Factors Impacting Recurrence Rate After Open Ganglion Cyst Excision

Abstract

Background: The recurrence rate after open excision of ganglion cysts is approximately 20%. However, this literature is based on a small series of subjects. This study aims to determine the rate and risk of recurrence after open excision of ganglion cysts in a large patient series. Methods: This study included 628 patients who had ganglion cyst excision from 2010 to 2018. A retrospective chart review recorded the following: age, sex, laterality, volar/dorsal location, and recurrence. An overall recurrence rate was calculated. In addition, a 1-way analysis of variance test was used to compare recurrence rates among the individual surgeons, and unpaired t tests were used to compare age of recurrence, dorsal cyst recurrence, laterality of cyst, and recurrence based on sex. Finally, a comparison of recurrence rate over time was conducted for surgeon 3. Results: The overall recurrence rate was 3.8% (24 of 628). The recurrence rates for each surgeon were 3% (9 of 353), 2% (3 of 167), and 11% (12 of 107), P = .02. The age of those with and without a recurrence did not differ (32 years vs 38 years), P = .06. The recurrence rate of dorsal ganglion cysts was 4.1% (14 of 341) compared with 3.5% (10 of 286) for volar ganglion cysts, P = .69. Male patients had a recurrence in 6.4% (13 of 204) of cases compared with 2.6% (11 of 424) of female patients, P = 0.01. There was a decrease in the rate of recurrence from 42.9% to 5.3% over 5 years for surgeon 3. Conclusion: In our sample, male sex and surgeon experience were significant risk factors in ganglion cyst recurrence.

Introduction

Ganglion cysts are common, benign soft tissue masses with a higher incidence in women. The cysts may occur in any joint of the upper extremity, but the highest incidence is in the wrist.^1-3 Approximately 70% of ganglion cysts occur on the dorsal aspect of the wrist, and 20% occur on the volar aspect of the wrist.^1,4-6 These masses are usually asymptomatic but may be associated with paresthesias, pain, and weakness.^1,4,7 Fortunately, approximately 50% to 60% of these masses will resolve spontaneously without treatment.^4,6 Most patients who choose to treat their ganglion cyst do so because of pain or for cosmetic reasons.^4,8-10 These ganglia may be treated with one of several methods: (1) nonsurgical interventions such as aspiration; (2) open excision; and (3) arthroscopic excision.^1,2,8,11 A firm understanding of the risks of complications and rates of recurrence is essential for informed consent.

Treatment of ganglion cysts by aspiration, open excision, and arthroscopic excision each have their own distinct complication profile and rates of recurrence. Studies find recurrence rates from aspiration to be between 60% and 95%.^1,2,9,12 Surgical excision has a risk of recurrence between 1% and 50%.^2,7,8 Arthroscopic resection was found to have a recurrence rate of 8.5% to 30%.^2,8,10,13 Some studies found that the recurrence rate of arthroscopic excision was identical to open excision, whereas others found a significant difference between the 2 methods, with open excision having a greater recurrence rate than arthroscopic excision.^2,6,8,9,11 In addition, studies have found a wide variety of risk factors that may predict recurrence, including excision method, surgeon experience, amount of resection, patient groups studied, location, sex, and age.^3,5,11 Given the wide range of recurrence rates and possible risk factors for recurrence, a study with a large sample size focusing on 1 method and many possible risk factors will help add to the literature and provide a more definitive risk of recurrence after resection of ganglion cysts of the wrist.

The aim of this study was to determine the recurrence rate of ganglion cysts after open excision at our institution over a 10-year-period by 3 board-certified orthopedic hand surgeons.

Methods

After institutional review board approval, a search was performed on the surgical patients of 3 board-certified orthopedic hand surgeons, from 2008 to 2018, using Current Procedural Terminology code 25111. Exclusion criteria included the following: (1) multiple cysts; (2) pathology not consistent with ganglion cyst; (3) lack of medical records; and (4) less than 1-year follow-up. A total of 753 patients were identified, and 628 were included in the study after exclusion criteria were applied (Figure 1).

Figure 1.

Flowchart of the total number of patients in the initial sample, the number of patients who were excluded and the reason for exclusion, the number lost to follow-up, and the final number of patients included in this study.

Information collected included age, sex, location of cysts (volar or dorsal), and whether or not the cyst recurred and when the cyst recurred.

Recurrence rate was calculated for each of the individual surgeons. A 1-way analysis of variance was then performed to compare the recurrence rates of the 3 surgeons. A series of unpaired t tests were then performed to analyze the various risk factors being examined in this study. These included the mean age of those who had a recurred ganglion cyst and the mean age of those who did not have a recurred ganglion cyst, and the percentage of recurred cysts that were located dorsally and the percentage of cysts that did not recur that were located dorsally. The rate of recurrence of dorsal ganglion cysts and volar ganglion cysts was calculated, and these rates were compared using an unpaired t test. In addition, the rates of recurrence between men and women were calculated, and these rates were compared using an unpaired t test. P values were associated with each of these comparisons. A value of P < .05 was determined to be significant for this study. Finally, an individual recurrence rate for each year in this study was calculated for surgeon 3, the most junior of the 3 surgeons included in this study, to elucidate the change of recurrence rate over time.

