Surgical and Patient-Centered Outcomes of Open versus Arthroscopic Ganglion Cyst Excision: A Systematic Review

Abstract

Introduction  As the popularity of wrist arthroscopy grows, it continues to prove useful in the treatment of ganglion cysts. Previous studies comparing an arthroscopic technique to traditional open excision have demonstrated generally equivalent results regarding complications and cyst recurrence. However, this systematic review compares the two treatment methods not only regarding cyst recurrence but also regarding patient-centered outcomes. Additionally, new studies in the available literature may allow for further analysis.

Methods  This systematic review identified 23 articles published between 2000 and 2021 that met inclusion criteria. Articles were assessed for quality, and reported cyst recurrence rates, patient satisfaction, patients' preoperative and postoperative pain, and complications associated with either open or arthroscopic excisions were pooled into open excision and arthroscopic excision groups for analysis.

Results  In total, 23 studies accounted for 1,670 cases. Pooled data for patient-centered outcomes indicated a significantly higher patient satisfaction rate (89.2 vs 85.6%, p  < 0.001) and higher reported pain relief (69.5 vs. 66.7%, p  = 0.011) associated with arthroscopic excision versus open excision. Recurrence rates were also significantly lower for the arthroscopic excision group (9.4 vs. 11.2%, p  < 0.001). Overall, the complication rate was significantly lower for arthroscopic excision (7.5 vs. 10.7%, p  < 0.001), but the complication profile distinctly differed between the two methods.

Conclusions  Both arthroscopic and open excision of dorsal wrist ganglions are viable treatment options. However, the results of this meta-analysis suggest benefits associated with the arthroscopic technique in both patient-centered outcomes and in traditional, surgical outcomes. This may prove advantageous as wrist arthroscopy becomes more common.

Multiple theories exist regarding the pathogenesis of ganglion cysts, the most common soft tissue tumor of the hand and wrist. ^{1 2 3 4} Two of these theories implicate chronic processes leading to joint capsule compromise. One possibility is that fibroblasts at the synovial–capsularinterface produce hyaluronic acid leading to cyst formation in response to repetitive microtrauma of capsular and ligamentous supporting structures. ¹ Alternatively, in the “capsular rent theory,” repetitive joint stress may cause an injury to the joint capsule, allowing synovial fluid to leak into periarticular space. ³ Due, in part, to the unclear etiology of dorsal wrist ganglion (DWG) cysts, many treatment options have been proposed.

In addition to observation and symptom management, nonoperative treatment options include aspiration with or without injection of corticosteroid, hyaluronidase, or a sclerosant and may also include multiple punctures of the cyst, electrocautery, and splinting after aspiration. Several studies note variability and often inadequacy of nonoperative treatment with respect to recurrence rates, which approach 50 to 75%. ^{2 3 5} In the cases of operative, both open and arthroscopic excision address joint capsule incompetence. A prior systematic review and meta-analysis comparing interventions found that open surgical excision offers a lower chance of recurrence rate compared with aspiration. ⁶ As wrist arthroscopy has gained in popularity and arthroscopic techniques have improved, arthroscopic excision has shown promising results. ^{7 8} However, its superiority over open excision has yet to be demonstrated. An additional systematic review of open versus arthroscopic excision of DWG from 2018 suggested that both approaches had comparable outcome profiles when assessing only recurrence and complication rates, which provides an incomplete comparison between open and arthroscopic surgeries. ⁹

The aim of this review is to review the most recent literature regarding open versus arthroscopic DWG excisions and to perform an updated analysis focusing on patient-centered outcomes rather than only the traditional metrics of recurrence and complications. Primary outcomes include patient satisfaction and recurrence rates; secondary outcomes are pain reduction and complications. We hypothesize that arthroscopically treated patients will demonstrate improved postoperative pain and patient satisfaction scores with comparable recurrence and complication rates between the two groups.

