- Email: [email protected]
Wrist Ganglia in Children: Nonsurgical Versus Surgical Treatment
SCIENTIFIC ARTICLE
Wrist Ganglia in Children: Nonsurgical Versus Surgical Treatment Gershon Zinger, MD, MS,* Michael Michailevich, MD,† Alexander Bregman, MD,* Genady Yudkevich, MD,* Kobi Steinberg, MD,* Amos Peyser, MD*
Purpose To compare the outcomes of nonsurgical and surgical treatment of children with wrist ganglia. Methods We performed a retrospective review of children with wrist ganglia treated at 2 separate institutions. In one, a clinic setting, children were treated with observation. In the other, a hospital referral center, children had surgical excision. Information obtained included persistent or recurrent cyst, and QuickeDisabilities of the Arm, Shoulder, and Hand measure. Patients aged 17 years or less at the time of cyst appearance with at least 1 year of follow-up were included. Results We successfully contacted 90 patients: 50 in the nonsurgical and 40 in the surgical group. Average follow-up was 4.6 years. The persistence rate in the nonsurgical group was 52%. The recurrence rate in the surgical group was 15%. In the nonsurgical group, if a ganglion resolved, it did so within 18 months in 94% of patients. Dorsal ganglions persisted more often than volar ones (63% vs 33%). Older children had a higher rate of persistence than did younger children (58% vs 31%). For children aged 10 or less, surgery was associated with a recurrence rate of 17%, compared with 31% persistence in the nonsurgical group. For children aged 11 and more, surgery was associated with a recurrence rate of 15%, compared with 58% persistence in the nonsurgical group. There was no significant difference between QuickeDisabilities of the Arm, Shoulder, and Hand scores in any group. Conclusions In a child with a wrist ganglion, if the cyst ultimately resolved, it usually did so within 18 months. Dorsal ganglion cysts and ganglion cysts in older children have a higher chance of persisting. In children treated with surgical excision, we found a 15% recurrence rate. (J Hand Surg Am. 2019;-(-):1.e1-e5. Copyright Ó 2019 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Children, ganglia, ganglion, pediatric, wrist.
From the *Department of Orthopedic Surgery, Shaare Zedek Medical Center and the †Department of Orthopedic Surgery, Clalit Health Center, Jerusalem, Israel. Received for publication November 22, 2018; accepted in revised form October 8, 2019. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Gershon Zinger, MD, MS, Department of Orthopedic Surgery, Shaare Zedek Medical Center, 12 Shmuel Bayit Street, Jerusalem 9103102, Israel; e-mail: [email protected]. 0363-5023/19/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2019.10.032
T
literature on management of wrist ganglia in children. A review of the subject supports both nonsurgical1e4 and surgical5e7 treatment. There is literature to suggest that the natural history of wrist ganglia is resolution1,4 and that surgically treated ganglia in children have a high recurrence rate.3 This would logically lead to nonsurgical treatment. Alternatively, there is literature to suggest the opposite, that HERE IS A SCARCITY OF
Ó 2019 ASSH
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Published by Elsevier, Inc. All rights reserved.
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WRIST GANGLIA IN CHILDREN
ganglia persist and that surgical excision has a low recurrence rate.5,7 The objective of this study was to evaluate children with wrist ganglia from 2 institutions. In one institution, all children with wrist ganglia were managed with observation alone. In the other institution, a hospital referral center, children with persistent or symptomatic ganglia were specifically referred for surgical treatment. This retrospective study evaluated nonsurgical and surgical treatment at these 2 institutions with a minimum follow-up of 1 year. The primary outcome measure was persistence rate in the nonsurgical group and recurrence rate in the surgical group. Additional outcome measures included QuickeDisabilities of the Arm, Shoulder, and Hand (QuickDASH) and surgical complications. The purpose of the study was to evaluate the natural history of wrist ganglia in children as well as the results of operative treatment.
of follow-up, persistence or recurrence of the cyst, and additional treatment such as aspiration or referral for surgery. In children who were treated with surgery, the following information was obtained from chart review and recent phone interview: age at presentation, time from presentation to surgery, sex, presenting signs and symptoms, location of the lesion (volar or dorsal), complications of treatment (such as stiffness or larger than normal scar), length of follow-up, and persistence or recurrence of the cyst. Both groups had QuickDASH scores obtained to evaluate function and pain. Data analysis Data was collected using Research Electronic Data Capture (Vanderbilt University, Nashville, TN). Comparisons between groups were made using chisquare associations and t tests. The level of significance was set at 0.05. The sample size of 90 subjects provided 80% power to detect a difference of 30% in the persistence or recurrence rate between nonsurgical and surgical groups.