Results

The overall recurrence rate of ganglion cysts in our population was 3.8% (24 of 628). The recurrence rate for each individual surgeon was 3% (9 of 353), 2% (3 of 167), and 11% (12 of 107), respectively, P = .02 (Table 1). The mean age of those who had a recurrence was 32 years, and the mean age of those who did not have a recurrence was 38 years, P = .06 (Table 2). The percentage of dorsal ganglion cysts in the group that had a recurrence was 58%, and the percentage of dorsal ganglion cysts in the group that did not have a recurrence was 58%, P = .99 (Table 3). The rate of recurrence in those who had a dorsal ganglion cyst was 4.1% (14 of 341), and the rate of recurrence in those with a volar ganglion cyst was 3.5% (10 of 286), P = .7 (Table 4). The recurrence rate in men was 6.4% (13 of 204), and the recurrence rate in women was 2.6% (11 of 424), P = .01 (Table 5). Finally, it was found that the recurrence rate for surgeon 3 decreased from 42.9% in 2013 to 5.3% in 2018 (Supplemental Table 1 and Figure 2).

Table 1.

Ganglion Cyst Recurrence for 3 Surgeons and 1-Way Analysis of Variance With the Calculated P Value.

Surgeon	Recurrences	Total excised	%	P value
Surgeon 1	9	353	3	.017
Surgeon 2	3	167	2
Surgeon 3	12	107	11

Table 2.

Mean Age of Those Who Had a Recurrence and Those Who Did Not With the Calculated P Value.

Surgeon	Mean age	P value
Had a recurrence	32	.06
No recurrence	38

Table 3.

Percentage of Dorsal Cysts in the Groups With and Without Recurred Cysts With the Calculated P Value.

Surgeon	% Dorsal	P value
Had a recurrence	58	.99
No recurrence	58

Table 4.

Rate of Recurrence Between Dorsal and Volar Ganglion Cysts and Calculated P Value.

Surgeon	Recurrences	Total	%	P value
Recurrence in dorsal	14	341	4.10	.69
Recurrence in volar	10	286	3.50

Table 5.

Recurrence Rates of Men and Women and the Calculated P Value.

Surgeon	Recurrences	Total	%	P value
Recurrence in men	13	204	6.37	.01
Recurrence in women	11	424	2.59

Discussion

The recurrence rate after open ganglion cyst excision in this series was 3.8%. Crawford et al found a pooled recurrence rate of 20% for open excision, and Kim et al found a recurrence rate of approximately 4% in a series of 50 patients. Head et al found a pooled recurrence of approximately 20% for open excision. The reasons for the lower recurrence rate are unclear. Perhaps surgeon experience and hand subspecialty training are important factors; however, that would require direct study in future research.^2,5,9

Surgeon experience and male sex were the 2 strongest predictors of recurrence in our series. Surgeon 3 had the least years of experience and the highest recurrence rate. This may suggest that surgeon experience is an important factor in preventing recurrence. Cahill et al found significantly higher rates of complications during idiopathic scoliosis surgery based on surgeon experience, with less experienced surgeons having many more complications. Browne et al found that surgeons who have a higher volume of hip fracture patients have a lower rate of in-hospital mortality compared with those with a lower volume of hip fracture patients.^14,15 These studies bolster the idea that surgeon experience affects recurrence rate the same way surgeon experience effects complications in these other orthopedic operations. In addition, at this institution, the 3 surgeons included in this study use the same technique for open ganglion cyst resection, removing a possible confounding variable to these observed recurrence rates. Finally, an analysis of the recurrence rates for surgeon 3, the most junior surgeon, demonstrated a decrease in the rate of recurrence over time (Figure 2). A future study with a larger population of surgeons with varying levels can help identify the significance of experience as a risk factor of ganglion cyst recurrence. Male sex seemed to be the most important and the greatest risk factor overall for recurrence, and more research should be conducted to establish the potential reason for this higher rate of recurrence.

Figure 2.

The recurrence rate of the most junior surgeon included in this study, Surgeon 3, from the time of employment in 2013 to the most recent year included in this study demonstrating a decrease in recurrence rate over time.

This study has several limitations. First, it is possible that patients had a recurrence but did not seek treatment or presented to a different physician for evaluation and treatment. However, while our local patient cohort is not strictly capitated, the vast majority of patients in this area are limited to our hospital network based on insurance factors, and our institution has access to patient records from nearby hospitals, so the number lost to follow-up is extremely small. Second, it may be difficult to differentiate between a recurrence and a new cyst that developed in very close proximity to the excised cyst. This may lead to an overestimation in recurrence rate in this population of patients. Third, this is a retrospective review that may have missed some patients. Finally, the patients of 3 different surgeons were included in this study; despite the fact that the same method is used, slight differences may still be present.