
==== Front
BMC Musculoskelet Disord
BMC Musculoskelet Disord
BMC Musculoskeletal Disorders
1471-2474
BioMed Central London

7797
10.1186/s12891-024-07797-0
Research
Outcome evaluation of dye-assist arthroscopic inside-out ganglionectomy: a retrospective study of 29 patients
Zhang Fei 1
Jiang Hong 2
Li Qian 1
Yang Haoyu 1
Mi Jingyi 3
Rui Yongjun ruiyongjun@suda.edu.cn

4
Zhao Gang zhaogangmd@suda.edu.cn

1
1 grid.263761.7 0000 0001 0198 0694 Department of Hand Surgery WuXi No.9, People’s Hospital Affiliated to SooChow University, WuXi, China
2 grid.263761.7 0000 0001 0198 0694 Suzhou Medical College of SooChow University, Suzhou, China
3 grid.263761.7 0000 0001 0198 0694 Department of Sport Medicine WuXi No.9, People’s Hospital Affiliated to SooChow University, WuXi, China
4 grid.263761.7 0000 0001 0198 0694 Department of Orthopeadics Surgery WuXi No.9, People’s Hospital Affiliated to SooChow University, WuXi, China
7 9 2024
7 9 2024
2024
25 7231 7 2024
19 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Objective

To evaluate the clinical outcomes of arthroscopic inside-out ganglionectomy of dominant dorsal wrist ganglion.

Methods

Patients with dominant wrist ganglion cyst treated in our hospital from January 1, 2014 to June 31, 2023 was enrolled in this retrospective analysis. All patients underwent dye-assist arthroscopic inside-out ganglionectomy. After discharge, the patients were followed for a minimum of 6 months. The primary outcomes were to assess patient wrist function using the Patient-Rated Wrist Evaluation (PRWE) and Mayo Modified Wrist Score (MMWS). The secondary outcomes were visual analog score (VAS), wrist active range of motion (ROM), grip strength, recurrence rate and complication.

Results

All ganglion were successfully resected after dye staining. Patients were followed for an average of 12.17 months. There were no significant changes between preoperative and postoperative wrist active ROM or grip strength, except for wrist flexion (which showed a slightly greater improvement after surgery, P = 0.049), there were notable improvements in VAS, MMWS, and PRWE postoperatively. Recurrence occurred in 3 patients. No major complications observed during the follow-up period.

Conclusion

Dye-assist arthroscopic inside-out ganglionectomy is safe and uncomplicated, worth of clinical promotion.

Keywords

Dye staining
Arthroscopic ganglionectomy
Dorsal wrist ganglion
Methylene blue
Inside-out
Subsidy Program for Young and Middle-aged Top Talents of Wuxi Municipal Health CommissionPostdoctoral Research Funding Program of Jiangsu Province2020Z359 issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
==== Body
pmcIntroduction

Ganglion cyst is the most benign tumor affecting the wrist, often originating from tissues adjacent to the dorsal aspect of scapholunate ligament [1]. Currently, its etiology is not well understood, making it difficult to treat strategy. The theory of joint capsule herniation, inflammatory irritation and others have been proposed and warrant consideration [2]. In addition, symptomatic ganglion was associated with ligamentous hyperlaxity [3]. Given the high recurrence rate associated with conservative treatments, surgery is considered as the superior option for wrist ganglion cysts [4]. While open excision remains the standard treatment, the arthroscopic approach has gained popularity in recent years due to its minimally invasive nature and favorable cosmetic outcomes [5]. Arthroscopic ganglionectomy aims to identify and thoroughly excise the ganglion stalk [6].

In some cases, it is difficult to distinguish ganglion from surrounding tissues under arthroscope. Ultrasound guided technique, or dye staining technique were utilized to solve this problem [7]. Dye-assisted location of ganglion stalk and cyst wall was first proposed by Jeffery Yao in 2011 [8]. The stalk and cyst wall can be efficiently identified after intracapsular injection of little dye. To achieve thorough resection and eliminate one-way valve, the extra-articular debridement should be considered following intra-articular debridement [9]. Therefore, we aimed to evaluate the multifaceted outcomes of dye-assisted arthroscopic inside-out ganglionectomy through a retrospective analysis.

