GENERAL ORTHOPAEDICS
Surgical versus nonsurgical treatment of acute minimally displaced and undisplaced scaphoid waist fractures: pairwise and network meta-analyses of randomized controlled trials
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OrthoEvidence Journal (OE Journal) - ACE Report
OE Journal. 2013;1(17):4 J Hand Surg Am. 2011 Nov;36(11):1759-1768.e1. doi: 10.1016/j.jhsa.2011.08.0336 studies (363 patients) examining outcomes of surgical and nonsurgical treatments of undisplaced or minimally displaced scaphoid waist fractures were evaluated through pairwise meta-analysis. An additional 3 trials were also identified for inclusion in a network meta-analysis. Following assessments of fracture union, complications, range of motion, grip strength, and osteoarthritis between patients who underwent either surgical or non-surgical treatment, there was a non-significant trend to increased union with surgical treatment. However this method of treatment was also associated with a higher risk of complications.
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Were the criteria used for assessing the validity of the included studies reported?
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)?
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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。
4/4
Introduction
3/4
Accessing Data
4/4
Analysing Data
3/4
Results
3/4
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？
When scaphoid waist fractures occur they should be immobilized in order to allow for anatomical union and to prevent midcarpal arthrosis and carpal malalignment. Treatment can occur either surgically or non-surgically using a cast, but it is still unknown which method is the most effective. Hence, this meta-analysis aimed to compare the odds ratio of fracture union, complications, and other clinical outcomes of surgical and nonsurgical treatment of scaphoid waist fractures.
主な研究課題は何ですか？
Was surgical treatment of scaphoid waist fractures more effective than nonsurgical treatments, in terms of the odds ratio of fracture union?
重要な知見は？
- In the Pairwise meta-analysis there were 6 studies included (7 publications) that compared non –operative and operative treatment of scaphoid waist fractures. The Network meta-analysis identified another 3 randomized controlled trials that compared 2 non-surgical treatments resulting in a total of 9 trials comparing 5 different treatment methods.
- The Pairwise meta-analysis resulted in an overall pooled odds ratio of fracture union rate that was 2.36 (95% CI: 0.02, 8.9; p=0.210; I-squared: 0%). Although, the pooled odds ratio of fracture union rate was higher in the nonsurgical treatment patients (ratio: 3.10; 95% CI: 0.46, 21.05; p=0.250; I-squared: 0%) than in the surgical patients (ratio: 1.46; 95% CI: 0.11, 20.57; p=0.780; I-squared: 46.1%), this was not significant.
- The Pairwise meta-analysis of complication rate had a pooled odds ratio of 6.96 (95% CI: 2.13, 27.73; p=0.001; I-squared: 0%), which indicated an elevated risk of complication for those undergoing surgical treatment.
- Although the mean overall percentage difference in the range of motion (2.1%; 95% CI: -0.03, 0.08; p=0.430; I-squared: 61.4%) and grip strength (2.6%; 95% CI: -0.013, 0.066; p=0.190; I-squared: 0%) between the surgical and nonsurgical groups in the Pairwise Meta-analysis favoured surgery, these variations were not significant.
- The pooled odds ratios for osteoarthritis of the scaphotrapeziotrapezoid joint (3.25; 95% CI: 0.073, 14.39; p=0.120; I-squared: 65.4%) between the surgical and nonsurgical groups favoured surgery, while the pooled odds ratios for osteoarthritis of the radiocarpal joint (0.75; 95% CI: 0.15, 3.82; p=0.730; I-squared: 67.2%) between the surgical and nonsurgical groups favoured nonsurgery, these differences were not statistically significant.
- The Network meta-analysis assessed the odds ratio of fracture union for all possible pairwise comparisons. The results indicated that long and short thumb spica casts had the highest probability of being the best treatment (0.810). This was influenced by the lower number of non-unions in the solitary trial that compared these treatments.
最も覚えておくべきことは？
Although the pair-wise analysis indicated a higher fraction union rate for the surgical treatment, this difference was not significant. Furthermore, surgical treatment appeared to have a higher risk of developing complications.
それが私の患者ケアにどのように影響するか？
Patients should be aware that there is a risk of developing complications by undergoing surgical treatment for scaphoid waist fractures. Although fracture union rates appeared to be higher with surgery in this study, this difference was not significant and there is no clear evidence indicating a significant increased union rates with surgery. Unless new evidence is released, then patients should continue to be treated using nonsurgical treatments.
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