To Compare Thread Technique Versus Aspiration Plus Steroid Injection of Wrist Ganglion in Terms of Frequency of Recurrence
Phase: PHASE1
Conditions: Ganglion Cyst
Sponsor: Benazir Bhutto Hospital, Rawalpindi

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TITLE PAGE 
Official Title: To compare thread technique versus aspiration plus steroid injection of wrist 
ganglion in terms of frequency of recurrence. 
Date of document: 31 January 2021 
 
 

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ABSTRACT 
Background: Ganglion is one the most common wrist soft tissue tumors and treatment strategies are 
aiming to reduce the frequency of recurrence. 
Objectives: To compare the recurrence of wrist ganglion following thread technique versus aspiration 
plus steroid injection. 
Study design: Randomized controlled trial 
Place and duration of study: Department of Surgery. HIT Hospital, Taxila from June 2020 to December 
2020. 
Materials and Methods: Sixty patients were randomized into two equal groups A and B after clinical 
diagnosis of wrist ganglion. Informed written consent was obtained after informing all pros and cons 
of the procedure. The thread technique was done in group A while in group B methyl prednisolone 
acetate 40 mg/ml was injected after aspiration. The patients were followed 2 weeks, 6 weeks, 3 months, 
and 6 months. The clinical examination was done to see the possible recurrence. 
Results: The mean age of the participants was 29.30 ± 6.0 years. Mean duration of ganglia was 19.33 
± 8.35 months. The location of ganglia was 37 (61.7%) dorsal and 23 (38.3%) volar. The male to female 
ratio was 22 (36.7%): 38 (63.3%). Collectively, the frequency of recurrence was 6 (10%), 10 (16.7%), 
12 (20%) and 16 (26.7%) at 2 weeks, 6 weeks, 3 months, and 8 months respectively. 
There was no difference between groups A and B in terms of age, gender, location, and duration of 
disease (p values 0.401, 0.592, 0.791, 0.783 respectively). The frequency of recurrence was 
significantly different among groups at and 6 months i.e. 12 (40.0%) in group A versus 4 (13.3%) in 
group B (p value 0.020). 

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Conclusion: The thread technique of wrist ganglia is superior to steroid injection in terms of recurrence. 
The RCTs with larger sample size and prolonged follow-up would provide more insight into this 
subject. 
Key words: Cyst, Ganglion, Thread technique, Wrist swelling, 

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INTRODUCTION 
Ganglia is the commonest cause of referral for upper extremity soft tissue tumors. More than 50% of 
referrals belong to this category. Ganglion originated from joint capsule or tendon sheaths. The most 
common site is wrist followed by the vicinity of interphalangeal joints. The dorsal ganglia mostly 
originate from scapho-lunate interosseous ligament while volar may arise from radio-scaphoid joint or 
scapho-trapezial joint.1, 2 The most common presentation is painless lump at abovementioned areas. 
The pain may arise when the ganglia exert pressure effects during movements. The diagnosis is clinical 
in most cases and additional laboratory, or radiological investigations are often not helpful.2, 3  
The treatment of ganglia is mainly sought out due to pain or cosmetic reasons. Management is tailored 
accordingly ranging from simple reassurance to surgical excision with in between options of aspiration 
with and without steroid injection, hyaluronidase injection and thread or seton insertion. The surgical 
excision may be orthoscopic as well.4, 5 The aspiration and steroid injection may be cost effective but 
is associated with skin pigmentation, atrophic changes, and increased chances of recurrence.6 Surgical 
excision is associated with operative cost, infections and possible chances of nerve, tendon, or joint 
damage. The thread technique has been seen in some early research but to some extent has been ignored 
irrespective of the fact that it is cost effective and has comparable outcomes. The recurrence is common 
with all the current procedures.7, 8 A study by Zangana, M. and K. Dizaye found that recurrence of 4% 
was observed in threading technique while 43% in aspiration plus steroid injection (p <0.001).9 
We conducted this study to determine the frequency of recurrence of wrist ganglia between threading 
technique and aspiration plus steroid injection. Both these procedures are being practiced as outpatient 
procedures in our setup. There is paucity in local and international literature regarding this specific 
subject. The result of our study would provide us with better insight into this subject and will leave us 
with a better choice to treat wrist ganglia.  

