Abstract
Background
Dorsal ganglia are the most common types of wrist ganglia. Though largely asymptomatic, they can cause pain, stiffness and require treatment. The different methods described for the management have high recurrence rates even up to 70%. We describe a new method which combines 3 of these methods thus aiming to achieve the best from each of the techniques.
Methods
A prospective observational study was undertaken to include patients requiring surgery for dorsal ganglion. The method involved a combination of aspiration, steroid instillation and tranfixation with silk suture for 3 weeks. Various demographic parameters, operative variables and functional criteria like QuickDASH Score and Numerical Pain Rating scale (NPRS) were used. The patients were followed up for atleast 24 months. Overall satisfaction rate was also recorded.
Results
83 patients were included with a mean age of 31.7 ± 12.4 years. The mean duration of surgery was 12.0 ± 4.9 min and follow up was 29.8 ± 7.1 months. 15 patients had complex multilobulated ganglia. The most common indication for surgery was cosmesis. 4 complications were encountered of which 2 were superficial infections, 1 whitish discoloration locally and 1 case of persistent pain. We achieved a success rate of 95.2% with only 4 recurrences with a mean reduction in size to be 82.2 ± 5.8%. NPRS and QuickDASH scores improved significantly. Mean satisfaction rate was 89% and 84.3% wished to have the surgery again for a similar complaint. The loss of work was 2.5 ± 1.4 days.
Conclusions
Triple Technique is an effective and safe technique with <5% recurrence at 2 years.
Keywords: Ganglion, Dorsal, Transfixation, Steroid, Recurrence, QuickDASH
1. Introduction
Ganglia are one of the most common presentations in the surgical and orthopaedic hand and wrist out-patient departments accounting for 50–70% cases of the swellings and tumorous lesions.1, 2, 3 They are cystic, benign fluid filled lesions which originate from the tendon sheath, joint capsule or even vessel walls.4,5 Carpal ganglia are most commonly found on the dorsal aspect accounting for around 70%.5 They usually remain asymptomatic and usually present once they develop pain, discharge or cosmetic concern. Ganglia present most commonly between the third and sixth decades of life with more prevalence in the females but may also arise in the paediatric age group.1,2,5,6
The etiology remains uncertain to the present day with the most common notion being the leakage and collection of fluid in the sheath with the constitution of the fluid being similar to that of joints and tendon sheaths. Even more debatable is the management.5,7,8 Asymptomatic lesions are almost uniformly conserved but the problem arises with the symptomatic lesions. A number of methods have been described with high rates of recurrence observed uniformly. The most surgical common methods are aspiration with or without steroid injection, surgical excision including those done arthroscopically and silk suture placement.7, 9, 8, 10, 11, 12 While surgical excision and aspiration have been widely described, suture placement is less widely practiced.
Gold standard as per the present-day literature is arthroscopic removal of the ganglion. Though the method boasts of impressive outcomes, the requirement of a specialized set of instruments is a pre-requisite for the same. This concern has made it out of reach of a number of surgeons, especially those practicing in developing countries and remote areas. This, along with the variable recurrence rates of the other methods has prompted the search for a method that deals with the above concerns while giving efficient results.13 Moreover, wrist arthroscopy has been shown to be associated with post-operative ganglion formation in wrists operated for other causes thereby raising doubts over the overall efficacy in long-term recurrence rates by a de novo ganglion formation.14 Further, a procedure that could be performed as an out-patient procedure with an equal efficacy is highly desirable especially in a setup with already strained facilities. So, in order to try and find a solution, the study was designed which combined three relatively simple techniques.
We present our study of “Triple Technique” for dorsal carpal ganglia with aspiration, steroid injection and trans-fixation with silk suture with regular manipulation of the suture and milking of the ganglion cavity.