MATERIALS AND METHODS In Israel, health care is nationally mandated through 4 health plan options. In one of these plans, a hand surgeon (M.M.) has been tracking children with wrist ganglia from the Jerusalem area for the past 10 years and managing these patients with observation alone. This approach was the impetus for this study to test the assumption that ganglia in children ultimately resolve spontaneously. This institution formed one arm of the study. In addition to patients on the tracking list, we searched a computerized database using all applicable International Classification of Diseases, Ninth Revision codes for wrist ganglia. Charts were identified for all children aged 17 years or less from the Jerusalem area from the same 10-year range with follow-up of at least 1 year. In Jerusalem, Israel, there are 2 large hospital referral systems. Children with wrist ganglia are referred to the hospital for surgical excision. The current series represents surgeries performed at one of these centers, Shaare Zedek Medical Center. We searched all cases performed at Shaare Zedek Medical Center since electronic database management started in 1990. Patients were included for review if the surgery was performed at least 1 year from when they were contacted. Institutional approval was obtained from both institutions before the study. In children who were treated with observation, the following information was obtained from a combination of chart review and recent phone interview: age at presentation, sex, presenting signs and symptoms, location of the lesion (volar or dorsal), length J Hand Surg Am.
RESULTS There were 90 patients in the study: 50 in the nonsurgical group and 40 in the surgical group (Table 1). Nonsurgical group A total of 67 patients identified in the database were treated with observation. Of those, 50 were included in the study (75%); 15 patients could not be contacted and 2 were contacted but were unwilling to participate. Surgical treatment In all, 46 patients were treated surgically. Of those, 40 were successfully contacted and willing to participate (87%). Average time from appearance of the cyst to surgical treatment was 13.6 months (SD, 8.4 months). Outcome measures The primary outcome measure in this study was defined as persistence in patients who were treated with observation and recurrence in those treated surgically. Patients who reported that the cyst initially resolved but then recurred were counted as having a cyst that persisted. Table 2 reports the overall rates; Tables 3 and 4 report the rates in those aged less than and greater than 10 years, respectively. r
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WRIST GANGLIA IN CHILDREN
TABLE 1.
Demographics and Descriptive Statistics Overall (n ¼ 90)
Variable Mean follow-up, mo (range)
55 (12e282)
Age at appearance, y (mean [range])
Nonsurgical (n ¼ 50)
Surgical (n ¼ 40)
44 (12e84)
70 (12e282)
12 (5e17.5)
13 (5e17.5)
Male (%)
27 (30)
16 (32)
11/40 (27)
Female (%)
63 (70)
34 (64)
29/40 (72)
Left- vs right-handed (%)
17 vs 83
20 vs 80
12.5 vs 87
Cyst dorsal (%)
55 (61)
32 (64)
23 (58)
Cyst volar (%)
35 (39)
18 (36)
Presenting problems (%)
Imaging studies ( 1)
17 (42)
Pain
74
Pain
74
Enlarging mass
49
Enlarging mass
25
Ugly mass
17
Ugly mass
25
Concern about tumor
30
Concern about tumor
3
Ultrasound
63
Ultrasound
75
X-ray
43
X-ray
50
Magnetic resonance imaging none Magnetic resonance imaging 6% No study
TABLE 2.
14
No study
19
All Ages: Nonsurgical Versus Surgical Variable
Persistence rate (nonsurgical) or recurrence rate (surgical) (%)
Nonsurgical (n ¼ 50)
Surgical (n ¼ 40)
26/50 (52)
6/40 (15)
18 (36)
17 (39)
Cyst volar (%) Cyst dorsal (%)
32 (64)
Persistence rate (nonsurgical) or recurrence rate (surgical) (%)
Volar 6/18 (33)
QuickDASH mean/median (range)
Dorsal 20/32 (63)
15/6.8 (0e73)
The overall persistence rate was 52% for those treated nonsurgically, compared with a recurrence rate of 15% in those treated surgically. The persistence rate in those who were aged 10 years or less was 31%, compared with 58% in those aged 11 years and more. This difference was not statistically significant. Volar cysts persisted in 33% of patients whereas dorsal cysts persisted in 63%; this was significantly different (P < .05). The QuickDASH had a mean of 15 in the nonsurgical group and 12 in the surgical group. In the nonsurgical group, 48% of cysts resolved and never recurred. The remainder of cysts either persisted (32%) or resolved and recurred (20%). Nearly all of the cysts that ultimately resolved did so by 18 months (94%). Specifically, of those that ultimately resolved, 79% did so by 12 months, 15% between 12 and 18 months, and 6% between 18 and 64 months. J Hand Surg Am.
