Treatment of Primary Dorsal Wrist Ganglion—A Systematic Review

Abstract

Purpose  The aim of this study was to compare the rates of recurrence and wound infection in patients with primary dorsal wrist ganglion treated with aspiration (with or without an injection of an additive), open excision, or arthroscopic resection.

Methods  This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and registered on PROSPERO. Systematic electronic searches in PubMed (MEDLINE), EMBASE, Web of Science, and the Cochrane Library of Controlled Trials were performed on May 5, 2020, and June 1, 2021, respectively. All clinical studies written in English determining the recurrence and wound infection rates after treatment of primary dorsal wrist ganglion with aspiration, open excision, or arthroscopic resection in patients over the age of 16 years were eligible for inclusion. Quality assessment was guided by the Cochrane Collaboration's tool for randomized controlled trials (RCTs) and the methodological index for nonrandomized studies (MINORS) tool for observational studies.

Results  The literature searches resulted in 1,691 studies. After screening, five RCTs, enrolling 233 patients, and six observational studies, enrolling 316 patients with primary dorsal wrist ganglions were included. Quality assessment of the included RCTs and observational studies determined the existing level of evidence pertaining to primary dorsal wrist ganglion treatment to be low. About 11 studies reported on recurrence rate, which ranged between 7 and 72% for patients initially treated with aspiration (with or without an injection of an additive). In comparison, the recurrence rate for the open excision and arthroscopic resection groups ranged between 6 to 41% and 0 to 16%, respectively. Four studies investigated wound-related complications, for which zero infections were reported, irrespective of treatment.

Conclusion  The evidence summarized in this systematic review demonstrates a considerable variability in recurrence rate following aspiration and open or arthroscopic resection of a primary dorsal wrist ganglion. The greatest variability in recurrence was displayed among studies on aspiration. The overall infection rate after treatment of dorsal wrist ganglions seems to be low regardless of the treatment type. However, the divergent results of individual studies highlight a pressing need for prospective controlled trials assessing outcomes following dorsal wrist ganglion treatment.

Level of Evidence  Systematic review on level 1 to 4 clinical therapeutic studies.

A ganglion cyst is recognized as a mucin-filled benign soft tissue mass most often observed at the dorsal aspect of the wrist. ^{1 2} Although a variety of procedures are available for the treatment of dorsal wrist ganglions, watchful waiting is often initially recommended in the absence of symptoms, as spontaneous resolution has been noted in up to 50% of cases. ^{3 4} Aspiration with or without a complementary injection of, for example, steroid or hyaluronidase is an accepted treatment method, often regarded as the first choice. Nevertheless, the benefit of aspiration remains questionable given the 57 to 77% recurrence rate reported across the literature. ^{5 6} More invasive treatment modalities, including open resection and arthroscopic excision, provide the advantage of reducing the recurrence risk to as low as 1 to 5% ^{7 8 9} with the drawback of subjecting patients to potential clinical morbidity due to the more invasive nature of such procedures. ^{9 10} In light of these findings, complication rates following aspiration (with or without injection of an additive) versus surgical excision of a primary dorsal wrist ganglion remain to be determined. The primary objective of this systematic review was to compare recurrence rates after treatment of primary dorsal wrist ganglions using either aspiration (with or without an injection of an additive), open excision or arthroscopic resection. The secondary objective was to determine wound infection rates among the different treatment groups.

Methods

This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. ¹¹ The protocol of this review was registered on PROSPERO )reg nr. CRD42020187127). The research question serving as the foundation of this systematic review was established using the PICO(S) framework ( Table 1 ).

Table 1. PICO(S).

Participants (P) of interest:  • Patients (>16 years of age) undergoing elective treatment of primary dorsal wrist ganglion

Intervention (I) of interest:  • Aspiration and open or arthroscopic surgical treatment. No restrictions to injections of additives when used following ganglion aspiration

Comparison (C) of interest:  • Patients undergoing aspiration, open excision or arthroscopic resection of a primary dorsal wrist ganglion

Outcome (O) of interest:  • Clinically diagnosed recurrence or reoperation due to recurrence and wound infection at the surgical site after the treatment of primary dorsal wrist ganglions

Study designs (S) of interest:  • Randomized or quasi-randomized, comparative or noncomparative observational studies

