- Email: [email protected]
A prospective study of two conservative treatments for ganglia of the wrist
A PROSPECTIVE STUDY OF TWO CONSERVATIVE T R E A T M E N T S F O R G A N G L I A OF T H E W R I S T A. B. STEPHEN, A. R. LYONS and T. R. C. DAVIS From the Department of Orthopaedic and Accident Surgeo, University Hospital, Queen's' Medical Centre, Nottingham, UK This randomized prospective study assessed whether multiple puncture of the ganglion wall improves the results of simple ganglion aspiration. We found that 32% of ganglia resolved after aspiration alone in comparison with 22% after aspiration and multiple puncture. This difference was not significant. However, only 18% of patients requested formal surgical excision, suggesting that aspiration allays fears of malignancy and allows the patient to accept a minor cosmetic embarrassment. Journal of Hand Surgery (British and European Volume, 1999)24B: 1:104 105 Surgical excision of wrist ganglia has been reported to have the best success rates in terms of recurrence; for example Angelides and Wallace (1976) reported a 99% success rate. However, it is relatively expensive and not without its complications (Paul and Sochart, 1997). Many conservative treatments have therefore been suggested as alternatives to surgical excision of wrist ganglia. The reported success rates for these vary considerably, possibly because of inadequate follow-up and because most ganglia resolve spontaneously over 1 or 2 years. Nield and Evans (1985) aspirated 34 ganglia and reported a recurrence rate of 59% after 1 year. Otu (1992) aspirated and injected hyaluronidase into 340 ganglia producing a 95% cure rate at 6 months. This outcome was significantly different from that reported by Nelson et al. (1972) who had a 43% recurrence rate after a single injection of hyaluronidase (35 patients followed up from 1 8 years). Aspiration and steroid injection has been reported to produce a 57% success rate in 35 ganglia at 2 years in one study (Paul and Sochart, 1997), whilst another had an 86% success rate in 22 ganglion followed up for between 2 months to 5 years (Derbyshire, 1966). It is thus difficult to draw any conclusions about the relative effectiveness of the different treatments. We report a randomized prospective study to assess whether multiple puncture of the ganglion wall, a relatively painful procedure, improves on the results of ganglion aspiration alone.
nature of ganglia. They were all invited to return for further treatment if the ganglia recurred and justified further intervention. All patients were sent a postal questionnaire after 1 year. RESULTS One hundred and nineteen ganglia were entered into this study of which 92 (77%) were followed up for 1 year. The male:female ratio was 1:3.1 and 64 (53%) were on the dominant side. The sites of the ganglia are shown in Figure 1. Sixty-five ganglia were randomized to the aspiration group and 54 to the aspiration and multiple puncture group. The groups were similar with regard to patient age, sex and sites of ganglia. The follow-up rates in the two groups were 51/65 and 41/54 respectively. Sixteen of 51 ganglia (31%) treated by aspiration alone resolved and did not recur in contrast to nine of 41 ganglia (22%) in the aspiration and multiple puncture group. This difference was not statistically significant (X2 analysis). There was no correlation between the success
407
1
35 30 Ca/)
25 20
PATIENTS AND M E T H O D S
15
All adult patients with ganglia referred to the hand clinic over a 1 year period were randomized into two treatment groups according to their hospital number. Odd numbers received multiple puncture, even numbers aspiration alone. The ganglia were either simply aspirated with a 19 G needle and a 5 ml syringe or aspirated and punctured at least four times with the needle tip. Wrist splints were not used after treatment but all patients were given an information sheet explaining the benign, usually self-limiting
10
/
5
0
r
- -
F
w
Dorso-
Dorsal
Palmar
Ulna
radial
midline
radial
border
Site Fig 1
104
Anatomical
sites of the ganglia on the wrists.
CONSERVATIVE T R E A T M E N T OF WRIST G A N G L I A
rate and the anatomical site of the ganglion, sex of the patient or working status. Those ganglia that recurred following treatment did so at a mean of 33 days (range, 1-334). Only 21 of the original 119 patients (18%) requested and were listed for surgical excision of a recurrent ganglion. DISCUSSION This study has demonstrated that multiple puncture of the ganglion wall does not improve the results of simple ganglion aspiration. Our reported success rate with multiple puncture was 22%, which may be an underestimate because of our incomplete (77%) follow-up. It is plausible that patients failed to respond to follow-up requests because they were cured and therefore saw no reason to return. Some patients with ganglia may have concerns about their "tumours" being malignant, as well as being bothered about the cosmetic appearance. After aspiration and discussion of the benign nature of ganglia, only a few wish to undergo surgical excision. There are significant cost implications in treating ganglia conservatively. Currently in the UK a single visit
105
to the outpatient department costs approximately onesixth of a day patient operation. Furthermore dorsal wrist ganglia can be safely aspirated by a general practitioner if indeed treatment is needed at all. REFERENCES Angelides A C, Wallace P F (1976). The dorsal ganglion of the wrist: its pathogenesis, gross and microscopic anatomy, and surgical treatment. Journal of Hand Surgery, 1: 228-235. Derbyshire R C (1966). Observations on the treatment of ganglia with a report on hydrocortisone. American Journal of Surgery, 112: 635~636. Nelson C L, Sawmiller S, Phalen G S (1972). Ganglions of the wrist and hand. Journal of Bone and Joint Surgery, 54A: 1459-1464. Nield D V, Evans D M (1986). Aspiration of ganglia. Journal of Hand Surgery, 11B: 264. Otu A A (1992). 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, 37: 405J,07. Paul A S, Sochart D H (1997). Improving the results of ganglion aspiration by the use of hyaluronidase. Journal of Hand Surgery, 22B: 219 221.
