Intraarticular injection of the interphalangeal joint for therapy of digital mucoid cysts.

Mucoid cysts are associated with osteoarthritis (OA) of the digital joints and frequently recur after needle drainage, injection, or surgical ablation. This study determined whether intraarticular injection of the adjacent interphalangeal joint rather than the cyst itself might be effective in resolving digital mucoid cysts. Using paired case series design and sterile technique, 25 consecutive OA digital joints with an adjacent mucoid cyst underwent dorsal non-transtendinous intraarticular injection with a 25-gauge needle and 20-mg triamcinolone acetonide, followed by puncture and manual expression of cyst fluid. Patient pain was measured with the 10-cm Visual Analogue Pain Scale prior to the procedure and at 6 months. Cyst resolution was determined at 6 months and 3 years. The subjects were 61.0 ± 7.7 years old and 60% (15/25) female. Mucoid cysts were adjacent to 19 distal interphalangeal, 3 metacarpophalangeal, and 3 interphalangeal joints. Pre-procedural pain was 4.7 ± 1.0; procedural pain was 6.2 ± 0.6 cm, and post-procedural pain at 6 months was 1.2 ± 0.8 cm (74.5% reduction, 95% CI of difference: 3.0 < 3.5 < 4.0 (p < 0.0001)). 84% (21/25) of the cysts resolved at 6 months; however, 60% (15/25) of the mucoid cysts recurred within 3 years and required retreatment (14 adjacent joints re-injected and 1 ablative cyst surgery). No complications were noted. Intraarticular corticosteroid injection using a dorsal non-transtendinous approach of the joint adjacent to a mucoid cyst is effective resolving cysts and reducing pain at 6 months; however, 60% of mucoid cysts reoccur within 3 years and may require reinjection or surgery.Trial registration: This was not a clinical trial.

Efficacy of corticosteroid injections in the treatment of 85 ganglion cysts of the dorsal aspect of the wrist.

INTRODUCTION: Ganglion cysts of the dorsal aspect of the wrist are a benign pathology frequently encountered in consultations for hand surgery. Their treatment, irrespective of the type, presents a risk of recurrence and there is no consensus on the management to adopt. Medical treatments such as corticosteroid injections have recurrence rates between 8 and 74%. Surgical treatments seem to have better results, with less disparate failure rates, at around 15%. HYPOTHESIS: The objective of this retrospective study was to determine the effectiveness of the aspiration and injection of corticosteroids under ultrasound guidance in the treatment of 85 ganglion cysts of the dorsal aspect of the wrist. PATIENTS AND METHODS: We retrospectively included 99 patients suffering from a non-occult ganglion cyst of the dorsal aspect of the wrist, who had received a referral for aspiration, and subsequent injection of corticosteroids between January 2015 and December 2020. Data collection was carried out by the analysis of files on the institution's software, and by a phone call. Data such as age, sex, pre- and post-treatment QuickDASH score, as well as recurrence and second-line treatments were collected. RESULTS: The average age of our cohort was 31, with a 65% female predominance. The recurrence rate after a first injection was 73.2% with a mean follow-up of 34 months. The QuickDASH score improved significantly by 26.2 points out of 100 in non-injected patients, and by 18.6 points out of 100 after injection, whether the cyst recurred or not. CONCLUSION: With 73.2% recurrence, corticosteroid injections do not appear to be effective in treating dorsal ganglion cysts of the wrist. They lead to an improvement in the functional score of the wrist, but not significantly compared to treatment abstinence. LEVEL OF EVIDENCE: IV.

Digital Myxoid Cysts: Correlation of Initial and Long-Term Response to Steroid Injections.

BACKGROUND: Digital mucous cysts (DMCs) are benign myxoid pseudocysts that develop on the distal interphalangeal joint's lateral or dorsal aspects. Management consists either of a surgical approach, conservative therapy, or simple follow-up. OBJECTIVE: To correlate the initial and long-term response with clinical and ultrasound parameters in DMCs treated with intralesional steroids as first-line therapy. METHODS: A single-center prospective open-label study recruited 15 patients affected by DMCs, who had been treated with a cycle of up to 3 steroid injections at a 6 to 9 week time interval. RESULTS: At the first follow-up visit, 53.3% of patients were cleared of DMCs, achieving a complete response, whereas 46.7% experienced a >30% decrease in their DMC volume, and were considered partial responders. After 1 year of follow-up, the cure rate decreased to 40%, and the recrudescence rate was 27.3%. Clinical and sonographic characteristics that positively correlated with a maintained complete response at follow-up were as follows: young age, absence of osteophytes, low volume, complete clearance at T1, and short disease duration (p < .05). CONCLUSION: Intralesional steroid therapy is an easy approach for DMC, with minimal side effects; identifying predictive hallmarks is useful to offer a straightforward surgical treatment to patients who have nonresponder characteristics.

