Clin Orthop Surg.  2018 Mar;10(1):64-73. 10.4055/cios.2018.10.1.64.

A Systematic Review and Meta-analysis of Randomized Controlled Trials Comparing Surgical versus Conservative Treatments for Acute Undisplaced or Minimally-Displaced Scaphoid Fractures

• Al-Ajmi TA
• Al-Faryan
• Al-Kanaan
• Al-Khodair AA
• Al-Faryan
• Al-Oraini
• Bassas AF

• KMID: 2405484
• DOI: http://doi.org/10.4055/cios.2018.10.1.64

Abstract

BACKGROUND
Surgical and conservative methods have been reported by various studies for high rates of fracture union and subsequent regain of function among patients with undisplaced or minimally-displaced scaphoid fractures. Hence, this study aims to analyze the best available evidence to comprehend the relative benefits and risks of these therapeutic options.
METHODS
A systematic search of the literature from different databases and search engines was performed with strict eligibility criteria to obtain the highest quality of evidence. All randomized controlled trials delineating the outcomes of surgical versus conservative treatments for acute undisplaced or minimally-displaced scaphoid fractures were included and then evaluated using scoring tools: Cochrane risk of bias tool and PEDro scale. Data were pooled using random-effects models with standard mean differences for continuous outcomes and risk ratios for dichotomous variables.
RESULTS
The search yielded 339 potentially related articles, further trimmed down to eight studies based on the eligibility criteria. The meta-analysis revealed that surgical treatment resulted in significantly better functional outcomes than conservative treatment. Furthermore, surgery resulted in the prevention of delayed union of fractures and reduction of time needed to return to work.
CONCLUSIONS
While four studies reported advantages of surgical treatment, evidence was insufficient to provide a definitive conclusion that surgery is a better option. Due to the significant limitations with respect to certain variables, the superiority of one method to the other could not be established.

Keyword

Scaphoid fracture; Operative treatment; Conservative treatment; Return to activities; Return to work

MeSH Terms

Bias (Epidemiology)
Humans
Methods
Odds Ratio
Return to Work
Risk Assessment
Search Engine

Figure

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  Fig. 1 Flowchart of selection of studies and specific reasons for exclusion from the present meta-analysis. RCT: randomized controlled trial.

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  Fig. 2 Forest plot for the weighted mean difference estimate for the time to return to work weighting given to the trial in the overall pooled estimate, taking into account the number of participants and the amount of interstudy variation (heterogeneity) rhombus, and combined effect size. SD: standard deviation, CI: confidence interval.

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  Fig. 3 Forest plot for the risk ratio estimate for the assessment of overall complication rate. CI: confidence interval.

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  Fig. 4 Risk of bias graph: authors' judgements about each risk of bias item presented as percentages across all included studies.

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  Fig. 5 Sensitivity analysis and publication bias analysis of the meta-analysis. The figure shows the influence of individual study on summary risk ratio (RR) computed by omitting each study in turn. The vertical axis indicates the overall RR and the two vertical axes indicate the 95% confidence interval (CI). Every circle indicates the pooled RR when the study is omitted in this meta-analysis. The two ends of the dotted lines represent the 95% CI.

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  Fig. 6 Begg's funnel plot for publication bias in the selection of studies. The horizontal axis represents the log risk ratio (RR) and the vertical axis indicates the standard error (SE) of the log RR. The vertical line and the sloping lines represent the effects summary RR and the expected 95% confidence interval for a given SE. Each circle represents the eight studies. The symmetrical appearance of the funnel means that there is no publication bias in the selection of the studies included in this metaanalysis. MD: mean difference.

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