2. Methodology
A prospective study was conducted in the Department of Orthopedics at ESIC Hospital, Mumbai from September 2017 to March 2019 after the approval of the local Ethics Committee. The patients aged 18 years to 60 years who had a dorsal ganglion measuring at least 5 mm in the largest diameter and not intervened upon earlier were to be included in the study. All the patients presenting to the out-patient department willing to get a surgery were counselled about the study and the objectives, design and other relevant details of the study and those willing were enrolled in the study and a written informed consent document signed. Diagnostic ultrasonography (USG) was done in all cases prior to the procedure and the findings noted and documented. Ganglions associated with the septic conditions, skin changes and patients having rheumatological conditions and immune-compromised conditions were excluded from the study (Table 1). The size of the swelling was measured by taking the mean of two measurements perpendicular to each other using a Vernier caliper with minimum calibrations of 1 mm. The days of work lost were also recorded.
Table 1.
Inclusion and exclusion criteria.
| Inclusion Criteria | Exclusion Criteria |
|---|---|
| Age 18–60 years | Previous history of intervention for the ganglion |
| Patients willing for intervention | Septic and skin changes associated with the ganglion |
| Size of ganglion at least 5 mm | Co-presence of rheumatological diseases |
| Follow-up of at least 2 years | Immunocompromised patients |
The primary endpoint was considered to be no recurrence at the end of 2 years. A recurrence was defined as either a residual swelling greater than 5 mm or having a diameter greater than 50% of the initial swelling at the end of 2 years. The size of the swelling was recorded in the case record form at each follow-up visit. The pain was monitored by the Numerical Pain Rating Scale (NPRS) ranging from 0 to 10 with 10 being the highest pain and 0 being no pain. The functional outcome was measured by asking the patients to fill the Quick-Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire preoperatively and at 1 week, 1 month, 6 months, 1 year and 2 years postoperatively with a higher score reflecting a severe functional impairment.
The patients were also asked of the overall satisfaction rate at the end of 2 years with a scale ranging from 0 to 10 with 0 representing completely unsatisfied and 10 representing completely satisfied. Whether in hindsight the patient would liked to have the procedure again for the same pathology was also asked and noted at the end of 2 years. Any complications arising during the treatment duration were also mentioned in the case record form. The range of motion was also recorded pre-operatively and at 3 months, 6 months, 1 year and 2 years for both the wrists.
The surgical method is described as following that was followed for all the patients.
2.1. Surgical technique (TRIPLE TECHNIQUE)
2.1.1. Materials
Xylocaine 2% without adrenaline, Disposable 24/23G needle, 18G IV cannula, 10 cc sterile syringe, Silk 1–0 (Ethicon), Inj. Triamcinolone acetonide 2 ml (80 mg).
2.1.2. Steps
The procedure was done on an out-patient basis (Fig. 1, Fig. 2). Under all aseptic precautions and after a single prophylactic intravenous antibiotic dose, area surrounding the lesion was infiltrated with xylocaine 2%. A sterile silk suture (1–0) was passed through the cyst and taken out from the opposite side (Fig. 1-b). 24/23G needle was passed in the cyst cavity perpendicular to the silk suture (Fig. 1-c). It was followed by an 18 G IV cannula insertion in cyst cavity in an opposite direction to the 24/23G needle and perpendicular to silk suture (Fig. 1-d). The contents of the cyst were aspirated (Fig. 1-e) from the 18G IV cannula. After the aspiration of contents 2ml/80 mg triamcinolone acetonide was injected into the cavity via the already placed 24/23G needle. The thread was then tied over the cyst over a sterile gauze piece to retain it (Fig. 1-f). Sterile roller bandage was then applied over the gauze piece.
Fig. 1.
Image depicting the steps of the Triple Technique.
A. Dorsal ganglion over the wrist
B. Silk thread passed through the swelling. Note the glistening covering as the thread exits the swelling
C. 24/23G needle passed in the cyst cavity perpendicular to the silk suture through which steroid will be instilled after aspiration
D. An 18
G IV cannula insertion in the cyst cavity in a direction opposite to the 24/23G needle and perpendicular to silk suture through which the contents are aspirated followed by steroid injection through the 24/23G needle
E. Contents aspirated which shows the gel like viscous and thick liquid
F. The silk thread tied over a sterile gauze on the cyst.
Fig. 2.
