O R I G I N A L CO N T R I B U T I O N / C L I N I C A L I N V E S T I G AT I O N
A new method in the management of wrist ganglion
(Silk thread passed through the ganglion); in comparison
with other traditional methods
Abdulqadir M. Zangana (1)
Kawa F. Dizaye (2)
(1) Professor of Surgery, CABS-FICS-MD, Head of Department of surgery, Consultant Surgeon,
College of Medicine, Hawler Medical University, Iraq.
(2) Professor of Pharmacology, HD, MSc, PhD, Head of department of Pharmacology College of
Medicine, Hawler Medical University, Iraq.
Correspondence:
Dr. Kawa Dizaye
Professor of Pharmacology, HD, MSc, PhD,
Head of department of Pharmacology College of Medicine,
Hawler Medical University, Iraq.
Tel: 009647504452392
Email: doctorkawa@gmail.com
Abstract
Objectives: To compare a new method of ganglion
management, eficacy of resolution, frequency of
complications and recurrence of managing dorsal
wrist ganglions with aspiration followed by intracystic injection of Methylprednisolone and surgical
excision and our new procedure Silk thread passed
through the ganglion.
Study Design : A prospective descriptive study.
Place and Duration of Study: This is a prospective
study conducted at the Department of Surgery Erbil
Teaching Hospital-Erbil, Kurdistan Region of Iraq
from April 2005 to June 2014.
Patients and Methods: A total of 785 patients were
included in this study,120 cases were excluded from
the study because they were lost to follow-up. All
patients were thoroughly examined to exclude the
other causes of wrist swelling. The patients were
divided into three groups A, B &C according to
their choice of treatment. Group A were treated by
surgical excision, Group B were treated by aspiration
followed by steroid injection and group C by Silk
thread passed through the ganglion. Baseline Data
were recorded preoperatively and postoperative
data were obtained at the intervals of 2 weeks,
6 weeks, 3 months, and 6 months. At the end of 6
months the data form was completed and results
analyzed.
Results: Patient’s satisfaction was higher in Group
C after Silk thread passed through the ganglion
followed by surgical excision even if the ganglions
recurred. The recurrence rate was 4 % in Silk thread
passed and 24% surgical excision group and 43%
in aspiration with steroid injection in group B.
Conclusion: In this study Silk thread passed
through the ganglion had better results compared to
surgical excision and to aspiration and injection of
Methylprednisolone.
Key words: Dorsal, Wrist Ganglion, Silk thread
passed through the ganglion, surgical excision,
aspiration, Methylprednisolone injection.
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Introduction
Ganglia are the most common benign soft tissue tumors
of the hand. They represent 50% to 70% of all soft tissue
tumors of the hand, and in some series, the percentage is
even higher (1).
These soft murine-illed cysts are usually attached to the
adjacent underlying joint capsule or tendon sheath (2).
The cyst expands in size and the luid cannot low freely
back into the synovial cavity. Dorsal wrist represents 70%
of all ganglion and volar writ ganglion up to 20 %.(3)
Dorsal ganglion cyst originates from the scapholunate
joint, often with direct attachment to the scapholunate
interosseous ligament (ISLIL) (4).
The ganglions usually appear spontaneously without
any particular cause; pain associated is dull aching pain
and severity is not related to the size of ganglions. The
diagnosis of the ordinary wrist ganglion should rarely be
in doubt when the mass is in typical site and has the usual
size, shape and consistency, though other serious entities
may simulate wrist ganglion (5).
Different treatment modalities for wrist ganglions have
been described in literature ranging from observation
reassurance, digital pressure rupture with mallet,
aspiration with or without different agents, subcutaneous
tenetomy dissection and cross ixation with heavy sutures
to orthoscopic resection and surgical excision (6).
