Operative treatment results in better short-term outcomes & recovery in scaphoid fractures .
OrthoEvidence Journal (OE Journal) - ACE Report
OE Journal. 2015;3(14):6 PLoS One. 2015 May 5;10(5):e01252476 randomized controlled trials (340 fractures) were pooled in this meta-analysis to analyze the efficacy of operative treatment compared to non-operative treatment in the management of minimally-displaced and acute undisplaced scaphoid fractures. Results demonstrated that operative treatment had better functional outcomes in the short-term, however these results were not sustained for more than a year post-treatment. Operative treatment was also associated with a more rapid rate of return to work, and earlier time to union of fractures.
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Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
El Índice de Fragilidad es una herramienta que ayuda en la interpretación de hallazgos significativos, proporcionando una medida de fuerza para un resultado. El Índice de Fragilidad representa el número de eventos consecutivos que es necesario añadir a un resultado dicotómico para que el hallazgo deje de ser significativo. Un número pequeño representa un hallazgo más débil y un número grande un hallazgo más fuerte.
¿Por qué se necesitaba ahora este estudio?
Acute, undisplaced, stable scaphoid fractures are often effectively treated by short- or long-arm casts. However, prolonged immobilization can cause complications that may delay rehabilitation, resulting in weaker outcomes after immobilization. Internal fixation, in theory, has benefits of early return of wrist movement, a higher rate of union and an earlier return to regular life, with the avoidance of cast immobilization. Reports have shown that operative treatment is safe and effective, yet outcomes from current studies comparing these methods are not conclusive. Recently, a number of randomized controlled trials have been published analyzing operative and non-operative treatment for these fractures and, thus, an updated analysis of current literature was prudent.
¿Cuál era la pregunta principal de la investigación?
How do operative and non-operative treatment compare for the treatment of minimally-displaced and acute undisplaced scaphoid fractures?
- Analysis of functional scores showed significant differences favoring operative treatment at 2 and 3 months (p<0.05, 2 studies), yet at 6, 12, and greater than 12 months the difference was non-significant (P>0.05, 2 studies)
- Analysis of ROM demonstrated no significant differences between groups at 2, 3, 6, 12 months (p>0.05, 2 studies), or greater than 12 months (p>0.05, 3 studies) and pinch strength data at more than 12 months showed that both treatments were similar (P=0.88, 2 studies)
- Pooled data at 2, 3, 6, and 12 months follow-up showed that patients in the operative treatment group had significantly greater grip strength than those in the non-operative group (P<0.05, 2 studies), however at follow-up greater than 12 months the difference was not significant (P=0.33, 3 studies)
- Patients receiving operative treatment had an advantage in terms of duration of absence from work (4 studies, WMD= -6.01, 95% CI [-9.17,-2.85], P<0.001)
- Overall complication did not significantly differ between treatments (6 studies, RR= 0.91, 95% CI [0.51, 1.62], P=0.75), yet risk of delayed union was significantly lower with operative treatment (P=0.049) with a 74.9% reduction in risk (4 studies, RR= 0.25, 95% CI [0.07, 0.99])
- Analysis of time to fracture union showed a significant difference, and the time was shorter with operative treatment (WMD= -4.99, 95% CI [-5.45 to -4.53], P<0.001)
- Analysis of nonunion, further surgery, malunion, osteoarthritis and symptomatic osteoarthritis revealed no significant differences between treatments
¿Qué es lo que más debo recordar?
Short-term functional outcomes favored operative treatment for minimally-displaced and acute undisplaced scaphoid fractures compared with non-operative treatment. while longer-term outcomes were generally similar between groups. Additionally, patients who underwent operative treatment had a more rapid return to work. Complications did not differ between treatments, yet surgery was advantageous in avoiding delayed union of fractures.
¿Cómo afectará esto al cuidado de mis pacientes?
Patients with minimally-displaced and acute undisplaced scaphoid fractures who were treated surgically exhibited earlier recovery, suggesting that primary operative treatment could be considered in patients that require fast restoration of normal function. Nevertheless, outcome beyond one year appeared to be similar between treatment options. Additional large-scale trials are needed to address factors such as patient age, cost, and fracture type, which may more clearly illustrate which method of treatment - operative or nonoperative - should be considered in primary treatment of this population of patients.
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