Image depicting the steps and the condition at final follow up in a 28 year old female
A. Silk suture passed through the ganglion cyst
B. A hypodermic needle introduced into the cyst cavity
C. Insertion of an IV canula for aspiration
D. Follow up at 2 years shows no recurrence.
Patient was allowed to go home with clear instructions regarding regular movement of the wrist joint and weekly follow-up till 3 weeks for manipulation of silk suture and removal of the same upon completion of the third week. Follow up was taken at 1, 3, 6 months, 1 year and finally at 2-year post-procedure.
2.2. Statistical analysis
Statistical analysis was performed using IBM SPSS Software version 26. Normality was tested using the Kolmogorov-Smirnov test. For descriptive analysis, mean and standard deviation was used. For quantitative continuous data, Wilcoxon Signed-Rank test was used as the data was not normally distributed. For categorical data, Chi Square test was used. All tests were performed at a significance level of p < 0.05.
3. Results
We performed the Triple Technique procedure on 86 patients out of which 3 patients lost to follow up over the span of study duration. Study included the rest 83 patients out of which 58 were females and 25 males. The mean age of the patients was 31.7 ± 12.4 years (range 18–59 years). The mean follow-up duration was 29.8 ± 7.1 months (range 24–41months). 5 patients had history of diabetes mellitus, 8 had hypothyroidism and 12 patients had history of hypertension. The mean duration of the swelling was 8.2 ± 3.4 months (range 5 months–15 months). (Table 2).
Table 2.
Preoperative and demographic variables.
| Variable | Value | |
|---|---|---|
| Gender | Male | 25 |
| Female | 58 | |
| Age (years) | Mean ± Standard Deviation | 31.7 ± 12.4 |
| Comorbidities | Hypertension | 12 |
| Diabetes Mellitus | 5 | |
| Hypothyroidism | 8 | |
| Duration of symptoms (months) | Mean ± Standard Deviation | 8.2 ± 3.4 |
| Reason for Surgery | Cosmesis | 59 |
| Pain | 16 | |
| Stiffness | 8 | |
| Nature of Ganglion | Simple | 68 |
| Complex | 15 | |
| Side | Right | 48 |
| Left | 35 | |
| Size on clinical measurement (in mm) | Mean ± Standard Deviation | 9.1 ± 2.9 |
| Size on ultrasonographic Measurement (in mm) |
Mean ± Standard Deviation | 9.5 ± 3.2 |
The mean diameter of the ganglion was 9.1 ± 2.9 mm (range 6 mm–24 mm) on clinical examination and 9.5 ± 3.2 mm (range 6 mm–25 mm) on the ultrasonographic examination. Of the 83 patients, 68 had a simple non-lobulated swelling and 15 had complex multilobulated swellings. The dominant hand was involved in 59 cases and 24 had a non-dominant hand involvement. Indications for surgery included cosmesis (59), pain (16) and stiffness with subjective interference in activity (8). The time taken for the procedure was between 7 min and 17 min with a mean of 12.0 ± 4.9 min.
With regards to the complications witnessed, 2 patients had a local infection at 1 week and 12 days post-operatively, both of which were managed with dressings and oral antibiotics. 1 patient developed a whitish patch on the injection site of the steroid which was not bothersome to the patient and had healed at 6-month follow-up. One patient complained of persistent pain following the procedure. None of the patients experienced a decrease in the range of motion of the wrist and it was similar in both the wrists (±10° of each other).