23 (61) Volar 3/17 (18)
Dorsal 3/23 (13)
12/0 (0e70)
In the 6 patients treated surgically who had a recurrence, the cyst recurred in 2 at 2 months, one at 3 months, and one each at 20, 48, and 60 months after the surgery. No patients who had a recurrence had additional surgery. Surgical complications Of 40 patients, 12 patients had recorded complications (30%). All were considered relatively minor and included scar problems (5), joint stiffness (4), infection (one, a dorsal cyst in a 14-year-old treated with oral antibiotics), numbness (one, a dorsal cyst in a 17year-old), and slight weakness (one). Although younger patients tended to have more volar cysts than did older children (64% vs 31%), the sample did not have sufficient power to make a statistical comparison. Of the 50 patients managed with observation, 4 had aspiration, all with dorsal cysts, but all recurred. r
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TABLE 3.
WRIST GANGLIA IN CHILDREN
Children Aged 10 Years and Less Nonsurgical (n ¼ 16)
Surgical (n ¼ 6)
Male
5/16 (31)
3/6 (50)
Female
11/16 (69)
3/6 (50)
Cyst volar
9/16 (56)
5/6 (83)
Variable
Cyst dorsal
7/16 (44)
1/6 (17)
Persistence rate (nonsurgical) or recurrence rate (surgical) (%)
5/16 (31)
1/6 (17)
Persistence rate (nonsurgical) or recurrence rate (surgical) volar vs dorsal (%)
Volar 2/9 (22)
QuickDASH mean/median (range)
TABLE 4.
Dorsal 4/7 (57)
14/4.5 (0e48)
Volar 1/5 (20)
Dorsal 0/1 (0)
0.75/0 (0e4.5)
Children Aged 11 Years and Greater Nonsurgical (n ¼ 34)
Surgical (n ¼ 34)
Male
11/34 (32)
8/34 (24)
Female
23/34 (67)
26/34 (76)
Cyst volar
9/34 (26)
12/34 (35)
Cyst dorsal
24/34 (70)
22/34 (65)
Persistence rate (nonsurgical) or recurrence (surgical) (%)
20/34 (58)
5/34 (15)
Variable
Persistence rate (nonsurgical) or recurrence rate (surgical) volar vs dorsal
Volar 4/9 (44)
QuickDASH mean/median (range)
Dorsal 16/25 (64)
14.9/9.1 (0e72.7)
DISCUSSION Ganglion cysts of the wrist in children are generally treated by either observation or surgical excision. In adults, there is the additional option of aspiration with or without steroid injection. In children, aspiration tends to be performed less often. Most of the literature on ganglion management is focused on persistence for nonsurgical treatment or recurrence after surgical excision.8,9 The overall rate of persistence in those treated nonsurgically ranges in the literature between 21% and 57% compared with the current study’s rate of 52%. The overall rate of recurrence in those treated surgically ranges from 2.8% to 37%, compared with the current study’s rate of 15%. Colberg et al10 presented their results of aspiration and then injection of steroid, performed under general anesthesia in 21 children, average age 7.2 years. Cysts were treated after 1 year of observation. They reported a rate of resolution of 62%. Korman et al11 reported on 52 carpal and wrist ganglia treated with aspiration and then either mobilized or left to move; their rate of resolution was 46%. Calif et al1 aspirated 4 cysts and only 1 recurred. Meyerson et al7 noted that patients who had attempted aspiration before eventual surgery J Hand Surg Am.