Surgical excision of wrist ganglia has been reported to have
the best success rates in terms of recurrence; for example
Angelides and Wallace in1976 reported a 99% success
rate (7). However, the treatment is relatively expensive
and can only be offered reliably in a specialist hand
center. The complications associated with the treatment by
surgical excision are recurrence, infection, wound healing,
neuromas, joint stiffness and decreased grip strength.
Aspiration and injection of steroid has higher recurrence
rate, but other complications are much lower than that of
surgical excision (8).
This prospective study was conducted to ind out whether
aspiration and injection of ganglion with Methylprednisolone
was effective as surgical excision and Silk thread passed
in a cross manner.
Patients and Methods
Seven hundred and eighty ive patients were included
from the outpatient department of surgery Erbil Teaching
Hospital, Erbil, Kurdistan Region of Iraq from April 2005
to June 2014. All patients were thoroughly examined by
the attending physician to exclude the other causes of
dorsal wrist swelling. All 785 patients were informed about
the three treatment modalities and they were divided into
three groups A, B and C according to their options. Group
16
A comprised 163 patients treated by surgical excision and
155 formed Group B and were dealt with by aspiration
and Methylprednisolone: 20-40 mg injections and 464
formed Group C dealt with Silk thread passed in a cross
manner (Figure 1).
There was no sex or age limit. Those patients who were
operated on or aspirated in the past were excluded
from this study. Blood test including blood CP, ESR, RA
factor and X-Rays wrist joint AP and Lateral view were
performed in all cases.
In Group A surgical excision was performed under
General Anaesthesia. Pneumatic tourniquet was applied
in most cases. The incision used respected the skin
creases and was long enough to give satisfactory
exposure of the skin lesion. Attempt was made to
exercise a generous capsular margin about its base
and joint capsule was left open and cauterized. One
shot of I.V 3rd generation Cephalosporin was given at
time of induction followed by 3 doses of oral antibiotics
postoperatively. Prior to wound closure tourniquet was
released, hemostasis secured and the wound was
closed with prolene. Patients were called for follow up on
the 2nd week, 6th week, and 3,6 month; indings were
documented. The patients in Group B and C were in OPD
in supine position with wrist lexed on a towel. The area
was prepared and draped.
Syringe (10ml) with 18 gauge needle was inserted in the
center of the ganglion; gelatinous content was aspirated
and demonstrated to the patient. Syringe was removed
leaving needle in place. 1.5ml local anesthetic injection
Xylocaine and 40 mg of methylprednisolone was injected.
In group C, no.1 silk on cutting needle was inserted in
the ganglion horizontally from side to side; a ring of silk
created gelatinous content was evacuated by gentle
digital pressure on the ganglion xylocaine lubricant was
applied on the silk ring and the patient advised to rotate
the silk ring and apply gentle digital pressure on the
ganglion 3 times\day for 7 days .
Patients were asked to follow up at the OPD and 2
weeks, 6 weeks, and 6 months indings were documented
and results were analyzed.
Technique of new in cross manner:
Under aseptic measures, a silk No.1 on a curved needle
passed through the ganglion (Figure 1) and aspiration
of the jelly like transparent material was performed by
applying pressure on the ganglion with the thumb jelly
material comes out at both sides of the needle puncture
and silk ixed as a Ring. After complete evacuation a
crepe bandaging was applied over the wrist (Figures
1, 2, 3, 4 ) On the second day after procedure the irst
dressing was removed and patients start to rotate the
silk in both directions with applying local digital pressure
and antibiotic ointment. Silk was removed on the 12th
day. In this procedure no anesthesia was used during the
procedure all patients were followed up every month for
an initial 3 months and at 6 months interval for one year.
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Figure 1: dorsal wrist ganglion classical site
Figure 2: Insertion of needle through the ganglion after application of topical anesthesia under aseptic
condition
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Figure 3: Farther advancement in the process of needle insertion creating a ring in the silk
Figure 4: The procedure has been completed
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Results
Table 1: Resolution of pain at different intervals
Table 2: Wrist stiffness in both groups at different intervals
During the study period from April 2005 to June 2014,785
patients with dorsal wrist ganglion were included in this
study 532 patients were female and 253 were male.