Materials and Methods

Literature Review and Article Eligibility

This study was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines without external funding. A literature search of the PubMed and Web of Science databases was performed with the search term “wrist ganglion excision” and with filters for English language, between the years 2000 and 2021, and among full-text articles. Two independent reviewers (S.N. and M.B.) assessed the titles and abstracts separately for relevancy. Abstracts that suggested inclusion in this review were saved for full manuscript review. Inclusion and exclusion criteria were then applied to select articles for analysis.

Inclusion criteria were (1) primary studies, (2) study design with level of evidence I, II, III, or IV, (3) studies including treatment and outcome data for wrist ganglion cysts, and (4) those with a minimum of 12-month follow-up.

Exclusion criteria included (1) case reports, expert opinions, or other studies with level V evidence, (2) studies published in languages other an English, (3) studies including pre-existing wrist instability, (4) studies with incomplete datasets, (5) studies involving nonhuman subjects or cadaveric studies, and (6) basic science studies or biomechanical studies ( Fig. 1 ).

Fig. 1.

PRISMA flow diagram of article attrition through search algorithm.

Data Extraction and Analysis

Qualified studies that met the criteria were examined, and the two reviewers extracted all relevant data including study sample size, patient demographics, average clinical follow-up, surgical technique (open versus arthroscopic), tourniquet use, method of anesthesia, cyst recurrence rates, patient satisfaction, patient's preoperative and postoperative pain, and other reported complications.

Primary outcomes were overall patient satisfaction and cyst recurrence rate for open excision and arthroscopic procedures. Patient satisfaction was either found as a reported outcome in the included studies or as part of reported postoperative questionnaires when possible, and recurrence rates were directly reported in included studies. Secondary outcomes were patient reported reduction in pain, pain score in the form of visual analog scale (VAS) numerical data, and other reported complications not including pain or recurrence.

Demographic data, primary outcome measures, and secondary outcome measures from comparable studies were extracted when available and pooled for all patients. These data were pooled, and weighted averages were obtained when possible. Categorical variables between the open excision group and the arthroscopic procedure group were evaluated as percentages, and continuous variable were compared with t -tests with a p -value of <0.05 for statistical significance. Rates and ratios were converted to percentages when applicable for descriptive comparison.

Quality Appraisal

Internal and external validity of the study was determined based on a set of 10 criteria. ¹⁰ Each affirmative answer resulted in one point for a maximum of 10 points per study ( Table 1 ).

Table 1. Quality assessment scoring criteria applied to included articles.

Scoring criteria (maximum of 10 points) a
1. Was the population included in the study described adequately?
2. Were the inclusion and exclusion criteria clearly defined?
3. Was the selection of patients for inclusion in the study unbiased? Was there systematic exclusion of any single group?
4. Was the included participant group similar to the population at large that is affected by the condition studied?
5. Was there significant attrition rate of study participants?
6. Was there a clear description of methodology and techniques in the study?
7. Was there unbiased and accurate assessment of outcomes and complications in the study?
8. Were potential confounding variables and risk factors identified and examined using acceptable statistical techniques?
9. Was the duration of follow-up reasonable for investigated outcomes?
10. Was the funding source and role of funder clearly defined in the study? Were there any conflicts of interest identified or easily apparent?

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Results

Literature Review

The literature search resulted in 137 unique results of which 37 articles were found to be appropriate for inclusion after a review of abstracts. After applying inclusion and exclusion criteria, 23 studies were incorporated for data extraction and meta-analysis. ^{11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33} All of the studies included met at least eight or more of the quality criteria set forth for assessing internal and external validities ( Table 2 ).

Table 2. Design and quality assessment of included studies.