Literature Search Strategy

An expert in electronic search methods at the Sahlgrenska University Hospital library, Sweden, performed the literature search on May 5, 2020. The systematic search was performed using PubMed (first available date), EMBASE (from 1974), Web of Science (first available date), and the Cochrane Library of Controlled trials (first available date). An updated search was performed on June 1, 2021, according to the protocol used during the primary search. The search strategy for each electronic database is provided in Appendices A B C D . A similar search strategy was applied for all databases where differences were solely related to database configuration. Additionally, the reference lists of relevant studies were independently screened by two authors for potentially missed articles otherwise eligible for inclusion. A manual search was performed in Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery , Techniques in Hand & Upper Extremity Surgery , Journal of Hand Surgery , Journal of Hand and Microsurgery , Journal of Wrist Surgery , Journal of Plastic Surgery and Hand Surgery , and Arthroscopy . Moreover, the World Health Organization (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov trial registers were reviewed.

Appendix A: Search strategy PubMed.

Electronic database: PubMed
Date: 2020–05–05
Publication date: From inception
Number of hits: 550
Search	Query	Items found
#10	Search #5 AND #8 Filters: English	550
#9	Search #5 AND #8	646
#8	Search #6 OR #7	12663145
#7	Search treatment OR surgery OR surgical OR operated OR operative OR operation OR arthroscop	12481092
#6	Search removal OR excision OR resection OR shaving OR aspiration	820186
#5	Search #1 OR #4	853
#4	Search #2 AND #3	161
#3	Search wrist Sort by: Author	43929
#2	Search “Ganglion Cysts”[Mesh] Sort by: Author	992
#1	Search wrist ganglia OR wrist ganglion OR wrist ganglions Sort by: Author	853
Date: 2021–06–01
Publication date: From 2020–05–06
Number of new hits: 57
Please note that the same search strategy has been applied for both dates.

Appendix B: Search strategy EMBASE.

Electronic database: EMBASE
Date: 2020–05–05
Publication date: 1974 to May 4, 2020
Number of hits: 646
#	Searches	Results
1	((wrist and ganglia) or (wrist and ganglion) or (wrist and ganglions)).af.	1121
2	exp wrist ganglion/	220
3	ganglion cyst/	1251
4	wrist.af,ab,kw,ti.	59863
5	3 and 4	219
6	1 or 2 or 5	1121
7	(removal or excision or resection or shaving or aspiration).af.	1238360
8	(treatment or surgery or surgical or operated or operative or operation or arthroscop$).af.	10290821
9	7 or 8	10609410
10	6 and 9	837
11	limit 10 to (embase or medline)	751
12	limit 11 to English	646
Date: 2021–06–01
Publication date: From 2020–05–06
Number of new hits: 45
Please note that the same search strategy has been applied for both dates.

Appendix C: Search strategy Web of Science.

Electronic database: Web of Science
Date: 2020–05–05
Publication date: From inception
Number of hits: 339
Set	Results	Search History
# 5	339	#4 AND #1 Indexes = SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, BKCI-S, BKCI-SSH, ESCI Timespan = All years
# 4	8,247,762	#3 OR #2 Indexes = SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, BKCI-S, BKCI-SSH, ESCI Timespan = All years
# 3	7,655,860	TOPIC: (treatment OR surgery OR surgical OR operated OR operative OR operation OR arthroscop) Indexes = SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, BKCI-S, BKCI-SSH, ESCI Timespan = All years
# 2	1,119,841	TOPIC: (removal OR excision OR resection OR shaving OR aspiration) Indexes = SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, BKCI-S, BKCI-SSH, ESCI Timespan = All years
# 1	665	TOPIC: (wrist ganglia OR wrist ganglion OR wrist ganglions) Indexes = SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, BKCI-S, BKCI-SSH, ESCI Timespan = All years
Date: 2021–06–01
Publication date: From 2020–05–06
Number of new hits: 33
Please note that the same search strategy has been applied for both dates.

Appendix D: Search strategy Cochrane Library.

Electronic database: Cochrane Library
Date: 2020–05–05
Publication date: From inception
Number of trials: 20
ID	Search	Hits
#1	(wrist ganglia OR wrist ganglion OR wrist ganglions):ti,ab,kw (Word variations have been searched)	32
#2	MeSH descriptor: [Ganglion Cysts] explode all trees	42
#3	(wrist):ti,ab,kw (Word variations have been searched)	5485
#4	#2 AND #3	5
#5	#1 OR #4	32
#6	(clinicaltrials or trialsearch):so	326418
#7	#5 NOT #6	20
Date: 2021–06–01
Publication date: From 2020–05–06
Number of new trials: 1
Please note that the same search strategy has been applied for both dates.

