Editor's Choice| Volume 48, ISSUE 1, P9-18, January 2023

Minimizing Costs for Dorsal Wrist Ganglion Treatment: A Cost-Minimization Analysis

Published:November 17, 2022DOI:https://doi.org/10.1016/j.jhsa.2022.09.002


      Dorsal wrist ganglions are treated commonly with aspiration, or open or arthroscopic excision in operating room (OR) or procedure room (PR) settings. As it remains unclear which treatment strategy is most cost-effective in yielding cyst resolution, our purpose was to perform a formal cost-minimization analysis from the societal perspective in this context.


      A microsimulation decision analytic model evaluating 5 treatment strategies for dorsal wrist ganglions was developed, ending in either resolution or a single failed open revision surgical excision. Strategies included immediate open excision in the OR, immediate open excision in the PR, immediate arthroscopic excision in the OR, or 1 or 2 aspirations before each of the surgical options. Recurrence and complications rates were pooled from the literature for each treatment type. One-way sensitivity and threshold analyses were performed.


      The most cost-minimal strategy was 2 aspiration attempts before open surgical excision in the PR setting ($1,603 ± 1,595 per resolved case), followed by 2 aspirations before open excision in the OR ($1,969 ± 2,165 per resolved case). Immediate arthroscopic excision was the costliest strategy ($6,539 ± 264 per resolved case). Single aspiration preoperatively was more cost-minimal than any form of immediate surgery ($2,918 ± 306 and $4,188 ± 306 per resolved case performed in the PR and OR, respectively).


      From the societal perspective, performing 2 aspirations before surgical excision in the PR setting was the most cost-minimal treatment strategy, although in reference to surgeons who do not perform this procedure in the PR setting, open excision in the OR was nearly as cost-effective. As patient preferences may preclude routinely performing 2 aspirations, performing at least 1 aspiration before surgical excision improves the cost-effectiveness of dorsal wrist ganglions treatment.

      Type of study/level of evidence

      Economic Decision Analysis II.

