Results of modified thread technique for the treatment of wrist ganglion

Abstract

Background

Ganglion cyst is the commonest swelling around the wrist. It usually presents as a painless swelling. There is no consensus as to the exact cause and the ideal modality of its treatment. Surgical excision has the best cure rates but has its share of complications. The aim of this study was to evaluate whether a modified thread technique can give reasonably good results with a low complication rate in patients with wrist ganglion.

Material and methods

One hundred and sixteen patients with wrist ganglion underwent a modified thread technique in which a sterile silk suture was passed through the ganglion, the contents of the ganglion were expressed out completely by firm pressure and the thread was tied over a sterile gauze piece forming a single loop. The thread was removed once serosanginous discharge was seen at entry point of the thread into the cyst.

Results

One hundred and eight patients were available for final analysis with minimum six months follow up. There was no recurrence in ninety eight patients giving success rate of ninety one percent. Recurrence was only seen in patients where complete evacuation of the contents of ganglion could not be achieved. Nine patients had minor complications in the form of superficial infection in two patients and mild pain around thread entry point in seven patients.

Conclusion

Modified thread technique for the treatment of wrist ganglion is a minimally invasive, low cost, day care procedure which can give reasonably good results with a very low complication rate.

1. Introduction

A ganglion is a benign tumor like cystic lesion. Although ganglion cysts may occur at any joint, they are most commonly encountered around the hand and wrist. They are commonly seen during the third to fifth decade of life and are more common in females.¹ The exact cause of ganglion is still unclear and multiple theories have been proposed to explain its causation.^2,3

The usual presenting symptoms and indication for excision include palpable mass, aching in the wrist, tenderness, pain with activity, weakness of grip and radiation of pain up the forearm.⁴

Spontaneous resolution has been reported in fifty to sixty percent of patients, usually within 2 years.³ Aspiration of the contents is the most common intervention but it has a reported recurrence of up to fifty percent.^5,6 To improve upon the results of aspiration, various adjuncts have been used like intralesional steroids, hyaluronidase, sclerosants etc. but the reported literature shows variable recurrence rates.7, 8, 9, 10, 11, 12 Surgical excision is the gold standard treatment for ganglion in terms of recurrence rates.^3,4 However surgical excision has its own share of complications like wound healing problems such as infection, neuroma or keloid formation and the presence of a scar. Other reported complications include scapho-lunate dissociation, joint stiffness, damage to the terminal branches of the posterior interosseous nerve and decreased grip strength along with the risks associated with the use of general anaesthesia and upper limb tourniquet.^3,13

Gang et al. introduced the technique of treating ganglion by passing a silk thread to induce chronic inflammation leading to obliteration of the cyst. They reported a cure rate of ninety five percent,¹⁴ which was comparable to the results obtained with surgical excision. However this technique has not been widely adopted due to concerns of infection. We conducted this study to evaluate whether slight modification to the “Thread technique” can yield good results without the risk of infection associated with the original technique.

2. Material & methods

A prospective study was conducted on one hundred and sixteen patients with wrist ganglion presenting to the orthopaedic out-patient department of our tertiary care institute. Compound palmar ganglion, ganglion less than 5 mm in size, infected ganglion and patients who had taken previous treatment in any form were excluded from the study. Patients were explained about the technique and informed consent was taken. The study duration was from April 2018 to March 2020.

The study group consisted of sixty eight females and forty eight males. The youngest patient was twelve years old and oldest was fifty-eight years old with an average age at presentation of thirty one years. Duration of symptoms ranged from one month to three years (average - five months). The swelling was located on the dorsal aspect of the wrist in eighty-two patients and volarly in thirty four patients. Size of the ganglion ranged from eight to 28 mm (average - 20 mm).

Presenting complaints were - painless swelling in seventy nine patients, dull aching pain in twenty one patients, pain on activity in twelve patients and radiating pain up to forearm in four patients. None of the patients complained of weakness of grip or pressure symptoms over surrounding nerves.

