Open resection versus arthroscopic resection for wrist ganglion cysts: A systematic review and meta-analysis

Abstract

This study aimed to review the postoperative outcomes of surgical treatment options for wrist ganglion cysts and perform a meta-analysis comparing the 2 most common techniques: open and arthroscopic resection. We searched PubMed, Embase, Web of Science, and Cochrane Library databases for articles that compared the clinical outcomes of patients who underwent arthroscopic or open resection of the wrist ganglion. After screening, we identified two randomized controlled trials and four retrospective comparative studies. Recurrence rates, complications, functional scores, pain, operative time, and postoperative satisfaction were analyzed. A total of 6 studies met inclusion criteria for data extraction and qualitative synthesis. The two groups had no significant differences in the recurrence rate, postoperative pain, patient satisfaction, and clinical scores. The arthroscopic group had better results than the open group in terms of time to return to work. However, the arthroscopic group had a longer operation time than the open group.

Keywords

ganglion cyst wrist arthroscopy meta-analysis

Introduction

Ganglion cysts are the most prevalent benign neoplasm of the upper extremity, most observed in the wrist region.^1,2 Ganglions are hypothesized to emerge due to the repetitive microtrauma inflicted on the capsular and ligamentous structures of the joint, thereby stimulating fibroblasts located at the synovial-capsule interface. This stimulation subsequently results in the secretion of hyaluronic acid. The presence of a substantial amount of hyaluronic acid, in conjunction with other mucopolysaccharides, leads to the accumulation of a clear and highly viscous fluid within the ganglion.^3,4

Most ganglion cysts do not manifest any symptoms, except for swelling. However, the presence of symptoms such as pain, stiffness, weakness, and activity limitation may indicate a requirement for treatment.^5,6 The management of ganglion cysts can be categorized broadly into two main methods: non-surgical interventions, which include needle aspiration, steroid injections, hyaluronidase injection, and surgical procedures, such as open surgical excision or arthroscopic resection.^2,7–11 Surgical treatment has been shown to have a significantly lower chance of recurrence when compared with non-operative treatments.^2,12 Recent technological advancements in wrist arthroscopy equipment, coupled with the growing sophistication of surgical skills, have resulted in the growing popularity of arthroscopic resection as an alternative approach to cyst removal, as opposed to open excision.^13,14

Several articles have been published that compare the outcomes of these two surgical techniques.^15–20 Nevertheless, there remains a degree of debate as to which of the two surgical techniques is to be preferred. Only a few systematic reviews have addressed this topic, but a meta-analysis using comparative studies has not been published until now.^12,21

The present systematic review and meta-analysis are, thus, designed to compare the outcomes of open resection and arthroscopic resection for ganglion cysts of the wrist.

Materials and methods

This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, as outlined in the latest edition of the Journal of the American Medical Association.²² The review protocol was registered on PROSPERO (Registration No.: CRD420261359398).

Literature search strategy and study eligibility

Relevant studies published between January 1, 2000, and December 31, 2025, were systematically searched for in PubMed, Embase, Web of Science, and the Cochrane Library. The search terms included a combination of synonyms (‘wrist ganglion’) and (‘Arthroscopic’ or ‘Arthroscopy’) and (‘open’). A manual search was conducted to identify potentially relevant articles.

The inclusion criteria for the studies were as follows: (1) studies comparing the outcomes of arthroscopic surgery to open surgery for wrist ganglion, (2) studies with a defined control or comparison group, and (3) studies that contain data suitable for analysis.

Exclusion criteria included: (1) editorial articles, review papers, case reports, or other non-specific formats; (2) studies that presented duplicate data; and (3) studies that did not report clinical outcomes.

Study selection and data extraction

The process and results of the literature search are summarized in a PRISMA flowchart. (Figure 1). Utilizing the search terms described above, we obtained information about articles from each database and imported them into Endnote X9 (Clarivate Analytics, London, England). After the elimination of duplicates, the titles and abstracts of the studies identified through a literature search were independently evaluated by two authors. Following the screening process, the remaining studies were subjected to a full-text review by two independent authors. This review was used to re-evaluate each study’s eligibility. In the event of conflicting opinions or disagreements, a third opinion was sought to reach a consensus. In addition, data including publication year, name of the first author, study design, surgical techniques, number of patients, and follow-up duration were extracted.