Materials and methods

Patients

Patients who underwent dye-assisted arthroscopic inside-out ganglionectomy in our institution from January 1, 2014 to June 31, 2023 were enrolled in this study. Overall, 46 patients were treated in our institution during this period. The inclusion criteria were: (1) age between 16 and 70 years old; (2) dominant dorsal wrist ganglion; (3) followed for at least 6 months. The exclusion criteria were: (1) occult dorsal wrist ganglion; (2) allergic to methylene blue dye; (3) history of wrist surgery or fracture; (4) combined with wrist arthritis. (5) combined with wrist deformity. In total, 33 subjects met the inclusion and exclusion criteria, among whom 4 were lost to follow-up. Finally, 29 subjects were enrolled in the study. Among these, 11 patients had tenderness over the ganglion or felt pain in the course of wrist flexion and extension movement. Other 18 patients had no obvious symptom and requested surgery for the sake of aesthetic impact of ganglion. The preoperative scaphoid shift tests were negative in all patients. All patients underwent preoperative MRI to confirm the ganglion diameter and cavity number, as well as the concomitant soft tissue injury.

Surgical technique

To minimize bias, the surgical procedure was performed by the same primary surgeon for all patients. Each patient received brachial plexus block anesthesia and was positioned supine. An inflatable tourniquet was applied at the root of the affected upper limb, then the vertical traction tower was used to suspend the forearm with a 10–15 lb weight. Preoperative MRI images were analyzed to identify the location of stalk and determine the surgical approach (Fig. 1a). 18-gauge needle was used to puncture the cyst and slight suction was performed to confirm the intracystic placement of the needle [10]. Subsequently, 0.3–0.5 ml methylene blue dye was inserted into the cyst (Fig. 1b). Slight pressure and kneading were applied on the cyst to effectively spread the dye [11].

Fig. 1 Operation maneuver. (a) Preoperative MRI image, the arrow shows the identification of stalk. (b) Injection methylene blue into ganglion. (c) Identification of stalk after injection of methylene blue, the arrow shows the location of stalk and cyst. (d) Complete resection of cyst and stalk, the arrow shows the exposure of extensor tendon after ganglionectomy

For ganglions originating from the dorsal aspect of the scapholunate ligament, a 1/2 or 3/4 portal was established as the viewing portal, while a 4/5 or 6/R portal was used as the working portal, depending on the size of the ganglion. A thorough examination of joint was applied, followed by insertion of 2.0 mm shaver (Conmed, NY, USA) through working portal to debride the abnormal synovium for better visualization. Next, the stalk of ganglion was identified based on the staining location. In this procedure, arthroscopic light was used to transilluminate the cyst for rapid location, and external pressure was applied for better exposure of the stalk (Fig. 1c). Once the stalk’s location was identified, inside-out debridement was performed. Intra-articular lesion was debrided preferentially. Subsequently, the arthroscope was evacuated and acted as endoscope to further debride extra-articular cyst until the dorsal extensor tendon was exposed (Fig. 1d). The longitudinal traction force was reduced to mitigate the tension of extensor tendon, thereby minimizing the risk of tendon rupture. Besides, the surrounding 5 mm of capsule was further debrided and sustained external pressure was applied to achieve ganglion complete decompression. For the case of enormous ganglion, the examination and treatment of midcarpal joint was essential. An additional small incision may be made to remove any superficial residual cyst. For cysts originating from the midcarpal joint, MCR and MCU portals were established, following the same procedure as described above. Subsequently, the concomitant intercarpal ligament injury, including scapholunate (SL) and lunotriquetral (LT) ligament injury, and the triangular fibrocartilage complex (TFCC) injury were treated according the degree of injury [3, 12, 13]. Finally, the wound was closed using the adhesive tape (3 M, St. Paul, MN, USA) without suturing.

Patients with no comorbidity were encouraged to conduct active motion exercise immediately. In the case of intercarpal ligament or TFCC injury, the affected wrist was immobilized with a splint for 4 weeks [14]. The adjacent joint was permitted to move freely without restraint early on. Rehabilitation began once the splint was removed.

Outcome measures

All patients were regularly reviewed at 1, 2, 3 and 6 months, one year postoperatively. The primary outcome parameters included the Patient-Rated Wrist Evaluation (PRWE) and Mayo Modified Wrist Score (MMWS) before and after surgery (postoperative 6 months and final follow up) [15, 16]. The secondary outcome parameters included the visual analog score (VAS), wrist active range of motion (ROM), grip strength, recurrence rate and complications at the three time points mentioned above. Wrist active ROM contained the range of flexion, extension, pronation and supination. All data were measured and recorded by the same recorder using the Jamar® Hands on Evaluation Kit.

Statistical analysis

Statistical analysis was performed using the SPSS v.25 (IBM SPSS Statistics 25, USA) software. Wrist active ROM was analyzed using the one-way analysis of variance (ANOVA). Data were presented as mean ± standard deviation (SD). Analyses testing for VAS, grip strength, MMWS and PRWE were performed with Wilcoxon’s rank sum test. Data were presented as the median value. The recurrence rate was presented as a percentage. P < 0.05 was considered significant.