2.2. Operative technique

The patients were operated in the outpatient department as a day care procedure. After cleaning the wrist with povidine iodine and isopropyl alcohol, the wrist was flexed/extended to make the ganglion prominent. The cyst was stabilised and a sterile silk/linen thread on a cutting needle was passed through the cyst and taken out from the opposite side(Fig. 1, Fig. 2). The thread gets a glistening appearance as it comes out because of the mucin content, which confirms its passage through the cyst. The contents of ganglion were expressed out by firm pressure(Fig. 3). After completely emptying the cyst of its contents (Fig. 4), a sterile gauze piece was placed over the ganglion and the thread was tied over it by making a single loop(Fig. 5). Care was taken to avoid puckering of the skin. A pressure bandage was applied. Patients were strictly instructed not to take any antibiotics or anti-inflammatory medication till the next follow up visit. Patients were allowed to take only oral paracetamol tablets in case of persistent pain. The patients were asked to follow up after three days. During follow up visit, the gauze piece was removed, gentle pressure was given over the ganglion site and entry point of the thread into the ganglion was inspected for appearance of yellowish discharge. The thread was removed if there was visible discharge at the entry site(Fig. 6, Fig. 7). Swab was taken from the discharge and sent for microbial culture. The remaining contents of the cyst if any were expressed out and sterile dressing was reapplied. If no discharge was seen, patient was again followed up after two days for wound inspection. Thread was removed on the seventh day irrespective of presence or absence of yellowish discharge. Patients were prescribed oral antibiotics for a period of five days after thread removal. All patients were allowed to do their routine work. Patients were followed up on the fifth day after thread removal and the entry points were inspected for any signs of infection. Patients were then followed at monthly intervals for first three months and for final follow-up at six months.

Fig. 1.

Pre-operative clinical photograph showing volar wrist ganglion.

Fig. 2.

Intra-operative clinical photograph showing thread on a cutting needle being passed through the ganglion.

Fig. 3.

Mucinous ganglion contents expressed out.

Fig. 4.

Ganglion contents completely evacuated by firm pressure.

Fig. 5.

Thread tied in a single loop over a sterile gauze piece.

Fig. 6.

Yellowish sero-sanginous discharge from thread entry points.

Fig. 7.

Clinical photograph after thread removal.

3. Observations & results

Out of the one hundred and sixteen patients who underwent the procedure, eight were lost to follow-up and were excluded from the study. Thus one hundred and eight patients (seventy six with dorsal ganglion and thirty two with volar ganglion) with minimum follow up of six months were available for final analysis.

Complete evacuation of the contents of the ganglion was possible only in eighty eight patients and twenty patients had some residual swelling at the end of the procedure.

Thread was removed after visualisation of yellowish discharge at entry site on day three in eighteen patients, day five in seventy four patients and day seven in twelve patients. Four patients did not show any discharge even at day seven, but of these three patients had redness around the entry point. Culture of swabs taken from the discharge revealed growth of staphylococcus epidermidis in two patients. This resolved with oral antibiotics and none of the patients had persistent infection around the entry points. None of the other patients showed any microbial growth in their swab cultures.

There was recurrence in four patients with dorsal wrist ganglion and in six patients with volar wrist ganglion giving an overall recurrence rate of nine percent. Recurrence was not seen in any of the patients in whom complete evacuation of the ganglion contents was achieved (Fig. 8). Of the twenty patients in whom complete evacuation was not achieved, ten patients had persistence of small residual swelling for which they did not seek any further intervention, while ten patients had recurrence of the swelling. Recurrence was seen between six to sixteen weeks post-procedure. Of the four patients who did not show discharge from entry site even at day seven, recurrence was seen only in the one patient who did not have redness at the entry point.

Fig. 8.

Long term follow up, clinical photographs of few patients treated with modified thread technique.

Of the ninety eight patients who did not have recurrence, seven patients had mild pain around the thread entry point, which resolved by four to six weeks. None of the patients had any restriction of wrist range of motion as compared to their pre-operative status.

