|Year : 2022 | Volume
| Issue : 2 | Page : 64-68
Comparative study between aspiration followed by Intralesional triamcinolone Injection, mixture of triamcinolone and hyaluronidase and surgical excision for the treatment of forearm ganglion in a medical college hospital
Yaqoob Hassan1, Ajaz Ahmad Rather1, Javid Ahmad Peer2
1 Department of General and Minimal Access Surgery, SKIMS Medical College, Srinagar, Jammu and Kashmir, India
2 Department of General and Minimal Access Surgery, Government Medical College, Srinagar, Jammu and Kashmir, India
|Date of Submission||19-Sep-2022|
|Date of Acceptance||27-Oct-2022|
|Date of Web Publication||10-Jan-2023|
Dr. Yaqoob Hassan
Assistant Professor, Department of Surgery, JN Medical College, AMU, Aligarh, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Ganglionic cysts are benign tumors of forearm commonly encountered in our day-to-day outdoor practice. This study compares the efficacy, safety, and recurrence rates of triamcinolone, a triamcinolone hyaluronidase mixture, and surgical excision for the treatment of forearm ganglion in a medical college hospital. Materials and Methods: This prospective comparative study was carried out at the SKIMS, Medical College, Hospital, over a period of 3 years. Between January 2018 and January 2021, 96 subjects with forearm ganglion were included and treated in three groups – Group A included patients who had aspiration and injection of triamcinolone; Group B patients had aspiration and injection of mixture of triamcinolone and hyaluronidase; and Group C patients underwent excision under anesthesia. The data were collected and analyzed using SPSS software 22. Results: Among 96 patients who met the inclusion criteria, the mean age was 35.74 years, with a male: female ratio of 0.63. The swelling was the most common clinical presentation recorded in 100% of patients. Swelling with symptoms such as pain and paresthesia was present in 59.38% of the patients, dissatisfaction with cosmetic appearance in 55.21% of the patients, and 36.46% subjects had apprehension of sinister lesion (malignant tumor). 47.92% of patients had aspiration and injection of triamcinolone (Group A), 43.75% of patients had aspiration and injection of triamcinolone-hyaluronidase mixture (Group B), and 8.33% of patients underwent surgical excision (Group C). The difference in recurrence rate was significantly lower in the Group B patients (15.22%) than in the Group A patients (2.38%) (P ≤ 0.05). We observed 100% success rate after surgical excision. No major postprocedure complications occurred in any of the patients. Conclusion: Aspiration and intracystic instillation of a triamcinolone-hyaluronidase mixture is a simple, effective, and safe treatment for ganglion with low recurrence rates. Following an unsuccessful primary therapy of aspiration and injection, surgical excision yielded excellent results.
Keywords: Ganglion, hyaluronidase, recurrence, surgical excision, triamcinolone
|How to cite this article:|
Hassan Y, Rather AA, Peer JA. Comparative study between aspiration followed by Intralesional triamcinolone Injection, mixture of triamcinolone and hyaluronidase and surgical excision for the treatment of forearm ganglion in a medical college hospital. Muller J Med Sci Res 2022;13:64-8
|How to cite this URL:|
Hassan Y, Rather AA, Peer JA. Comparative study between aspiration followed by Intralesional triamcinolone Injection, mixture of triamcinolone and hyaluronidase and surgical excision for the treatment of forearm ganglion in a medical college hospital. Muller J Med Sci Res [serial online] 2022 [cited 2023 Jun 2];13:64-8. Available from: https://www.mjmsr.net/text.asp?2022/13/2/64/367414
| Introduction|| |
Ganglionic cysts are smooth, fluctuant swellings that transilluminate brightly and are frequently observed in our general surgery outpatient practice. These are benign soft-tissue tumors representing myxomatous degeneration of the synovial sheath of concerned joint or tendon. These are the most common causes of hand swelling and are most commonly found on the dorsal and volar wrist surfaces. The swelling may occur over the dorsum of the distal interphalangeal joint referred to as a digital mucosal cyst, or at the base of the finger, within flexor tendon sheath, commonly known as seed ganglion. Approximately 88% of ganglionic cysts are found in small joints of the hand and wrist, with the remaining 11% found near the foot and ankle joint. About 60%–70% of ganglionic cysts are found on the dorsal aspect of the wrist near scapholunate joint, 18%–20% on the volar aspect of the wrist arising from the radiocarpal joint or pisotriquetral joint, and 10%–12% from retinaculum of the wrist, distal interphalangeal joint, ankle joint, and foot. The majority of ganglia patients present as an asymptomatic mass that lasts months to years. Some patients may describe swelling that waxes and wanes in size, wrist pain, weakness, and loss of sensation in their hands. Others may present with symptoms of nerve compression such as carpel tunnel syndrome, trigger finger, neuropraxia, or in rare cases ischemia. Clinically, the lesion is smooth, well-circumscribed, slightly mobile, and transilluminating without any overlying skin changes. The treatment is essential in symptomatic cases, unsightly cosmetic appearance, and a history of interference in daily activities. This study compared the efficacy and recurrence rates of triamcinolone, mixture of triamcinolone and hyaluronidase, and surgical excision for the treatment of forearm ganglion at our tertiary care center.
