HAND & WRIST
Comparison of operative and non-operative treatment of acute undisplaced or minimally-displaced scaphoid fractures: a meta-analysis of randomized controlled trials
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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Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?
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報告基準評価では、著者が出版物内で試験の方法論的特徴や試験特性を報告する際の透明性を評価します。評価は以下の5つのカテゴリーに分類されます。
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Introduction
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Analysing Data
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Results
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Discussion
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
Fragility Indexは、重要な所見の解釈を助けるツールで、結果の強さの尺度を提供します。Fragility Indexは、その所見が有意でなくなるために、二項対立の結果に追加する必要がある連続した事象の数を表します。数値が小さいほど弱い所見を表し、数値が大きいほど強い所見を表します。
なぜ今この研究が必要なのですか？
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.
主な研究課題は何ですか？
How do operative and non-operative treatment compare for the treatment of minimally-displaced and acute undisplaced scaphoid fractures?
重要な知見は？
- 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
最も覚えておくべきことは？
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.
それが私の患者ケアにどのように影響するか？
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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