Figure 1.

Flow chart for literature identification using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines.

The recurrence rate, the incidence of postoperative complications, and the pain experienced by the patient in the postoperative period were selected as the primary factors for comparison of postoperative outcomes between the two surgical techniques in this analysis. Furthermore, postoperative Disabilities of the Arm, Shoulder, and Hand (DASH), satisfaction rate, and operation time were utilized for sub-analysis.

Risk-of-bias assessment

The present meta-analysis encompassed both randomized controlled trials (RCTs) and retrospective comparative studies that included data to compare both arms. In assessing RCTs, Version 2 of the Cochrane risk of bias tool for randomized trials (RoB 2.0) was utilized to evaluate the individual risks of bias inherent in the included studies.^23,24 The methodological quality of the included comparative studies was evaluated using the Newcastle–Ottawa Scale (NOS). The quality of each study was then classified as either ‘good’, ‘fair’, or ‘poor’. The evaluation of each study was conducted by two independent researchers, who assigned a rating to each study in duplicate. Disagreements between the two evaluators were resolved through discussion with a third author. A funnel plot analysis was conducted to assess the potential for publication bias in the results. Furthermore, Egger’s test was used for data reported in more than three studies, with a p-value of <0.05 indicating possible publication bias.

Statistical analysis

The analysis was conducted utilizing RevMan 5.4 software. (The Cochrane Collaboration, Oxford, England). A heterogeneity test was conducted on each analysis to ascertain the heterogeneity within the data, employing the I² statistic to quantify the degree of inconsistency across outcomes. In instances where evidence of homogeneity was identified (I² ≥ 50%), a random-effects model was employed. Conversely, a fixed-effects model was used when the I² value was <50%.

The assessment of results was conducted by employing standard mean differences (SMDs) for continuous data, pooled odds ratios (ORs) for dichotomous data, and their 95% confidence intervals (CIs). The statistical significance threshold was set at p < 0.05.

Results

Study selection and characteristics of the studies

A total of 213 potential studies were identified through PubMed (n = 137), Embase (n = 44), Web of Science (n = 27), and the Cochrane Library (n = 5). Initially, 62 duplicates were eliminated, following which a comprehensive review of titles and abstracts was conducted on the remaining articles. Following a thorough evaluation, 22 papers were deemed suitable for the subsequent stage of review. Of these, 16 were excluded for various reasons related to inadequate data. Finally, six studies (two RCTs and four retrospective comparative studies) were included in the meta-analysis. None of the RCTs were considered high risk based on the methodological assessment, and all the cohort studies assessed by the NOS were subsequently found to be of good quality (Table 1 and Table 2). A total of 435 patients underwent either open or arthroscopic wrist ganglion resection (234 and 201 patients in the open and arthroscopic groups, respectively). Table 3 describes the detailed characteristics of each study.

Table 1.

Methodological quality of the randomized controlled trials included in the meta-analysis based on the risk of bias tool recommended by the Cochrane collaboration.

Authors (year)	Randomization process	Deviations from intended interventions	Missing outcome data	Measurement of the outcome	Selection of the reported result	Overall risk of bias
Kang et al. (2008)	Some concerns	Some concerns	Low risk	Low risk	Low risk	Some concerns
Rocchi et al. (2008)	Low risk	Low risk	Low risk	Low risk	Low risk	Low risk

Table 2.

Methodological quality of cohort studies evaluated using Newcastle–Ottawa scale.

Authors (year)	Selection				Comparability	Outcome			Total score
Authors (year)	Representativeness of cohort	Selection of non-exposed cohort	Ascertainment of exposure	Demonstration that outcome of interest was not present at start of study	Comparability	Assessment of outcome	Follow-up long enough for outcomes to occur	Adequacy of follow-up cohorts	Total score
Amaro et al. (2020)	★	★	★	★	★	★	★	★	8 (good)
Gürpınar et al. (2020)	★	★	★	★	★★	★	★	★	9 (good)
Konigsberg et al. (2023)	★	★	★	★	★★	★	★	★	9 (good)
Lee et al. (2017)	★	★	★	★	★★	★	★		8 (good)

Table 3.

Characteristics of the included studies. Abbreviations: LOE: level of evidence, FU: follow-up, RCT: randomized controlled trial, DASH: Disabilities of the Arm, Shoulder, and Hand, PRWE: Patient-Rated Wrist Evaluation, VAS: visual analog scale.