| Materials and Methods|| |
The comparative study was conducted in the Department of General Surgery at SKIMS Medical College, Hospital, from January 2018 to January 2021. The study was approved by the Departmental Academic and Research Committee (Approval Number: SKIMS/MCH/GS/17/399). A total of 96 patients of both the sexes were enrolled in the study. A diagnosis of ganglion was based on history, clinical examination, and fine-needle aspiration cytology reports. Selected patients were advised local radiograph and ultrasonogram to rule out other suspicious lesions. All the patients with forearm ganglion ≥ 1 cm in size and 12–70 years of age were included in the study. Patients with active infection, underlying psychiatric illness, skin and endocrine problems, kidney/liver disease, pregnant and breastfeeding mothers, and immunocompromised patients were excluded from the study.
Before any intervention, the various treatment options were discussed with each patient in their native language, and an informed written consent was obtained. Patients were divided into three groups based on the treatment they received, using computer-generated numbers.
Group A: Aspiration of Cystic Content and Injection of triamcinolone 40 mg alone (Brand name: Kenocort 40 mg injection Abbot Healthcare Pvt. Ltd.).
Group B: Aspiration of Cystic Content and Injection of triamcinolone 40 mg and Hyaluronidase 1500 IU mixture (Brand name: Hynidase 1500 iu Shreya life sciences Pvt. Ltd.)
Group C: Excision under regional anesthesia.
Aspiration and injection in Group A and B patients were performed using single dart method. Under all aseptic precautions, we used a 16-gauge needle to aspirate the cyst content, followed by the instillation of triamcinolone or triamcinolone-hyaluronidase mixture. The needle was removed, and pressure bandage dressing was applied for the next 24–48 h. Group C included patients who developed recurrence after two stings of either Group A or Group B treatments protocols. The surgical excision was performed as a day-care procedure in our minor operation theater under anesthesia.
In the case of a dorsal wrist ganglion, a transverse incision was made and meticulous dissection was performed to expose the pedicle of cyst without rupturing it. In the case of a volar wrist ganglion, great care was taken to avoid any injury to the surrounding vessels or nerves. Due precautions were taken to remove the ganglion at the origin and entire ganglionic complex including stalk and cuff in the adjacent joint capsule. To rule out any recurrence, all subjects were attached to the outpatient department room for follow-up, initially after 2 weeks and then at 6-month intervals for 2 years. The data were collected and analyzed.
The statistical analysis was performed using SPSS software (SPSS version 22, IBM, Armonk, NY, USA). The distribution of continuous variables was evaluated according to the Shapiro–Wilk normality test. If the distribution was normal, Student's t-test was used for statistical analysis; if the distribution was not normal, Mann–Whitney U test was used. The categorical variables were analyzed by Fisher's exact test (two-tailed) or Chi-square. The P value was estimated and a value <0.05 was considered statistically significant. The mean and frequency were calculated using Microsoft Excel 2016.
| Results|| |
A total of 96 patients were recruited in our study. The youngest patient was a 12-year-old boy and the oldest was a 66-year-old woman. Females (61.46%) outnumbered males (38.54%) with a male:female ratio of 0.63. The mean age in the study population was 35.74 years. The most number of subjects were in the age group of 31–40 years (32.29%) followed by 21–30 years (28.13%), 41–50 years (26.04%), 12–20 years (6.25%), 51–60 years (5.21%), and 61–70 years (2.08%). The right side was more frequently involved (70.83%) than the left side (29.17%). There were no significant differences in age, gender, and site of the ganglion among the three groups [Table 1].
Swelling was the most common clinical presentation in the study which was recorded in 100% of the patients. Swelling with symptoms such as pain and paresthesia was present in 59.38% of subjects, unsightly appearance and cosmetic issues were present in 55.21% and 36.46% of subjects had apprehension of sinister lesion (malignant tumor). 18.75% of subjects reported a previous history of local trauma. None of our patients experienced symptoms of gross nerve or vessel compression such as carpel tunnel syndrome, trigger finger, or ischemia.
