Clinical outcomes after arthroscopic revision excision of recurrent dorsal wrist ganglion cyst: a case series study

Abstract

Background

The recurrence of dorsal wrist ganglion (DWG) cyst following excision has been reported up to 40%. This study aimed to evaluate clinical outcomes regarding the functional evaluation and recurrence rate after the arthroscopic excision of recurrent DWG cysts.

Methods

From November 2017 to March 2020, 11 consecutive patients diagnosed as recurrent DWG cysts underwent revision excision in an arthroscopic approach. The magnetic resonance imaging (MRI) examination was performed routinely before the surgery to identify the location and limits of the cyst. All patients were followed up for a minimum of 2 years. The second recurrence was recorded if a mass reappeared at the same site, with a positive transillumination test. Pain during activity was evaluated by the visual analog scale (VAS). Active range of motion (ROM) of the wrist was measured by a goniometer, and the hand grip strength was measured using a digital dynamometer.

Results

After a mean follow-up period of 29.3 months (range, 24 to 34 months), no second recurrence of the cyst was recorded. The VAS score improved from 1.4 to 0.3 (P = 0.003), and the residual pain was reported by 3 patients (VAS score was 1 for each). The active wrist flexion increased from 73.6° to 78.2° (P = 0.016). No significant change was found in active wrist extension and hand grip strength (P > 0.05).

Conclusion

Arthroscopic excision of recurrent DWG cyst yielded satisfactory results with no second recurrence, significant pain relief, and good wrist function at a minimum 2-year follow-up. Clear identification of the location and limits of the ganglion based on the preoperative MRI could be helpful to achieve a complete excision and to prevent a second recurrence.

Background

Dorsal wrist ganglion (DWG) cysts are one of the most common masses afflicting the wrist [1]. As most of these benign masses are asymptomatic and spontaneously resolve with time [2]. nonsurgical interventions such as observation or needle aspiration represent the primary treatment approaches [3]. However, in patients with persistent symptoms - such as pain, weakness, limited range of motion, and increasing size - who have failed conservative treatments, surgical excision is often recommended [3].

Although the DWG excision in an open approach is considered the gold standard and yielded satisfactory outcomes with pain relief and function improvement according to previous studies [4, 5], a high postoperative recurrence was still reported and found in up to 40% [6]. Therefore, a recurrent DWG cyst may be frequently encountered in clinical practices, and its treatment decision and the benefit of re-excision should be evaluated with caution.

Recently, the arthroscopic DWG excision is becoming an alternative to open surgery for advantages in a smaller scar, less pain, and earlier return to work [3]. Meanwhile, the recurrence following arthroscopic DWG excision was reported to be approximately 10% at > 1-year follow-up [7–11], indicating the possible superiority of arthroscopic approach in lowing the recurrence of DWG. However, in patients with recurrent DWG, it is unclear whether a re-excision under arthroscopy would achieve a low recurrence as the primary surgery.

Currently, only a single study reported the surgical outcomes of recurrent ganglion cysts [6]. In this study, 20 recurrent cases received the revision ganglion excision by an open technique, and the second recurrence rate within 1 year postoperatively was 15%. But regarding the revision excision in arthroscopic approach, there are no available data on the patient-reported outcomes and second recurrence.

The purpose of this study was therefore to evaluate clinical outcomes regarding the functional evaluation and recurrence rate after arthroscopic excision of recurrent DWG cysts. The hypothesis was that the ganglionectomy in an arthroscopic approach would be a reliable procedure with good clinical outcomes and a low recurrence rate for patients with recurrent DWG.

Methods

Patient Selection

From November 2017 to March 2020, a total of 11 continuous patients diagnosed as recurrent DWG were retrospectively reviewed. All patients underwent revision DWG cyst excision in an arthroscopic approach at the same center by the same surgeon. The recurrent DWG was defined as the reappearance of a DWG cyst from the radiocarpal or midcarpal joint at the same area as prior and was confirmed by both ultrasonography (US) and magnetic resonance imaging (MRI). The previous excision could be open or arthroscopically (Figure 1). Patients with other concomitant wrist pathology including fracture or ligamentous tear were excluded from the study. This study was approved by our Institutional Ethics Board and was complied with each participant’s consent.

Preoperative Evaluation

Ultrasonography

The wrist US examination was routine before the revision excision and was performed by an expert musculoskeletal sonographer. A GE LOGIQ E9 color Doppler ultrasound system (GE Medical Systems Ultrasound & Primary Care Diagnostics) was used. The criteria used to diagnose a ganglion cyst was a well-defined, anechoic or hypoechoic, unilocular or multilocular fluid collection not representing an anatomic bursa or joint recess, as described in the literature [12]. The largest diameter of the ganglion cyst was then measured (Figure 1).

