Advice on ganglions is flawed
http://www.100md.com
《英国医生杂志》
EDITOR—The POEM headline "Half of all ganglions resolve spontaneously" is likely to lead to dangerous conclusions about a common hand condition among casual readers.1 The text discusses a form of ganglion that constitutes only 18-20% of all such lesions, which is not made clear in the bottom line.
This POEM draws on the evidence of a flawed paper and then suggests its findings apply to all ganglia. Patients do not like these lesions, and the commonest dorsal form (60-70% of cases) causes discomfort. In my experience, symptoms are closely related to the degree of inflation of the lesion, waxing and waning in unison, which suggests they are probably caused by local compressive effects.
Patients come to hand specialists seeking removal, and the quoted article by Dias and Buch makes it quite clear that the selection of patients to be managed by masterly neglect was not impartial or objective: "the surgeon's preference dictated" whether surgery or observation was chosen.2
The case made for non-operative management is further weakened by the manner of arrival at figures for post-surgical recurrence, said by Dias and Buch to have been 42%.2 Volar wrist ganglion surgery is challenging and yet was carried out by a mixed bag of "senior and junior surgeons." In properly experienced hands, however, the recurrence rate after surgery for ganglia is "very low."3
The bottom line of this POEM is that patients with ganglia will be misled by being told not to worry as their painful lump is likely to do just as well by leaving it alone. And cash strapped local management will be only too happy to reinforce this unfortunate advice.
Peter J Mahaffey, consultant plastic and hand surgeon
Lister Hospital, Stevenage, Hertfordshire SG1 4AB mahaffey@lycos.co.uk
Competing interests: None declared.
References
POEM. Half of wrist ganglions resolve spontaneously. BMJ 2004; 328. (3 April.)
Dias J, Buch K. Palmar wrist ganglion: does intervention improve outcome? A prospective study of the natural history and patient-reported treatment outcomes. J Hand Surg (Br) 2003;2: 172-6.
Angelides AC. Ganglions of the hand and wrist. In: Green DP, ed. Green's operative hand surgery. Vol 2. 4th ed. New York. Churchill Livingstone, 1998: 2171-83.
This POEM draws on the evidence of a flawed paper and then suggests its findings apply to all ganglia. Patients do not like these lesions, and the commonest dorsal form (60-70% of cases) causes discomfort. In my experience, symptoms are closely related to the degree of inflation of the lesion, waxing and waning in unison, which suggests they are probably caused by local compressive effects.
Patients come to hand specialists seeking removal, and the quoted article by Dias and Buch makes it quite clear that the selection of patients to be managed by masterly neglect was not impartial or objective: "the surgeon's preference dictated" whether surgery or observation was chosen.2
The case made for non-operative management is further weakened by the manner of arrival at figures for post-surgical recurrence, said by Dias and Buch to have been 42%.2 Volar wrist ganglion surgery is challenging and yet was carried out by a mixed bag of "senior and junior surgeons." In properly experienced hands, however, the recurrence rate after surgery for ganglia is "very low."3
The bottom line of this POEM is that patients with ganglia will be misled by being told not to worry as their painful lump is likely to do just as well by leaving it alone. And cash strapped local management will be only too happy to reinforce this unfortunate advice.
Peter J Mahaffey, consultant plastic and hand surgeon
Lister Hospital, Stevenage, Hertfordshire SG1 4AB mahaffey@lycos.co.uk
Competing interests: None declared.
References
POEM. Half of wrist ganglions resolve spontaneously. BMJ 2004; 328. (3 April.)
Dias J, Buch K. Palmar wrist ganglion: does intervention improve outcome? A prospective study of the natural history and patient-reported treatment outcomes. J Hand Surg (Br) 2003;2: 172-6.
Angelides AC. Ganglions of the hand and wrist. In: Green DP, ed. Green's operative hand surgery. Vol 2. 4th ed. New York. Churchill Livingstone, 1998: 2171-83.