Study Selection Process

The initial review process involved title and abstract screening. The full-text versions of potentially eligible studies were then assessed to determine whether they met the a-priori defined eligibility criteria. The reviewing process was performed independently by two authors and a third author confirmed the full-text assessments. Disagreements were resolved by discussion or by consulting with the first author.

Eligibility Criteria

Clinical studies reporting outcomes in patients over the age of 16 years who underwent aspiration, open excision, or arthroscopic resection as treatment for a primary dorsal wrist ganglion were considered for inclusion. Studies were included regardless of whether aspiration was used alone or combined with injections of an adjuvant, for example, steroids or hyaluronidase. Only English language studies published in indexed medical journals were deemed eligible. Studies, with the exception of case reports, were included regardless of study design. Studies with less than 10 participants were excluded from this systematic review. Additionally, studies that reported outcomes of arthroscopic dorsal wrist ganglion resection with concomitant treatment to ligamentous structures adjacent or nearby the dorsal wrist ganglion were not further considered. Studies including arthroscopic procedures for ligamentous diagnostic purposes, where concomitant resections of dorsal wrist ganglions were performed, were considered eligible for inclusion.

Data Extraction

Data were extracted independently by two authors and confirmed by a third author Appendix E . Discrepancies were resolved by discussion. Data was extracted to a piloted electronic data extraction form (Microsoft Excel for Mac, version 16.36; Microsoft Corporation, Redmond, WA). The following data were extracted: study design, number of enrolled patients, patient characteristics, study completion rates, treatment method, length of follow-up, primary and secondary outcome measures, and conclusion.

Appendix E. Summary of included studies determining the recurrence and wound infection rates in patients with primary dorsal wrist ganglion.

Authors	Aim	No of patients	Treatment method	Recurrence rate % ( n )	Wound infection rate % ( n )	Conclusion
Dias et al 4	To study the recurrence rate, patient satisfaction, and residual symptoms following the treatment of three different methods for dorsal wrist ganglia	181 a	Aspiration ( n  = 78)	58% (45/78)	NR	Neither excision nor aspiration is superior to that of no treatment in the long-term
			Open excision ( n  = 103)	41% (42/103)	NR
Gümüs 15	To evaluate sclerotherapy and aspiration as a viable conservative ganglion treatment modality	15 b	Aspiration + sclerotherapy ( n  = 15)	7% (1/15)	NR	The treatment of dorsal wrist ganglion with aspiration and sclerotherapy provides an acceptable recurrence rate compared with other treatment methods such as open surgery
Gündeş et al 16	To investigate the results of surgical excision between dorsal and volar wrist ganglia	24 b	Open excision ( n  = 24)	8% (2/24)	NR	Recurrence rate of volar ganglia after surgical excision is greater than for dorsal wrist ganglia, therefore the former should be approached more carefully
Hatchell et al 20	To determine whether aspiration followed by injection of Tisseel is superior at reducing the recurrence rate than aspiration alone in dorsal wrist ganglia	79	Aspiration ( n  = 39)	72% (21/29) c	NR	Aspiration with following Tisseel injection does not reduce the recurrence rate compared with aspiration alone
			Aspiration + Tisseel ( n  = 40)	64% (16/25) c
Jagers et al 5	To compare the administration of hyaluronidase and subsequent aspiration, with surgical excision of dorsal wrist ganglia, volar wrist, and foot ganglia	53 b	Aspiration + hyaluronidase ( n  = 28)	NR	NR	Surgery is preferable to aspiration for dorsal wrist, volar, and foot ganglia due to lower recurrence rate
			Open excision ( n  = 25)	28% (7/25)
Kang et al 9	To compare recurrence rates between arthroscopic and open excision of dorsal wrist ganglion	72 d	Arthroscopic resection ( n  = 41)	11% (3/28)	0% (0/28)	The technique of arthroscopic resection does not achieve superior results compared with open excision.
Khan and Hayat 17	To compare results of open excision with aspiration in combination with intralesional triamcinolone and immobilization therapy in patients with dorsal wrist ganglion	36	Aspiration + triamcinolone ( n  = 18)	39% (7/18)	0% (0/18)	Surgery is the more effective treatment option when considering the cure rate of dorsal ganglions of the wrist
			Open excision ( n  = 18)	6% (1/18)	0% (0/18)
Lee et al 19	To investigate the clinical course of patients undergoing open and arthroscopic resection with respect to pain	52	Arthroscopic resection ( n  = 28)	16% (4/25)	0% (0/25)	The source of pain is more easily assessed with the open technique; hence it is potentially more valuable when pain relief is the main reason for surgery
			Open excision ( n  = 24)	15% (3/20)	0% (0/20)
Limpaphayom and Wilairatana 18	To compare the results of DWG treatment between surgical excision and aspiration with methylprednisolone injection plus immobilization	24 e	Aspiration + methylprednisolone ( n  = 13)	62% (8/13)	0% (0/13)	Surgery provides superior results compared with aspiration in the treatment of dorsal wrist ganglion
			Open excision ( n  = 11)	18% (2/11)	0%(0/11)
Shih et al 21	To investigate the outcome after arthroscopic resection of dorsal wrist ganglion	32	Arthroscopic resection ( n  = 32)	0% (0/32)	NR	Arthroscopic resection of dorsal wrist ganglion is equal to or better than the open technique for recurrence prevention
Yasuda et al 22	To investigate cases with dorsal wrist syndrome undergoing surgical treatment	12 b	Open excision ( n  = 12)	8% (1/12)	NR	The described open surgical procedure is effective for preventing recurrences of dorsal wrist ganglion without concurrent scapholunate ligament tears