Volar 2/12 (16)
Dorsal 3/22 (14)
14.2/3.4 (0e70.4)
had a significantly higher rate of recurrence. In the current study, in 4 patients who had aspiration, all ganglia recurred. The strength of this study is the focus on only wrist ganglia, only in children, and with at least 1 year of follow-up. Because the clinician must ultimately recommend either observation or surgery, the current emphasis was on comparing the results of 2 groups, nonsurgical and surgical. The surgically treated group had longer follow-up than did the nonsurgical group (70 vs 44 months). This would tend to favor the nonsurgical group, because the longer follow-up in the surgical group would give more time for a cyst to recur. Despite that, the surgical group had better results. The primary limitation of this study was that the determination of recurrence or persistence of the wrist ganglia was subjective and based on a phone interview. One would predict underreporting of recurrent or persistent ganglia. In the literature reviewed for this study, we found that most studies reported similar methodology with subjective outcomes. Wong et al12 performed 11 phone interviews and examined 3
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patients. Cypel et al5 performed a retrospective chart review. MacKinnon and Azmy6 had 128 patients in their study, 53 of whom were seen (41%). Satku et al3 sent a questionnaire to 45 patients and examined 11 of them. Meyerson et al7 performed a retrospective chart review. Ideally, all patients evaluated for wrist ganglia would be evaluated clinically and an ultrasound or magnetic resonance imaging would be performed for those with uncertain clinical findings. Another limitation of this study was the uneven follow-up period. Moreover, only 75% of patients treated with observation were included in the study. The average time from cyst appearance to surgery was 14 months, compared with the 18 months it took for most cysts in the nonsurgical group to resolve. Diagnosis of wrist ganglia is usually made clinically based on examination and typical location and appearance. Additional imaging studies were common, including x-rays performed in 43% and 50% of those observed and surgically treated, respectively. Ultrasound was performed in 63% of those observed and in 50% of those treated surgically. We found little in the literature on the subject of ganglion imaging. Wong et al12 evaluated the use of routine radiography in patients with a wrist ganglion cyst. In their report of 103 patients, in only one patient did xrays affect management. They concluded that routine imaging is not cost-effective. Although surgery was more successful in all groups, there was a 30% rate of minor surgical complications. Therefore, considering both the literature review and our experience, we recommend observation for at least 18 months, because 94% of cysts that ultimately resolved did so within that
J Hand Surg Am.
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interval. If the cyst persists and is symptomatic, surgical excision is a safe and reasonable option. Patients and their parents should be aware of the 15% recurrence rate. ACKNOWLEDGMENTS The authors would like to thank Bat-el Harris for her dedication and energy that helped make this research possible. REFERENCES 1. Calif E, Stahl S, Stahl S. Simple wrist ganglia in children: a follow-up study. J Pediatr Orthop. 2005;14(6):448e450. 2. MacCollum MS. Dorsal wrist ganglions in children. J Hand Surg Am. 1977;2(4):325. 3. Satku K, Ganesh B. Ganglia in children. J Pediatr Orthop. 1985;5(1): 13e15. 4. Wang AA, Hutchinson DT. Longitudinal observation of pediatric hand and wrist ganglia. J Hand Surg Am. 2001;26(4):599e602. 5. Cypel TKS, Mrad A, Somers G, Zuker RM. Ganglion cyst in children: reviewing treatment and recurrence rates. Can J Plast Surg. 2011;19(2):53e55. 6. MacKinnon AE, Azmy A. Active treatment of the ganglia in children. Postgrad Med J. 1977;53(621):378e381. 7. Meyerson J, Pan YL, Spaeth M, Pearson G. Pediatric ganglion cysts: a retrospective review. Hand (N Y). 2019;14(4):445e448. 8. Trivedi NN, Schreiber JJ, Daluiski A. Blunt force may be an effective treatment for ganglion cysts. HSS J. 2016;12(2):100e104. 9. Barnes WE, Larsen RD, Posch JL. Review of ganglia of the hand and wrist with analysis of surgical treatment. Plast Reconstr Surg. 1964;34:570e578. 10. Colberg RE, Sánches CF, Lugo-Vincente H. Aspiration and triamcinolone acetonide injection of wrist synovial cysts in children. J Pediatr Surg. 2008;43(11):2087e2090. 11. Korman J, Pearl R, Hentz VR. Efficacy of immobilization following aspiration carpal and digital ganglions. J Hand Surg Am. 1992;17(6): 1097e1099. 12. Wong AS, Jebson PJL, Murray PM, Trigg SD. The use of routine wrist radiography is not useful in the evaluation of patients with a ganglion cyst of the wrist. Hand (N Y). 2007;2(3):117e119.