About 47.92% of patients had aspiration and injection of triamcinolone (Group A), 43.75% had aspiration and injection of mixture of triamcinolone and hyaluronidase (Group B), and 8.33% of patients underwent surgical excision under anesthesia (Group C). Over a period of 2 years, 15.22% of patients had a recurrence in Group A, while only 2.38% of patients developed recurrence in Group B. None of our subjects experienced recurrence after surgical excision. There was significantly positive relationship between the Group A and Group B treatment protocols and recurrence rates (P ≤ 0.05) [Table 2].
Except for minor pain, none of our patients in Groups A or B experienced any major post-procedure complications. Complications observed in Group C patients included moderate pain, restricted wrist movement, and stiffness for a few days following surgery. All the patients responded well to oral NSAID's (Non-steroidal Anti inflammatory Drug). During the procedure, none of our subjects suffered any nerve or vessel damage.
| Discussion|| |
Ganglion cysts are widely recognized benign tumors commonly observed in conjunction with joints and tendons. These are smooth, firm, fluctuant, mobile, highly transilluminate swellings caused by myxomatous degeneration of fibrous tissue of the capsule, ligaments, and retinacula and consist of an outer fibrous coat and an inner synovial lining. Histologically, ganglia have a thin connective tissue capsule filled with jelly-like gelatinous fluid rich in hyaluronic acid and mucopolysaccharides. A ganglionic cyst usually develops on its own and can affect anyone at any age, but it affects women three times more frequently than men. Some patients may report a history of previous trauma around the concerned joint. Ganglionic cysts can occur within the muscle, minici, tendons, and bones, however, they are most commonly (70%–80%) encountered in relation to the wrist and hand. After a thorough patient history, the diagnosis of ganglion can be made clinically as a well-circumscribed swelling firm to the touch and below the surface of the skin around the joints and tendons that transilluminates brightly. Majority of the patients present as a painless mass of months to years of duration. Others may experience pain, paresthesia, tenderness to the touch, wrist stiffness, weakness, or tingling in the affected area and may interfere with the joint's range of motion or unsightly appearance. Most cysts show anechoic to hypoechoic lesions with well-defined margins on ultrasonography, and some may show internal septations as well as acoustic enhancement., It can also help distinguish a cyst from a vascular malformation. Magnetic resonance imaging (used in the diagnosis of occult wrist ganglion) shows the cyst as a unilocular or multilocular fluid-filled mass that appears isointense or hyperintense on T1-weighted images and typically high-signal density on T2-weighted images. The treatment is necessary in symptomatic cases and includes conservative (watchful waiting and observation, reassurance, immobilization of involved joint), semi-invasive (aspiration, aspiration, and injection of sclerosant/steroids), and surgical excision. Due to the benign pathology and spontaneous resolution in half of the subjects, simple watchful waiting, and nonsurgical semi-invasive methods of treatment are initially advised for these lesions., Historically, a cyst bursting with a blow from a heavy object was used with high recurrence rates (book was commonly used and bible appeared to be preferred one so named as Bible cyst). In our study, the majority of patients (32.29%) were in the age group of 31–40 years and the mean age was 35.74 years. Females (61.46%) outnumbered males (38.54%) with a male:female ratio of 0.63. The right side (70.83%) was more frequently involved than the left side (29.17%). The findings were compared with the majority of the published literature.,, According to studies from the British and African populations, females outnumber males by a ratio of 1/1.4 and 1/1.5, respectively.,
Ganglionic cysts have a recurrence rate of 15%–20% and recurrence is the most common complication after treatment., Local steroid instillation arrests the secretions of cystic wall cells and has shown promising results., Hyaluronidase acts by improving the liquefaction of the gelatinous content of the ganglionic cyst., Simple aspiration of the cyst shows recurrence in 65% of patients, surgical removal in 20% of cases, hyaluronidase sclerotherapy has a recurrence rate of 25%, and triamcinolone sclerotherapy recur in 8.4% patients. The study compared the efficacy of various treatment methods for ganglionic cysts. 47.92% of our patients had aspiration and injection of triamcinolone (Group A), 43.75% patients had aspiration and injection of mixture of triamcinolone and hyaluronidase (Group B), and 8.33% patients underwent surgical excision under anesthesia (Group C). Over a period of 2 years, 15.22% of patients had a recurrence in Group A, while as only 2.38% of patient's developed recurrence in Group B. The difference in recurrence rates in Group A and Group B patients was statistically significant. None of our subjects developed recurrence after surgical excision. Because this study was conducted on a small sample size, a long-term randomized study with a larger sample size is required to properly validate these conclusions.
| Conclusion|| |
Aspiration and intracystic instillation of a triamcinolone and hyaluronidase mixture is a simple, effective, and safe treatment for ganglion with a low recurrence rates. In the treatment of ganglion, the combination of triamcinolone and hyaluronidase is superior to triamcinolone alone in terms of recurrence. After primary treatment with aspiration and injection, surgical excision produces an excellent result with only moderate postprocedural pain.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Williams N, Ronan O'Connell P, McCaskie A. Upper Limb. In: Bailey & Love's Short Practice of Surgery. 27th
ed., the Collector's edition. Boca Raton, FL: CRC Press; 2018.