4. Discussion

Ganglions are the most common cystic tumors around the wrist and hand. The most common site of a ganglion cyst is the dorsal aspect of wrist (sixty to seventy percent). Thirteen to twenty percent are seen on the volar aspect and flexor tendon sheath in the hand accounts for approximately 10% of ganglion cysts. Occurrence in other joints as well as intraosseus and intratendinous ganglia are much less common.³

Wrist ganglions are usually 1–2 cm cystic, firm structures that are well tethered in place by their attachment to the underlying joint capsule or tendon sheath. Ganglion cysts are not considered true cysts because they lack a cellular epithelial lining, seen in synovial tissue or adventitial bursa. Ganglion cysts contain a clear viscous jelly-like mucinous material made of up of glucosamine, albumen, globulin & high concentration of hyaluronic acid.³

The exact cause of origin of ganglion is still not clear and multiple theories have been proposed. One theory suggests that chronic joint stress leads to capsular rent leading to leakage of synovial fluid into peri-articular tissue. As per another theory, joint stress leads to mucoid degeneration of extra-articular connective tissue. Yet another theory suggests that joint stress may stimulate mucin secretion by mesenchymal cells in the surrounding tissue. Ultimately, there is coalescence of small pools of mucin to form the ganglion cyst.³

Most wrist ganglions are asymptomatic and patients consult their treating doctors mostly for cosmetic reasons. A few present due to fear that the swelling may be a malignant growth and less than thirty percent patients may experience symptoms like aching in the wrist, pain with activity or palpation of the mass, decreased range of motion and decrease grip strength.¹⁵ Volar ganglion may also cause paresthesias from compression of the ulnar or median nerves or their branches.

The treatment of ganglion varies from reassurance to complete excision, the most ancient being bursting the ganglion with a heavy book (traditionally “the Bible”). If left untreated, spontaneous resolution has been reported in up to fifty eight percent of patients. Therefore reassurance can be the option if the patient does not want any intervention.¹³

Aspiration of the contents of the ganglion is the most commonly practiced intervention, but has a high recurrence rate of around sixty to seventy percent.^5,6 Various adjuncts have been used to attempt to reduce the recurrence rate after aspiration. Results of aspiration with instillation of steroid injection has been found to be no better than aspiration alone.⁷ Aspiration with multiple puncture of ganglion wall with or without immobilisation has also been tried but with a recurrence rate of fifty seven to seventy one percent.⁸ Multiple aspirations up to three times have shown to reduce the recurrence rate but the success rate drops with each subsequent aspiration.⁹ Instillation of injection hyaluronidase prior to aspiration of the contents has been proposed to reduce the viscosity of the cyst material leading to better evacuation and lower recurrence. However the success rate reported varies from ninety-five percent to thirty three percent in different papers.^10,11 Sclerosants were also tried but have been now abandoned due to fear of risk of injury to the joint and overlying tendons.¹²

The recurrence rate after simple surgical excision of ganglion cyst is quite high and many authors have reported recurrence rates up to thirty to forty percent.^16,17 The results of surgical excision were greatly improved after Angelides and Wallace introduced the concept of radical excision in which the ganglion was excised along with its stalk and a portion of the underlying joint capsule. They reported a success rate of ninety nine percent with this technique.⁴ Clay and Clement also reported a success rate of ninety seven percent with radical excision.¹⁸ The extremely low recurrence rate achieved by these two group of authors can also be attributed to the fact that the patients were operated by highly trained hand surgeons and subsequent studies by other authors haven’t been able to match the excellent results achieved by these two authors.^19,20 Arthroscopic excision of dorsal wrist ganglion was first described by Osterman and Raphael in 1995. The potential advantages of arthroscopic excision being, a minimal scar, ability to evaluate and address any intraarticular pathology of the radiocarpal or mid carpal joints and complete excision of the stalk leading to a low recurrence.²¹ However, a prospective randomised study in 2008 found that the results of arthroscopic excision were comparable and not superior to open excision.²² With refinement of surgical technique in future, arthroscopic treatment may yield superior results than open excision.