The impact of ganglion cell layer cysts in diabetic macular oedema treated with anti-vascular endothelial growth factor.

PURPOSE: To investigate the prevalence and impact of ganglion cell layer cysts (GCLC) in patients with diabetic macular oedema (DME) under continuous anti-vascular endothelial growth factor (VEGF) therapy. METHODS: The clinical findings and spectral domain optical coherence devices of baseline visits and follow-up after 12-24 and 36 months of DME patients under continuous anti-VEGF therapy were retrospectively collected and analysed for the impact of GCLC cysts. Previously established prognostic parameters were also assessed. RESULTS: A total of 110 eyes of 110 DME patients (mean age 64 ± 10 years) were included. At baseline, 17% eyes had GCLC. With GCLC, the best-corrected visual acuity (BCVA) improvement was in mean 8.4 ± 2.4 Early-Treatment-Diabetic-Retinopathy-Study (ETDRS) letters less over the course of 36 months compared to the group lacking GCLC (p = 0.0009). Eyes with GCLC showed 68 ± 23.4 µm less central retinal thickness (CRT) decrease than eyes lacking GCLC (p < 0.0001). In the linear mixed effect models including external limiting membrane disruption, disintegration of inner retinal layer and epiretinal membrane, GCLC remained a statistical significant factor for the outcome parameter CRT, but missed statistical significance for BCVA. CONCLUSION: Ganglion cell layer cysts (GCLC) seem to impact outcome in DME in patients receiving long-term treatment. This prognostic factor warrants further evaluation in the context of already well-established outcome parameters.

Treatment of Distal Interphalangeal Ganglion Cysts by Volar Corticosteroid Injection.

BACKGROUND: Various options exist for operative and nonoperative treatment of symptomatic distal interphalangeal (DIP) ganglion cysts. We describe the technique and efficacy of a novel treatment of DIP ganglion cysts using a volar, transtendon, intra-articular injection of corticosteroid. METHODS: This was a single center, retrospective study (2010-2015) of 21 patients who received a volar, intra-articular corticosteroid injection for treatment of DIP ganglion cysts. The patients were contacted via mailing with a short survey. For those potential study participants who did not respond to the mailing or were not seen in follow-up, contact was made via telephone. The primary study outcome was resolution of the cyst; secondary outcomes included pain and postinjection complications. RESULTS: A total of 21 patients (14 female; 7 male) with 23 DIP ganglion cysts were treated in this study. The dominant hand was involved in 56.5% cases. Twelve (52.2%) resolved or had near complete resolution following injection at an average follow-up of 20 months. CONCLUSIONS: For patients with DIP ganglion cysts, this newly described technique of volar, transtendon, intra-articular injection of corticosteroid provides a safe and effective treatment. This technique allows for ease and consistency of needle placement for intra-articular corticosteroid delivery while minimizing the potential soft tissue and infection concerns described with other techniques.

The effect of polydeoxyribonucleotide on the treatment of radiating leg pain due to cystic mass lesion in inner aspect of right sciatic foramen: A CARE compliant case report.

RATIONALE: Radiating leg pain usually originates from the lumbar spine and occasionally from peripheral lesions. Here we report a case involving a patient with radiating pain in the right leg who exhibited 2 suspicious lesions, including 1 spinal lesion and 1 extraspinal cystic mass lesion, on magnetic resonance imaging. Polydeoxyribonucleotide sodium (PDRN) was recently noted as such a substitute. PDRN has anti-inflammatory effects, as it lowers the expression of inflammatory cytokines including interleukin-6 and tumor necrosis factor-alpha. PATIENT CONCERNS: A 51-year-old man (weight, 93 kg; height, 168 cm) working as a bus driver presented at the pain clinic with continuous right buttock pain, radiating leg pain and a tingling sensation involving the calf and dorsum of the foot, since 1 week. DIAGNOSES: He was definitively diagnosed using differential blocks, which revealed the cyst to be the actual cause of the pain. INTERVENTIONS: Surgical resection was not feasible because of the position of the cyst; therefore, corticosteroid injection under ultrasonographic guidance was attempted. However, this provided short-term relief. Subsequently, a solution containing PDRN was injected around the piriformis muscle and repeated 3 more times at intervals of 2 weeks. OUTCOMES: After PDRN injection, we conducted two follow-up monitoring every two months for 2 months. Last follow-up, the patient no longer complained of pain. this resulted in relatively long-term relief from pain. LESSONS: The findings from this case suggest that PDRN is an effective alternative for steroids in patients with radiating leg pain, although its efficacy and safety needs to be evaluated in further large-scale studies.

