A Systematic Review and Meta-analysis of Randomized Controlled Trials Comparing Surgical versus Conservative Treatments for Acute Undisplaced or Minimally-Displaced Scaphoid Fractures

Alajmi, Turki; Alfaryan, Khalid Hisham; Al-Kanaan, Naif F.; Alkhodair, Abdulmalik A.; Alfaryan, Thamer; Al-Oraini, Maher I.; Bassas, Abdulelah F.

doi:10.4055/cios.2018.10.1.64

Cited by 24 publications

(12 citation statements)

References 22 publications

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“…The studies reported are small, with different time points, and some reviews 29 and meta-analyses have also included case series. 24,44,149,150 The data from these studies have been extracted systematically and meta-analysed on numerous occasions. [29][30][31][32][33][34]36,37 One study reported PRWE score at 10 years in 75 of 83 patients randomised to scaphoid cast treatment or surgical fixation with a Herbert headless screw and the mean score was 6 in each group.…”

Section: Sensitivity Analyses Of the Patient-rated Wrist Evaluationmentioning

confidence: 99%

Surgical fixation compared with cast immobilisation for adults with a bicortical fracture of the scaphoid waist: the SWIFFT RCT

Dias

Brealey

Cook

et al. 2020

Health Technol Assess

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Background Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. Immediate surgical fixation of this fracture has increased. Objective To compare the clinical effectiveness and cost-effectiveness of surgical fixation with cast treatment and early fixation in adults with scaphoid waist fractures that fail to unite. Design Multicentre, pragmatic, open-label, parallel two-arm randomised controlled trial with an economic evaluation and a nested qualitative study. Setting Orthopaedic departments of 31 hospitals in England and Wales recruited from July 2013, with final follow-up in September 2017. Participants Adults (aged ≥ 16 years) presenting within 2 weeks of injury with a clear, bicortical fracture of the scaphoid waist on plain radiographs. Interventions Early surgical fixation using Conformité Européenne-marked headless compression screws. Below-elbow cast immobilisation for 6–10 weeks and urgent fixation of confirmed non-union. Main outcome measures The primary outcome and end point was the Patient-Rated Wrist Evaluation total score at 52 weeks, with a clinically relevant difference of 6 points. Secondary outcomes included Patient-Rated Wrist Evaluation pain and function subscales, Short Form questionnaire 12-items, bone union, range of movement, grip strength, complications and return to work. Results The mean age of 439 participants was 33 years; 363 participants were male (83%) and 269 participants had an undisplaced fracture (61%). The primary analysis was on 408 participants with valid Patient-Rated Wrist Evaluation outcome data for at least one post-randomisation time point (surgery, n = 203 of 219; cast, n = 205 of 220). There was no clinically relevant difference in the Patient-Rated Wrist Evaluation total score at 52 weeks: the mean score in the cast group was 14.0 (95% confidence interval 11.3 to 16.6) and in the surgery group was 11.9 (95% confidence interval 9.2 to 14.5), with an adjusted mean difference of –2.1 in favour of surgery (95% confidence interval –5.8 to 1.6; p = 0.27). The non-union rate was low (surgery group, n = 1; cast group, n = 4). Eight participants in the surgery group had a total of 11 reoperations and one participant in the cast group required a reoperation for non-union. The base-case economic analysis at 52 weeks found that surgery cost £1295 per patient more (95% confidence interval £1084 to £1504) than cast treatment. The base-case analysis of a lifetime-extrapolated model confirmed that the cast treatment pathway was more cost-effective. The nested qualitative study identified patients’ desire to have a ‘sense of recovering’, which surgeons should address at the outset. Limitation There were 17 participants who had initial cast treatment and surgery for confirmed non-union, which in 14 cases was within 6 months from randomisation and in three cases was after 6 months. Three of the four participants in the cast group who had a non-union at 52 weeks were not offered surgery. Conclusions Adult patients with an undisplaced or minimally displaced scaphoid waist fracture should have cast immobilisation and suspected non-unions immediately confirmed and urgently fixed. Patients should be followed up at 5 years to investigate the effect of partial union, degenerative arthritis, malunion and screw problems on their quality of life. Trial registration Current Controlled Trials ISRCTN67901257. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 52. See the NIHR Journals Library website for further project information.

