Evaluating the Optimal Treatment Pathway for Volar Wrist Ganglia: A Cost-Minimization Analysis.

Abstract

Blind aspiration before surgical excision minimizes overall treatment costs for dorsal wrist ganglia. It is unclear whether this translates to volar wrist ganglia (VWG), as an ultrasound (US)-guided aspiration may be required to minimize risk of radial artery injury. We hypothesized that performing one aspiration prior to considering surgical excision will be more cost-minimal than immediate surgical excision. A microsimulation decision analytic model was developed for four treatment pathways: 1) initial aspiration before proceeding to open excision, 2) aspiration prior to arthroscopic excision, 3) initial open excision, and 4) initial arthroscopic excision. The model concluded at VWG resolution, or a single failed open revision excision. We assumed all aspirations occurred at a separate visit under ultrasound guidance. Resolution rates following each treatment were pooled from the literature. Direct costs were derived from the literature and from our institution's cost database. Indirect costs were derived from the Bureau of Labor and Statistics. We performed one-way sensitivity analyses (OWSA) and threshold analyses on key input variables. Weighted averages for recurrence were 42 ± 8%, 27% ± 2%, and 2% ± 2% following aspiration, open excision, and arthroscopic excision, respectively. US-guided aspiration prior to open excision was the least costly treatment pathway ($2,106 ± $2,233 per resolved case). Initial arthroscopic excision was the costliest strategy ($7,293 ± $521). These findings were robust to all OWSA (including resolution rate and cost estimates). To maximize value of care, one aspiration should be attempted prior to open VWG excision. The cost would be further reduced for hand surgeons who perform their own US-guided aspirations. The role of initial open or arthroscopic excision for VWG treatment is questionable from a cost standpoint.Level of Evidence: III, economic decision analysis.