Abbreviations: DWG, dorsal wrist ganglion; n , number, NR, not reported.

The table denotes numbers relating to primary dorsal wrist ganglion if not otherwise stated.

^aPatients who did not receive any treatment were excluded from the qualitative synthesis.

^bPatients with conditions other than primary dorsal wrist ganglion were excluded from the qualitative synthesis.

^cRecurrence rate at the final follow-up at 12 months.

^dPatients undergoing open excision were excluded from the qualitative synthesis due to age range of included patients (10–54 years).

^eTotal study group consisted of 28 patients of which descriptive data was provided for 24 patients.

Risk of Bias and Quality Assessment of Individual Studies

The risk of bias in randomized controlled trials (RCTs) was assessed using the Cochrane Collaboration's tool, ¹² while the methodological index for nonrandomized studies (MINORS tool) was used to assess the quality of observational studies. ¹³ All assessments were performed independently by two authors and discrepancies were resolved by discussion. With respect to the Cochrane Collaboration's tool, the appraisal of each item involves assessing the risk of bias as “low risk,” “high risk,” or “unclear risk,” where the latter category indicates either a lack of information or uncertainty over the potential for bias. The MINORS tool is comprised of eight items for noncomparative studies and 12 items for comparative studies. Each item is scored from 0 to 2 points. A score of 0 is equivalent to an unreported item, 1 corresponds to an inadequately reported item, and 2 indicates an adequately reported item. As a result, noncomparative studies have a maximum score of 16 points, while comparative studies may reach a total of 24 points. Studies that were noncomparative were classified as high quality (12–16 points), moderate-to-low quality (0–11 points), while comparative studies into high quality = (17–24 points) and moderate-to-low quality (0–16 points), respectively. ¹³

Outcome

Outcomes of interest were defined prior to the conduction of this systematic review. The primary outcome included the rates of clinical recurrence or reoperation due to recurrence among the patient groups. The secondary outcome was defined as a wound infection at the surgical site, including superficial surgical site infection (SSI), deep SSI, or wound disruption. Reporting of wound-related infections was based on the terminology established by the Centers for Disease Control and Prevention. ¹⁴

Data Synthesis

All outcomes were qualitatively summarized and stratified according to the primary and secondary outcomes of this systematic review. Moreover, if a study provided descriptive continuous variables such as age and length of follow-up for each participating patient without reporting the mean or median for the total study population, the mean and range were calculated using IBM SPSS Statistics for Mac (version 26; IBM, Chicago, IL).

Results

Search Results

The study selection process is reported in Fig. 1 . In total, 1,691 potentially eligible studies were initially identified in the electronic literature search. Following removal of duplicates, 952 studies underwent title and abstract screening, and 843 studies were excluded, as they were unrelated to the treatment of primary dorsal wrist ganglions. The full-text articles for the remaining 109 studies were read and assessed for eligibility, resulting in 11 studies that met the inclusion criteria. ^{4 5 9 15 16 17 18 19 20 21 22}

Fig. 1.