      Key words

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        • Mathoulin C.
        • Gras M.
        Arthroscopic management of dorsal and volar wrist ganglion.
        Hand Clin. 2017; 33: 769-777
        • Head L.
        • Gencarelli J.R.
        • Allen M.
        • Boyd K.U.
        Wrist ganglion treatment: systematic review and meta-analysis.
        J Hand Surg Am. 2015; 40: 546-553 e8
        • Dermon A.
        • Kapetanakis S.
        • Fiska A.
        • Alpantaki K.
        • Kazakos K.
        Ganglionectomy without repairing the bursal defect: long-term results in a series of 124 wrist ganglia.
        Clin Orthop Surg. 2011; 3: 152-156
        • Young L.
        • Bartell T.
        • Logan S.E.
        Ganglions of the hand and wrist.
        Southern Med J. 1988; 81: 751-760
        • Angelides A.C.
        • Wallace P.F.
        The dorsal ganglion of the wrist: its pathogenesis, gross and microscopic anatomy, and surgical treatment.
        J Hand Surg Am. 1976; 1: 228-235
        • Rocchi L.
        • Canal A.
        • Fanfani F.
        • Catalano F.
        Articular ganglia of the volar aspect of the wrist: arthroscopic resection compared with open excision. A prospective randomised study.
        Scand J Plast Reconstr Surg Hand Surg. 2008; 42: 253-259
        • Lee V.S.
        • Kawamoto K.
        • Hess R.
        • et al.
        Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality.
        JAMA. 2016; 316: 1061-1072
        • Kawamoto K.
        • Martin C.J.
        • Williams K.
        • et al.
        Value driven outcomes (VDO): a pragmatic, modular, and extensible software framework for understanding and improving health care costs and outcomes.
        J Am Med Inform Assoc. 2015; 22: 223-235
        • Papanicolas I.
        • Woskie L.R.
        • Jha A.K.
        Health care spending in the United States and other high-income countries.
        JAMA. 2018; 319: 1024-1039
        • Fisher E.S.
        • Bynum J.P.
        • Skinner J.S.
        Slowing the growth of health care costs--lessons from regional variation.
        N Engl J Med. 2009; 360: 849-852
        • Pang E.Q.
        • Zhang S.
        • Harris A.H.S.
        • Kamal R.N.
        Cost minimization analysis of ganglion cyst excision.
        J Hand Surg Am. 2017; 42: 750 e1-750 e4
        • Van Demark Jr., R.E.
        • Smith V.J.S.
        • Fiegen A.
        Lean and green hand surgery.
        J Hand Surg Am. 2018; 43: 179-181
        • Alter T.H.
        • Warrender W.J.
        • Liss F.E.
        • Ilyas A.M.
        A cost analysis of carpal tunnel release surgery performed wide awake versus under sedation.
        Plast Reconstr Surg. 2018; 142: 1532-1538
        • Kazmers N.H.
        • Presson A.P.
        • Xu Y.
        • Howenstein A.
        • Tyser A.R.
        Cost implications of varying the surgical technique, surgical setting, and anesthesia type for carpal tunnel release surgery.
        J Hand Surg Am. 2018; 43: 971-977 e1
        • Davison P.G.
        • Cobb T.
        • Lalonde D.H.
        The patient's perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study.
        Hand (N Y). 2013; 8: 47-53
        • Sanders G.D.
        • Neumann P.J.
        • Basu A.
        • et al.
        Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine.
        JAMA. 2016; 316: 1093-1103
        • Hatchell A.
        • Meathrel K.
        • Farrokhyar F.
        • Hynes N.
        A prospective randomized controlled trial of aspiration and fibrin sealant use versus aspiration alone in the treatment of dorsal wrist ganglia.
        Plast Surg (Oakv). 2019; 27: 22-28
        • Khan P.S.
        • Hayat H.
        Surgical excision versus aspiration combined with intralesional triamcinolone acetonide injection plus wrist immobilization therapy in the treatment of dorsal wrist ganglion; a randomized controlled trial.
        J Hand Microsurg. 2011; 3: 55-57
        • Limpaphayom N.
        • Wilairatana V.
        Randomized controlled trial between surgery and aspiration combined with methylprednisolone acetate injection plus wrist immobilization in the treatment of dorsal carpal ganglion.
        J Med Assoc Thai. 2004; 87: 1513-1517
        • Nasab S.A.M.
        • Mashhadizadeh E.
        • Sarrafan N.
        Comparative study between three methods of aspiration alone, aspiration plus steroid injection and aspiration plus ethanol injection for treatment of dorsal wrist ganglions.
        Pak J Med Sci. 2012; 28: 404-407
        • Nishikawa S.
        • Toh S.
        • Miura H.
        • Arai K.
        • Irie T.
        Arthroscopic diagnosis and treatment of dorsal wrist ganglion.
        J Hand Surg Br. 2001; 26: 547-549
        • Kang L.
        • Akelman E.
        • Weiss A.P.
        Arthroscopic versus open dorsal ganglion excision: a prospective, randomized comparison of rates of recurrence and of residual pain.
        J Hand Surg Am. 2008; 33: 471-475
        • Rathod C.M.
        • Nemade A.S.
        • Badole C.M.
        Treatment of dorsal wrist ganglia by transfixation technique.
        Niger J Clin Pract. 2011; 14: 445-448
        • Kurkis G.
        • Anastasio A.
        • DeVos M.
        • Gottschalk M.B.
        Ultrasound-guided aspiration does not reduce the recurrence rate of ganglion cysts of the wrist.
        J Wrist Surg. 2019; 8: 100-103
        • Aslani H.
        • Najafi A.
        • Zaaferani Z.
        Prospective outcomes of arthroscopic treatment of dorsal wrist ganglia.
        Orthopedics. 2012; 35(3): e365-e370
        • Gallego S.
        • Mathoulin C.
        Arthroscopic resection of dorsal wrist ganglia: 114 cases with minimum follow-up of 2 years.
        Arthroscopy. 2010; 26(12) (1675-82)
        • Rocchi L.
        • et al.
