Surgery vs Conservative Treatment for Scaphoid Fractures
Surgery vs Conservative Treatment for Scaphoid Fractures
Buijze GA, Doornberg JN, Ham JS, Ring D, Bhandari M, Poolman RW
J Bone Joint Surg Am. 2010;92:1534-1544
Nondisplaced or minimally displaced scaphoid fractures have traditionally been treated conservatively. More recently, early surgical intervention has been advocated despite a lack of supporting long-term data. Buijze and colleagues performed a meta-analysis to review the current literature comparing conservative treatment (ie, cast immobilization) to surgery. The results indicate that surgical intervention was superior to conservative management in short-term patient-reported functional outcomes, patient satisfaction, grip strength, shorter time to union, and earlier return to work. No significant differences were seen with pain, range of motion, nonunion rates, infection, complications, or total treatment costs.
The authors note significant caveats in reporting these potential differences. They cite low-quality evidence and significant heterogeneity in secondary outcomes.
There was also substantial variability in study times, which varied from 16 weeks to 12 years. Bias against the conservative group also occurred in measuring functional outcome, due to an overall shorter mobilization time. Furthermore, complication rates were noted to be much higher in the surgical group (23.7%) compared to the conservative treatment group (9.1%).
While early surgical intervention has been recommended for displaced, unstable scaphoid fractures based on the literature, current research does not necessarily show the same clear-cut, long-term benefit from early surgery in patients with acute, nondisplaced, or minimally displaced fractures, particularly when complication rates are taken into account. Perhaps, as the article notes, increased patient expectation for an earlier return to functional activities may play a significant role in recent trends toward surgery. These expectations, however, should be balanced carefully with the long-term benefits and risks of such intervention.
Abstract
Surgical Compared With Conservative Treatment for Acute Nondisplaced or Minimally Displaced Scaphoid Fractures: A Systematic Review and Meta-analysis of Randomized Controlled Trials.
Buijze GA, Doornberg JN, Ham JS, Ring D, Bhandari M, Poolman RW
J Bone Joint Surg Am. 2010;92:1534-1544
Summary
Nondisplaced or minimally displaced scaphoid fractures have traditionally been treated conservatively. More recently, early surgical intervention has been advocated despite a lack of supporting long-term data. Buijze and colleagues performed a meta-analysis to review the current literature comparing conservative treatment (ie, cast immobilization) to surgery. The results indicate that surgical intervention was superior to conservative management in short-term patient-reported functional outcomes, patient satisfaction, grip strength, shorter time to union, and earlier return to work. No significant differences were seen with pain, range of motion, nonunion rates, infection, complications, or total treatment costs.
The authors note significant caveats in reporting these potential differences. They cite low-quality evidence and significant heterogeneity in secondary outcomes.
There was also substantial variability in study times, which varied from 16 weeks to 12 years. Bias against the conservative group also occurred in measuring functional outcome, due to an overall shorter mobilization time. Furthermore, complication rates were noted to be much higher in the surgical group (23.7%) compared to the conservative treatment group (9.1%).
Viewpoint
While early surgical intervention has been recommended for displaced, unstable scaphoid fractures based on the literature, current research does not necessarily show the same clear-cut, long-term benefit from early surgery in patients with acute, nondisplaced, or minimally displaced fractures, particularly when complication rates are taken into account. Perhaps, as the article notes, increased patient expectation for an earlier return to functional activities may play a significant role in recent trends toward surgery. These expectations, however, should be balanced carefully with the long-term benefits and risks of such intervention.
Abstract
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