Although surgical excision remains the gold standard treatment of ganglion in terms of recurrence rates, it has been shown that the complication rates after surgical excision are significantly higher than that after aspiration.²³ Commonly reported complications include wound infection, neuroma formation and hypertrophic scar.¹³ Other reported complications include residual pain, scapho-lunate instability,¹⁸ joint stiffness,^4,24 damage to the terminal branches of the posterior interosseous nerve and decreased grip strength.¹⁸ Serious complications like median nerve and radial artery damage have also been reported in few papers.24, 25, 26

Gang et al. introduced the thread technique for treatment of ganglion in late 1980s. They passed a 2-0 mersilk through the substance of the ganglion in a criss cross manner. The contents of the ganglion were expressed out completely by firm pressure. The thread was tied over a sterile gauze piece to form two loose loops. The dressing was changed every week and the thread was removed after three weeks. They reported a cure rate of ninety-five percent with this technique. However they reported microbial growth in culture swabs of seven of the sixty two patients.¹⁴ This may be the result of keeping the thread inside the ganglion for a prolonged period of three weeks.

In the present study, we have used a modified method of the thread technique. Instead of two loops we are using only one loop of the thread around the gauze piece, so that needle needs to be passed only once, minimising pain to the patient. Patient is strictly advised not to take any anti-inflammatory medications or antibiotics to allow low-grade inflammation to set in, leading to formation of yellowish serosanginous fluid at the entry point of thread into the cyst. We feel that the purpose of the thread is to incite a foreign body reaction and hence once inflammation sets in there is no advantage of keeping the thread for a longer period. The thread is hence removed and patient put on oral antibiotics to prevent secondary bacterial infection of the cyst. Early removal of the thread is probably the reason why majority of our patients’s swabs did not show any microbial growth on culture. Also none of our patients showed any clinical signs of infection post-procedure. The aseptic inflammation caused due to the foreign body reaction heals by fibrosis, thus obliterating the cyst cavity and prevents recurrence in a majority of patients.

Since arthographic studies have shown that there is a communication between the ganglion cyst and the wrist joint, there has been a concern in few papers that the inflammation caused due to thread technique may lead to spread of infection into the joint.³ These concerns are unfounded as it has been shown by the cystogram studies of Andren and Aiken that the communication between the joint and cyst is one way and the dye does not travel from the cyst to the joint. A one way valve system has been postulated to explain this phenomenon.²⁷ Also unlike Gang’s technique, where the thread was retained for three weeks, we removed the thread early and this probably reduced the possibility of infection.

This technique has a lot of advantages. It can be done as an outpatient procedure without need for any anaesthesia, hence cuts down on the expenses as compared to surgical excision. There is no scar. As the thread is removed early, the risk of persistent infection is minimised. Unlike surgical excision where post operative time lost from work has been reported to be up to two weeks on an average,³ patients can continue to work even with the thread in situ. Also, none of the patients reported wrist stiffness post procedure.

Expulsion of the entire contents of the ganglion is crucial to the success of this technique, as this allows the cyst cavity to collapse and get obliterated in due course due to ensuing fibrosis. This is very evident from the high recurrence rate in our initial patients in which we could not achieve complete evacuation.

Although we achieved a success rate of ninety one percent, our study has a few limitations. There is no comparative group. The minimum follow up period was 6 months and a longer follow up might give better idea as to late recurrences if any.

5. Conclusion

The modified thread technique is a minimally invasive treatment modality for the treatment of wrist ganglion. It gives reasonably good results with a very low complication rate, is cost effective and can be easily done by the average orthopaedic surgeon with minimum resources.

CRediT authorship contribution statement

Sumedh Chaudhary: Conceptualization, Methodology, Formal analysis, Writing - original draft, Writing - review & editing. Sourav Mandal: Investigation, Data curation. Vikram Kumar: Investigation.

Declaration of competing interest

None.