Dickkopf2 rescues erectile function by enhancing penile neurovascular regeneration in a mouse model of cavernous nerve injury.

Penile erection is a neurovascular event and neurologic or vascular disturbances are major causes of erectile dysfunction (ED). Radical prostatectomy for prostate cancer not only induces cavernous nerve injury (CNI) but also results in cavernous angiopathy, which is responsible for poor responsiveness to oral phosphodiesterase-5 inhibitors. Dickkopf2 (DKK2) is known as a Wnt signaling antagonist and is reported to promote mature and stable blood vessel formation. Here, we demonstrated in CNI mice that overexpression of DKK2 by administering DKK2 protein or by using DKK2-Tg mice successfully restored erectile function: this recovery was accompanied by enhanced neural regeneration through the secretion of neurotrophic factors, and restoration of cavernous endothelial cell and pericyte content. DKK2 protein also promoted neurite outgrowth in an ex vivo major pelvic ganglion culture experiment and enhanced tube formation in primary cultured mouse cavernous endothelial cells and pericytes co-culture system in vitro. In light of critical role of neuropathy and angiopathy in the pathogenesis of radical prostatectomy-induced ED, reprogramming of damaged erectile tissue toward neurovascular repair by use of a DKK2 therapeutic protein may represent viable treatment option for this condition.

Chemical Substances Used in the Treatment of Ganglions Located in the Hand and Wrist.

The aim of this work was to compare different chemical substances used in the treatment of ganglions located in the hand and wrist region. Their basic properties and mechanisms of action have been described. Moreover, the risks associated with the use of particular substances have been highlighted and potential complications connected with their administration have been discussed. On the basis of the available literature, the results of ganglion aspiration treatment followed by an injection of a chemical substance into the cyst cavity have been assessed. In the authors' opinion, due to the existing risk of complications associated with this treatment, as well as the relatively high rate of ganglion recurrence, this procedure should only be performed by qualified medical personnel. The authors recommend observation in cases of asymptomatic ganglions of the hand and wrist, and operative treatment in cases in which pain, restriction of limb mobility and weakening of handgrip strength are observed.

Treatment of ganglions; a five year experience.

OBJECTIVE: To evaluate and determine the effectiveness of surgical excision, aspiration and injection in the treatment of symptomatic ganglions. METHODS: The prospective randomized control trial based on non-probability convenience sampling was conducted at the Department of Surgery, Combined Military Hospital, Sialkot, from June 2007 to August 2010, and at the Department of Surgery, Islam Teaching Hospital, Sialkot, from September 2010 to December 2012. The last patient was included in June 2012. Adult patients referred by general practitioners with ganglia of wrist, ankle and knee were included. All the patients were offered treatment options of intralesional steroid injection or excision of ganglion.The study population was distributed in two groups: Group I opted for aspiration and injection treatment, while Group II went for surgical treatment. A minimum follow-up of six months was mandatory for inclusion in the study. Data was compared and analyzed using SPSS version 22. RESULTS: The study had 173 patients with 187 ganglia. Group I had 143(76.4%) patients, while Group II had 44(23.3%). In the short term, 82(57.3%) of the patients achieved complete resolution after one episode of aspiration and injection, and success rate after second injection repeated after 3 weeks was 116(81%). Overall success rate of aspiration and injection of Triamcinolone acetonide six months after the treatment was 116(81%). On the surgical side the success rate was 41(93%). Complications like pain, joint stiffness and ugly scar were few and not significant. Comparison of failure rates of the two groups (19% vs 7%) showed significant difference (p<0.028). CONCLUSION: In symptomatic ganglia, surgical excision was a better treatment option as the failure rate was less compared to injection-aspiration. The injection treatment should be offered to those who are not willing for surgery, but they should be properly counselled about the chances of failure.

Aspiration and triamcinolone acetonide injection of wrist synovial cysts in children.