Patient’s age ranged from 18-38 years, mean age was 25
years. In this study 120 patients were lost during follow up
leaving 665 patients.
One hundred and twenty three patients in group A , 115
patients in group B and 427 in group C were available for
follow up at 6 month. Complete resolution of pain in group
A, B & group C at different follow up intervals are shown
in Table 1.
Stiffness of wrist was observed in all 3 groups which
improved at different intervals in group A. In group B
stiffness increased in late follow up probably because of
more recurrence and completely improved in the irst month
shown in Table 2. At the end of six month recurrence rate
was 24% (29 patients) in group A as compared to group B
where 43 % (49 patients) presented with recurrence while
recurrence rate in group C was 4%(17) . There were four
cases of supericial infection in group A which responded to
antibiotics and dressing. There was one case of change in
skin color in group B, and 8 cases with supericial infection
in group C.
Discussion
A ganglion in a musculoskeletal system is spherical
accumulation of luid produced from an adjacent joint
capsule or tendon sheath. It’s not a neoplasm because it is
a cellular, and it’s not a cyst because the collection of clear
viscous luid is contained in the cavity, which is not lined by
epithelium(1). Dorsal wrist ganglion is the most common
non-tumorous swelling of the wrist (2, 5, 6).
This prospective clinical trial compared the treatment
of ganglion by either aspiration and steroid injection
or surgical excision and Silk thread passed through the
ganglion. Different treatment methods for wrist ganglion are
reassurance, rupture, and aspiration with or without different
agents, surgical excision and arthroscopic resection (7, 9).
Explanation of the benign nature of ganglion and natural
history that it may luctuate in size over time can relieve
the fear of malignancy (10). Results of different treatment
methods reported literature are variable. There is general
impression that Silk thread passed in through the ganglion
offers excellent result comparing with open excision and
aspiration with or without different agents, probably on the
basis of Angelides and Wallace’s (2006) study reporting 1
% recurrence rating (11) Clay and Clement (2008) have
also shown low recurrence rate of 3 % (12), while other
studies reported higher recurrence rate (7, 13).
Regarding open excision, McEvedy (1999) reported 40 %
recurrence rate (14), Jacobs and Govaers (2006) reported
28 % and Dias et al (2007) 39 % recurrence rate (3,
15). We had a recurrence rate of 24 % in our study. The
variability in results to some extent seems to be surgeons
dependent. Recurrence rate after aspiration and injection
of different agents are higher and least with Silk thread
passed through the ganglion. Gerhard et al reported 85
% recurrence rate after hyaluronidase injection aspiration.
McEvedy (1999) reported 80 % recurrence rate after
sclerosant (14). Derbyshire (1966) reported 60-85%
recurrence rate after aspiration and injection of steroid
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(16). We have low recurrence of 43 % after aspiration and
injection of methylprednisolone compared to other studies.
Arthroscopic resection of ganglion of wrist originally
described by Osterman and Raphael (1995) is technically
dificult and demanding (17). Different series of arthroscopic
resection wrist ganglion have shown promising results. We
did not have any signiicant complication.
Reviewing the literature and with our results it seems Silk
thread passed through the ganglion has better results in
comparison with other methods of treatment and is an
acceptable option in our setup.
Conclusion
In this study we have concluded that recurrence rate,
postoperative joint stiffness and pain resolution was least
in a new method technique comparing with other classical
surgical and non-surgical groups. Further studies with
more patients are needed to elucidate the clinical impact
of Silk thread passed in cross manner in the management
of wrist ganglion.
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12- Clay NR, Clement DA,The treatment of dorsal wrist
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13- Singhal R, Angmo N, Gupta S, Kumar V, Mehtani
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