Flowchart for the literature searches.

Risk of Bias and Quality Assessment

Figs. 2 and 3 represent the risk assessment of bias for the included five RCTs. ^{5 9 17 18 20} Two of the included RCTs ^{5 20} reported random sequence generation and allocation concealment, while the risk of bias was unclear or high in three RCTs. ^{9 17 18} Detection and performance bias were considered high in all five RCTs. ^{5 9 17 18 20} Attrition bias was considered high in two RCTs ^{17 20} due to high rates of dropout during the follow-up. Reporting bias was unclear in two RCTs, ^{5 17} although three RCTs ^{9 18 20} provided predefined outcomes of interest. As a result, the overall risk of bias in the included RCTs was deemed moderate to high.

Fig. 2.

Risk of bias summary: review of the judgement of each author about each risk of bias item in every included study.

Fig. 3.

Risk of bias graph: review of the judgement of each author about each risk of bias item across all included studies, presented as percentages.

Details pertaining to the quality assessment of the six included observational studies ^{4 15 16 19 21 22} are presented in Table 2 . The median (range) scores based on the MINORS tool for noncomparative studies ^{15 16 21} were 6 (3–7) and 14 (12–16) for comparative studies. ^{4 19 22} Thus, all observational studies were determined to be low-to-moderate in terms of quality. All six observational studies had at least one unreported or inadequately reported item according to the MINORS assessment. The most common limitations among observational studies were identified in items 3, 5, 7, and 8, which refer to prospective data collection, unbiased outcome assessment, loss to follow-up, and sample size calculations, respectively.

Table 2. Quality assessment of observational studies according to the MINORS tool.

	Clearly stated aim	Inclusion of consecutive patients	Prospective data collection	Endpoints appropriate to the aim	Unbiased assessment of study endpoint	Follow-up period appropriate to the aim	Lost to F/U less than 5%	Prospective calculation of study size	Control group	Contemporary groups	Baseline equivalence of groups	Adequate statistical analyses
Author	Item 1	Item 2	Item 3	Item 4	Item 5	Item 6	Item 7	Item 8	Item 9	Item 10	Item 11	Item 12	Total score	Study type
Dias et al 4	2	0	2	2	0	2	0	0	2	0	2	0	12	C
Gümüs 15	1	2	0	0	0	0	0	0	N/A	N/A	N/A	N/A	3	N-C
Gündeş et al 16	2	2	0	2	0	1	0	0	N/A	N/A	N/A	N/A	7	N-C
Lee et al 19	2	2	0	2	2	2	0	0	2	2	2	0	16	C
Shih et al 21	0	2	0	0	0	2	2	0	N/A	N/A	N/A	N/A	6	N-C
Yasuda et al 22	2	2	2	2	0	0	0	0	2	2	2	0	14	C

Abbreviations: C, comparative; F/U, follow-up; MINORS, methodological index for nonrandomized studies; N-C, noncomparative.

The items are scored 0 (not reported), 1 (reported but inadequate), or 2 (reported and adequate). The total ideal score is 16 for noncomparative studies and 24 for comparative studies, respectively.

Study Characteristics

Included studies consisted of the following study designs; RCT ( n  = 5; 311 patients), ^{5 9 17 18 20} prospective cohort study ( n  = 2; 253 patients), ^{4 15} retrospective chart review ( n  = 2; 58 patients), ^{16 22} case-control ( n  = 1; 52 patients), ¹⁹ and case-series ( n  = 1; 32 patients). ²¹ The study characteristics are described in Table 3 . In one prospective comparative study, ⁴ a subgroup of 55 patients underwent watchful waiting and was therefore excluded from further synthesis. Additionally, across one prospective cohort study, ¹⁵ two retrospective chart reviews, ^{16 22} and one RCT, ⁵ a total of 71 patients had diagnoses other than primary dorsal wrist ganglion. These subpopulations were consequently excluded from further analyses. Lastly, in one RCT, ⁹ 31 patients with a minimum age of 10 years were treated for dorsal wrist ganglion with open excision. This subgroup was excluded from subsequent analyses due to the inclusion of participants aged under 16 years. Following the exclusion of patients due to the aforementioned reasons, a total of 549 patients were included in the final analyses of the current review.

Table 3. Demographic data of included studies in the systematic review.

