Abstract
Background Ganglion excision is performed for pain, functional impairment, or cosmetic reasons, with recurrence rates ranging between 9 and 20%. The aim of this study was to evaluate the recurrence and reoperation rates after ganglion excision, along with assessing patient-reported outcomes.
Methods Retrospectively, 1,076 patients, with 1,080 wrist ganglia, were identified who underwent open excision ( n = 1,055) and arthroscopic excision ( n = 25). The ganglia were predominantly dorsal (59%) and volar (37%). Additionally, 149 patients who underwent open excision and all who underwent arthroscopic excision were contacted to complete a questionnaire on recurrence and reoperation, the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), and the Patient-Rated Wrist Evaluation (PRWE). Seventy-seven patients responded at a median of 4 years postoperatively. A matched case-control analysis was performed to identify factors associated with reoperation, along with a bivariate analysis to assess what factors influence patient-reported outcomes.
Results The reoperation rate was 3.3%, with no factors statistically associated with reoperation in case-control analysis. Among the contacted patients, 13% reported a recurrence, of which 2.6% reported reoperation. The median QuickDASH score was 2.3 (interquartile range [IQR]: 0–12), the median PRWE score was 0 (IQR: 0–12), and the median pain score was 0 (IQR: 0–3), with female sex being associated with higher scores.
Conclusion The reoperation rate after ganglion excision is low (3.3%) and is mostly performed within 3 years. The self-reported ganglion recurrence is higher (13%), but only one-fifth of these patients reported a repeat excision. After surgery, patients report good functional scores, with little persistent pain.
Keywords: wrist ganglion, ganglion excision, surgical outcomes
Wrist ganglia are the most prevalent wrist mass and are more common in females. 1 In men, there is often a history of trauma. Wrist ganglia are most commonly found dorsally, attached to the scapholunate ligament, often communicating with the radiocarpal joint. 2 3 4 5 The exact pathophysiology is unclear, but the development of a wrist ganglion may be related to damage of the joint capsule by either changes in biomechanics of the wrist or joint stress, and the latter may also stimulate mucin secretion. 6 The presence of intercarpal ligament joint laxity among patients with a wrist ganglion supports this hypothesis. 4 5 Microscopically ganglion cysts are lined by loose layers of collagen, unlike common joint cysts, which are lined with synovium, with few fibroblasts and contain hyaluronic-rich mucinous fluid. 6
Diagnosis can be made based on patient history and physical examination. Ganglion cysts transilluminate and are generally 1 to 2 cm. 7 Patients are often (16–28%) concerned for malignancy and advanced imaging should be considered in patients presenting with a swelling greater than 3 cm, pain, and rapid increase in size. 8 9 Many wrist ganglia resolve spontaneously, but surgical excision remains an option, with pain and cosmesis being the predominant indications. 8 10 Following surgical excision, recurrence rates are 9 to 20%, 5 7 11 12 but the factors associated with reoperation are not fully understood.
The aim of this study was to report the reoperation rate following wrist ganglion cyst excision, along with identifying the factors associated with reoperation. An additional aim was to report the long-term patient-reported outcomes and self-reported recurrence among these patients.
Methods
After Institutional Board Review approval, we retrospectively identified patients who underwent ganglion excision using Current Procedural Terminology (CPT) codes ( Supplemental Material S1 (online only)). We included all adult patients who underwent open or arthroscopic ganglion (volar, dorsal, midcarpal) excision of the wrist at a single institutional system from January 2002 to July 2016 ( n = 2420). Wrist ganglia were verified by manual chart review using operative notes and pathology reports. We excluded patients with a ganglion of the hand, that is, retinacular cysts, flexor tendon sheath ganglia, and mucoid cysts ( n = 1138), patients who underwent arthroscopy for a different reason ( n = 90), patients with a missing surgical note ( n = 31), patients who did not undergo ganglion excision surgery ( n = 29), patients without a ganglion ( n = 27), patients with retinacular cysts ( n = 13), patients with a giant cell tumor ( n = 11), patients with Dupuytren's disease ( n = 3), patients with De Quervain's tenosynovitis ( n = 1), and patients with an intratendinous ganglion ( n = 1). We analyzed 1,076 patients, with a total of 1,080 ganglia. Three (0.28%) patients had bilateral ganglia, which were excised simultaneously and one (0.1%) patient had two ganglia on the same wrist, which were excised simultaneously.