We could achieve a success rate of 95.2% with only 4 patients reporting recurrences. The mean reduction in size was 82.2 ± 5.8% (range 60%–100%) with 56 reporting complete resolution at the end of 1 year. 2.5 ± 1.4 days of work were lost. (range 1–7 days) (Table 3). The NPRS improved from a preoperative score of 3.4 ± 1.7 (range 0–6) to 1.3 ± 0.9 (range 0–3) which was significant as per the Wilcoxon Signed-Rank Test (p < 0.05) (Fig. 3). The mean QuickDASH score decreased significantly from 12.5 ± 4.3 to 6.5 ± 2.4 (p < 0.05, Wilcoxon Signed-Rank Test) (Fig. 4). Of the 4 recurrences, only 1 underwent repeat surgery for the swelling and the rest 3 accepted the residual swelling. Among the recurrences, 3 had preoperative complex multilobulated ganglion cysts and 1 had a simple cyst. In terms of complexity of cysts, simple cysts attained a successful outcome in 98.5% cases and complex multilobulated in 80% of the cases. (p < 0.05, Chi-Square test). The mean satisfaction rate was 8.9 ± 1.4 with 61 patients giving a score of complete satisfaction. (range 4–10). On asked if in hindsight, they would like to have the surgery again for the pathology 70 (84.3%) were affirmative, 5 (6.0%) did not wish to have the surgery and 6 (7.2%) could not decide.
Table 3.
Operative and Outcome variables.
| Variable | Total | |
|---|---|---|
| Recurrence | Yes | 4 |
| No | 79 | |
| Reduction in size (in%) | Mean ± Standard Deviation | 82.2 ± 5.8 |
| Satisfaction Rate (Out of 10) | Mean ± Standard Deviation | 8.9 ± 1.4 |
| Willingness to be operated upon again | Yes | 70 |
| No | 5 | |
| Not decided | 6 | |
| Operative time (in minutes) | Mean ± Standard Deviation | 12.0 ± 4.9 |
| Days of work lost (days) | Mean ± Standard Deviation | 2.5 ± 1.4 |
Fig. 3.
Numerical Pain Rating Scale (NPRS) taken at preoperative and various postoperative follow up periods
A constant fall is seen over the duration of 1 year with the final score significantly better than the preoperative score. (p < 0.05, Wilcoxon Signed-Rank Test).
Fig. 4.
Quick-Disabilities of the Arm, Shoulder and Hand (QuickDASH) score taken at preoperative and various postoperative follow up periods
A constant fall is seen over the duration of 1 year with the final score significantly better than the preoperative score. (p < 0.05, Wilcoxon Signed-Rank Test).
4. Discussion
Dorsal ganglia are the most common form of ganglia presenting for evaluation. There is no universal management protocol for the symptomatic ones and it varies from institute to institute and even surgeon to surgeon. The reason behind it being the high rates of recurrences with almost all the present modes of treatment. Though arthroscopic excision and open surgical excision remain the most commonly used with nearly identical outcomes, a number of less invasive procedures have been described like aspiration with or without steroid/sclerosant injection and suture transfixation.8,13, 14, 15, 16
The recurrence rate with open surgical excision varies from 6% to 42% with the probable reason being incomplete excision or leftover remnant.13,14,17,18 Another factor is the suture line and scar complications with Lidder at al reporting 34.6% patients reporting moderate to severe scar tenderness and 3.4% complaining of poor scar cosmesis.19 Though open excision remained the gold standard for a long time, the advent of arthroscopy of the wrist has overtaken it in terms of better recurrence rates. Arthroscopic dorsal ganglion removal is associated with recurrence rate of about 0–26%.20, 21, 22 The need for specialized instrumentation and a dedicated arthroscopy setup leads to a lesser widespread use of the same. Also, the lack of theatre time and the preference given to the more serious and debilitating hand conditions make this option less favourable.