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METHODS AND MATERIALS 
This randomized controlled trial was conducted at HIT hospital Taxila from January 2020 to June 2020 
for period of one year with clinical diagnosis of wrist ganglion. This study was conducted in accordance 
with ethical standards and principles. Institutional Review Board (IRB) or Ethics Committee approval 
was obtained prior to the commencement of the research (Reference number: ERC/19/15(b). Informed 
consent was acquired from all participants involved in the study. The research was conducted with 
respect for participant privacy, confidentiality, and autonomy. The trial was registered on 
clinicaltrails.gov (NCT). The sample size of 60 patients (30 in each group) was calculated by taking 
recurrence rates of 4% and 43% for threading technique and aspiration plus steroid injection 
respectively from a study.9 The level of significance was 5% and power of test was 90%. The age range 
of 18 to 50 years from both gender groups with clinical and radiological diagnosis of wrist ganglion 
was included. Patients with history of previous invasive treatments, compound ganglion, diabetes 
mellitus, bleeding diathesis, immunosuppression or rheumatoid arthritis were excluded from the study. 
The sampling technique was consecutive non-probability. Randomization of patients was done into 
two equal groups by computer generated numbers. In group A, the aspiration of ganglion was done by 
18G needle attached to a 10 ml syringe. After full aspiration, methylprednisolone (40 mg/ml) was 
injected into the cavity. In group B, the silk suture size 1 was passed horizontally through the ganglion 
and tied over sterile gauze. The evacuation of mucinous contents was done manually, and patients were 
instructed to do manual massage three times daily for 7 days.  The thread was removed after 2 weeks 
or when only serosanguinous discharge was observed at the entry points of thread. Both procedures 
were done with full aseptic measures and under local anesthesia of 1% lignocaine. The patients were 
followed in OPD after 2 weeks, 6 weeks, 3 months, and 6 months. The recurrence was noted down on 
specially designed proforma for study. 

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The data was analyzed by Statistical Package for Social Science (SPSS) version 25 registered for 
Microsoft windows. The quantitative variables like age and duration of disease were expressed by 
mean and standard deviation. The qualitative variables like gender and recurrence at follow up visits 
were expressed as frequency and proportions. Both groups A and B were compared among each other 
in terms of recurrence at 2 week, 6 weeks, 3 months, and 6 months by Chi Square test. P value of <0.05 
was considered statistically significant. 
 

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RESULTS 
We aimed at our target sample size of 60 patients (30 in each group). The total patients selected were 
73 out of which 13 lost follow up. The mean age of the participants was 29.30 ± 6.0 years. Mean 
duration of symptoms was 19.33 ± 8.35 months. The location of ganglia was 37 (61.7%) dorsal and 23 
(38.3%) volar. The male to female ratio was 22 (36.7%): 38 (63.3%). Collectively, the frequency of 
recurrence was 6 (10%), 10 (16.7%), 12 (20%) and 16 (26.7%) at 2 weeks, 6 weeks, 3 months, and 8 
months respectively. 
There was no difference between groups A and B in terms of age, gender, location, and duration of 
disease (p values 0.401, 0.592, 0.791, 0.783 respectively, Table I).  The frequency of recurrence 
changed over subsequent follow up visits.    The frequency of recurrence was significantly different 
among groups at 6 weeks and 6 months (p values 0.038 and 0.020, Table II).  The recurrence was 
different at 2 weeks and 3 months’ time but fell below the required level of significance (p values 0.085 
and 0.053 respectively).  There was no difference gender and location groups in terms of recurrence at 
six months (p value 0.936 and 0.603).

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DISCUSSION 
Ganglion cysts are synovial cysts which are filled with mucinous contents. These are most common in 
upper extremity.  The diagnosis is mainly clinical with few clinical signs like Tadpole sign. 
Occasionally radiological evaluation is required. The exact etiology is unknown but microtrauma 
leading to mucinous degeneration is considered responsible for it. Female gender is more prone to have 
ganglia as well as patients with wrist hyperlaxity. About 60-70% of the ganglion cysts are found in 
dorsal wrist area.10, 11 Dorsal ganglia are commonly located superficial to scapholunate ligament while 
dorsal cysts are located between the radial artery and flexor carpi radialis.12 Main reasons to seek 
medical attention is pain, tenderness, and cosmetic concerns. Both surgical and non-surgical options 
are available, but pros and cons should be clearly explained to patients.2, 13 
Simple reassurance is enough for some patients as 58% ganglion cysts resolve spontaneously over 
time. The symptomatic treatment is enough for some patients. Aspiration alone of wrist ganglia has 
high frequency of recurrence and injection of steroids after aspiration improved outcomes. The results 
in difference studies are variable after steroid injection.10, 14 The recurrence in my study was 40% after 
steroid injection. The difference may arise since in our study we used 18G single needle to aspirate and 
inject while above study used double 18G lines i.e. distal for aspiration and proximal for injection. 
The surgical excision has been traditionally advocated due to increased patient’s satisfaction and 
decreased frequency on recurrence in short and long term follow up as compared to aspiration alone or 
with steroid injection. Cluts, L. M. and J. R. Fowler had recurrence of 3.8% after surgical excision in 
a short term follow up. The recurrence is associated with surgeon’s expertise and male gender.8 A study 
with long term follow up of 5 years showed that recurrence after surgical excision may reach up to 8%. 
The location of ganglion has no impact on the recurrence. The surgical excision has some concerns 
over it due to the proximity of neurovascular elements in excision of volar ganglia.15 The surgery of 