A manual medical chart review was performed to collect information regarding patient characteristics, including hand dominance, history of smoking, obesity, diabetes, rheumatoid arthritis, previous fracture at the location of ganglion or scapholunate injury, and previous aspiration. These factors were included because they may be associated with an increased risk of soft-tissue healing, and/or increased risk of recurrence. In addition, data regarding reoperations were collected. A reoperation was defined as any unplanned additional surgery for a recurrent ganglion. Follow-up time was defined as the time from surgery to last clinical visit recorded in medical charts.
Study Population
Of the 1,076 patients with 1,080 ganglia, there were a total of 1,055 (98%) open excisions and 25 (2.3%) arthroscopic excisions. The mean age was 41 ± 15 years and the majority of the patients were females ( n = 745, 69%). There were 633 (59%) dorsal ganglia and 399 (37%) volar ganglia, along with 40 ganglia that were in other locations (radial, ulnar, carpometacarpal; 3.7%; Table 1 ). In eight ganglia, the location could not be classified due to ambiguity within the operative reports. The decision for surgery was taken when the mass significantly affected the patient, with common complaints being wrist pain and cosmesis. The median postoperative follow-up was 4.8 years (interquartile range [IQR]: 1.6–9.4).
Table 1. Open ganglion excision versus arthroscopic ganglion excision.
| All patients | Open excision | Arthroscopic excision | p value | |
|---|---|---|---|---|
| Characteristic | n = 1,076 | n = 1,055 | n = 25 | |
| Age (y), mean (SD) | 41 (15) | 41 (15) | 39 (12) | 0.39 a |
| Male, n (%) | 331 (31) | 324 (31) | 8 (32) | >0.99 b |
| Race, n (%) | ||||
| Caucasian | 671 (62) | 654 (62) | 21 (84) | 0.055 b |
| African American | 112 (10) | 111 (11) | 1 (4) | |
| Hispanic | 178 (17) | 178 (17) | 0 | |
| Asian | 25 (2.3) | 25 (2.4) | 0 | |
| Other | 90 (8.3) | 87 (8.3) | 3 (12) | |
| Location ganglion, n (%) c | ||||
| Dorsal | 633 (59) | 617 (59) | 16 (89) | 0.036 |
| Volar | 399 (37) | 397 (38) | 2 (11) | |
| Other | 40 (3.7) | 40 (3.8) | 0 | |
| Reoperation, n (%) | 36 (3.3) | 35 (3.3) | 1 (4.0) | 0.58 |
Abbreviations: SD, standard deviation.
Note: Values in bold indicate p < 0.05.
Using Student's t -test.
Using Fisher's exact test.
Eight missing values.
Patient-Reported Outcomes
To evaluate long-term outcomes, we contacted all patients ( n = 25) who underwent arthroscopic excision and all consecutive patients ( n = 149) that underwent open excision from June 2014 until July 2016. The patients were contacted by invitation letters or phone and were invited to participate in this study to complete patient-reported outcome questionnaires, along with a custom questionnaire evaluating ganglion recurrence or additional treatment for a recurrent ganglion. Of the 174 patients who were contacted, 77 (44%) patients responded and filled part of the questionnaires at a median follow-up of 4.0 years (IQR: 3.4–4.6). Three (3.9%) patients did not complete the Patient-Rated Wrist Evaluation (PRWE) and six (7.8%) patients did not complete the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH).
The QuickDASH consists of 11 items addressing the symptoms and functionality of patients with any or multiple disorders of the upper extremity, with a higher score indicating increased disability. 13 The PRWE is a 15-item questionnaire addressing wrist pain and disability in activities of daily living, with a higher score indicating increased pain and disability. 14 Additionally, the “worst pain in the past 7 days” was extracted from the PRWE to determine a pain score, ranging from 0 to 10.
Study data were collected and managed using REDCap (Research Electronic Data Capture) electronic data capture tools hosted at our institution. 15 REDCap is a secure, web-based software platform designed to support data capture for research studies, providing (1) an intuitive interface for validated data capture, (2) audit trails for tracking data manipulation and export procedures, (3) automated export procedures for seamless data downloads to common statistical packages, and (4) procedures for data integration and interoperability with external sources.