Magnetic Resonance Imaging

All patients underwent MRI examinations routinely before the revision excision. MRI was performed in a 3.0-T superconducting magnet (Sigma; GE Medical Systems) with a standardized institutional protocol. The MRI protocols included coronal, sagittal, and axial sequences. Each sequence included the T1- and T2-weighted phases. MRI scans were firstly evaluated by an expert musculoskeletal radiologist, and a ganglion cyst was defined as a focal lesion in the soft tissue with signal isointense to fluid [13]. The location and limits of the cyst were then evaluated on T2-weighted axial and sagittal planes by the surgeon. It should be noted that the cyst was probably multilocular due to the local scaring in patients undergoing previous excision [9, 10], therefore the limits of the cyst and the location of extensor tendons should be identified carefully on MRI scans (Figure 2).

Surgical Technique

The surgery was performed under ultrasound-guided axillary block anesthesia, and a pneumatic tourniquet was used with 260 mmHg of pressure to allow a good view on arthroscopy.

All patients underwent wrist arthroscopy in a supine position, with the arm fixed to the table and the elbow flexed to 90° with the wrist in a vertical distraction of 10-15 lbs using a traction tower. A 2.5-mm arthroscope of a visual angle of 30° (ConMed Linvatec) was used, and the normal saline solution was provided through the arthroscopic cannula.

An arthroscopic inspection was performed through the midcarpal ulnar (MCU) portal with the arthroscope, systematically evaluating the wrist following a sequence from radial to ulnar, distal to proximal, and volar to dorsal so as not to miss any concomitant pathology (Figure 3). The dorsal capsule in the region of the scapholunate interosseous ligament was carefully checked and a ganglion stalk was often identified, which usually appeared transparent, gray, or opalescent. Sometimes a real stalk was not present and an external pressure applied over the mass was helpful to localize the ganglion base. 

Once the stalk was visualized, a needle was introduced through the ganglion into the midcarpal joint from the midcarpal radial (MCR) portal (Figure 4). A direct transcystic MCR approach was created and a 2.9-mm shaver (ConMed Linvatec) was introduced through the ganglion into the joint. Based on the location and limits of the cyst on preoperative MRI, the ganglion stalk and adjacent pathological dorsal capsule were excised under arthroscopic vision, until the extensor carpi radialis brevis (ECRB) and extensor digitorum communis (EDC) of the index finger were exposed (Figure 5). The extrusion of gelatinous material was usually the evidence of a successful decompression of the cyst. Because of thick scarring after previous surgery, clear visualization of the inner wall of a recurrent cyst could be difficult, and the ganglion could be multilocular. Percutaneous squeezes of the ganglion in multiple directions could help to locate limits of the cyst, then a complete excision of the ganglion wall and stalk proceeded. Great caution should be taken to prevent injuries to ECRB and EDC tendons while ganglion excision was under external pressure. After the ganglionectomy was completed, the disappearance of the ganglion should be confirmed arthroscopically, followed by palpation of the dorsal wrist to reconfirm after the arthroscope was removed. The portals were closed with nylon sutures.

A bulky dressing was applied immediately after the procedure and no plaster or brace was utilized. Patients were encouraged to gently use their hands as tolerated, avoiding strenuous work and weight lifting for 4 weeks. Physical therapy was recommended to all patients.

Data Collection

Demographic Data and Medical History

A questionnaire was used to record the age, gender, dominant side, affected side, prior surgical approach, and time of recurrence. The time of recurrence was documented by the patient recall and determined by the interval between primary excision and the first reappearance of the cyst.

Pain and Function Evaluation

Pain during activity was evaluated using the visual analog scale (VAS) of 0 (no pain) to 10 (worst pain ever felt), and the residual pain was recorded if VAS score >0 at the final follow-up. Active range of motion (ROM) of the wrist in flexion and extension in degrees was measured with a goniometer, and the hand grip strength in kilograms was measured using a digital dynamometer. The above evaluations were performed before surgery and at the final visit. Postoperative evaluations were performed at a minimum of 24 months.

Second Recurrence

After revision arthroscopic excision, a second recurrence was defined as a reappearance of the mass at the same site, with a positive transillumination test [9]. Time of the second recurrence was recorded based on the patient’s first observation instead of the surgeon’s confirmation. At the final visit, all patients were asked to receive a wrist US to confirm the recurrence or not.