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Wrist Ganglia in Children: Nonsurgical Versus Surgical Treatment Gershon Zinger, MD, MS,* Michael Michailevich, MD,† Alexander Bregman, MD,* Genady Yudkevich, MD,* Kobi Steinberg, MD,* Amos Peyser, MD*
Purpose To compare the outcomes of nonsurgical and surgical treatment of children with wrist ganglia. Methods We performed a retrospective review of children with wrist ganglia treated at 2 separate institutions. In one, a clinic setting, children were treated with observation. In the other, a hospital referral center, children had surgical excision. Information obtained included persistent or recurrent cyst, and QuickeDisabilities of the Arm, Shoulder, and Hand measure. Patients aged 17 years or less at the time of cyst appearance with at least 1 year of follow-up were included. Results We successfully contacted 90 patients: 50 in the nonsurgical and 40 in the surgical group. Average follow-up was 4.6 years. The persistence rate in the nonsurgical group was 52%. The recurrence rate in the surgical group was 15%. In the nonsurgical group, if a ganglion resolved, it did so within 18 months in 94% of patients. Dorsal ganglions persisted more often than volar ones (63% vs 33%). Older children had a higher rate of persistence than did younger children (58% vs 31%). For children aged 10 or less, surgery was associated with a recurrence rate of 17%, compared with 31% persistence in the nonsurgical group. For children aged 11 and more, surgery was associated with a recurrence rate of 15%, compared with 58% persistence in the nonsurgical group. There was no significant difference between QuickeDisabilities of the Arm, Shoulder, and Hand scores in any group. Conclusions In a child with a wrist ganglion, if the cyst ultimately resolved, it usually did so within 18 months. Dorsal ganglion cysts and ganglion cysts in older children have a higher chance of persisting. In children treated with surgical excision, we found a 15% recurrence rate. (J Hand Surg Am. 2019;-(-):1.e1-e5. Copyright Ó 2019 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Children, ganglia, ganglion, pediatric, wrist.
From the *Department of Orthopedic Surgery, Shaare Zedek Medical Center and the †Department of Orthopedic Surgery, Clalit Health Center, Jerusalem, Israel. Received for publication November 22, 2018; accepted in revised form October 8, 2019. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Gershon Zinger, MD, MS, Department of Orthopedic Surgery, Shaare Zedek Medical Center, 12 Shmuel Bayit Street, Jerusalem 9103102, Israel; e-mail: [email protected]. 0363-5023/19/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2019.10.032
T
literature on management of wrist ganglia in children. A review of the subject supports both nonsurgical1e4 and surgical5e7 treatment. There is literature to suggest that the natural history of wrist ganglia is resolution1,4 and that surgically treated ganglia in children have a high recurrence rate.3 This would logically lead to nonsurgical treatment. Alternatively, there is literature to suggest the opposite, that HERE IS A SCARCITY OF
Ó 2019 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1.e1
1.e2
WRIST GANGLIA IN CHILDREN
ganglia persist and that surgical excision has a low recurrence rate.5,7 The objective of this study was to evaluate children with wrist ganglia from 2 institutions. In one institution, all children with wrist ganglia were managed with observation alone. In the other institution, a hospital referral center, children with persistent or symptomatic ganglia were specifically referred for surgical treatment. This retrospective study evaluated nonsurgical and surgical treatment at these 2 institutions with a minimum follow-up of 1 year. The primary outcome measure was persistence rate in the nonsurgical group and recurrence rate in the surgical group. Additional outcome measures included QuickeDisabilities of the Arm, Shoulder, and Hand (QuickDASH) and surgical complications. The purpose of the study was to evaluate the natural history of wrist ganglia in children as well as the results of operative treatment.
of follow-up, persistence or recurrence of the cyst, and additional treatment such as aspiration or referral for surgery. In children who were treated with surgery, the following information was obtained from chart review and recent phone interview: age at presentation, time from presentation to surgery, sex, presenting signs and symptoms, location of the lesion (volar or dorsal), complications of treatment (such as stiffness or larger than normal scar), length of follow-up, and persistence or recurrence of the cyst. Both groups had QuickDASH scores obtained to evaluate function and pain. Data analysis Data was collected using Research Electronic Data Capture (Vanderbilt University, Nashville, TN). Comparisons between groups were made using chisquare associations and t tests. The level of significance was set at 0.05. The sample size of 90 subjects provided 80% power to detect a difference of 30% in the persistence or recurrence rate between nonsurgical and surgical groups.