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dorsal ganglia is prone to develop unsightly scar that’s provide the opportunity of arthroscopic 
procedures to get in.16 
A study by Zangana, M. and K. Dizaye compared thread technique with traditional methods for 
treatment of wrist ganglia. With a sample size of 785 patients with dorsal ganglia, three methods i.e. 
surgical excision, aspiration and steroid injection, thread technique were compared among each other. 
At the end of six months, recurrence of 24%, 43% and 4% was noted in surgical excision, aspiration 
plus steroid injection and thread technique respectively.9 A recent study by Chaudhary, S., et al. (2021) 
on thread technique demonstrated that after six months of follow up, the recurrence rate was 9%. Most 
of the patients were satisfied and the procedure was almost painless without any significant 
complications. The technique was a bit modified in this study as the silk suture was passed over a sterile 
gauze to keep the entry and exit sites of silk relatively wide enough to permit early flow of thick 
mucinous contents. The recurrence was observed in cases in which the evacuation of entire contents 
was not possible.7 Another recent study found the recurrence after threading technique as 3.8%.4 The 
study by Saeed, B., et al. included a total sample of 204 patients, with mean age of 29.26 ± 8.16 years. 
Dorsal wrist ganglions accounted for 160 cases (78.43%), whereas volar ganglions were identified in 
44 cases (21.57%). The mean duration of symptoms was 10.07 ± 3.74 months. Recurrence rates showed 
no significant difference between the groups, with threading group recording 7 recurrences (4.35%) 
and surgical excision group 2 recurrences (4.65%) (p = 0.931).17 The use of thread other than silk have 
been studied also which show similar recurrence rates as compared to silk e.g., nylon showed 6.6% 
recurrence rate.18 A prospective study evaluated 30 patients with dorsal wrist ganglia larger than 5 mm 
treated at the General Surgery outpatient department of Government Hospital Sarwal, Jammu, India. 
The mean age of the patients was 44.29 ± 2.59 years, with the majority being female, and the primary 

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reason for intervention was cosmesis. The study achieved a cure rate of 93.3%, with a recurrence rate 
of 6.7% (2 cases).19 
My study targeted a sample size of 60 patients, with 30 in each group. A total of 73 patients were 
initially selected, but 13 were lost to follow-up. The mean age of participants was 29.30 ± 6.0 years, 
and the average symptom duration was 19.33 ± 8.35 months. Ganglia were located dorsally in 61.7% 
of cases (37 patients) and volarly in 38.3% (23 patients), with a male-to-female ratio of 36.7% to 63.3%. 
Recurrence rates were 10% at 2 weeks, 16.7% at 6 weeks, 20% at 3 months, and 26.7% at 8 months. 
The recurrence rates differed significantly between groups at 6 weeks (p = 0.038) and 6 months (p = 
0.020). While differences at 2 weeks and 3 months were noted, they were not statistically significant 
(p = 0.085 and 0.053, respectively). Gender and location showed no association with recurrence at six 
months (p = 0.936 and 0.603). Shakya et al. describe the "Triple Technique," a new outpatient 
procedure for treating dorsal wrist ganglions, which combines aspiration, steroid injection, and trans 
fixation with silk suture for 3 weeks. The study included 83 patients with a mean age of 31.7 ± 12.4 
years with overall success rate of 95.2%. The Triple Technique is an effective and safe method, with a 
recurrence rate of less than 5% at 2 years.20 
 
 
 
 
 

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CONCLUSION 
The threading technique of wrist ganglia is superior to steroid injection in terms of recurrence rate in 
short term follow up. The RCTs with larger sample size and prolonged follow-up would provide more 
insight into this subject.  
 