Results

Patient characteristics

A total of 29 patients were enrolled with a mean follow-up duration of 12.17 ± 6.12 (6–36) months. There were 11 (37.93%) males and 18 (62.07%) females in the study cohort. The mean age was 35.90 ± 11.68 (16–70) years old. The left wrist was affected in 12 (41.38%) while the right was affected in 17 (58.62%). The affected dominant wrist was 17 (58.62%). The average ganglion diameter was 17.76 ± 5.76 mm. Cavity number varied from 1 to 4. Notably, 10 cases had a comorbidity of SL ligament injury (7), LT ligament injury (1) and TFCC injury (2) under arthroscopy. The intercarpal ligament injuries of patients were grade I or II according to Geissier classification [12]. We debrided and deflated the damaged and loose ligaments. Both two cases of TFCC injury were located at central articular disc and did not affect the stability of wrist. One TFCC injury was detected by preoperative MRI while another was missed due to the limited sensitivity of MRI. We debrided the lesions of TFCC with the shaver. Details were displayed in Table 1.

Table 1 Demographic data

Characteristics	N = 29	
Gender, n (%)	
 Male

 Female

	11 (37.93%)

18 (62.07%)

	
Age (years)	
Mean ± SD	35.90 ± 11.68	
Occupation, n (%)	
Worker

Clerk

Teacher

Student

Doctor

Self-employed

Farmer

Unemployed

Retired

	8 (27.59)

8 (27.59)

3 (10.34)

4 (13.79)

1 (3.45)

2 (6.90)

1 (3.45)

1 (3.45)

1 (3.45)

	
Affected side, n (%)	
Left

Right

	12 (41.38%)

17 (58.62%)

	
Affected dominant wrist, n (%)	
Yes

No

	17 (58.62%)

12 (41.38%)

	
Ganglion diameter (mm)	
Mean ± SD	17.76 ± 5.76	
Cavity number, n (%)	
1

2

3

4

	11 (37.93%)

9 (31.03%)

8 (27.59%)

1 (3.45%)

	
Comorbidity, n (%)	
TFCC injury

SL ligament injury

LT ligament injury

	2 (6.90%)

7 (24.14%)

1 (3.45%)

	
Recurrence, n (%)	3 (10.34%)	
Follow-up period (months)	
Mean ± SD	12.17 ± 6.12	
TFCC: triangular fibrocartilage complex; SL: scapholunate; LT: lunotriquetral

SD: standard deviation; N: number

Outcome measures

All ganglion stalks were stained and thoroughly resected under arthroscopy without the need for conversion to open surgery. At the final follow up, recurrence was observed in 3 patients (10.34%), all of whom underwent secondary arthroscopic surgery. The analysis revealed that all patients were satisfied with appearance and function (Fig. 2). Notably, no significant differences were observed between preoperative and postoperative values in wrist active ROM and grip strength except flexion (P = 0.049). Several parameters including VAS, MMWS and PRWE were significantly improved (P < 0.01) after surgery (Table 2).

Fig. 2 Postoperative appearance and wrist active ROM at the final follow-up. (a) Postoperative appearance view, the yellow circle shows the region of surgical scar. (b) Flexion view. (c) Extension view. (d) Pronation view. (e) Supination view

Table 2 Outcome measures

Group	Preoperative	Postoperative 6 months	Final follow up	P value	
VAS	1	0	0	< 0.001	
Wrist active ROM (°)	
Flexion

Extension

Pronation

Supination

	74.93 ± 6.750

81.21 ± 6.721

85.86 ± 7.352

111.90 ± 14.544

	77.72 ± 5.063

81.24 ± 3.916

85.69 ± 4.958

111.55 ± 12.302

	78.41 ± 4.866

82.14 ± 3.691

86.31 ± 5.245

112.41 ± 11.900

	0.049

0.722

0.919

0.968

	
Grip strength (kg)	27	26	26	0.893	
MMWS	75	90	90	< 0.001	
PRWE	5.0	3	2.5	0.002	
VAS: visual analog score; ROM: range of motion;

MMWS: Mayo Modified Wrist Score; PRWE: Patient-Rated Wrist Evaluation

Complications

There was little residual dye in the subcutaneous area and did not cause any discomfort or irritation. No severe complications, including tendon rupture and tattoo effect, happened during the follow up period. However, 2 patients suffered mild scar hypertrophy and felt discomfort during wrist flexion, which resolved spontaneously without medication.