MATERIALS AND METHODS In Israel, health care is nationally mandated through 4 health plan options. In one of these plans, a hand surgeon (M.M.) has been tracking children with wrist ganglia from the Jerusalem area for the past 10 years and managing these patients with observation alone. This approach was the impetus for this study to test the assumption that ganglia in children ultimately resolve spontaneously. This institution formed one arm of the study. In addition to patients on the tracking list, we searched a computerized database using all applicable International Classification of Diseases, Ninth Revision codes for wrist ganglia. Charts were identified for all children aged 17 years or less from the Jerusalem area from the same 10-year range with follow-up of at least 1 year. In Jerusalem, Israel, there are 2 large hospital referral systems. Children with wrist ganglia are referred to the hospital for surgical excision. The current series represents surgeries performed at one of these centers, Shaare Zedek Medical Center. We searched all cases performed at Shaare Zedek Medical Center since electronic database management started in 1990. Patients were included for review if the surgery was performed at least 1 year from when they were contacted. Institutional approval was obtained from both institutions before the study. In children who were treated with observation, the following information was obtained from a combination of chart review and recent phone interview: age at presentation, sex, presenting signs and symptoms, location of the lesion (volar or dorsal), length J Hand Surg Am.
RESULTS There were 90 patients in the study: 50 in the nonsurgical group and 40 in the surgical group (Table 1). Nonsurgical group A total of 67 patients identified in the database were treated with observation. Of those, 50 were included in the study (75%); 15 patients could not be contacted and 2 were contacted but were unwilling to participate. Surgical treatment In all, 46 patients were treated surgically. Of those, 40 were successfully contacted and willing to participate (87%). Average time from appearance of the cyst to surgical treatment was 13.6 months (SD, 8.4 months). Outcome measures The primary outcome measure in this study was defined as persistence in patients who were treated with observation and recurrence in those treated surgically. Patients who reported that the cyst initially resolved but then recurred were counted as having a cyst that persisted. Table 2 reports the overall rates; Tables 3 and 4 report the rates in those aged less than and greater than 10 years, respectively. r
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WRIST GANGLIA IN CHILDREN
TABLE 1.
Demographics and Descriptive Statistics Overall (n ¼ 90)
Variable Mean follow-up, mo (range)
55 (12e282)
Age at appearance, y (mean [range])
Nonsurgical (n ¼ 50)
Surgical (n ¼ 40)
44 (12e84)
70 (12e282)
12 (5e17.5)
13 (5e17.5)
Male (%)
27 (30)
16 (32)
11/40 (27)
Female (%)
63 (70)
34 (64)
29/40 (72)
Left- vs right-handed (%)
17 vs 83
20 vs 80
12.5 vs 87
Cyst dorsal (%)
55 (61)
32 (64)
23 (58)
Cyst volar (%)
35 (39)
18 (36)
Presenting problems (%)
Imaging studies ( 1)
17 (42)
Pain
74
Pain
74
Enlarging mass
49
Enlarging mass
25
Ugly mass
17
Ugly mass
25
Concern about tumor
30
Concern about tumor
3
Ultrasound
63
Ultrasound
75
X-ray
43
X-ray
50
Magnetic resonance imaging none Magnetic resonance imaging 6% No study
TABLE 2.
14
No study
19
All Ages: Nonsurgical Versus Surgical Variable
Persistence rate (nonsurgical) or recurrence rate (surgical) (%)
Nonsurgical (n ¼ 50)
Surgical (n ¼ 40)
26/50 (52)
6/40 (15)
18 (36)
17 (39)
Cyst volar (%) Cyst dorsal (%)
32 (64)
Persistence rate (nonsurgical) or recurrence rate (surgical) (%)
Volar 6/18 (33)
QuickDASH mean/median (range)
Dorsal 20/32 (63)
15/6.8 (0e73)
The overall persistence rate was 52% for those treated nonsurgically, compared with a recurrence rate of 15% in those treated surgically. The persistence rate in those who were aged 10 years or less was 31%, compared with 58% in those aged 11 years and more. This difference was not statistically significant. Volar cysts persisted in 33% of patients whereas dorsal cysts persisted in 63%; this was significantly different (P < .05). The QuickDASH had a mean of 15 in the nonsurgical group and 12 in the surgical group. In the nonsurgical group, 48% of cysts resolved and never recurred. The remainder of cysts either persisted (32%) or resolved and recurred (20%). Nearly all of the cysts that ultimately resolved did so by 18 months (94%). Specifically, of those that ultimately resolved, 79% did so by 12 months, 15% between 12 and 18 months, and 6% between 18 and 64 months. J Hand Surg Am.
