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What is the Value of Nonsurgical Intervention in the Treatment of Pediatric Ganglion Cysts?
Carolyn Shanks, BS1; Tyler Shaeffer, BS2; David Falk, MD3; Carl Nunziato, MD4; Danielle A Hogarth, BS5; Andrea S. Bauer, MD6; Apurva S Shah, MD MBA3; Hilton P. Gottschalk, MD7; Joshua M Abzug, MD5; Christine Ann Ho, MD8
1University of Texas Southwestern Medical School, Dallas, TX; 2Boston University Medical School, Boston, MA; 3Children's Hospital of Philadelphia, Philadelphia, PA; 4University of Texas Dell Medical School, Austin, TX; 5University of Maryland School of Medicine, Baltimore, MD; 6Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA; 7Orthopaedic Surgery, University of Texas Dell Medical School, Austin, TX; 8Orthopaedics, Children's Medical Center-Texas Scottish Rite Hospital for Children, Dallas, TX

Introduction:
The treatment of ganglion cysts remains understudied in the pediatric population, with the literature showing variable recurrence rates following different types of intervention. This study sought to determine if surgical and nonsurgical management of ganglion cysts improved resolution rates, when compared to observation alone.
Materials and Methods:
We retrospectively reviewed 654 cases of pediatric ganglion cysts treated across 5 institutions between 2012-2017. Mean age at presentation was 11.65.2 years. 469 patients (71.7%) had >6 months follow-up, either via chart review or telephone callbacks (mean 36.9 months). 315 (48.2%) patients had >2 years follow-up (mean 50.0 months). Patients were grouped into 4 different treatment groups: (1) observation, (2) cyst aspiration, (3) removable splint, and (4) surgical excision. Chi-square test was used to make comparisons between groups, and a Z-test was used to determine outcomes of different aspiration techniques.
Results:
For patients followed >2 years, the cyst resolved in 44.2% (72/163) of those observed. Only 18.4% (9/49) of those treated with aspiration resolved, and 54.5% (12/22) of those treated with splint resolved. Surgical excision (open and arthroscopic) led to a resolution of the cyst in 72.8% (59/81) of patients. Observation had higher rates of resolution compared to aspiration (p=0.0011). Splinting and observation showed no difference in cyst resolution (p=0.3590). Surgery had the highest rates of resolution, statistically significant when compared to observation (p<0.0001) and aspiration (p<0.0001). Mean age was not statistically significantly different between patients whose cyst resolved and those who did not, regardless of treatment (p>0.05). Patients older than 10 years were less likely to have the cyst resolve with observation (35%, 28/80) than those younger than 10 years (53%, 44/83) at >2 years follow-up (p=0.02). Additional analysis of the data failed to show a significant difference in resolution of cysts aspirated with ultrasound guidance and those aspirated without ultrasound. There was no statistically significant difference in resolution for cysts aspirated with steroid injection and those without steroid.
Conclusions:
This study did not find evidence that initial nonoperative treatments improved the rate of cyst resolution compared to observation alone in a large pediatric sample. Surgical excision had the overall lowest rate of recurrence. Despite the cost and increased clinic time of splinting and aspiration (in addition to pain to the aspirated pediatric patient), these treatments did not improve rates of cyst resolution in pediatric ganglion cysts compared to observation, with aspiration having higher rates of recurrence.


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