Camasta C. Excision of the Ganglion Cyst. Biology, Medicine. 2012.
Scott WW, William CP, Scott HK, Mark SC. Green I: Green's Operative Hand Surgery. Philadelphia, PA: Elsevier; 2017.
Plate AM, Lee SJ, Steiner G, Posner MA. Tumorlike lesions and benign tumors of the hand and wrist. J Am Acad Orthop Surg 2003;11:129-41.
Beaman FD, Peterson JJ. MR imaging of cysts, ganglia, and bursae about the knee. Radiol Clin North Am 2007;45:969-82, vi.
Trivedi NN, Schreiber JJ, Daluiski A. Blunt force may be an effective treatment for ganglion cysts. HSS J 2016;12:100-4.
Wang G, Jacobson JA, Feng FY, Girish G, Caoili EM, Brandon C. Sonography of wrist ganglion cysts: Variable and noncystic appearances. J Ultrasound Med 2007;26:1323-8.
Teefey SA, Dahiya N, Middleton WD, Gelberman RH, Boyer MI. Ganglia of the hand and wrist: A sonographic analysis. AJR Am J Roentgenol 2008;191:716-20.
Athanasian EA. Bone and soft tissue tumors. In: Scott W. Wolfe, William C. Pederson, Scott H. Kozin, Mark S. Cohen. Green's Operative Hand Surgery. New York: Elsevier Churchill Livingstone; 2011;2:2150-6.
Singhal R, Angmo N, Gupta S, Kumar V, Mehtani A. Ganglion cysts of the wrist: A prospective study of a simple outpatient management. Acta Orthop Belg 2005;71:528-34.
Afridi SP, Rahman HU, Baig N. Use of Seton on ganglion of the wrist. J Surg Pak 2006;11:121-2.
Oztürk K, Esenyel CZ, Demir BB, Sönmez MM, Kara AN. Occult scapholunate ganglion in patients with dorsoradial wrist pain. Acta Orthop Traumatol Turc 2007;41:349-54.
Minotti P, Taras JS. Ganglion cysts of the wrist. J Am Soc Surg Hand 2002;2:102-7.
Nield DV, Evans DM. Aspiration of ganglia. J Hand Surg Br 1986;11:264.
Gang RK, Makhlouf S. Treatment of ganglia by a thread technique. J Hand Surg Br 1988;13:184-6.
Kim JY, Lee J. Considerations in performing open surgical excision of dorsal wrist ganglion cysts. Int Orthop 2016;40:1935-40.
Büchler L, Hosalkar H, Weber M. Arthroscopically assisted removal of intraosseous ganglion cysts of the distal tibia. Clin Orthop Relat Res 2009;467:2925-31.
Varley GW, Needoff M, Davis TR, Clay NR. Conservative management of wrist ganglia. Aspiration versus steroid infiltration. J Hand Surg Br 1997;22:636-7.
Colberg RE, Sánchez CF, Lugo-Vicente H. Aspiration and triamcinolone acetonide injection of wrist synovial cysts in children. J Pediatr Surg 2008;43:2087-90.
Jagers Op Akkerhuis M, Van Der Heijden M, Brink PR. Hyaluronidase versus surgical excision of ganglia: A prospective, randomized clinical trial. J Hand Surg Br 2002;27:256-8.
Paul AS, Sochart DH. Improving the results of ganglion aspiration by the use of hyaluronidase. J Hand Surg Br 1997;22:219-21.
Tanaka Y, Takakura Y, Kumai T, Sugimoto K, Taniguchi A, Hattori K. Sclerotherapy for intractable ganglion cyst of the hallux. Foot Ankle Int 2009;30:128-32.
Westbrook AP, Stephen AB, Oni J, Davis TR. Ganglia: The patient's perception. J Hand Surg Br 2000;25:566-7.
Paramhans D, Nayak D, Mathur RK, Kushwah K. Double dart technique of instillation of triamcinolone in ganglion over the wrist. J Cutan Aesthet Surg 2010;3:29-31.
] [Full text]
[Table 1], [Table 2]