The Treatment of Wrist Ganglion Cyst by the Chinese Acupotomy and Crisscross Thread

Background: The current treatments of wrist ganglion have considerable recurrence rate, we developed a new treatment for ganglion cysts in our clinical practice, which combined acupotomy with crisscross thread method, so we now to compare the clinical effectiveness of Chinese acupotomy and crisscross thread with aspiration followed by injection of steroid and open excision for ganglion cysts treatment. Methods: Recruited patients with wrist ganglion were divided into three groups according to the treatments. Among them, 27 patients who were treated by a new combined treatment of Chinese acupotomy and crisscross thread method in group A, 30 patients who were treated by aspiration followed by steroid injection in group B, and 28 patients who were treated by open excision in group C. The data of age, gender, weight, size of ganglion cysts, visual analogue scale (VAS) , cost were recorded and compared by One-way analysis of variance, followed by an LSD (Least Signicant Difference)test. The recurrence rates were recorded were analysed by chi-square test. Results: At the rst day and one week after treatment, VAS score of group A was similar to group B with no statistic difference. VAS score of group C was higher than group A and B with statistic difference. Six months later, there was no statistic difference among the three groups about VAS. The recurrence rate was 3.7% in group A and 36.7% in group B and 10.7% in group C. No patient infected in three groups. The cost of group A was more than group B with no statistic difference. The cost of group A was much less than group C with statistic difference. Conclusions: The combination of Chinese acupotomy and crisscross thread method was a simple, economical and effective procedure for wrist ganglion cysts.


Background
Ganglion cysts are benign soft tissue masses most commonly encountered in the hand and wrist [1], among which 60%-70% occurred in the dorsal aspect of wrist, communicating with the joint via a pedicle [2]. Ganglion cysts usually originate from scapholunate ligament [3], but several studies have demonstrated that ganglion cysts can arise from a number of other sites over the dorsal wrist capsule [4].
The symptoms of ganglion cysts include pain in the wrist, palpation of the mass, decreased range of motion and decreased grip strength, paraesthesia [5,6] .
The treatment of ganglion cysts often begins with non-surgical management due to the limited morbidity and high potential for spontaneous resolution [7]. As the main non-surgical treatment, aspiration has been shown as an effective method. However, most studies report that its success rate is only 36-51% [8]. To improve the success rate of simple aspirations, numerous adjunctive measures have been developed, including injection of steroid, sclerosant or hyaluronidase after aspiration, and aspiration with multiple punctures [6]. However, lack of success, high recurrence rate and potential side effects have led to general abandonment of these approaches [6,9]. Using blunt force to disrupt the capsule is another treatment of ganglion cysts [1], while its recurrence rate is up to 44.7% [1]. Although surgical excision is the golden standard treatment for ganglion cysts, including open or arthroscopic surgical excision, its surgical trauma, postoperative complications (including unsightly scar) and high cost are the main reasons for patients to refuse surgery [6]. In addition, the recurrence rate of surgical excision varies from 3.8-42% [2,10]. So surgeons still attempt to nd a new treatment for ganglion cysts, with the advantages, including high success rate, low recurrence rate, low cost, safe and less surgery trauma.
Recently, we have developed a new treatment of traditional Chinese medicine for ganglion cysts, which combines Chinese acupotomy (Fig. 1)  For the patients in group A: after the area of ganglion cysts was cleaned with tincture of iodine solution and a localized anesthesia was performed with 0.5% lidocaine. A 1/0 mersilk on a needle (Ethicon) was passed in one direction through the skin and the substance of the ganglion cysts were taken out through the skin on the other side. Another 1/0 mersilk on a needle was passed in the same way, perpendicular to the rst thread. Both threads were cut off from the needle, leaving the silk thread in a crisscross manner ( Fig. 3). A Chinese acupotomy (Fig. 1, Jiangsu Huayou Medical Devices Co., Ltd. China) was inserted directly into the ganglion cysts in multiple direction to puncture the wall (Fig. 4). Adequate pressure and massage on the ganglion cyst continued until the ganglion cyst disappeared. A sterile cotton ball was placed over the ganglion cysts and was xed by the two threads (Fig. 5). After ten days, the cotton ball and threads were removed ( Fig. 6a and b).
For the patients in group B, the localized clean and anesthesia were the same with group A. The ganglion cyst was aspirated with a 18G (Becton Dickinson S.A.) hypodermic needle and a 5 ml syringe. The aspiration was facilitated by milking the ganglion contents towards the needle. After the uid was completely aspirated, 1 ml 20 mg/ml triamcinolone acetonide (Zhejiang Xianju Pharmaceutical Co., Ltd. China) was injected into the ganglion cysts. A sterile gauze dressing was applied with a rm bandage for ten days.
For the patients in group C, the localized clean was the same with group A. The operation was performed under brachial plexus block anesthesia. A tourniquet was applied and in ated during surgery. A transverse skin incision was made over the ganglion cyst. The ganglion cyst was isolated by meticulous dissection, without disrupting the ganglion cyst. The ganglion cyst and its capsular attachments were tangentially excised to avoid damage to the dorsal ligaments. After the incision was closed, a sterile gauze dressing was applied with a rm bandage for ten days.
Outcome measurement Patient demographics data (age, gender, weight, size of ganglion cysts) were recorded. Pain level was assessed using a visual analogue scale (VAS, 0 means no pain while 10 means most severe pain imaginable) and assessments were performed pre-operatively, and at 1 day, 1 week, 6 months after the operation. Recurrence was de ned as reappearance of cyst at the same site being visualized by ultrasound. The secondary outcomes include cost and infection. Wound culture positive was categorized as infection.