Statistical Analysis

Statistical analyses were performed using SPSS 25.0 software package (SPSS Inc., IBM, USA). Descriptive statistics were conducted for all variables. Continuous variables (age, time of recurrence, largest cyst diameter, length of follow-up, VAS score, active ROM, hand grip strength, and time of the second recurrence) were reported as mean ± standard deviation (SD), and the comparative analysis between the pre- and post-operation was performed by Student t test or Mann-Whitney U test according to the assumption of normality and homoscedasticity. Categorical variables (gender, dominant side, affected side, prior surgical approach, and residual pain) were reported as numbers (percentage). Statistical significance was set at P<0.05 for all analyses.

Results

Patient Characteristics

The 11 patients undergoing revision arthroscopic cyst excisions all completed the final follow-up of a minimum of 24 months. This study cohort consisted of 4 males and 7 females with a mean age of 38.2 years. All patients were dextral, and the dominant side was affected in 4/11 patients. At the time of revision arthroscopic excision, the largest diameter of the cyst was 15.8 mm on preoperative US (Table 1).

Table 1. Patient characteristics

Prior Surgery and Recurrence

The primary ganglion excision was performed with an open technique in 9 cases and an arthroscopic approach in 2 cases. The time of recurrence of the ganglion after prior surgery was 20.5 months on average, ranging from 2 months to 4.7 years. Specifically, it was <1 year in 4 cases, 1-2 years in 4 cases, and >2 years in 3 cases (Table 2). 

Table 2. Prior surgery and recurrence

Clinical Outcomes

The mean follow-up period was 29.3 months after revision arthroscopic excision. At the final visit, the VAS score significantly decreased from 1.4 to 0.3 (P=0.003), and the residual pain was reported in 3 patients (VAS score =1 for each). Moreover, the active wrist flexion significantly increased from 73.6° to 78.2° (P=0.016). Although the active wrist extension and hand grip strength improved postoperatively, the differences were not of statistical significance (P>0.05). No second recurrence of the ganglion cyst was confirmed within the follow-up period.

Table 3. Clinical Outcomes

Values are presented as mean ± SD or n (%).

VAS, visual analog scale.

Discussion

The most important finding of this case series study could be concluded as that the arthroscopic excision of recurrent DWG cysts could achieve satisfactory outcomes with pain relief, ROM improvement, and no second recurrence at a minimum of 24-month follow-up.

While the open excision of DWG cysts led to a lower recurrence than conservative treatments such as aspiration and intralesional injection, the reported recurrence rates were variable and worrying [2, 14]. Dias et al. [2] reported the 6-year follow-up outcomes after different interventions with reassurance, aspiration, and open excision for patients with DWG. The recurrence rate of open excision was significantly higher than that of reassurance and aspiration, however, still as high as 39%. Given the widely developed open excision, a current DWG cyst could be common in clinical scenarios.

Since firstly described by Osterman and Raphael in 1995 [15], the arthroscopic excision of DWG cysts has increased in popularity and showed inspiring results with a lower recurrence rate of approximately 10% [7–11]. In a study by Gallego and Mathoulin [10], a total of 114 patients underwent arthroscopic excisions of DWG cysts, and there were 14 (12.3%) recurrences at a mean of 16.9 months after surgery. Borisch [8] performed 30 arthroscopic DWG excisions and found 4 (13.3%) cases with reoccurred symptoms at an average of 28.5-month follow-up. Fernandes et al. [7] evaluated 34 cases of DWG cysts in patients who underwent arthroscopic excisions, and only 1 (2.9%) recurrence was noted (at 3 months postoperatively) within a minimum of 4-year follow-up. Such results showed the advantage of the arthroscopic approach in primary DWG excision regarding the recurrence reduction. However, in cases of recurrent DWG cysts, the effectiveness of arthroscopic ganglionectomy is unclear.

Currently, only a study performed by Graham et al. [6] reported the surgical outcomes of revision excision for the recurrent wrist ganglion cyst. In their study, an open excision was performed in 20 patients with recurrence, including 8 on the dorsal and 12 on the volar side. Within the follow-up period of 1 year, 3 (15%) cases had a second recurrence but none were on the dorsal side, which is similar to the result of this study. In this study, 11 patients received arthroscopic excisions for a recurrent DWG cyst, and no recurrence was confirmed at a minimum of 2-year follow-up, indicating that the ganglionectomy with an arthroscopic technique was effective in preventing second recurrence following revision excisions.