Authors (year)	Study design (LOE)	Open, n	Arthroscopic, n	Mean age, years (range)	Mean FU	Location of ganglion	Outcomes recorded
Amaro et al. (2020)	Retrospective cohort (III)	20	36	Open: 42 ± 20	44 ± 19 months	Dorsal wrist ganglion	-Recurrence rate
				Arthroscopic: 32 ± 12			-Satisfaction
							-Time to return to work after surgery
							-Surgical time
							-Preoperative and postoperative pain (VAS)
							-Quick-DASH
							-Complications
Gürpınar et al. (2020)	Retrospective cohort (III)	20	20	Open: 26.9 ± 5.7	Minimum of 18-months	Dorsal wrist ganglion	-Recurrence rate
				Arthroscopic: 25.8 ± 4.9			-Satisfaction
							-Time to return to work after surgery
							-Surgical time
							-Incision length
							-Grip strength
							-Preoperative and postoperative pain
							-Quick-DASH
							-Complications
Kang et al. (2008)	RCT (I)	31	41	Open: 36 (10–54)	Minimum of 12 months	Dorsal wrist ganglion	-Recurrence rate
				Arthroscopic: 34 (16–54)			-Residual pain
				Arthroscopic: 34 (16–54)			-Complications
Konigsberg et al. (2023)	Retrospective cohort (III)	118	54	37.78	93.56 days	Dorsal wrist ganglion	-Recurrence rate
Konigsberg et al. (2023)	Retrospective cohort (III)	118	54	37.78	93.56 days	Dorsal wrist ganglion	-Complications
Lee et al. (2017)	Retrospective cohort (III)	20	25	Open: 34.4 (18–60)	Open: 31.9 (18–47) months	Dorsal wrist ganglion	-Recurrence rate
				Arthroscopic: 34.6 (19–56)	Arthroscopic: 30.4 (19–49) months		-Satisfaction numeric rating scale
							-Reoperation
							-Pain (VAS)
							-PRWE
							-Complications
Rocchi et al. (2008)	RCT (I)	25	25	37 (16–64)	At 24 months follow-up	Volar wrist ganglion	-Recurrence rate
							-Functional recovery time
							-Time lost from work
							-Pain
							-Grip strength
							-Complications

Recurrence rate and other complications

A significant factor in determining the prognosis of ganglion surgery is the rate of recurrence and the occurrence of complications. All the included studies reported adequate data for analysis regarding recurrence rates, and five studies^15–19 complications other than recurrence. The findings of the analysis revealed that there was no statistically significant discrepancy between the two cohorts in terms of recurrence rate (Odds Ratio = 0.64; 95% CI = 0.35, 1.18; I² = 0%), and other complications (Odds Ratio = 1.33; 95% CI = 0.38, 4.61; I² = 32%) (Figure 2).

Figure 2.

Meta-analysis results of (a) recurrence rate and (b) complications except recurrence. Abbreviations: IV: weighted mean difference, CI: confidence interval.

In the sensitivity analysis excluding retrospective studies, it was concluded that there was no difference between the two groups in terms of recurrence rate (Odds Ratio = 0.55; 95% CI = 0.13, 2.36; I² = 0%) and other complications (Odds Ratio = 2.71; 95% CI = 0.61, 12.09; I² = 37%), a finding that is consistent with the results of the overall analysis (Figure 3).

Figure 3.

Sensitivity analysis results of (a) recurrence rate and (b) complications except recurrence. Abbreviations: IV: weighted mean difference, CI: confidence interval.

Pain scores

A visual analog scale (VAS) was utilized to assess postoperative pain scores, and three of the included studies^15,16,18 provided sufficient data for analysis. Postoperative VAS (SMD = −0.32; 95% CI = −0.66, 0.02; I² = 0%) was not significantly different between the two groups (Figure 4).

Figure 4.

Meta-analysis results of postoperative VAS. Abbreviations: SD: standard deviation, IV: weighted mean difference, CI: confidence interval.