        Results and complications in dorsal and volar wrist Ganglia arthroscopic resection.
        Hand Surg. 2006; 11(1-2): 21-26
        • Dias J.J.
        • Dhukaram V.
        • Kumar P.
        The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention..
        J Hand Surg Eur. 2007; 32(5): 502-508
        • Zeidenberg J.
        • et al.
        Ultrasound-guided aspiration of wrist ganglions: a follow-up survey of patient satisfaction and outcomes.
        Acta Radiol. 2016; 57(4) (481-6)
        • Craik J.D.
        • Walsh S.P.
        Patient outcomes following wrist ganglion excision surgery..
        Hand Surg Eur Vol. 2012; 37(7) (673-7)
        • Faithfull D.K.
        • Seeto B.G.
        The simple wrist ganglion--more than a minor surgical procedure?.
        Hand Surg. 2000; 5(2) (139-43)
        • Finsen V.
        • Haberg O.
        • Borchgrevink G.E.
        Surgery for wrist Ganglia: one-hundred and twenty-two patients reviewed 8 years after operation..
        Orthop Rev (Pavia). 2014; 6(1): 5162
        • Gundes H.
        • et al.
        Prognosis of wrist ganglion operations..
        Acta Orthop Belg. 2000; 66(4) (363-7)
        • Kulinski S.
        • et al.
        Dorsal and volar wrist ganglions: The results of surgical treatment.
        Adv Clin Exp Med. 2019; 28(1): 95-102
        • Lidder S.
        • Ranawat V.
        • Ahrens P.
        Surgical excision of wrist ganglia; literature review and nine-year retrospective study of recurrence and patient satisfaction.
        Orthop Rev (Pavia). 2009; 1(1): 5
        • Jagers Op Akkerhuis M.
        • Van Der Heijden M.
        • Brink P.R.
        Hyaluronidase versus surgical excision of ganglia: a prospective, randomized clinical trial.
        J Hand Surg Br. 2002; 27(3) (256-8)
        • Edwards S.G.
        • Johansen J.A.
        Prospective outcomes and associations of wrist ganglion cysts resected arthroscopically.
        J Hand Surg Am. 2009; 34(3): 395-400
        • Fernandes C.H.
        • et al.
        Arthroscopic Resection of Dorsal Wrist Ganglion: Results and Rate of Recurrence Over a Minimum Follow-up of 4 Years.
        Hand (N Y). 2019; 14(2): 236-241
        • Ho P.C.
        • et al.
        Current treatment of ganglion of the wrist.
        Hand Surg. 2001; 6(1): 49-58
        • Kim J.P.
        • et al.
        Arthroscopic excision of dorsal wrist ganglion: factors related to recurrence and postoperative residual pain.
        Arthroscopy. 2013; 29(6) (1019-24)
        • Luchetti R.
        • et al.
        Arthroscopic resection of dorsal wrist ganglia and treatment of recurrences.
        J Hand Surg Br. 2000; 25(1): 38-40
        • Mathoulin C.
        • Hoyos A.
        • Pelaez J.
        Arthroscopic resection of wrist ganglia.
        Hand Surg. 2004; 9(2) (159-64)
        • Osterman A.L.
        • Raphael J.
        Arthroscopic resection of dorsal ganglion of the wrist.
        Hand Clin. 1995; 11(1): 7-12
        • Rizzo M.
        • et al.
        Arthroscopic resection in the management of dorsal wrist ganglions: results with a minimum 2-year follow-up period.
        J Hand Surg Am. 2004; 29(1): 59-62
        • Shih J.T.
        • et al.
        Dorsal ganglion of the wrist: results of treatment by arthroscopic resection.
        Hand Surg. 2002; 7(1): 1-5
        • Yamamoto M.
        • et al.
        Sonography-guided arthroscopic excision is more effective for treating volar wrist ganglion than dorsal wrist ganglion.
        Acta Orthop Belg. 2018; 84(1): 78-83
        • Centers for Medicare & Medicaid Services
        Medicare provider utilization and payment data: physician and other supplier.
        (Accessed May 19, 2020.)
        • Agency for Healthcare Research and Quality
        • Healthcare Cost & Utilization Project (HCUP) State Ambulatory Surgery and Services Databases (SASD)
        Rockville, MD: Agency for Healthcare Research and Quality.
        (Accessed May 19, 2020.)
        • Bureau of Labor Statistics
        Usual weekly earnings of wage and salary workers: first quarter 2020.
        • Bureau of Economic Analysis
        Table 2.3.4. Price indexes for personal consumption expenditures by major type of product: health care.
        • Lalonde D.
        • Eaton C.
        • Amadio P.
        • Jupiter J.
        Wide-awake hand and wrist surgery: a new horizon in outpatient surgery.
        Instr Course Lect. 2015; 64: 249-259
        • Lalonde D.
        • Martin A.
        Tumescent local anesthesia for hand surgery: improved results, cost effectiveness, and wide-awake patient satisfaction.
        Arch Plast Surg. 2014; 41: 312-316
        • Kazmers N.H.
        • Stephens A.R.
        • Presson A.P.
        • Xu Y.
        • Feller R.J.
        • Tyser A.R.
        Comparison of direct surgical costs for proximal row carpectomy and four-corner arthrodesis.
        J Wrist Surg. 2019; 8: 66-71
        • Luther G.A.
        • Murthy P.
        • Blazar P.E.
        Cost of immediate surgery versus non-operative treatment for trigger finger in diabetic patients.
        J Hand Surg Am. 2016; 41: 1056-1063
        • Yoo M.
        • Nelson R.E.
        • Illing D.A.
        • Martin B.I.
        • Tyser A.R.
        • Kazmers N.H.
        Cost-effectiveness analysis comparing proximal row carpectomy and four-corner arthrodesis.
        JB JS Open Access. 2020; 5e0080
        • Maliha S.G.
        • Cohen O.
        • Jacoby A.
        • Sharma S.
        A cost and efficiency analysis of the WALANT technique for the management of trigger finger in a procedure room of a major city hospital.
        Plast Reconstr Surg Glob Open. 2019; 7e2509
        • Kerrigan C.L.
        • Stanwix M.G.
        Using evidence to minimize the cost of trigger finger care.
        J Hand Surg Am. 2009; 34: 997-1005

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