Author	Journal	Study design	Treatment	No of patients		Male/Female, n	Age (y)	Diagnostic workup	Outcome
				Total	PDWG
Dias et al 4	J Hand Surg Eur	Prospective cohort	Aspiration	236	78	22/56	Mean: 39 (SE = 1.9)	Physical examination	(1)
			Open excision		103	36/67	Mean: 35.3 (SE = 1.5)
Gümüs 15	Ann Plast Surg	Prospective cohort	Aspiration with sclerotherapy	17	15	NR	Mean: 32.7 (range: 28–52)	US	(1)
Gündeş et al 16	Acta Orthop Belg	Retrospective chart review	Open excision	40	24	7/17	Mean: 30.2 (range: 16–52)	US	(1)
Hatchell et al 20	Plast Surg (Oakv)	RCT	Aspiration	79	39	14/25	Mean: 32.2 (SD: 12.2)	NR	(1)
			Aspiration + Tisseel		40	18/22	Mean: 37.1 (SD: 14.0
Jagers et al 5	J Hand Surg Br	RCT	Aspiration + hyaluronidase	100	28	NR	Mean: 41.0 (SD: 15.6)	NR	(1)
			Open excision		25		Mean: 38 (SD: 17.1)
Kang et al 9	J Hand Surg Am	RCT	Arthroscopic resection, open excision	72	41	11/30	Mean: 34.0 (range: 16–54)	NR	(1), (2)
Khan and Hayat 17	J Hand Microsurg	RCT	Aspiration + triamcinolone	36	18	4/14	Mean: 31.0 (range: 17–45)	NR	(1), (2)
			Open excision		18	3/15
Lee et al 19	Acta Orthop Belg	Case–control	Arthroscopic resection	52	28	10/18	Mean: 34.6 (range: 19–56)	Physical examination, US, MRI	(1), (2)
			Open excision		24	8/16	Mean: 34.4 (range: 18–60)
Limpaphayom and Wilairatana 18	J Med Assoc Thai	RCT	Aspiration + methylprednisolone	24	13	2/11	Mean: 32.0 (SD: 13.08)	NR	(1), (2)
			Open excision		11	2/9	Mean: 29.9 (SD: 9.79)
Shih et al 21	Hand Surg	Case series	Arthroscopic resection	32	32	20/12	Mean: 23.7 (range: 21–35)	US	(1)
Yasuda et al 22	Hand Surg	Retrospective review	Open excision	18	12	7/5	Mean: 31.0 (range: 18–47)	Physical examination	(1)

Abbreviations: Min, minimum; MRI, magnetic resonance imaging; n , number; NR, not reported; PDWG, primary dorsal wrist ganglion; RCT, randomized controlled trial; SD, standard deviation; SE, standard error; US, ultrasound; Y, years; (1)—recurrence rate, (2)—wound infection rate.

Among the included studies, seven different types of treatment methods were applied, of which aspiration with or without the injection of an additive was most commonly performed, encompassing a total of 231 patients. ^{4 5 15 17 18 20} Open excision ^{4 5 16 17 18 19 22} was performed in 217 patients and arthroscopic resection ^{9 19 21} in 101 patients.

Patient Characteristics

Across the included studies with 549 primary dorsal wrist ganglions, the majority of patients were female (66 vs. males 34%). However, the patient sex distribution was not reported in two studies. ^{5 15} The age range was 16 to 60 years in the study population ( Table 3 ).

Recurrence Rate

Eleven studies, ^{4 5 9 15 16 17 18 19 20 21 22} including five RCTs and six observational studies, reported the recurrence rate following treatment of a primary dorsal wrist ganglion ( Table 4 ). The risk of bias for the included RCTs ^{5 9 17 18 20} was assessed as moderate to high. The study quality, as determined by the MINORS tool of observational studies, was deemed moderate to low. Median (range) score for noncomparative and comparative studies ^{15 16 21} was 6 (3–7) and 14 (12–16), respectively. ^{4 19 22} The follow-up period of the included studies ranged between 6 and 66 months, with a total of 113 patients lost to follow-up. However, one study ¹⁶ did not declare the exclusion of patients due to loss to follow-up. Additionally, one study ⁵ did not provide the number of recurrences in the subpopulation of patients with aspiration + hyaluronidase. Accordingly, the total number of patients included in the final synthesis was 476 patients (aspiration with or without an injection of an additive; n  = 178; open excision; n  = 213; arthroscopic resection; n  = 85). The time to recurrence was reported by two studies ^{15 19} and ranged between 3 and 30 months. There were in total 163 patients with a recurrent ganglion. Of the patients with recurrence, 98 were initially treated with aspiration (with or without the injection of an additive), 58 patients with open excision, and 7 patients with arthroscopic resection. The recurrence rate for the individual studies investigating aspiration (with or without the injection of an additive) ^{4 5 15 17 18 20} was 7 to 72%. In the open excision group, ^{4 5 16 17 18 19 22} the recurrence rate among included studies ranged between 6 and 41%, while a 0 to 16% recurrence rate was reported in the arthroscopic resection group. ^{9 19 21}

Table 4. Overview of recurrence and wound infection rates across included studies.