Statistical Analysis
Categorical data were presented as frequencies and percentages and continuous data were expressed as either means and standard deviations or as median and IQRs. To compare patients who underwent open ganglion excision with patients who underwent arthroscopic ganglion excision, we used Fisher's exact test for categorical variables and Student's t- test for continuous variables. To evaluate the factors associated with reoperation following open ganglion excision, we matched all patients who had a reoperation-to-controls ratio of 1:2. Matching was done based on sex, age, race, and location of the ganglion. A total of 108 patients were included as case controls. We used conditional logistic regressions for bivariate analysis. We presented the reoperations after open excision in a Kaplan–Meier survival curve. To evaluate the correlation between the patient-reported outcomes (PRWE, QuickDASH, and pain score) and patient characteristics, we used the Mann–Whitney U test. Statistical significance was defined as p < 0.05. All analyses were performed with Stata (StataCorp LLC, College Station, TX).
Results
Overall, the patient characteristics in those who underwent open excision and arthroscopic excision were similar. Arthroscopic excision was mostly performed for dorsal ganglia ( n = 16, 89%) compared with open excision, with which both dorsal ( n = 617, 59%) and volar ganglia ( n = 397, 38%) were excised ( p = 0.036). The overall reoperation rate following surgical ganglion excision was 3.3% (35 of 1,055 open excisions and 1 of 25 arthroscopic excisions; Table 1 ). Reoperations were performed at a median of 1.9 years (IQR: 0.9–3.1; Fig. 1 ). No statistically significant factors associated with reoperation could be identified ( Table 2 ).
Fig. 1.
Kaplan–Meier survival curve for reoperation following open ganglion excision.
Table 2. Factors associated with reoperation after open ganglion excision.
| Reoperation | Control | p value | |
|---|---|---|---|
| n = 36 | n = 72 | ||
| Diabetes mellitus, n (%) | 2 (5.6) | 3 (4.2) | 0.73 a |
| Smoking, n (%) b | 9 (27) | 22 (32) | >0.99 a |
| Previous fracture at location of occurrence, n (%) | 3 (8.3) | 2 (2.8) | 0.23 a |
| Previous aspiration, n (%) | 8 (22) | 11 (15) | 0.35 a |
| Incomplete excision, n (%) | 3 (8.3) | 3 (4.2) | 0.40 a |
| Midcarpal ganglion, n (%) | 3 (8.3) | 15 (21) | 0.11 a |
| Immobilization, n (%) c | 29 (81) | 48 (68) | 0.18 a |
Using conditional logistic regression.
Six missing values.
One missing value.
Among the 77 patients who completed the questionnaires at a median follow-up of 4.0 years (IQR: 3.4–4.6), 65 (84%) patients underwent open ganglion excision and 12 (16%) patients underwent arthroscopic ganglion excision. A total of 10 (13%) patients reported a recurrence (14% [9 of 65] after open excision and 8.3% [1 of 12] after arthroscopic excision) and 2 patients (2.6%) reported they underwent reoperation for recurrence. One reoperation was performed 6.4 months following open excision and the other reoperation was performed at 4.2 years following arthroscopic excision. The median PRWE score was 0 (IQR: 0–12), the median QuickDASH score was 2.3 (IQR: 0–9.1), and the median pain score was 0 (IQR: 0–3). In bivariate analysis, higher PRWE scores (0; IQR = 0–2 vs. 4.0; IQR = 0–17; p = 0.0070), higher QuickDASH scores (0; IQR = 0–1.1 vs. 4.5; IQR = 0–11; p < 0.0010), and higher pain scores (0; IQR = 0.0 vs. 0; IQR = 0–4.0; p = 0.010) were associated with female sex ( Table 3 ).
Table 3. Patient-reported outcomes.