Generally, surgical errors, mainly an incomplete removal of the ganglion cyst and its stalk during the excision is considered to be the most important factor increasing the risk of recurrence [5, 9]. Recent studies described a color-aided technique to improve the visualization of the ganglion stalk during arthroscopic excision with a low recurrence rate of 3.7% [16], implying the importance of the identification and excision of the stalk. In this study, percutaneous squeezes on the mass were repeatedly performed to confirm the stalk and limits of the cyst while excising the ganglion, which could be helpful in a complete excision. However, as described by the literature, the ganglion stalk might be hardly identified as a discrete structure in many cases [5, 9, 11, 15], especially in recurrent patients undergoing previous surgery. Moreover, Kim et al. [9] found that the recurrence rate of following arthroscopic excision was similar between patients with and without the stalk identification. Therefore, to prevent the recurrence, an extensive excision of the ganglion including the dorsal capsular tissue adjacent to the scapholunate ligament was performed in this study until ECRB and EDC of the index finger were visualized. This could be noteworthiness as the EDC is not exposed necessarily at the primary excision.

In patients with recurrent DWG cysts, especially for those after open surgery, thick scarring commonly occurred between the scapholunate ligament and the capsule on the dorsal wrist [9, 17], which might result in a recurrent cyst of a multilocular feature. Previous studies demonstrated that a multiloculated ganglion cyst could be identified clearly on MRI scans [18]. In this study, a comprehensive evaluation based on preoperative wrist MRI scans was performed, including the unilocular or multilocular characteristics of the cyst as well as limits between the ganglion wall and extensor tendons, to direct the capsulectomy and cyst excision under the arthroscopic view. This could be another potential reason for the low recurrence in this study.

The ganglionic pain is postulated from the compression of terminal branches of the posterior interosseous nerve, and decompression of the ganglion is believed to relieve the pain [1]. Previous study reported an incidence of residual pain following arthroscopic DWG excisions as 3.5–21% [5, 9, 10, 17]. In this study, the residual pain under activity was found in 27% of patients, and the postoperative VAS score was only 1 in each of those. Regarding the active wrist ROM in this study, a slight but statistically significant improvement in the palmar flexion was found at the final follow-up, which probably resulted from the pain relief aforementioned. Furthermore, the hand grip strength was normal preoperatively and maintained postoperatively in this study, indicating that the symptom of weakness could be not so prevalent among recurrent cases.

Overall, the clinical implication of this study is to provide further understandings of the arthroscopic technique in resecting recurrent DWG cysts. Clear identification of the location and limits of the ganglion based on preoperative MRI helps direct arthroscopic excision. For the greatest prevention of a second recurrence, extensive excision of the ganglion and the surrounding pathological capsule should be performed until the ECRB and EDC of the index finger are exposed.

The limitations of this study can be summarized as follows. First, the recurrence rate could be underestimated as the follow-up period was short. More recurrences might be found at > 2-year follow-up, as reported by the literature [2, 5]. However, the only one study of an open excision for recurrent DWG cysts demonstrated no second recurrence within 1 year after the surgery [6], which was comparable to our results. Second, a comparison analysis between patients with different characteristics is improper to perform because of the small sample size, although this is the largest cohort of recurrent DWG cases in the literature. Third, the functional outcome was not evaluated by any specialized scale such as the Disabilities of the Arm, Shoulder and Hand system, which can measure the meticulous function of the upper extremity. Fourth, the medical documents at the time of primary surgery were not collected, so the original feature of recurrent cases before any surgical excision is hard to trace. Last but not least, the retrospective design should be regarded as an important limitation.

Conclusion

Arthroscopic excision of recurrent DWG cysts achieved satisfactory outcomes with no second recurrence, significant pain relief, and good wrist function at a minimum 2-year follow-up. Preoperative MRI examinations could be helpful in the identification of the location and limits of the ganglion. Extensive cyst excision and capsulectomy should be performed to prevent a second recurrence.

Abbreviations

Declarations

Ethics approval and consent to participate

This study was approved by Beijing Jishuitan Hospital Institutional Review Board.

Consent for publication

Human research participants provided informed consent for publication of the images in Figures 1, 2, 3, 4, and 5.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

Tong Zheng and Xingjian Huang contributed equally to this article.

Other authors declare that they have no competing interests.

Funding

None.

Authors' contributions

T.Z. drafted the manuscript and conducted the statistical analysis. X.H. researched literature and helped to draft the manuscript. Y.Y. conceived the study, gained ethical approval, and performed operations. B.L. and F.L. were involved in patient recruitment and data collection. Z.L. participated in the study design. All authors read and approved the final manuscript.

Acknowledgements

None.

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