Author	Follow-up	Loss to follow-up % ( n )	Treatment	Time to recurrence	Recurrence rate % ( n )	Wound infection rate % ( n )
Dias et al 4	Mean: 70.4 mo (SE: 0.9 mo)	17% (47)	Aspiration	NR	58% (45/78)	NR
			Open excision		41% (42/103)
Gümüs 15	Mean: 17 mo (range: 6–29 mo)	0% (0)	Aspiration + sclerotherapy	3 mo	7% (1/15)	NR
Gündeş et al 16	Mean: 29.1 mo (range: 6–48 mo)	NR	Open excision	NR	8% (2/24)	NR
Hatchell et al 20	12 mo	32% (25)	Aspiration	NR	72% (21/29)	NR
			Aspiration + Tisseel		64% (16/25)
Jagers et al 5	12 mo	9% (9)	Aspiration + hyaluronidase	NR	NR	NR
			Open excision		28% (7/25)
Kang et al 9	Min 12 mo	29% (21)	Arthroscopic resection	NR	11% (3/28)	0% (0/28)
Khan and Hayat 17	12 mo	0% (0)	Aspiration + triamcinolone	NR	39% (7/18)	0% (0/18)
			Open excision		6% (1/18)	0% (0/18)
Lee et al 19	Mean: 32 mo (range: 18–49 mo)	13% (7)	Arthroscopic resection	Mean: 15.2 mo (range: 5–30 mo)	16% (4/25)	0% (0/25)
			Open excision		15% (3/20)	0% (0/20)
Limpaphayom and Wilairatana 18	6 mo	14% (4)	Aspiration + methylprednisolone	NR	62% (8/13)	0% (0/13)
			Open excision		18% (2/11)	0% (0/11)
Shih et al 21	Mean: 26.8 mo (range: 15–37)	0% (0)	Arthroscopic resection	NR	0% (0/32)	NR
Yasuda et al 22	Mean: 36 mo (range: 7–66 mo)	0% (0)	Open excision	NR	8% (1/12)	NR

Abbreviations: Mo, months; NR, not reported.

Wound Infection Rate

Four studies, ^{9 17 18 19} including three RCTs and one case-control study presented data related to wound infections at the surgical site following treatment of a primary dorsal wrist ganglion ( Table 4 ). The risk of bias in the included RCTs ^{9 17 18} was determined to be moderate to high, while the MINORS assessment for the observational comparative study ¹⁹ yielded a score of 16 out of 24 points, considered moderate-to-low quality. The follow-up period of studies ranged between 6 and 49 months. During this time period, a total of 32 (21%) patients were lost to follow-up. Accordingly, the total number of patients included in the final synthesis was 133 patients (with or without the injection of an additive; n  = 31; open excision; n  = 49; arthroscopic resection; n  = 53). No study reported any type of surgical site-related wound infection, irrespective of treatment method.

Discussion

The main finding of this review was that the literature on the recurrence rate among patients with primary dorsal wrist ganglions undergoing either aspiration (with or without the injection of an additive), open or arthroscopic surgery varies considerably. Specifically, the recurrence rate following aspiration ranged between 7 and 72% across studies. As for patients undergoing open excision or arthroscopic resection, the corresponding ranges were 6 to 41% and 0 to 16%, respectively. Lastly, as for the secondary outcome for the current review, no wound infections were reported irrespective of the treatment method.

Most RCTs had a moderate-to-high risk of bias, possibily indicating heterogenous patient populations. The included RCTs demonstrated limitations in several of the assessed outcomes, most importantly, the allocation and randomization processes, which are generally considered crucial elements of RCTs. While none of the RCTs reported any blinding of patients, personnel, or outcome assessors, it is worth noting that these may have been difficult to implement given the nature of the treatments they evaluated. Similarly, the overall quality of the included observational studies was classified as moderate to low. Most commonly, observational studies did not predefine the outcomes of interest, had dropout rates of more than 5%, and failed to provide 95% confidence intervals and power estimates. Altogether, these limitations may subject the included studies to multiple sources of bias. Accordingly, the level of evidence and quality of studies on primary dorsal wrist ganglions is considered low, warranting a cautious interpretation of results.