Study author (year published)	Study design	Level of evidence	Quality criteria a (Max of 10)	Follow-up (years)
Ahsan and Yao (2014) 11	Case Series	4	9	2.1
Aslani et al (2012) 12	Case Series	4	10	3.3
Balazs et al (2015) 13	Case Series	4	9	3.8
Borisch (2016) 14	Case Series	4	9	2.4
Chen et al (2010) 15	Case Series	4	10	1.3
Cluts and Fowler (2020) 16	Case Series	4	8	1.0
Craik and Walsh (2012) 17	Case Series	4	8	3.7
Dermon et al (2011) 18	Case Series	4	8	3.5
Dias et al (2007) 19	Randomized control trial	1	10	5.9
Edwards and Johansen (2009) 20	Case Series	4	10	2.0
Gallego and Mathoulin (2010) 21	Case Series	4	10	3.5
Gurpinar and Çarkçı (2020) 22	Randomized control trial	2	9	1.5
Jagers et al (2002) 23	Randomized control trial	1	9	1.0
Kang et al (2008) 24	Randomized control trial	1	9	1.0
Kang et al (2013) 25	Cohort	3	8	3.3
Khan and Hayat (2011) 26	Randomized control trial	1	9	1.0
Kim et al (2013) 27	Case series	4	9	2.7
Lee et al (2017) 28	Cohort	3	9	2.7
Mathoulin et al (2004) 29	Cohort	3	9	2.8
Rizzo et al (2004) 30	Case series	4	10	4.0
Shih et al (2002) 31	Cohort	3	9	2.3
Yamamoto et al (2012) 32	Case series	4	9	1.8
Yamamoto et al (2018) 33	Case series	4	9	1.8

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Study Details

A total of 1,670 cases were compiled from all 23 studies, which included 737 cases not accounted for in the most recent systematic review evaluating open and arthroscopic DWG excision. ⁹ The arthroscopic excision group included 802 patients with an average age of 33.6 years and 64% female. The open excision group included 868 patients with an average age of 34.9 years and 58% female. When a study reported on both arthroscopic and open excision patients, the data were extracted and pooled into the correct subgroup for the meta-analysis (available in Appendix).

Patients in the arthroscopic excision cohort trended toward a greater likelihood of having additional preoperative imaging such as an ultrasound or magnetic resonance imaging but it did not reach statistical significance ( p  = 0.056).

Anesthesia type was separated into four categories: local, regional block, general, or any of the above. Regional nerve blocks most often consisted of axillary anesthetization of the brachial plexus. The arthroscopic technique varied; most commonly the 3–4 portal was used in conjunction with the 4–5 or 6R portal. Open excision consisted of an incision on the dorsal aspect of the hand and dissection of the ganglion until complete visualization was obtained of the ganglion and the stalk. When described, patients were immobilized for an average of 4 days postoperatively. Approximately, half the studies reported the use of only soft dressings postoperatively ( Table 3 ).

Table 3. Surgical factors of included studies.

Study	Number of surgeons	Surgical technique	Number of cases	Anesthesia type
Ahsan and Yao (2014) 11	Single	Arthroscopic excision	27	NR
Aslani et al (2012) 12	Single	Arthroscopic excision	52	Block
Balazs et al (2015) 13	Single	Open excision	125	NR
Borisch (2016) 14	Single	Arthroscopic excision	40	Block
Chen et al (2010) 15	Single	Arthroscopic excision	15	Block
Cluts and Fowler (2020) 16	Multiple	Open excision	341	NR
Craik and Walsh (2012) 17	NR	Open excision	29	Any
Dermon et al (2011) 18	NR	Open excision	46	Block
Dias et al (2007) 19	Multiple	Open excision	103	Block
Edwards and Johansen (2009) 20	Single	Arthroscopic excision	55	NR
Gallego and Mathoulin (2010) 21	NR	Arthroscopic excision	114	Block
Gurpinar and Çarkçı (2020) 22	Single	Arthroscopic versus open excision	40	Any
Jagers et al (2002) 23	Single	Open excision	25	Block
Kang et al (2008) 24	Multiple	Arthroscopic versus open excision	51	Any
Kang et al (2013) 25	Single	Arthroscopic excision	41	General
Khan and Hayat (2011) 26	NR	Open excision	18	Block
Kim et al (2013) 27	Single	Arthroscopic excision	115	Block
Lee et al (2017) 28	Single	Arthroscopic versus open excision	45	Any
Mathoulin et al (2004) 29	Multiple	Arthroscopic excision	96	Block
Rizzo et al (2004) 30	NR	Arthroscopic excision	41	NR
Shih et al (2002) 31	NR	Arthroscopic excision	32	Block
Yamamoto et al (2012) 32	Multiple	Arthroscopic excision	21	Block
Yamamoto et al (2018) 33	Multiple	Arthroscopic excision	26	NR