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Section: Sensitivity Analyses Of the Patient-rated Wrist Evaluationmentioning

confidence: 99%

Surgical fixation compared with cast immobilisation for adults with a bicortical fracture of the scaphoid waist: the SWIFFT RCT

Dias

Brealey

Cook

et al. 2020

Health Technol Assess

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“…Most often, athletes with a scaphoid fracture of their dominant hand are treated with surgical options for various reasons including return to play. This can be supported by a meta-analysis performed by Al-Ajmi et al which revealed that the return to work time was significantly lower (p < 0.05) among patients treated surgically [10]. In the case presented, it was decided to try non-operative treatments first with the thought that if she did not achieve adequate healing on X-ray, she would advance to surgical treatments to ensure complete healing of the fracture.…”

Section: Discussionmentioning

confidence: 86%

Conservatively Managed, Displaced Scaphoid Fracture in a Young, Female Collegiate Basketball Player

Braun

Yelinek

2020

Cureus

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Fractures of the scaphoid bone occur in 60-70% of wrist bone fractures. It most often occurs after a fall onto outstretched hand injury. Many times, the diagnosis of a scaphoid fracture is missed due to the unique anatomy and positioning of this carpal bone. Treatment options vary depending on the type of fracture and degree of displacement. We present the case of a 19year-old female patient. She reported to the urgent care facility after a fall on an outstretched hand while playing basketball. She was diagnosed with a wrist sprain. After having continued pain she sought care at the sports medicine clinic where she was diagnosed with a displaced scaphoid fracture. She was managed conservatively with thumb-spica casting and later adjuvant therapy treatments with low-intensity pulsed ultrasound (LIPUS) technology.

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“…Most authors of randomized trials and meta-analyses observed that ROM and grip strength do not differ between operative and conservative groups, at 12 months or later follow-up consultations. 11,[24][25][26][27] A difference can be statistically evident at 2, 3, or 6 months follow-up favoring surgery, but not at 1 year following treatment. Outcomes remained similar even after more than 12 months of follow-up.…”

Section: Discussionmentioning

confidence: 95%

Comparison of Minimally Invasive Operative Treatment with Conservative Treatment for Acute, Minimally Displaced Scaphoid Fractures at 12 Months' Follow-up

et al. 2021

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Background Minimally displaced scaphoid fractures can be challenging to diagnose and treat. Cannulated scaphoid screws have made percutaneous stabilization highly effective. Questions Would minimally invasive operative treatment of minimally displaced scaphoid fractures yield faster return to work when compared with patients treated conservatively? How do functional and patient satisfaction scores compare between the two groups at 12-months follow-up? Patients and Methods Records from 18 patients (mean age 28.6 years) treated surgically were retrospectively reviewed and compared with a group of 10 patients (mean age 33.3 years, p = 0.74) treated nonoperatively. Inclusion criteria were a minimum follow-up period of 12 months and radiographic union. Time to return to work was compared between groups. At 12 months' follow-up, wrist range of motion (ROM) and grip strength were compared, as well as pain, satisfaction, and overall wrist function were evaluated by the visual analogue scale (VAS) and the Mayo modified wrist score (MMWS). Results The mean time to return to work for the operated group was 39.75 days, while for the nonoperated group it was 88.14 days (p = 0.002). At the 12 months' follow-up, mean ROM, grip strength, and VAS score did not differ between groups. The mean MMWS was 98.75 for the operated group and 87.5 for the nonoperated group, indicating a better result in patients treated operatively (p = 0.03). In addition, two failures of instrumentation were recorded, a seldom seen complication. Conclusion Percutaneous fixation of minimally displaced scaphoid fractures allows faster return to work and leaves patients more satisfied with their wrist function compared with plaster immobilization at 12 months' follow-up. Level of evidence This is a Level III, retrospective, case–control study.

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A Systematic Review and Meta-analysis of Randomized Controlled Trials Comparing Surgical versus Conservative Treatments for Acute Undisplaced or Minimally-Displaced Scaphoid Fractures

Cited by 24 publications

References 22 publications

Surgical fixation compared with cast immobilisation for adults with a bicortical fracture of the scaphoid waist: the SWIFFT RCT

Surgical fixation compared with cast immobilisation for adults with a bicortical fracture of the scaphoid waist: the SWIFFT RCT

Conservatively Managed, Displaced Scaphoid Fracture in a Young, Female Collegiate Basketball Player

Comparison of Minimally Invasive Operative Treatment with Conservative Treatment for Acute, Minimally Displaced Scaphoid Fractures at 12 Months' Follow-up

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