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Surgical treatment of non- and minimally-displaced acute scaphoid fractures favours over-conservative treatment but only in the short term: an updated meta-analysis
  1. Bastiaan N P de Boer,
  2. Job N Doornberg,
  3. Wouter H Mallee,
  4. Geert A Buijze
  1. Department of Orthopaedic Surgery Academic Medical Centre, University of Amsterdam, Amsterdam, North Holland, The Netherlands
  1. Correspondence to Dr Bastiaan NP de Boer, Department of Orthopaedic Surgery Academic Medical Centre, University of Amsterdam, Amsterdam, NH 1100 DD, The Netherlands; b.n.deboer{at}amc.uva.nl

Abstract

Importance Fractures of the scaphoid are relatively common in young adults, with an incidence of 23 per 100 000. There has been a trend over the past decades towards surgical intervention, however, it was supported by limited evidence as we have reported previously. Using subsequently published data, this updated review will re-evaluate the pros and cons of conservative versus surgical treatment for non-displaced and minimally displaced acute scaphoid fractures.

Objective To assess the functional outcome, benefits and harms of conservative versus surgical treatment for non-displaced and minimally displaced acute scaphoid fractures.

Evidence review All the included studies were graded for quality of evidence according to the GRADE criteria, as reported by the Cochrane collaboration. One review author assessed the Risk of bias in the included studies. 10 randomised controlled trials were selected. Data from included studies was pooled using fixed-effects and random-effects models with standard mean differences (SMD) and risk ratios for continuous and dichotomous variables, respectively. Heterogeneity across studies was assessed with Forest plots and calculation of the I2 statistic.

Findings 452 patients with 453 fractures from 10 studies were included. 254 were treated conservatively, 242 patients (with 243 fractures) were treated surgically. The primary outcome: the, subjective patient-based,—standardised short-term functional outcome—measured in 285 patients from four trials showed a significant difference in favour of surgical intervention (p<0.00001). According to our secondary outcomes, there was a significant difference in favour of surgical treatment in time to union and in time to return to work.

Conclusion and relevance Based on limited quality evidence, these findings suggest that surgical treatment for non-displaced and minimally displaced acute scaphoid fractures may be slightly favourable compared to conservative treatment for standardised functional outcome on the short term (within 2 years). Perhaps the most clinically relevant advantage of surgical treatment these fractures are a significantly faster return to work, with a SMD of 7 weeks. In the long term (6–12 years) there were no significant differences. Slightly favourable short-term functional benefits need to be weighed carefully against risks and complications of surgical treatment in shared decision-making.

Level of evidence I.

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Footnotes

  • Contributors BNPdB took part in data assembly, data extraction, data analysis and writing the manuscript. JND was involved in study design, data assembly and revision of the manuscript. WHM took part in data extraction and revision of the manuscript. GAB was involved in study design, data assembly and revision of the manuscript.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

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