Abbreviation: NR, not reported.

Patient-Centered Outcomes

Twenty studies, accounting for 1,245 patients in either open or arthroscopic groups, included patient-centered outcome measures. ^{12 13 14 15 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32} Eight studies (344 patients) reported directly on patient satisfaction obtained in surgical follow-up. ^{13 15 16 18 20 23 25 29} Analysis of reported patient satisfaction revealed a statistically significant difference with more patients satisfied after undergoing arthroscopic excision than open excision (89.2 vs. 85.6%, p  < 0.001).

Additionally, 18 studies reported the number of patients endorsing significant relief or resolution of pain. ^{12 13 14 15 17 18 19 20 21 22 24 25 27 28 30 31 32 33} The arthroscopic excision cohort reported a greater percentage of patients who endorsed pain relief (69.5 vs. 66.7%, p  = 0.011). However, the open excision cohort began with a statistically and clinically significantly higher VAS (6.4 vs. 3.6, p  < 0.001) compared with the arthroscopic excision cohort in the 11 studies that reported average preoperative and postoperative VAS scores. ^{14 18 20 21 22 25 27 28 30 32 33}

Recurrence

All studies reported on recurrence. There was a statistically significant lower recurrence rate with arthroscopic excision compared with open excision (9.4 vs. 11.2%, p  < 0.001). This resulted in a “number needed to treat” of 56 excisions.

Complications

There were 16 studies that reported complications. ^{11 12 13 15 19 20 21 22 24 25 26 28 29 30 32 33} Overall, significantly fewer complications were associated with arthroscopic excision (7.5 vs. 10.7%, p  < 0.001). This resulted in a “number needed to treat” of 33 excisions. The most common complication after arthroscopic excision was extensor synovitis or tendonitis (47.4%) followed by neuropraxia likely secondary to portal placement (31.6%), postoperative hematoma (15.8%), and conversion to open excision due to inability to reach the ganglion through either portal (5.3%). The most common complications after open excision were stiffness (48.3%), wound healing issues (24.1%), scar tenderness or keloids (17.2%), and numbness (10.3%).

Discussion

This systematic review aimed to evaluate both patient-centered outcomes and recurrence and complication rates associated with open and arthroscopic excision of DWG. Additional studies with 737 additional cases were identified by systematic review for inclusion since the last review of this subject, which improves the ability of meta-analysis to discern differences between study groups. The findings of this meta-analysis not only suggest previously-unidentified differences in recurrence and complications rates between the two treatments, but these findings also evaluate the two excision techniques in the context of patient-centered outcomes.

The two primary outcomes of this study were selected because the focus of our meta-analysis was to compare patient satisfaction and a patient-centered metric that is gaining importance, while still considering the previous standard of cyst recurrence. For both of the primary outcomes, patient satisfaction and recurrence rate, the available data indicated significantly favorable outcomes following arthroscopic excision compared with open excision.