Discussion

Wrist ganglion is one of the most common tumors of the upper limb. In general, most of them do not cause noticeable symptoms. Some patients complain of pain or influencing the esthetics [17]. Given the high recurrence rate of conservative treatment, the surgical intervention is recommended as the first option [18].

Since Osterman and Raphael first reported the case of wrist arthroscopic ganglionectomy, arthroscopic surgery has since been the preferred approach over open surgery [19, 20]. The variability in recurrence rates of cysts following arthroscopic surgery is primarily attributed to inadequate exposure and incomplete resection of the stalk [21]. Therefore, precise identification and complete removal of the stalk is crucial. However, previous reports on the visibility of the stalk under arthroscopy are conflicting. Kang’s study of 45 cases demonstrated successful exposure of the stalk in all instances [22]. In contrast, Edwards and Rizzo reported significantly lower proportions of visible stalks, with 4 out of 45 and 12 out of 41 cases, respectively [23, 24]. Nishikawa categorized cysts into three types based on stalk visibility under arthroscopy [25]. For type II-b, the stalk cannot be identified under compression. Some techniques, including intraoperative ultrasound guidance and dye staining, have been applied to locate the stalk of type II-b cysts [7, 26]. In studies conducted by Yao and Zahab in 2011 and 2013, respectively, the stalk position was stained and identified with indigo carmine dye [8, 27]. Similarly, Lee and Su employed methylene blue staining to determine the stalk location [6, 11]. Notably, Su utilized methylene blue staining in open resection rather than arthroscopic operation. In this trial, we selected methylene blue and identified stalks successfully under an arthroscope. The stalk of dorsal ganglion always originates from SL ligament, extends outside the wrist joint. Inside-out debridement can efficiently eliminate stalk and one-way valve. During intra-articular debridement, the lesions of SL ligament should be repaired to decrease recurrence rates [5]. During the process of extra-articular debridement, the shaver consistently turned back to the extensor tendon to prevent iatrogenic injury.

In previous literature, arthroscopic ganglionectomy was mainly performed to evaluate postoperative recurrence, but limited attention has been given to postoperative patient-centered outcomes [28]. Here, we compared the preoperative and postoperative patient-centered outcomes to assess its safety and efficacy. We found no significant difference in wrist active ROM and grip strength between preoperative and postoperative outcomes except flexion, largely due to minimal invasion and less iatrogenic injury. Postoperative flexion motion was improved compared with preoperative flexion motion, which was associated with the alleviation of pain. Some patients complained of pain when performing extreme wrist flexion or lifting bulky items based on the analysis of VAS, MMWS and PRWE, which interrupts their daily routine and work before surgery. The source of pain may arise from compression of terminal branch of posterior interosseous nerve, or intercarpal ligament injury as described in previous literature [2]. Nerve compression and ligament hyperlaxity were significantly improved postoperatively, contributing to the alleviation of pain. At the final follow-up, only 6 patients complained of mild pain, and the rest resumed daily routine and work.

Unfortunately, 3 patients (10.34%) experienced recurrence in the original lesion site. This may be linked to residual dispersed stalk, which could not be identified by arthroscopy even with the assistance of dye staining. Extensive capsule debridement may decrease the risk of recurrence, but this is not recommended because it may also increase the risk of scapholunate instability [29].

There are several limitations in this study. In the first place, the sample size is rather small, which may cause bias and error easily. Furthermore, this is a single-center study that solely reflects the experience of this center, limiting its generalizability. Furthermore, the study did not include a control group. Therefore, further prospective studies with large samples from multiple-centers are advocated to validate our findings.

In conclusion, dye-assisted arthroscopic ganglionectomy is safe and effective. This technique has remarkable patient satisfaction, indicating its potential for widespread adoption.

Acknowledgements

Not applicable.

Author contributions

GZ and YR designed this study. JY and LQ worked on data acquisition and analysis. HY and HJ prepared Tables 1 and 2; Figs. 1 and 2. FZ drafted this manuscript, and GZ revised and completed this manuscript. All authors reviewed the manuscript and approved the submitted version.

Funding

This study was supported by the Subsidy Program for Young and Middle-aged Top Talents of Wuxi Municipal Health Commission and the Postdoctoral Research Funding Program of Jiangsu Province (2020Z359).

Data availability

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

Declarations

Ethical approval

This study was approved by the Ethics Committee of Wuxi 9th People’s Hospital Affiliated to Soochow University. Informed consent was obtained from all individual participants included in the study. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Consent to participate

Not applicable.

Consent to publish

Not applicable.

Competing interests

The authors declare no competing interests.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Fei Zhang and Hong Jiang contributed equally to this work as co-first authors.
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