Open Excision of Dorsal Wrist Ganglion.

Background: Ganglion cysts are benign soft-tissue tumors that are most commonly found in the wrist. Within the wrist, 60% to 70% of ganglion cysts occur on the dorsal side and 20% to 30% occur on the volar side. Although ganglia arise from multiple sites over the dorsal wrist, dorsal ganglia most commonly originate at the scapholunate joint. Open excision is the standard surgical treatment for dorsal wrist ganglia. This procedure is considered when symptoms such as pain and range-of-motion deficits begin to impact activities of daily living.

Description: Open excision of a dorsal wrist ganglion is commonly performed with the patient under general anesthesia or a regional block. The patient is placed in the supine position, and a tourniquet is applied on the affected upper limb. After outlining the periphery of the palpable ganglion, the surgeon makes a transverse or longitudinal incision over the ganglion. The surgeon then begins a deep dissection, dissecting through the subcutaneous tissue and isolating the ganglion while avoiding any rupture, if possible. Once the cyst has been identified, extensor tendons surrounding the cyst are retracted and the cyst and stalk are mobilized. The cyst and stalk are subsequently excised, and the wound is closed.

Alternatives: Alternative treatments for dorsal wrist ganglia include nonoperative interventions such as observation, aspiration, controlled rupture, and injection. Operative treatments include arthroscopic and open dorsal wrist ganglion resections.

Rationale: Although nonoperative treatment can produce successful outcomes, the various modalities have been associated with recurrence rates ranging from 15% to 90%. As a result, surgical excision remains the gold standard of treatment and is typically indicated when weakness, pain, and limited range of motion interfere with activities of daily living. Among surgical interventions, arthroscopic excision is a minimally invasive procedure that has become more common because of the reduced scarring and faster recovery. However, open excision, which does not involve complex equipment, is regarded as the standard among surgical treatments. Although the rates of recurrence for arthroscopic versus open dorsal ganglion excision are similar, arthroscopic excision is less effective with regard to pain relief. This difference in pain relief could potentially be the result of the neurectomy of the posterior interosseous nerve in an open excision. In contrast, an arthroscopic procedure may provide less relief of pain from the posterior interosseous nerve stump attaching to the scarred capsule.

Expected Outcomes: Open excision of a dorsal wrist ganglion is a safe, reliable procedure. The recurrence rate after open excision is similar to that after arthroscopic excision and significantly lower recurrence than that after ganglion cyst aspiration. Additionally, not all ganglion cysts can be aspirated. In a retrospective study assessing the risk of recurrence after open excision of ganglion cysts in 628 patients, researchers reported a recurrence rate of 4.1% among the 341 who underwent open dorsal ganglion excision. Furthermore, the authors reported male sex and less surgeon experience as significant risk factors for cyst recurrence. In a study assessing outcomes of open dorsal ganglion excision in 125 active-duty military personnel, researchers reported a recurrence rate of 9%. More notably, the researchers found persistent pain at 4 weeks postoperatively in 14% of the participants. The authors recommended that patients whose daily activities require forceful wrist extension, such as athletes and military personnel, should be counseled on the potential functional limitations and residual pain from open dorsal wrist ganglion excision.

Important Tips: When conducting an open excision, it is beneficial to identify the stalk of the cyst, allowing the surgeon to excise the complete ganglion complex and prevent recurrence.For large cysts that adhere to the surrounding soft tissue, it is helpful to rupture the ganglion in order to facilitate an easier deep dissection.Excising the scapholunate interosseous ligament could possibly lead to scapholunate dissociation and instability.The posterior interosseous nerve courses past the 4th dorsal compartment and may be resected during the deep dissection.