DASH scores and patient satisfaction

Only two studies^15,16 reported on DASH scores and patient satisfaction rates. There were no significant differences in both DASH scores (SMD = 0.1; 95% CI = −0.31, 0.51; I² = 0%) and patient satisfaction rate (Odds Ratio = 0.45; 95% CI = 0.15, 1.34; I² = 0%). Due to the limited number of available studies, the pooled estimates for DASH scores and patient satisfaction should be regarded as preliminary (Figure 5).

Figure 5.

Meta-analysis results of (a) postoperative DASH and (b) satisfaction rate. Abbreviations: DASH: Disabilities of the Arm, shoulder, and Hand Abbreviations, SD: standard deviation, IV: weighted mean difference, CI: confidence interval.

Operation time and time lost from work

Two studies^15,16 reported on the operative time. For the analysis of operative time, a random-effects model and SMDs were used. The results of the analysis showed that the operation time was longer in the arthroscopic group than in the open group. (SMD = −1.02; 95% CI = −1.99, −0.05; I² = 78%). The two included studies provided sufficient data on the time lost from work. The time taken to resume work activities was found to be reduced in the arthroscopic group compared to the open group. (SMD = 1.14; 95% CI = 0.48, 1.81; I² = 59%). In view of the restricted number of studies available, the pooled estimates for operative time and return to work should be regarded as provisional (Figure 6).

Figure 6.

Meta-analysis results of (a) operation time and (b) time lost from work complications. Abbreviations: SD: standard deviation, IV: weighted mean difference, CI: confidence interval.

Publication bias

Funnel plot analysis was employed to evaluate the presence of potential publication bias. In addition, Egger’s test was conducted for all variables. (Recurrence rate, p = 0.6023; other complications, p = 0.3509; VAS, p = 0. 0.7279).

Discussion

Surgical intervention is one of the primary treatments for wrist ganglion and has the advantage of a lower recurrence rate when compared with less invasive treatment options, including aspiration and steroid injections.^17,19,25,26 Despite this advantage, open resection is subject to limitations resulting from complications including scarring caused by incision, stiffness, and postoperative pain. To overcome this, resection with arthroscopy was devised, which has the advantages of earlier return to function, minimized postoperative pain, lower recurrence rates, and the opportunity to assess for concomitant intra-articular pathology.^26,27 Several RCTs^17,19 and comparative studies^15,16,18,20 have been reported, aiming to compare the outcomes of open and arthroscopic resection. However, the results of these studies have been inconsistent. To the best of our knowledge, only a few systematic reviews^10,12,21 have been conducted on this issue, and only one meta-analysis has been reported to have pooled comparative studies. However, this meta-analysis is not without its limitations; firstly, it includes only two comparative studies, and secondly, it performs only an analysis of recurrence rates.²⁸ The objective of this meta-analysis was to provide a comparative analysis of the postoperative outcomes following open resection and arthroscopic resection for wrist ganglion. The findings of this meta-analysis demonstrate that arthroscopic resection does not yield superior postoperative outcomes in comparison with open resection in terms of recurrence rate, additional complications, pain score, functional scores, and patient satisfaction.

The recurrence of a ganglion cyst after the administration of treatment has the potential to result in the reappearance of associated symptoms and reoperation. Consequently, the rate of recurrence represents an essential primary outcome measure when assessing outcomes following treatment for a ganglion cyst.²⁹ Clark et al. reported a statistically significant lower recurrence rate with arthroscopic excision (9.4%) compared with open excision (11.2%). In contrast, Konigsberg et al. suggested that open excision leads to a lower recurrence rate of dorsal wrist ganglia than does arthroscopic excision.²⁰ Two RCTs comparing arthroscopic and open resection reported no significant difference in recurrence rates.^17,19 This finding is consistent with the results of the present meta-analysis.

In addition to the possibility of recurrence, complications that may frequently occur after surgical treatment of wrist ganglion include neuropraxia, injury of the vessel, tenosynovitis, hematoma, and wound problems.¹⁰ Several previous studies reported that common complications after arthroscopic excision are related to portal placement, including extensor tenosynovitis (47.4%), neuropraxia (31.6%), and postoperative hematoma (15.8%). In contrast, complications of open exsanguination are more likely to be due to the incision, with stiffness (48.3%), wound healing issues (24.1%), and scar tenderness or keloids (17.2%) reported.^21,30–33 Two previously reported systematic reviews arrived at divergent conclusions. The systematic review by Clark et al. found significantly lower rates of complications associated with arthroscopic excision (7.5% compared to 10.7% respectively).²¹ Conversely, the other by Crawford found similar pooled complication rates between open and arthroscopic excision groups (3% vs 5% respectively), a finding which is consistent with that of our own analysis.¹² The analysis of complication type with a higher probability of occurrence for each surgical method was not performed due to insufficient data. A literature review of the included studies showed no difference in the types of complications between the two groups.