As more orthopaedic research focuses on patient-centered outcomes, it becomes increasingly important to include them when analyzing common problems. Our pooled data yielded a patient satisfaction rate of 89.2% for patients who underwent arthroscopic excision and 85.6% for patients who underwent open excision, a small but statistically significant difference. Previous systematic reviews have not compared patient outcomes in this context, but it has become possible as more recent primary studies have included these measures. If reviewed studies did not directly describe patient satisfaction, those studies were not included in this portion of the meta-analysis. As a result, only eight of the included studies reported patient satisfaction. Although there is not an established minimal clinically important difference, this finding should be discussed with patients, and it should be considered when additional studies are performed on this subject. Our conclusions regarding patient satisfaction are further strengthened when considered together with recurrence rates.

For our second primary outcome, cyst recurrence rate, a significant difference was found between open and arthroscopic treatment that favored arthroscopic excision. As cyst recurrence has served as a historical standard when evaluating ganglion cyst treatment, it was consistently reported in the studies included in this review. Prior reviews did not discern a significant difference between open and arthroscopic excision. ^{6 9} In this current meta-analysis, the addition of new studies and patients into the pooled dataset may have helped detect small changes.

For the two secondary outcomes of this meta-analysis, pain and complications, only postoperative complications demonstrated a significant difference between the two groups. Our secondary outcomes were selected as additional factors that both patients and surgeons may consider when selecting the treatment option. The difference in postsurgical pain reduction following arthroscopic excision or open excision did not reach clinical significance. It is not entirely surprising that there was more variability and reported pain since cyst excision is not always prompted by pain. For example, many patients also cite cosmetic reasons as the impetus for pursuing surgery. ^{19 34} On the contrary, this meta-analysis did discern a significant difference in the complication rate, favoring arthroscopic excision. What must be considered further is that the complication profiles also varied between the two surgical options. For example, wound healing contributed to the open excision complication profile, but complications related to portal placement accounted for a greater portion of the arthroscopic complications. Therefore, when counseling patients or considering a surgical option, it is important to be clear on the rationale for surgery and to be aware of which complications are likely to arise given the selected modality.

Although many of the differences seen in the outcomes evaluated in the study reached clinical significance, there are some caveats and weaknesses that must be considered.

The first limitation of this study was the level of available evidence. We attempted to offset this limitation by grading the quality of evidence with a 10-point grading scheme, and each study met at least 8 out of the 10 criteria. Another difficulty when performing any meta-analysis is navigating inconsistencies in reporting both preoperative symptoms and postoperative outcomes. For example, the recurrence rate was the only metric for which all studies reported outcomes. For the other included metrics, reporting was consistent enough for the performance of meta-analysis. The final limitation we encountered was variability in the arthroscopic technique. This is likely because these techniques are still changing and evolving as the literature is being developed.

Based on this systemic review and meta-analysis, we have found arthroscopic excision of ganglion cysts to be favorable when compared with open excision, with respect to patient-centered outcomes and complication profile without compromising the historical outcome measure of cyst recurrence. Furthermore, the systematic review found a significant improvement in cyst recurrence where previous studies were not able to find a difference. Therefore, as arthroscopic surgery becomes more mainstream, and techniques improve we believe this serves as a valuable treatment option for a common wrist pathology.

Appendix. Summary data from included studies.

Outcome measured ( n  = sample size reporting)	Arthroscopic excision group- averages and standard deviation between studies	Open excision group- averages and standard deviation between studies	Significant difference ( p ≤ 0.05)
Average age in years (1,670)	33.6 ± 4.1	34.9 ± 3.8	0.48
Gender % female (1670)	64% ± 0.12%	58% ± 0.14%	0.35
Right hand dominance (427)	58% ± 0.06%	51% ± 0.11%	0.85
Patient satisfaction reported (344)	89.2% ± 0.10%	85.6% ± 0.06%	<0.001
Pain relief reported (831)	69.7% ± 0.23%	66.7% ± 0.13%	0.011
Cyst recurrence (1670)	9.4% ± 0.05%	11.2% ± 0.11%	<0.001
Complications (1670)	7.5% ± 0.10%	10.7% ± 0.09%	<0.001

Note: Bold values denote significance ( p ≤ 0.05).

Funding Statement

Funding None.