 

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TABLES 
 
 
 
 
Parameter 
Group A 
(Steroid group) 
(n=30) 
Group B 
(Thread group) 
(n=30) 
P value 
Age (years) 
29.83 ± 6.21 
28.37 ± 7.17 
0.401* 
Gender (M/F) 
10/20 
12/18 
0.592† 
Location 
(Dorsal/Volar) 
19/11 
18/12 
0.791† 
Duration of 
symptoms 
(months) 
19.03 ± 8.10 
19.63 ± 8.73 
0.783* 
 
Table I. Age, gender, and duration among groups 
 
 
 
 
* Independent sample t test 
 
† Chi square test 

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Frequency of 
recurrence 
Group A 
(Steroid group) 
(n=30) 
Group B 
(Thread group) 
(n=30) 
P value‡ 
After 2 weeks 
5 (16.7%) 
1 (3.3%) 
0.085 
After 6 weeks 
8 (26.7%) 
2 (6.7%) 
0.038 
After 3 months 
9 (30.0%) 
3 (10.0%) 
0.053 
After 6 months 
12 (40.0%) 
4 (13.3%) 
0.020 
Table II. Recurrence among groups 
 
 
 
‡ Chi square test 

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REFERENCES 
 
1. 
Federer AE, Yoo M, Stephens AS, Nelson RE, Steadman JN, Tyser AR, Kazmers NH. 
Minimizing Costs for Dorsal Wrist Ganglion Treatment: A Cost-Minimization Analysis. J Hand 
Surg Am. 2023;48(1):9-18 10.1016/j.jhsa.2022.09.002: 
http://doi.org/[10.1016/j.jhsa.2022.09.002]. 
2. 
Gregush RE, Habusta SF. Ganglion Cyst.  StatPearls. Treasure Island (FL): StatPearls 
Publishing 
Copyright © 2021, StatPearls Publishing LLC.; 2025. 
3. 
Craik JD, Walsh SP. Patient outcomes following wrist ganglion excision surgery. J Hand 
Surg Eur Vol. 2012;37(7):673-7 10.1177/1753193411434376: 
http://doi.org/[10.1177/1753193411434376]. 
4. 
Kumar P, Giroti C, Dhobal A, Singh AR. Management of ganglion by double loop suture 
technique. Asian J Med Sci. 2023;14(2):188-91. 
5. 
Koehl P, Rueth MJ, Sesselmann S, Necula R, Mada L, Schuh A. [Wrist ganglion]. MMW 
Fortschr Med. 2023;165(2):56-7 10.1007/s15006-022-2131-1: http://doi.org/[10.1007/s15006-
022-2131-1]. 
6. 
Hamlin K, Haddon A, Khan Y, Miller C, Lawrie D. Dorsal Wrist Ganglion: Pilot for 
Randomized Control Trial Comparing Aspiration Alone or Combined with Injection of Platelet-
Rich Plasma. J Wrist Surg. 2023;12(1):18-22 10.1055/s-0042-1744367: 
http://doi.org/[10.1055/s-0042-1744367]. 
7. 
Chaudhary S, Mandal S, Kumar V. Results of modified thread technique for the treatment 
of wrist ganglion. J Clin Orthop Trauma. 2021;13:57-62 10.1016/j.jcot.2020.08.018: 
http://doi.org/[10.1016/j.jcot.2020.08.018]. 
8. 
Cluts LM, Fowler JR. Factors Impacting Recurrence Rate After Open Ganglion Cyst 
Excision. Hand (N Y). 2022;17(2):261-5 10.1177/1558944720921477: 
http://doi.org/[10.1177/1558944720921477]. 
9. 
Zangana AM, Dizaye KF. A New Method in the Management of Wrist Ganglion ( Silk 
Thread Passed through the Ganglion ) in Comparison with Other Traditional Methods. World 
Family Medicine Journal/Middle East Journal of Family Medicine. 2016;14(1):15-20 
10.5742/mewfm.2015.92791: http://doi.org/[10.5742/mewfm.2015.92791]. 
10. 
Ahmad Shah A, Raina AH, Ganie MA, Kumar IA. Comparison of Aspiration Followed 
by Intra-Lesional Steroid Injection and Surgical Excision in Management of Dorsal Wrist 
Ganglion. World J Plast Surg. 2019;8(2):181-4 10.29252/wjps.8.2.181: 
http://doi.org/[10.29252/wjps.8.2.181]. 