Statistical analysis
The data of age, gender, weight, size of ganglion cysts, VAS and cost were compared among three groups by One-way analysis of variance, followed by an LSD (Least Signi cant Difference)test. The recurrence rates were analysed by chi-square test, and continuous correction chi-square values were selected.
Statistical signi cance was de ned as P < 0.05.

Results
From June 2015 to June 2018, 89 patients with ganglion cysts in dorsal aspect of wrist were divided into three groups and received treatment in our hospital. Among these patients, 4 were lost in follow-up. There were 27 patients in Group A included in the nal study and analysis, and 30 in Group B and 28 in Group C.
No differences in demographic data among the three groups were found (Table 1). On the rst day after treatments, VAS score in Group C was higher than Groups A and B (P2 < 0.001; P3 < 0.001, respectively), there was statistic difference, but there was no statistic difference between Groups A and B regarding VAS score (P1 = 0.849). One week after treatment, VAS score in Group C was higher than that of Groups A and B (P2 < 0.001; P3 < 0.001, respectively), there was statistic difference. But there was no statistic difference between Group A and Group B regarding VAS score (P1 = 0.621). Six months after treatment, there was no statistic difference among the three groups in VAS score.
Six months after the treatments, one case in Group A, eleven in Group B and three in Group C had recurrence. The recurrence rate in Group A (3.7%,1/27)was lower than Group B (36.7%,11/30) and Group C(10.7%,3/28). But, there was no statistic difference between Group A and Group C regarding recurrence rate (P2 = 0.630). No patient had infection in the three groups. Regarding cost, the cost of Group A was higher than that of Group B with no statistic difference. Compared with Group C, the cost of Group A was lower, there was statistic difference between two groups. Compared with group C, the cost of group B was lower, there was statistic difference between the two groups( Table 2).