| PRWE ( n = 74) | p value | QDASH ( n = 71) | p value | Pain score ( n = 74) | p value | |
|---|---|---|---|---|---|---|
| Median (IQR) | Median (IQR) | Median (IQR) | ||||
| All patients ( n = 77) | 0 (0–12) | 2.3 (0–9.1) | 0 (0–3.0) | |||
| Age (y) | ||||||
| >40 | 0 (0–9.0) | 0.32 a | 0 (0–8.0) | 0.50 a | 0 (0–2.0) | 0.21 a |
| <40 | 4.0 (0–14) | 2.3 (0–9.1) | 0.5 (0–4.0) | |||
| Sex | ||||||
| Male | 0 (0–2.0) | 0.007 a | 0 (0–1.1) | <0.001 a | 0 (0–0) | 0.010 a |
| Female | 4.0 (0–17) | 4.5 (0–11) | 0 (0–4.0) | |||
| Rheumatoid arthritis b | ||||||
| Yes | 0 (0–4) | 0.59 a | 0 (0–2.3) | 0.59 a | 0 (0–2) | 0.56 a |
| No | 0 (0–12) | 2.3 (0–8.0) | 0 (0–3) | |||
| Inflammatory disease b | ||||||
| Yes | 0 (0–4) | 0.62 a | 0 (0–2.3) | 0.46 a | 0 (0–2) | 0.68 a |
| No | 0 (0–12) | 2.3 (0–6.8) | 0 (0–3) | |||
| Wrist location c | ||||||
| Dorsal | 4.0 (0–13) | 0.43 a | 2.3 (0–11) | 0.29 a | 0.5 (0–4.0) | 0.31 a |
| Volar | 0 (0–12) | 0 (0–6.8) | 0 (0–1.0) | |||
| Surgery type | ||||||
| Open | 0 (0–12) | 0.98 a | 2.3 (0–9.1) | 0.56 a | 0 (0–3.0) | 0.84 a |
| Arthroscopic | 0.5 (0–12) | 2.4 (0–11) | 0 (0–4.0) | |||
| Reoperation | ||||||
| Yes | 6.5 (0–13) | 0.94 a | 2.3 (0–4.5) | 0.83 a | 1.5 (0–3.0) | >0.99 a |
| No | 0 (0–12) | 2.3 (0–9.1) | 0 (0–3.5) | |||
Abbreviations: IQR, interquartile range; PRWE, Patient-Rated Wrist Evaluation; QDASH, Quick Disabilities of the Arm, Shoulder, and Hand.
Note: Values in bold indicate p < 0.05.
Using Mann–Whitney U test.
One missing value.
Three missing values.
Discussion
This study evaluated the reoperation rate among 1,076 patients with dorsal (59%) or volar (41%) wrist ganglia with a median follow-up of 4.8 years. The majority of patients were treated by open excision (98%), and a few arthroscopic excisions were performed for dorsal ganglia. Based on this population, the reoperation rate after ganglion excision was 3.3%, with the majority (75%) undergoing reoperations within 3.1 years; no factors associated with reoperation could be identified. Additionally, a subset of patients ( n = 77) completed questionnaires regarding patient-reported outcomes along with self-reported ganglion recurrence and reoperation at a median follow-up of more than 4 years. Among these patients, 10 (13%) reported recurrence, of which 2 (2.6%) reported a reoperation. In most patients, there was little disability following wrist ganglion excision and it was noted that female patients experienced significantly inferior outcomes compared with male patients.
The results of this study need to be interpreted in the light of its limitations. First, this is a large series of patients who were evaluated retrospectively, without standardized operative and postoperative treatment protocols. However, this makes the data more generalizable to other settings and helps us understand the expectations of wrist ganglion excision. Second, there may have been patients who underwent re-excision for a recurrent wrist ganglion at an outside hospital and would not have been recorded in this series, which may lead to underestimation of the reoperation rates. Additionally, not all 1,076 patients could be contacted as this would not have been financially feasible and only 44% of the patients contacted responded. In a study from the United Kingdom, a response rate of 81% was achieved, contacting a total of 48 patients who underwent ganglion excision, and they reported a recurrence rate of 8%. 16 The lower response rate in our study can be explained by the geographic differences. Additionally, longer follow-up time (median: 4 years) at which the questionnaires are completed has been shown to be associated with lower response rates. 17 Furthermore, among the contacted patients, ganglion recurrence was merely based on patient perception, without confirmation by a trained physician. Additionally, the time to reoperation is subject to recall bias and should be interpreted with caution. In spite of these limitations, we had long-term patient-reported outcomes, recurrence, and reoperation rates in 77 patients who completed the questionnaires. Additionally, this is one of the larger series reporting reoperation rates after ganglion excision.
In the current study, the reoperation rates following arthroscopic excision (4.0%) and open excision (3.3%) were similar, but the self-reported recurrence rate was higher after open excision (14%) and arthroscopic excision (8.3%). However, this study was underpowered to draw any conclusions regarding recurrence rates based on surgical technique. Previous studies have reported recurrence rates ranging from 0 to 20% 7 12 16 18 following open excision and 2.4 to 12.3% 5 11 19 20 21 following arthroscopic excision.