PURPOSE: The aim of this case series report is to assess the effectiveness of aspiration and injection of triamcinolone acetonide for treatment of wrist synovial cysts in children. METHODS: Twenty-one records of pediatric patients with synovial cyst on the wrist treated with aspiration and triamcinolone acetonide injection were selected for analysis of their outcomes. All cases were aspirated and injected at the operating room under mask induction anesthesia. Three categories were used to classify the patients' outcomes: (1) successful treatment with no recurrence, (2) successful treatment with residual sclerotic lump, and (3) recurrence of cyst. RESULTS: Fourteen females and 7 males with an average age of 7.2 years had a mean time with the cyst of 1 year. All children were asymptomatic. After aspiration, 13 (62%) of 21 patients experienced successful treatment of the synovial cyst with no recurrence after a single intervention. Five patients had a residual lump at the site of the cyst (24%), which disappeared after an average of 6 months. Three patients experienced true recurrence of the synovial cyst (14%). Average follow-up was 2.5 years. CONCLUSIONS: Aspiration and injection of triamcinolone accounted for a considerable reduction in recurrence. Aspiration and triamcinolone acetonide injection of wrist synovial cysts is an effective and safe treatment that may be considered as first-line treatment in the pediatric population if there is no resolution after 1 year of observation.

Musculoskeletal ultrasound intervention: principles and advances.

Ultrasound scan is an invaluable tool in the diagnosis and treatment of disorders of the musculoskeletal system. Core concepts that are common to most ultrasound-guided procedures are reviewed, including an in-depth discussion regarding the use of injectable corticosteroids. Various aspects of intra-articular, intratendinous, bursal, and ganglion cyst intervention are discussed and promising advances in the treatment of chronic tendon disorders are presented.

Experimental pseudocyst model resembling human ganglion.

There is no animal model of ganglion. We describe a simple and reproducible animal model of pseudocystic diseases. First, we experimented to establish a pseudocystic model. We used cylindrical glass implants (6 mm diameter, 30 mm long) to create fibrous capsules in rats. The implants were inserted in the subcutaneous tissue in the dorsum of rats. Sixty implants were carried out (two implants per rat). Twelve weeks after implantation, the glass implants were removed and 0.5 mL sodium hyaluronate solution was injected into each cavity. Next, we tested the model by histological examination after OK-432 administration. Microscopic examination revealed that the wall was composed of a layer of collagenous fibers similar to those noted in ganglia; the lumen was retained for 3 weeks. Histopathological changes after OK-432 administration showed nonspecific inflammatory response induced by OK-432, resulting in in vivo activation of many inflammatory cells and then fast and reliable closure of cavities. No harmful reactions to OK-432 were observed histopathologically. These data suggest that our experimental cyst is a suitable model for studying pseudocystic diseases. This model can be used for research evaluating safe drug doses, conducting therapeutic comparison of several agents, and histopathological time course studies of the affected tissues. OK-432 administration on this model showed the potential of one of the ideal agents to treat pseudocystic lesions like ganglion.

Alternative to ganglionic blockade with anticholinergic and alpha-2 receptor agents.

The ganglionic blocking agent trimethaphan (TMP) is no longer produced. Therefore, a need exists for alternative pharmacological approaches to investigate baroreflex control of the circulation. The aim of the present study was to examine baroreflex-mediated cardiovascular responses during the administration of a muscarinic receptor antagonist (glycopyrrolate; GLY: ) and a selective alpha-2 receptor agonist (dexmedetomidine; DEX: ) and to compare responses to ganglionic blockade with TMP. We hypothesized that combined GLY-: DEX: would inhibit the baroreflex similar to TMP. Ten volunteers participated in two study days and were instrumented with pulse oximeter, nasal cannula, ECG, continuous blood pressure monitoring (Finapres), and I.V. catheter for drug infusions. Each study day consisted of a control condition followed by either combined GLY: -DEX: or TMP on alternating days. A Valsalva maneuver was performed under each condition with every subject and six subjects received bolus phenylephrine (25 mug) during GLY: -DEX: and TMP. Combined GLY: -DEX: increased (P < 0.05) blood pressure (99 +/- 4 mmHg) and heart rate (99 +/- 3 bpm) relative to control condition (BP: 90 +/- 2 mmHg; HR: 64 +/- 3 bpm) and TMP infusion decreased (P < 0.05) blood pressure (79 +/- 3 mmHg) while increasing heart rate (88 +/- 3 bpm). Valsalva maneuver elicited a persistent drop in arterial pressure (no phase IIb recovery) with the absence of a phase IV overshoot during both GLY: -DEX: and TMP conditions. Phenylephrine increased systolic pressure 34 +/- 4 mmHg under GLY: -DEX: and 23 +/- 3 mmHg with TMP (P < 0.05). Heart rate only decreased 1 +/- 2 bpm during GLY: -DEX: and 1 +/- 1 bpm with TMP. Taken together, our results suggest that GLY: -DEX: is a reasonable alternative to TMP for baroreflex inhibition.