23 (61) Volar 3/17 (18)
Dorsal 3/23 (13)
12/0 (0e70)
In the 6 patients treated surgically who had a recurrence, the cyst recurred in 2 at 2 months, one at 3 months, and one each at 20, 48, and 60 months after the surgery. No patients who had a recurrence had additional surgery. Surgical complications Of 40 patients, 12 patients had recorded complications (30%). All were considered relatively minor and included scar problems (5), joint stiffness (4), infection (one, a dorsal cyst in a 14-year-old treated with oral antibiotics), numbness (one, a dorsal cyst in a 17year-old), and slight weakness (one). Although younger patients tended to have more volar cysts than did older children (64% vs 31%), the sample did not have sufficient power to make a statistical comparison. Of the 50 patients managed with observation, 4 had aspiration, all with dorsal cysts, but all recurred. r
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TABLE 3.
WRIST GANGLIA IN CHILDREN
Children Aged 10 Years and Less Nonsurgical (n ¼ 16)
Surgical (n ¼ 6)
Male
5/16 (31)
3/6 (50)
Female
11/16 (69)
3/6 (50)
Cyst volar
9/16 (56)
5/6 (83)
Variable
Cyst dorsal
7/16 (44)
1/6 (17)
Persistence rate (nonsurgical) or recurrence rate (surgical) (%)
5/16 (31)
1/6 (17)
Persistence rate (nonsurgical) or recurrence rate (surgical) volar vs dorsal (%)
Volar 2/9 (22)
QuickDASH mean/median (range)
TABLE 4.
Dorsal 4/7 (57)
14/4.5 (0e48)
Volar 1/5 (20)
Dorsal 0/1 (0)
0.75/0 (0e4.5)
Children Aged 11 Years and Greater Nonsurgical (n ¼ 34)
Surgical (n ¼ 34)
Male
11/34 (32)
8/34 (24)
Female
23/34 (67)
26/34 (76)
Cyst volar
9/34 (26)
12/34 (35)
Cyst dorsal
24/34 (70)
22/34 (65)
Persistence rate (nonsurgical) or recurrence (surgical) (%)
20/34 (58)
5/34 (15)
Variable
Persistence rate (nonsurgical) or recurrence rate (surgical) volar vs dorsal
Volar 4/9 (44)
QuickDASH mean/median (range)
Dorsal 16/25 (64)
14.9/9.1 (0e72.7)
DISCUSSION Ganglion cysts of the wrist in children are generally treated by either observation or surgical excision. In adults, there is the additional option of aspiration with or without steroid injection. In children, aspiration tends to be performed less often. Most of the literature on ganglion management is focused on persistence for nonsurgical treatment or recurrence after surgical excision.8,9 The overall rate of persistence in those treated nonsurgically ranges in the literature between 21% and 57% compared with the current study’s rate of 52%. The overall rate of recurrence in those treated surgically ranges from 2.8% to 37%, compared with the current study’s rate of 15%. Colberg et al10 presented their results of aspiration and then injection of steroid, performed under general anesthesia in 21 children, average age 7.2 years. Cysts were treated after 1 year of observation. They reported a rate of resolution of 62%. Korman et al11 reported on 52 carpal and wrist ganglia treated with aspiration and then either mobilized or left to move; their rate of resolution was 46%. Calif et al1 aspirated 4 cysts and only 1 recurred. Meyerson et al7 noted that patients who had attempted aspiration before eventual surgery J Hand Surg Am.