In 2015, Head et al published a meta-analysis reporting on 809 open excisions and 512 arthroscopic ganglion excisions, recurrence rates of 21 and 6%, respectively. 12 This suggests a lower recurrence rate following arthroscopic excision. However, a randomized control trial by Kang et al including 72 patients, which was powered to detect a 13% difference in recurrence rate, failed to confirm this. 18 Similarly, the current study reported a reoperation rate of 3.3% following open excision. However, the actual recurrence rate may have been higher as the patient-reported recurrence of 13% may suggest. Kuliński et al used a similar study design as this study and retrospectively evaluated the outcomes following open ganglion excision in 394 patients with a median follow-up of greater than 2 years. 22 They reported a recurrence rate of 12.1% among dorsal wrist ganglia, which is similar to our findings. Balazs et al retrospectively evaluated the outcomes of open dorsal ganglion in 125 active-duty military personnel with at least 1 year of follow-up. 7 They reported a recurrence rate of 9% and all the patients underwent reoperation. This difference compared with our study may be because the patients in their study were younger and on active duty. With regard to arthroscopic ganglion excision, Edwards and Johansen prospectively evaluated 55 patients who underwent arthroscopic dorsal ganglion cyst excision and did not identify any recurrences within 2 years. 4 Additionally, Fernandes et al reported a recurrence rate of 2.9% following arthroscopic ganglion excision in 34 patients with a minimum follow-up of 4 years. 20 Our study confirms previous reoperation and recurrence rates in a large series from a single institutional system and highlights the difference in reoperation and recurrence rates.
Complete ganglion excision has been suggested to reduce recurrence rates. It has been suggested that identification of the ganglion stalk may be easier through an arthroscopic approach. 19 23 The retrospective nature of this study does not make it possible to determine the role of complete stalk excision. It is an interesting finding that not all patients with a recurrence sought a second excision, which may be related to minimal pain interference of the recurrence, as this has been shown to be an important driver to elect surgery. 24 Furthermore, it has been proposed that complications occur more frequently after open excisions (14%) and that they are more severe compared with arthroscopic excision (5%). 12 25 26 This may be related to the fact that volar wrist ganglia are more commonly excised through an open approach and are especially at risk of complication due to the close vicinity of the radial artery to the palmar cutaneous branch of the median nerve. 27 28
Additionally, younger age, ganglia of the dominant hand, duration of symptoms greater than 1 year, and manual occupation have been reported as risk factors for recurrence. 27 29 30 There are contradictory reports regarding the role of sex on ganglion recurrence. 27 29 30 This study aimed to identify factors associated with reoperation using a case-control design, but did not find any significant findings, similar to other studies, 2 7 highlighting the difficulty of achieving sufficient statistical power. Among the 108 patients included in the case-control analysis, there was no statistical difference in recurrence if patients were immobilized. There is no consistency regarding postoperative immobilization with little existing evidence. A previous study by Korman et al showed that immobilization after dorsal wrist ganglion aspiration does not affect outcomes. 31 The role of splinting after ganglion cyst excision remains unclear.
Surgical excision of a ganglion reduces pain and leads to a high degree of patient satisfaction. 8 Following surgical excision, the pain scores are low, with average pain scores of 0 to 1.8. 4 20 21 32 33 In the current study, the Numerical Rating Scale (NRS) pain score at long-term follow-up was similar (median: 0 and mean: 1.8). Interestingly, only female patients (10 of 49, 20%) reported NRS pain scores greater than 5, which is considered a cutoff for moderate or severe pain. 34
Female patients had higher PRWE, QuickDASH, and NRS pain scores at long-term follow-up compared with male patients. The reason for this difference is unclear. Some studies suggested that males are less likely to report their pain. 35 Additionally, differences in coping may play a role in perceived pain or disability following ganglion excision. 36 Another explanation could be that females have increased joint laxity compared with males. 37
In conclusion, the reoperation rate following ganglion excision was 3.3%, with reoperations mostly occurring within the first 3 years after initial surgery. Although the self-reported ganglion recurrence rate was roughly 13%, only 1:5 patients underwent a secondary surgery. Long-term outcomes after ganglion excision show little persisting disability; however, female patients may experience more discomfort in the long term.
Funding Statement
Funding None.
Conflict of Interest None declared.
Statement of Human and Animal Rights
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5). Informed consent was obtained from all patients for being included in the study.
Statement of Informed Consent
Informed consent was waived by the Institutional Review Board given the retrospective nature of this study, along with the large number of patients.
Supplementary Material
References
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