The drawbacks of both these methods of excision make one search for other methods to both enable management with lesser resources and time and at the same time maintaining a lower recurrence rate and a decent functional outcome. With this regard, traditionally described techniques like aspiration and steroid injection do not hold much promise. While the recurrence rate with aspiration alone varies from 15% to 67%, the same with an injection of steroid is 8.4%–83%.5,23 The probable causes of failure are the viability of the cavity which can get either fully refilled over time or develop a new and sometimes complex swelling. To potentiate the action of this treatment modality, the injection of a sclerosant in order to obliterate the cavity has also been attempted and described.15,24 The recurrence rate still remained around 35% in both the studies even after the addition of the sclerosant. Further, it carries the danger of inadvertent injection into a critical structure like an artery or the joint.
Another method is the transfixation method that uses the phenomenon of foreign body reaction leading to fibrosis and the resultant obliteration of the cyst cavity. The success rate varied from 71% to 95%.2,7,16,25
Here we describe the Triple Technique comprising of aspiration, instillation of a steroid and silk suture application with regular manipulation. In comparison with other methods, the recurrence rate observed was 4.8%.
The probable mechanism of action is the sum of the three different constituents of the technique. The aspiration empties the cyst cavity thus creating a void lined by the cyst wall having a potential space. The steroid acts by its direct action on the mesenchymal cells lining the cyst and inhibits their secretory action thus decreasing the fluid production.23 Triamcinolone acetonide has proven to be an effective drug for local instillation with its better safety profile, longer action, easy availability and lower cost and hence was chosen. The silk suture was selected because of its tendency to cause more severe fibrotic reaction as compared to others.26 It is due to the formation of bacterial plaques and surface debris leading to an intense foreign body reaction. It was further augmented by regular manipulation which caused a further inflammatory reaction surrounding the suture by harboring dermal bacteria.7,25 Thus the convergence of three processes i.e. creation of a void, suppression of fluid production and gradual obliteration of the cavity by fibrosis created a well healed, obliterated lesion with no further fluid accumulation. The direct action of steroid causing a decrease in the fluid production while also decreasing the local inflammation probably does not last long enough to offset the inflammatory process produced by the silk thread even after its removal at three weeks. This is probably why the three processes act synergistically thereby causing a better resolution of the swelling.
Our prospective triple technique study of 83 cases showed cure rate of 95.2% and recurrence rate of 4.8% which was comparable and even better than most of the other studies employing either a single or a combination of different techniques. As the wrist joint itself is not violated with this technique which might happen with surgical excision, the wrist function and range of motion is not compromised. The complication rate was 4.8% in our study and they were not serious enough to warrant further invasive treatment and resolved conservatively. The complication rate ranged between 0% and 30% with higher rates seen in the open surgical excision cohort as described in the literature.8 The rate of infection in our study was 2.4% as compared to 10% obtained by Gang et al.25 The post-operative pain remaining in some patients could be explained by the development of Complex Regional Pain Syndrome 2 or damage to some nerve fibres of the posterior interosseous nerve.7,22
The mean age of presentation was comparable to that in the published literature. We could also find a female preponderance as seen in the other studies. The mean procedure time of 12 min and mean days of work lost of 2.5 days meant a relatively fast and early rehabilitation with no extra load on the operation theatres. An overall satisfaction rate of 89% was seen and 84.3% of the patients were happy with their management in retrospect.
Our study is limited by a small sample size and a shorter duration of follow-up. We plan to follow up the cohort of patients for at least 5 years. A multi-centre randomized comparative study with a larger sample size to evaluate the efficacy of the method with those already described in the literature may help in further evaluating the efficacy of the method.
5. Conclusion
Dorsal wrist ganglion management is aimed at complete resolution, with no recurrence and negligible complications. Different types of modalities have their respective pros and cons. We propose the triple technique for its cost effectiveness, time efficiency, minimally-invasive day care attribute, a low rate of recurrence and a better cosmetic outcome. Complication profile associated with the procedure is minimal to negligible. A high satisfaction rate close to 90% and 82.2% reduction in size of the swelling is a testament to the above facts.
Ethical approval
This study was approved by our institutional review board.
Statement of human and animal rights
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.
Statement of informed consent
Informed consent was obtained from all individual participants included in the study.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Declaration of competing interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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