Received: 15 July 1998 Accepted after revision: 31 August 1998 Mr A. B. Stephen, Department of Orthopaedic and Accident Surgery, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH, UK. E-maih [email protected] (~'1999The British Society for Surgery of the Hand Arlicle no. jhsbA998.0037
nature of ganglia. They were all invited to return for further treatment if the ganglia recurred and justified further intervention. All patients were sent a postal questionnaire after 1 year. RESULTS One hundred and nineteen ganglia were entered into this study of which 92 (77%) were followed up for 1 year. The male:female ratio was 1:3.1 and 64 (53%) were on the dominant side. The sites of the ganglia are shown in Figure 1. Sixty-five ganglia were randomized to the aspiration group and 54 to the aspiration and multiple puncture group. The groups were similar with regard to patient age, sex and sites of ganglia. The follow-up rates in the two groups were 51/65 and 41/54 respectively. Sixteen of 51 ganglia (31%) treated by aspiration alone resolved and did not recur in contrast to nine of 41 ganglia (22%) in the aspiration and multiple puncture group. This difference was not statistically significant (X2 analysis). There was no correlation between the success
407
1
35 30 Ca/)
25 20
PATIENTS AND M E T H O D S
15
All adult patients with ganglia referred to the hand clinic over a 1 year period were randomized into two treatment groups according to their hospital number. Odd numbers received multiple puncture, even numbers aspiration alone. The ganglia were either simply aspirated with a 19 G needle and a 5 ml syringe or aspirated and punctured at least four times with the needle tip. Wrist splints were not used after treatment but all patients were given an information sheet explaining the benign, usually self-limiting
10
/
5
0
r
- -
F
w
Dorso-
Dorsal
Palmar
Ulna
radial
midline
radial
border
Site Fig 1
104
Anatomical
sites of the ganglia on the wrists.
CONSERVATIVE T R E A T M E N T OF WRIST G A N G L I A
rate and the anatomical site of the ganglion, sex of the patient or working status. Those ganglia that recurred following treatment did so at a mean of 33 days (range, 1-334). Only 21 of the original 119 patients (18%) requested and were listed for surgical excision of a recurrent ganglion. DISCUSSION This study has demonstrated that multiple puncture of the ganglion wall does not improve the results of simple ganglion aspiration. Our reported success rate with multiple puncture was 22%, which may be an underestimate because of our incomplete (77%) follow-up. It is plausible that patients failed to respond to follow-up requests because they were cured and therefore saw no reason to return. Some patients with ganglia may have concerns about their "tumours" being malignant, as well as being bothered about the cosmetic appearance. After aspiration and discussion of the benign nature of ganglia, only a few wish to undergo surgical excision. There are significant cost implications in treating ganglia conservatively. Currently in the UK a single visit
105
to the outpatient department costs approximately onesixth of a day patient operation. Furthermore dorsal wrist ganglia can be safely aspirated by a general practitioner if indeed treatment is needed at all. REFERENCES Angelides A C, Wallace P F (1976). The dorsal ganglion of the wrist: its pathogenesis, gross and microscopic anatomy, and surgical treatment. Journal of Hand Surgery, 1: 228-235. Derbyshire R C (1966). Observations on the treatment of ganglia with a report on hydrocortisone. American Journal of Surgery, 112: 635~636. Nelson C L, Sawmiller S, Phalen G S (1972). Ganglions of the wrist and hand. Journal of Bone and Joint Surgery, 54A: 1459-1464. Nield D V, Evans D M (1986). Aspiration of ganglia. Journal of Hand Surgery, 11B: 264. Otu A A (1992). 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, 37: 405J,07. Paul A S, Sochart D H (1997). Improving the results of ganglion aspiration by the use of hyaluronidase. Journal of Hand Surgery, 22B: 219 221.
Received: 15 July 1998 Accepted after revision: 31 August 1998 Mr A. B. Stephen, Department of Orthopaedic and Accident Surgery, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH, UK. E-maih [email protected] (~'1999The British Society for Surgery of the Hand Arlicle no. jhsbA998.0037