Previous studies have reported a reduction in postoperative pain following arthroscopic cyst excision.^6,34 However, the present meta-analysis found no cases in which postoperative VAS was lower in the arthroscopic group than in the open group. Amaro et al. reported mean postoperative VAS scores of 1.43 and 0.65 for the arthroscopic and open groups, respectively.¹⁵ Similarly, Lee et al. reported similar postoperative VAS scores for the arthroscopic and open groups (1.9 and 0.8, respectively).¹⁵ This meta-analysis found no significant differences in postoperative pain scores between the two groups. Existing literature reports not only postoperative VAS but also significant relief or resolution of pain. However, in many cases, the data provided are not suitable for meta-analysis, thus precluding the possibility of analysis of changes in pain levels before and after surgery.

This meta-analysis found no significant differences in the functional scores and patient satisfaction between the two groups. The DASH scores are a reliable measurement of evaluating functional impairment. Amaro et al. reported no significant difference in the DASH scores between the two groups (4.11 and 4.81, respectively).¹⁵ This is consistent with the findings of the present analysis. A recent systematic review revealed a statistically significant difference, with a higher percentage of patients expressing satisfaction after undergoing arthroscopic excision in comparison to open excision (89.2% vs 85.6%, respectively). However, the present analysis revealed no statistically significant difference between the two groups.

Amaro et al. and Gürpınar et al. both reported that the arthroscopic group had a significantly longer operation time than the open group.^15,16 This is interpreted as being due to the greater difficulty of arthroscopy instrument installation, in addition to the arthroscopy technique being more difficult than in the open group. On the other hand, substantial heterogeneity in operative time (I² = 78%) was observed, which is likely to reflect differences in surgeons’ learning curves and the specific surgical instruments used across different centers. Despite the absence of granular data in the included studies, which precluded formal subgroup analysis, these factors must be considered when interpreting the efficiency of the procedures. In contrast, the return-to-work period was shown to be shorter in the group that underwent arthroscopic resection. A study published recently reported a statistically significant difference of 25 days for the arthroscopy group, in comparison with 45 days for the open excision group.¹⁵ It is hypothesized that this difference is attributable to the smaller size of the incision, and the faster recovery associated with wound healing.

Strengths and limitations

This is the first meta-analysis using comparative studies to compare clinical outcomes between open resection and arthroscopic resection for wrist ganglion cysts. However, this meta-analysis has several limitations. Firstly, the quality of the studies included was found to be relatively low. Of the studies reviewed, only two were of high quality and were RCTs, comparing two groups. The remainder of the studies were of a retrospective comparative design. Secondly, despite efforts to achieve comparable baseline characteristics across all included studies, differences between studies were inevitable, given the inherent heterogeneity of the research designs. Furthermore, a subgroup analysis was conducted on operation time, return-to-work time and patient satisfaction. However, data from only two studies were used in this analysis. Consequently, the results of this subgroup analysis are preliminary, and further research is required. Lastly, variations in surgical procedures, operator proficiency, and rehabilitation protocols were significant factors that could influence outcomes.

Conclusion

In this meta-analysis, we compared the clinical outcomes of arthroscopic resection with those of open surgery for ganglion cysts of the wrist. The findings of this analysis indicate that arthroscopic resection for wrist ganglion cysts does not yield significantly enhanced outcomes in terms of recurrence rate, postoperative pain, patient satisfaction, and clinical scores. Despite the disadvantage of a relatively long operation time, the time until return to work following surgery is shorter than that of the open group. Consequently, it appears that the surgical technique can be determined by the surgeon’s expertise and the patient’s occupational characteristics.

Footnotes

ORCID iDs

Hyun-Gyu Seok

Sam-Guk Park

Ethical considerations

This trial was a meta-analysis that collected data from the other included studies. Ethical approval and consent to participate were not required.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data supporting the findings of this analysis (including the data collection forms and extracted data) are available from the corresponding author upon reasonable request.*

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