Volar 2/12 (16)
Dorsal 3/22 (14)
14.2/3.4 (0e70.4)
had a significantly higher rate of recurrence. In the current study, in 4 patients who had aspiration, all ganglia recurred. The strength of this study is the focus on only wrist ganglia, only in children, and with at least 1 year of follow-up. Because the clinician must ultimately recommend either observation or surgery, the current emphasis was on comparing the results of 2 groups, nonsurgical and surgical. The surgically treated group had longer follow-up than did the nonsurgical group (70 vs 44 months). This would tend to favor the nonsurgical group, because the longer follow-up in the surgical group would give more time for a cyst to recur. Despite that, the surgical group had better results. The primary limitation of this study was that the determination of recurrence or persistence of the wrist ganglia was subjective and based on a phone interview. One would predict underreporting of recurrent or persistent ganglia. In the literature reviewed for this study, we found that most studies reported similar methodology with subjective outcomes. Wong et al12 performed 11 phone interviews and examined 3
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patients. Cypel et al5 performed a retrospective chart review. MacKinnon and Azmy6 had 128 patients in their study, 53 of whom were seen (41%). Satku et al3 sent a questionnaire to 45 patients and examined 11 of them. Meyerson et al7 performed a retrospective chart review. Ideally, all patients evaluated for wrist ganglia would be evaluated clinically and an ultrasound or magnetic resonance imaging would be performed for those with uncertain clinical findings. Another limitation of this study was the uneven follow-up period. Moreover, only 75% of patients treated with observation were included in the study. The average time from cyst appearance to surgery was 14 months, compared with the 18 months it took for most cysts in the nonsurgical group to resolve. Diagnosis of wrist ganglia is usually made clinically based on examination and typical location and appearance. Additional imaging studies were common, including x-rays performed in 43% and 50% of those observed and surgically treated, respectively. Ultrasound was performed in 63% of those observed and in 50% of those treated surgically. We found little in the literature on the subject of ganglion imaging. Wong et al12 evaluated the use of routine radiography in patients with a wrist ganglion cyst. In their report of 103 patients, in only one patient did xrays affect management. They concluded that routine imaging is not cost-effective. Although surgery was more successful in all groups, there was a 30% rate of minor surgical complications. Therefore, considering both the literature review and our experience, we recommend observation for at least 18 months, because 94% of cysts that ultimately resolved did so within that
J Hand Surg Am.
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interval. If the cyst persists and is symptomatic, surgical excision is a safe and reasonable option. Patients and their parents should be aware of the 15% recurrence rate. ACKNOWLEDGMENTS The authors would like to thank Bat-el Harris for her dedication and energy that helped make this research possible. REFERENCES 1. Calif E, Stahl S, Stahl S. Simple wrist ganglia in children: a follow-up study. J Pediatr Orthop. 2005;14(6):448e450. 2. MacCollum MS. Dorsal wrist ganglions in children. J Hand Surg Am. 1977;2(4):325. 3. Satku K, Ganesh B. Ganglia in children. J Pediatr Orthop. 1985;5(1): 13e15. 4. Wang AA, Hutchinson DT. Longitudinal observation of pediatric hand and wrist ganglia. J Hand Surg Am. 2001;26(4):599e602. 5. Cypel TKS, Mrad A, Somers G, Zuker RM. Ganglion cyst in children: reviewing treatment and recurrence rates. Can J Plast Surg. 2011;19(2):53e55. 6. MacKinnon AE, Azmy A. Active treatment of the ganglia in children. Postgrad Med J. 1977;53(621):378e381. 7. Meyerson J, Pan YL, Spaeth M, Pearson G. Pediatric ganglion cysts: a retrospective review. Hand (N Y). 2019;14(4):445e448. 8. Trivedi NN, Schreiber JJ, Daluiski A. Blunt force may be an effective treatment for ganglion cysts. HSS J. 2016;12(2):100e104. 9. Barnes WE, Larsen RD, Posch JL. Review of ganglia of the hand and wrist with analysis of surgical treatment. Plast Reconstr Surg. 1964;34:570e578. 10. Colberg RE, Sánches CF, Lugo-Vincente H. Aspiration and triamcinolone acetonide injection of wrist synovial cysts in children. J Pediatr Surg. 2008;43(11):2087e2090. 11. Korman J, Pearl R, Hentz VR. Efficacy of immobilization following aspiration carpal and digital ganglions. J Hand Surg Am. 1992;17(6): 1097e1099. 12. Wong AS, Jebson PJL, Murray PM, Trigg SD. The use of routine wrist radiography is not useful in the evaluation of patients with a ganglion cyst of the wrist. Hand (N Y). 2007;2(3):117e119.
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