Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial

Abstract

BackgroundScaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. Immediate surgical fixation of this fracture has increased, in spite of insufficient evidence of improved outcomes over non-surgical management. We compared the clinical effectiveness of surgical fixation with cast immobilization and early fixation of those that fail to unite, for ≤2 mm displaced scaphoid waist fractures in adults. MethodsThis pragmatic, multicentre, open-label, parallel-group, two-arm randomised clinical trial included adults who presented to orthopaedic departments of 31 hospitals in England and Wales with a clear, bicortical fracture of the scaphoid waist on radiographs. Participants were randomly assigned to early surgical fixation or below-elbow cast immobilization followed by immediate fixation of confirmed non-union. The primary outcome was the Patient Rated Wrist Evaluation (PRWE) total score at 52 weeks post-randomisation. Registration ISRCTN67901257. FindingsOf 439 randomised patients (mean age 33 years, 363 [83%] men), 408 (93%) were included in the primary analyses. There was no difference in PRWE score at 52 weeks (adjusted mean difference -2•1 points, 95% CI -5•8 to 1•6, p=0•27). There were no differences at 52 weeks for the PRWE pain or function subscales. More participants in the surgery group experienced a surgery-related potentially serious complication than in the cast group (n=31, 14% vs n=3, 1%), but fewer had cast-related complications (n=5, 2% vs n=40, 18%). The number experiencing a medical complication (n=4, 2% vs n=5, 2%) was similar in the two groups." InterpretationAdult patients with ≤2 mm displaced scaphoid waist fracture should have initial cast immobilization and suspected non-unions confirmed and immediately fixed. This will help avoid risks of surgery and mostly limit its use to fixing non-union.

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

“…These were assessed at hospital visits at baseline and at 6, 12 and 52 weeks post randomisation. 89 Copyright (2020), with permission from Elsevier.…”

“…For non-union alone, the NNT is 73 and 12 in the first and second scenario, respectively. 89 Copyright (2020), with permission from Elsevier.…”

“…396, Dias JJ, Brealey SD, Fairhurst C, Amirfeyz R, Bhowal B, Blewitt N, et al, Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial, pp. 390-401,89 Copyright (2020), with permission from Elsevier.CLINICAL EFFECTIVENESS RESULTSNIHR Journals Library www.journalslibrary.nihr.ac.uk…”

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

“…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.…”

Questions regarding the evidence guiding treatment of displaced scaphoid fractures

“…The optimal management of a displaced fracture is not yet established. The large, multi-centre Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT), which compared cast and surgical management of fractures with displacement of less than 2 mm, has recently demonstrated cast immobilization is as effective as surgical fixation if suspected nonunions are identified early and fixed (Dias et al., 2020).…”