Discussion
Acupotomology originated from traditional Chinese medicine, and gradually absorb modern anatomical theories. It is easily accepted by the patients because it has the advantages of simple operation, no condition limitation, minimal invasive, small damage to the body tissue, rare in inducing infection, low adverse reaction and quick recovery. In clinical practice, acupotomology is usually used for the treatment of chronic soft tissue injury and also suitable for traumatic bursitis, tenosynovitis, and muscle fasciitis. In our hospital, we have cured ganglion cysts with the acupotomy therapy. Our study demonstrates that patients who received the new combined treatment of acupotomy and crisscross thread had pain level similar to the patients who received treatment of aspiration followed by steroid injection, and had less pain than the people who experienced open excision.
There are various treatments being tried out for permanent cure of ganglion cysts, and all these treatments have different recurrence rates. The recurrence rate of blunt force is 44.7% [1], while aspiration 15%-69% [11]. Moreover, a number of techniques have been developed to close the potential space of the empty cysts and to prevent recurrence, including aspiration with multiple punctures of the wall and aspiration with injection of steroid or hyaluronidase. However, the recurrent rate of aspiration with steroid is 14%-83%, aspiration with multiple puncture 49%-78% [6], aspiration with sclerotherapy varying between 10%-35% [12]. The recurrence rate is 36.7% in our research of aspiration with steroid group, it is similar to previous reports. Surgical excision remains the golden standard for treatment of ganglion cysts and it is the choice when conservative treatment fails. In most previous studies, the recurrence rate of surgical excision varies from 3.8-42% [2,10]. One meta-analysis [13]found that open excision had a mean recurrence of 21%, reduced by 76% in recurrence compared with aspiration. The above meta-analysis reported the recurrence of arthroscopic excision was 6% across all studies [13]. Chung [14] found their recurrence of arthroscopic excision was 10%. In our study, the recurrent rate of the open excision was 10.71%, which was consistent with previous studies. But surgical excision is usually accompanied by many complications, including unsightly scar, infection, keloid, radial artery injury and neurapraxia, decreased range of motion, postoperative stiffness, grip weakness [3]. One meta-analysis [13] reported the complication incidence of open excision was 14%, while arthroscopic excision was 4%. In our view, some complications could be avoided by the combined treatment. As a kind of closed lysis between surgery and non-surgery, the acupotomy therapy is a minimally invasive method. It has no incision and its surgical trauma is minor. In our hospital, there was no patient had infection or other complications in any group.
Several other thread techniques was also reported. Rathod [15] introduced the trans xation technique, by which two sterile silk sutures were passed through the cyst at right angles to each other, the content of the cyst were aspirated using a syringe needle, and the threads was tied over the cyst over a sterile gauze rmly. They reported the failure rate was 5%. Mohan [16]described the same thread technique without aspiration of the cyst content, their recurrent rate was 5.56%. Zangana [17]reported another thread technique-when the ganglion content was aspirated, one silk thread was passed through the ganglion horizontally and tied to a silk ring, and the patients were advised to rotate the silk ring and apply gentle digital pressure on the ganglion interval every day. They found the recurrence rate was 4% nally. Compared with previously reported thread techniques, the novel feature of our technique was coalesced with acupotomy, which originated from traditional Chinese medicine. In our study, the recurrent rate of the new combined treatment was 3.7%, which was a little lower than other thread technique. This may be because the lining of the cysts wall was damaged by the multiple punctures of the acupotomy, and a low grade chronic in ammation was caused by the silk thread between cysts walls. What's more, adequate pressure produced by the cotton ball was conducive to closing the potential space of the empty cyst.
There is few report about the cost of the ganglion cysts treatment. One rearch [18]from Stanford University of America showed that the average total cost of an open excision was $1,821± $1,127 ,while an arthroscopic excision was $3,668 ± $872, Surgical costs from arthroscopic ganglion excision are signi cantly higher than open excision. In our hospital, open excision cost was only ¥3061.11 ± 474.72, which was much less than that in America. The new combined treatment cost about ¥ 476.89 ± 40.43, and aspiration with steroid group was ¥ 322.39 ± 60.90. Groups A and B spent much less than Group C so that the nancial burden of patients was reduced greatly.

Conclusions
According to our treatment experience and the existing research analysis, the combination of Chinese acupotomy and crisscross thread method was a simple, economical and effective procedure for wrist ganglion cysts.
The limition of this study was that the number of patients was too small, and more time was needed to observe the long term effects. However, it is worthwhile to explore the value of traditional Chinese medicine and combine modern medical knowledge to treat diseases.