All included studies evaluated the recurrence rate following treatment with aspiration (alone or complemented with the injection of an additive), open or arthroscopic surgery. This outcome was demonstrated to be inconsistent between individual studies and treatment modalities. The reported range of dorsal wrist ganglion recurrence was greatest for those undergoing aspiration and varied between 7 and 72%, followed by 6 to 41% and 0 to 16% in the open excision and arthroscopic resection groups, respectively. However, due to the wide ranges and overlaps in the recurrence rate, insufficient evidence exists to recommend one technique over another. The pooled recurrence rate of wrist ganglions has previously been determined by a meta-analysis, which reported mean recurrence rates of 59, 21, and 6% corresponding to aspiration, open, and arthroscopic treatments, respectively. ²³ However, the authors incorporated studies concerning both volar and dorsal wrist ganglions in their meta-analysis, ²³ which could be regarded as separate diagnostic entities. In this review, aspiration alone or combined with the injection of an additive demonstrated a higher recurrence rate compared with the other treatment modalities, with the greatest recurrence rate of 72% observed in the study by Hatchell et al. ²⁰ The relatively high risk of recurrence following aspiration could possibly be attributed to the underlying pathophysiological mechanism of a ganglion. Dorsal wrist ganglions usually communicate with the joint by a pedicle originating from the scapholunate ligament or from other locations over the dorsal wrist capsule. ^{7 24} As aspiration does not involve excision of the ganglion complex, comprised of the cyst, pedicle, and a section of the adjacent joint capsule, the potential underlying cause remains untreated. Similarly, higher recurrence rates following surgical excision could be accredited to inadequate dissection of the ganglion duct system at the joint capsule. Ultimately, these findings underscore the importance of clinical wrist evaluation in this population of patients.

Previously, wound infections have been reported in 0% of patients following arthroscopic treatment, ²⁵ while a 6% infection rate was observed following open excision. ²⁶ Conversely, the reported incidence of SSIs was 0% in all studies included in this review. Our results are limited by the low number of studies on the topic and therefore preclude conclusions with regard to SSIs following primary dorsal wrist ganglion treatment. Additionally, the time from treatment to follow-up, as well as the type of follow-up (physical examinations, questionnaires, and telephone calls) varied considerably between studies. Considering the latter factors, it is possible that the SSIs remained undetected by the individual studies, providing a partial explanation for the absence of infection-related complications in the current review.

This systematic review has several limitations. One drawback stems from the heterogeneity among the eligible studies, incorporating both nonrandomized and RCTs in the data synthesis. Due to a high variability in the designs of the included studies, it was deemed inappropriate to perform a quantitative meta-analysis. The inclusion of patient populations in this review was limited to a minimum age of 16 years. Moreover, during the screening process, studies investigating the outcome of patients undergoing ligamentous reconstruction and simultaneous ganglion shaving were excluded, as we aimed only to include studies addressing ganglion treatment without any concomitant procedures. The aforementioned criteria resulted in the exclusion of numerous studies. With respect to the secondary objective of this review, only four studies investigated wound infection rates, limiting the conclusions to be drawn regarding infection rates following the different interventions. Lastly, the qualitative summaries of this review did not separate studies applying aspiration alone or in combination with the injection of an additive. Specific strengths of this systematic review include the strictly defined eligibility criteria, which aimed to increase the homogeneity of the patient population receiving treatment for primary dorsal wrist ganglions. Moreover, various literature search approaches were utilized, including electronic database queries, as well as manual searches of reference lists, hand surgery-related web sites, and trial registry web sites.

In conclusion, this systematic review found that the recurrence rate following aspiration, and open or arthroscopic resection of primary dorsal wrist ganglions varied considerably between studies, with studies reporting on aspiration showing the greatest variability. The infection rate after treatment of dorsal wrist ganglions seems to be low regardless of the treatment method; however, there is a paucity of research evaluating this outcome. Given the inconclusive and limited literature on the treatment outcomes of primary dorsal wrist ganglions, further prospective controlled trials are warranted.