale, decreased from 3.7 before surgery to 0.5 at the final follow-up. Regarding satisfaction, 16 patients were completely satisfied (80%), 3 patients were partially satisfied (15%), and the patient with recurrent ganglion was completely unsatisfied. Mean of satisfaction score was 9.1 (from minimum 1 to maximum 10). Only one patient preferred a different kind of surgery if he had ganglion in his other wrist.

The mean score for scar evaluation was 1.4 (0–3) according to Vancouver scar scale. No patient had a significant complaint about the surgical scars. Range of motion was measured in the involved wrist before surgery. Mean of flexion was 54.2 degrees (35–100 degrees) and mean of extension was 47.4 degrees (30–80 degrees). There was a significant difference with the opposite side (mean of flexion = 67.4 degrees and mean of extension = 65.5 degrees; p  < 0.005). Postoperative range of motion of both wrists was similar and without a significant difference ( p  > 0.05). Comparison of preoperative and postoperative range of motion in the operated wrists showed a significant improvement of 11 degrees in flexion (54.2 vs. 65.2 degrees) and 14.1 degrees in extension (47.4 vs. 61.5 degrees) ( p  < 0.005).

We did not evaluate grip strength before surgery. However, when we asked the patients about it at the final follow-up, 19 patients (95%) answered that they feel they got a better grip strength, 12 patients (60%) could go back to work the day after the surgery, 7 within 2 weeks, and 1 after 6 weeks. Regarding complications, besides recurrence in one patient, there was transient paresthesia in the dorsal hand in two patients that was resolved completely.

Discussion

Ganglion cysts of the wrist are the most common benign tumors of the wrist. ⁵ Spontaneous regression can occur in more than half of the patients. ⁶ Patients seek treatment because of pain, range of motion restriction, or cosmetic concern. ⁷ Needle aspiration is a simple treatment that can be done in the clinic. However, its recurrence rate is high: 59% with a low rate of complication (3%). ⁸

Its surgical alternatives are open or arthroscopic excision. In a systematic review and meta-analysis, Head et al found a lower rate of recurrence (21%) but a higher rate of complications (14%) for open surgical excision in comparison to arthroscopic excision. Arthroscopic excision has yielded promising outcomes with a 6% recurrence rate and 4% complication rate. ⁸ However, the data from comparative clinical trials are limited and have not demonstrated the advantage of either approach. ¹

Recurrence rate after arthroscopic excision of wrist ganglion ranges from 0 to 26%. ^{1 4 7 9 10 11 12 13} In another study with 114 dorsal wrist ganglia with a minimum of 2 years follow-up, the recurrence rate was 11%. Arthroscopic treatment of ganglion cyst seems to be at least as good as open surgery with fewer complications. ³ Fernandes et al reported 6% recurrence rate after arthroscopical ganglion resection in a literature review. ⁴

In our study, there was 5% recurrence rate, although the small number of cases could have been influential. However, long-term follow-up of the patients is a strength of our study. As a subjective outcome of treatment, the visual analog score decreased from 3.7 preoperatively to 0.5 at the final follow-up. Kang et al found a decrease in visual analog scale to 0.6 2 years after arthroscopic excision. ¹⁴

Regarding patient satisfaction is the other subjective outcome, 16 patients (80%) were completely satisfied, 3 patients (15%) were partially satisfied, and 1 patient (who had recurrence) was completely unsatisfied. Mean of satisfaction score was 9.1 (from minimum 1 to maximum 10). In another study, more than 96% of patients were satisfied with arthroscopic resection of wrist ganglion. ³

We evaluated scar quality and wrist's range of motion as the objective outcomes of the surgery. To the best of our knowledge, this is the first study that has evaluated scar formation after arthroscopic dorsal wrist ganglion excision. Mean of Vancouver scar scale of our patients was 1.4. Sensitive scar and keloid formation have been reported in some studies after open surgery of the wrist ganglia. ^{15 16 17}

Range of motion improved significantly after the surgery ( Fig. 2 ). It was not different from the normal side. Beside recurrence in one patient (5%), we did not observe any major complication. Two patients (10%) had transient paresthesia in the dorsal of the hand that was resolved without treatment.

Fig. 2.

Range of flexion and extension before and after surgery. ROM, range of motion.

Conclusion

Arthroscopic resection of dorsal wrist ganglia seems to be an effective operation with low rate of recurrence and complications, and very advantageous scar formation in long-term follow-up. Our cases can add some more insight to the literature since arthroscopic ganglion excision is established as an acceptable method of ganglion excision