15 
 
11. 
Bram JT, Falk DP, Chang B, Ty JM, Lin IC, Fazal FZ, Shah AS. Clinical Presentation 
and Characteristics of Hand and Wrist Ganglion Cysts in Children. J Hand Surg Am. 
2021;46(12):1122 e1- e9 10.1016/j.jhsa.2021.02.026: http://doi.org/[10.1016/j.jhsa.2021.02.026]. 
12. 
Zhang A, Falkowski AL, Jacobson JA, Kim SM, Koh SH, Gaetke-Udager K. Sonography 
of Wrist Ganglion Cysts: Which Location Is Most Common? J Ultrasound Med. 
2019;38(8):2155-60 10.1002/jum.14912: http://doi.org/[10.1002/jum.14912]. 
13. 
Lyon C, Eldred SV, Desanto K. What is the best treatment for wrist ganglion cysts? J 
Fam Pract. 2020;69(1):E23-E4. 
14. 
Horvath A, Zsidai B, Konaporshi S, Svantesson E, Hamrin Senorski E, Samuelsson K, 
Zeba N. Treatment of Primary Dorsal Wrist Ganglion-A Systematic Review. J Wrist Surg. 
2023;12(2):177-90 10.1055/s-0042-1753542: http://doi.org/[10.1055/s-0042-1753542]. 
15. 
Kulinski S, Gutkowska O, Mizia S, Martynkiewicz J, Gosk J. Dorsal and volar wrist 
ganglions: The results of surgical treatment. Adv Clin Exp Med. 2019;28(1):95-102 
10.17219/acem/81202: http://doi.org/[10.17219/acem/81202]. 
16. 
Shanks C, Schaeffer T, Falk DP, Nunziato C, Hogarth DA, Bauer AS, et al. The Efficacy 
of Nonsurgical and Surgical Interventions in the Treatment of Pediatric Wrist Ganglion Cysts. J 
Hand Surg Am. 2022;47(4):341-7 10.1016/j.jhsa.2021.12.005: 
http://doi.org/[10.1016/j.jhsa.2021.12.005]. 
17. 
Saeed B, Ullah JS, Aziz M, Shahid M, Siraj AS, Tariq SR. Comparison of Recurrence 
Rate of Wrist Ganglion Between Seton and Open Surgical Excision in Military Hospitals of 
Pakistan. Pak Armed Forces Med J 2023;73(1):50-3. 
18. 
Thapa P, Lakhey RB. Successful Outcome of Transfixation Technique with Linen in 
Dorsal Wrist Ganglion: A Descriptive Cross-sectional Study. JNMA J Nepal Med Assoc. 
2021;59(243):1150-4 10.31729/jnma.6574: http://doi.org/[10.31729/jnma.6574]. 
19. 
Kour R, Sharma G, Kour G, Gupta K, Sharma R. Determine the results of treatment of 
dorsal wrist ganglia by using the transfixation technique: an observational study. JK Practitioner. 
2021;26(3). 
20. 
Shakya A, Garje V, Rathore A. The triple technique: A simple and effective outpatient 
procedure for the dorsal wrist ganglion. J Clin Orthop Trauma. 2021;23:101619 
10.1016/j.jcot.2021.101619: http://doi.org/[10.1016/j.jcot.2021.101619]. 
 
 
 

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CONSENT FORM 
Project Title 
To compare thread technique versus aspiration plus steroid injection of 
wrist ganglion in terms of frequency of recurrence 
Principal investigator 
Dr. Abdul Basit 
Research team contact 
+923002166598 
Importance of study / 
purpose of study 
The study intends to know to better technique to reduce the recurrence of 
wrist ganglion. 
Description of study 
Methodology will be explained verbally 
Confidentiality 
Names, contact information or any other personal information of the 
patients will be held in strict confidentiality. The results will be reported in 
aggregate form only, and will not be identified individually 
Authorization 
 
I, ------------------- W/O ----------------- ID NO----------------------------------------- -hereby fully agree 
to contribute to the above-mentioned study and future related studies on these sample I was given 
ample time to think and discuss the study  I understand that this study is designed to add  to the 
medical knowledge I have been informed about the nature of the procedure and the possible risk (s) 
discomfort(s) involved I had the opportunity to ask any questions about the study and I agree to  give 
my consent as requested by Dr. Abdul Basit (the researcher). 
 
I have also been informed about my explicit right to withdraw from the study at any time if I want 
to  
 
I have no objection in case the data obtained from me and my investigations (s) is published in a 
research journal maintaining confidentiality. 
 
I have also been conveyed that my participation / non-participation will not affect my treatment (if 
applicable)   
Patients’ name: 
Signature: 
Researcher name: 
Signature: