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Conservative management of wrist ganglia
CONSERVATIVE MANAGEMENT
OF W R I S T G A N G L I A
A s p i r a t i o n versus steroid infiltration G. W. VARLEY, M . N E E D O F F , T. R. C. DAVIS and N. R. CLAY
From Queen's Medical Centre, Nottingham and Glan Clwyd Hospital, Bodelwyddan, UK
Wrist ganglia were randomly allocated for conservative treatment by either aspiration or aspiration and injection of steroid. Both treatment methods had 33% success rates. Almost all ganglia which recurred after one aspiration did not resolve with further aspirations. After aspiration and explanation of the benign nature of ganglia, only a quarter of patients requested surgical treatment.
Journal of Hand Surgery (British and European Volume, 1997) 22B: 5:63~637 Table 1--The reported results of conservative treatments of ganglia
Wrist ganglia cause cosmetic deformity and pain and many patients, despite reassurance, are fearful that the swelling is malignant. Many treatment methods have been advocated, some with widely differing success rates (Table 1). This is probably because most studies are small and have incomplete follow-up, ranging from a few weeks to 10 years. Length of follow-up is an important consideration as many ganglia resolve spontaneously. In the United Kingdom ganglia are commonly treated by aspiration, and aspiration and steroid injection. This randomized prospective study compares the results of these treatments in order to assess whether steroid injection improves the results of simple aspiration.
Reported
Reference
SHccess rate
No treatment Rupture Aspiration alone Aspiration and hyaluronidase injection Aspiration and sclerosant injection Aspiration and steroid injection
PATIENTS AND M E T H O D S
Surgery
This study was performed at the Queen's Medical Centre, Nottingham and Clywd General Hospital during 1992. Patients requesting treatment for wrist ganglia which had been present for more than 3 months were randomized according to hospital number for treatment by aspiration alone or aspiration and steroid injection. All ganglia were aspirated with a 19G (white) hypodermic needle and 2 ml syringe. The surgeon facilitated aspiration by milking the ganglion contents towards the needle with a finger. The volume of fluid aspirated was recorded and ganglia in the aspiration and steroid group were then reflated with up to 1 ml 40 mg/ml methylprednisolone (Depomedrone). The wrist was never splinted postoperatively. Patients were invited to return to clinic at 2 and 4 months if their ganglia persisted and they wished further treatment. Their original treatment was then either repeated (to a maximum of three aspirations) or they were listed for surgical excision. All patients were sent a questionnaire at least 6 months after, and within 2 years of, their initial treatment, enquiring whether their ganglia persisted and whether they wished further treatment.
40% 66% 36% 41% 85% 57%
McEvedy, 1954 Nelson et al, 1972 Richman et al, 1987 Nield and Evans, 1986 Zubowicz and Ishii, 1987 Nelson et al, 1972
81%
McEvedy, 1954
60% 65"/0 86% 73% 87% 97% 99%
Holm and Pandey, 1973 Nelson et al, 1972 Derbyshire, 1966 McEvedy, 1954 Nelson et al, 1972 Clay and Clement, 1988 Angelides and Wallace, 1976
Table 2--The current employment of the 113 patients presenting with ganglia % Not working (housewife or unemployed) Office worker Light manual Heavy manual
35 23 37 10
workers (Table 2) and 70% rated their ganglia as constantly or intermittently painful. The treatment groups were comparable for demographic factors and ganglion characteristics (site, size, duration). Fifty-eight per cent of ganglia arose from the non-dominant wrist and the average volume of ganglion fluid aspirated was 0.95 ml. Aspiration alone and aspiration and steroid injection both had a 33% success rate (Table 3). Ganglion size and site did not affect the success rate. All but one of the 28 ganglia which resolved did so following the first treatment. Only one of the 24 ganglia aspirated on a second occasion and none of the five treated for a third time resolved. Only 22 of the 57 patients whose ganglia
RESULTS One hundred and thirteen patients were recruited into this study but 28 were lost to follow-up (75% follow-up). Most patients were housewives, unemployed or light manual 636
MANAGEMENT OF WRIST GANGLIA
637
Table 3 - - T h e demographic data and the results of treatment for the two groups
Number M e a n age (range) Male/Female F o l l o w - u p (weeks) ( m e a n + range) Palmar/dorsal ganglion Surgical excision Recurrence Resolved
Aspiration alone
Aspiration and steroid
42 38 (13-71) 10/32 48 (26-89)
43 35 (15-75) 12/31 46 (26-89)
13/29 10 18 14
8/35 12 17 14
allowed ganglia to resolve spontaneously, might explain the superior results of the other studies. As observed in a previous study (Oni, 1992), relatively few patients requested surgical excision, even if the ganglion persisted. This may reflect the fact that many patients simply seek reassurance that the ganglion is benign. We provided all our patients with an information sheet which explained the benign nature of ganglia and stressed that mo'st resolve spontaneously. Many patients were obviously impressed and reassured by the immediate, if temporary, disappearance of their ganglia after aspiration and the syringe containing its obviously benign contents. References
recurred requested surgical excision; the remainder chose to await spontaneous regression. DISCUSSION This study demonstrates that 33% of ganglia are successfully treated by aspiration: additional injection of steroid injection is of no benefit and may cause subcutaneous fat atrophy and skin depigmentation. Multiple aspirations are of little benefit and our results suggest that the success of aspiration depends on a characteristic of the ganglion rather than an unrecognized treatment factor: some ganglia resolve with aspiration and others do not, even if repeat aspirations are performed. Our 33% success rate for ganglion aspiration, with or without subsequent steroid injection, is lower than those of other studies (Table 1). Our success rate would be an underestimate if the majority of ganglia lost to follow-up were successfully treated. Alternatively, insufficient length of follow-up which did not give ganglia sufficient time to recur, or excessive length of follow-up which
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. Clay N R, Clement D A (1988). The treatment of dorsal wrist ganglia by radical excision. Journal of Hand Surgery, 13B: 187-191. Derbyshire R C (1966). Observation on the treatment of ganglia. With a report on hydrocortisone. American Journal of Surgery, 112: 635-636. Holm P C A, Pandey S D (1973). Treatment of ganglia of the hand and wrist with aspiration and injection of hydrocortisone. The Hand, 5: 63-68. McEvedy B V (i954). The simple ganglion. A review of modes of treatment and an explanation of the frequent failures of surgery. Lancet, 1: 135 136, Nelson C L, Sawmiller S, Phalen G S (1972). Ganglions of the wrist and hand. Journal of Bone and Joint Surgery, 54A: 145%1464. Nield D V, Evans D M (i986). Aspiration of ganglia. Journal of Hand Surgery, 11B: 264. Oni J A (1992). Treatment of ganglia by aspiration alone. Journal of Hand Surgery, 17B: 660. Richman J A, Gelberman R H, Engber W D, Salamon P B, Bean D J (1987). Ganglions of the wrist and digits: results of treatment by aspiration and cyst wallpuncture. Journal of Hand Surgery, I2A: I041 1041. Zubowicz V N, Ishii C H (1987). Management of ganglion cysts of the hand by simple aspiration. Journal of Hand Surgery, 12A: 618-620.
Received: 15 January 1997 Accepted after revision: 2 April I997 ]2 R. C. Davis,Department of Trauma and Orthopaedic Surgery, Queen'sMedical Centre, Nottingham NG 17 4JL, UK. © 1997The British Society lbr Surgeryof the Hand
OF W R I S T G A N G L I A
A s p i r a t i o n versus steroid infiltration G. W. VARLEY, M . N E E D O F F , T. R. C. DAVIS and N. R. CLAY
From Queen's Medical Centre, Nottingham and Glan Clwyd Hospital, Bodelwyddan, UK
Wrist ganglia were randomly allocated for conservative treatment by either aspiration or aspiration and injection of steroid. Both treatment methods had 33% success rates. Almost all ganglia which recurred after one aspiration did not resolve with further aspirations. After aspiration and explanation of the benign nature of ganglia, only a quarter of patients requested surgical treatment.
Journal of Hand Surgery (British and European Volume, 1997) 22B: 5:63~637 Table 1--The reported results of conservative treatments of ganglia
Wrist ganglia cause cosmetic deformity and pain and many patients, despite reassurance, are fearful that the swelling is malignant. Many treatment methods have been advocated, some with widely differing success rates (Table 1). This is probably because most studies are small and have incomplete follow-up, ranging from a few weeks to 10 years. Length of follow-up is an important consideration as many ganglia resolve spontaneously. In the United Kingdom ganglia are commonly treated by aspiration, and aspiration and steroid injection. This randomized prospective study compares the results of these treatments in order to assess whether steroid injection improves the results of simple aspiration.
Reported
Reference
SHccess rate
No treatment Rupture Aspiration alone Aspiration and hyaluronidase injection Aspiration and sclerosant injection Aspiration and steroid injection
PATIENTS AND M E T H O D S
Surgery
This study was performed at the Queen's Medical Centre, Nottingham and Clywd General Hospital during 1992. Patients requesting treatment for wrist ganglia which had been present for more than 3 months were randomized according to hospital number for treatment by aspiration alone or aspiration and steroid injection. All ganglia were aspirated with a 19G (white) hypodermic needle and 2 ml syringe. The surgeon facilitated aspiration by milking the ganglion contents towards the needle with a finger. The volume of fluid aspirated was recorded and ganglia in the aspiration and steroid group were then reflated with up to 1 ml 40 mg/ml methylprednisolone (Depomedrone). The wrist was never splinted postoperatively. Patients were invited to return to clinic at 2 and 4 months if their ganglia persisted and they wished further treatment. Their original treatment was then either repeated (to a maximum of three aspirations) or they were listed for surgical excision. All patients were sent a questionnaire at least 6 months after, and within 2 years of, their initial treatment, enquiring whether their ganglia persisted and whether they wished further treatment.
40% 66% 36% 41% 85% 57%
McEvedy, 1954 Nelson et al, 1972 Richman et al, 1987 Nield and Evans, 1986 Zubowicz and Ishii, 1987 Nelson et al, 1972
81%
McEvedy, 1954
60% 65"/0 86% 73% 87% 97% 99%
Holm and Pandey, 1973 Nelson et al, 1972 Derbyshire, 1966 McEvedy, 1954 Nelson et al, 1972 Clay and Clement, 1988 Angelides and Wallace, 1976
Table 2--The current employment of the 113 patients presenting with ganglia % Not working (housewife or unemployed) Office worker Light manual Heavy manual
35 23 37 10
workers (Table 2) and 70% rated their ganglia as constantly or intermittently painful. The treatment groups were comparable for demographic factors and ganglion characteristics (site, size, duration). Fifty-eight per cent of ganglia arose from the non-dominant wrist and the average volume of ganglion fluid aspirated was 0.95 ml. Aspiration alone and aspiration and steroid injection both had a 33% success rate (Table 3). Ganglion size and site did not affect the success rate. All but one of the 28 ganglia which resolved did so following the first treatment. Only one of the 24 ganglia aspirated on a second occasion and none of the five treated for a third time resolved. Only 22 of the 57 patients whose ganglia
RESULTS One hundred and thirteen patients were recruited into this study but 28 were lost to follow-up (75% follow-up). Most patients were housewives, unemployed or light manual 636
MANAGEMENT OF WRIST GANGLIA
637
Table 3 - - T h e demographic data and the results of treatment for the two groups
Number M e a n age (range) Male/Female F o l l o w - u p (weeks) ( m e a n + range) Palmar/dorsal ganglion Surgical excision Recurrence Resolved
Aspiration alone
Aspiration and steroid
42 38 (13-71) 10/32 48 (26-89)
43 35 (15-75) 12/31 46 (26-89)
13/29 10 18 14
8/35 12 17 14
allowed ganglia to resolve spontaneously, might explain the superior results of the other studies. As observed in a previous study (Oni, 1992), relatively few patients requested surgical excision, even if the ganglion persisted. This may reflect the fact that many patients simply seek reassurance that the ganglion is benign. We provided all our patients with an information sheet which explained the benign nature of ganglia and stressed that mo'st resolve spontaneously. Many patients were obviously impressed and reassured by the immediate, if temporary, disappearance of their ganglia after aspiration and the syringe containing its obviously benign contents. References
recurred requested surgical excision; the remainder chose to await spontaneous regression. DISCUSSION This study demonstrates that 33% of ganglia are successfully treated by aspiration: additional injection of steroid injection is of no benefit and may cause subcutaneous fat atrophy and skin depigmentation. Multiple aspirations are of little benefit and our results suggest that the success of aspiration depends on a characteristic of the ganglion rather than an unrecognized treatment factor: some ganglia resolve with aspiration and others do not, even if repeat aspirations are performed. Our 33% success rate for ganglion aspiration, with or without subsequent steroid injection, is lower than those of other studies (Table 1). Our success rate would be an underestimate if the majority of ganglia lost to follow-up were successfully treated. Alternatively, insufficient length of follow-up which did not give ganglia sufficient time to recur, or excessive length of follow-up which
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. Clay N R, Clement D A (1988). The treatment of dorsal wrist ganglia by radical excision. Journal of Hand Surgery, 13B: 187-191. Derbyshire R C (1966). Observation on the treatment of ganglia. With a report on hydrocortisone. American Journal of Surgery, 112: 635-636. Holm P C A, Pandey S D (1973). Treatment of ganglia of the hand and wrist with aspiration and injection of hydrocortisone. The Hand, 5: 63-68. McEvedy B V (i954). The simple ganglion. A review of modes of treatment and an explanation of the frequent failures of surgery. Lancet, 1: 135 136, Nelson C L, Sawmiller S, Phalen G S (1972). Ganglions of the wrist and hand. Journal of Bone and Joint Surgery, 54A: 145%1464. Nield D V, Evans D M (i986). Aspiration of ganglia. Journal of Hand Surgery, 11B: 264. Oni J A (1992). Treatment of ganglia by aspiration alone. Journal of Hand Surgery, 17B: 660. Richman J A, Gelberman R H, Engber W D, Salamon P B, Bean D J (1987). Ganglions of the wrist and digits: results of treatment by aspiration and cyst wallpuncture. Journal of Hand Surgery, I2A: I041 1041. Zubowicz V N, Ishii C H (1987). Management of ganglion cysts of the hand by simple aspiration. Journal of Hand Surgery, 12A: 618-620.
Received: 15 January 1997 Accepted after revision: 2 April I997 ]2 R. C. Davis,Department of Trauma and Orthopaedic Surgery, Queen'sMedical Centre, Nottingham NG 17 4JL, UK. © 1997The British Society lbr Surgeryof the Hand