Department of Orthopaedic Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
J Bone Joint Surg Am. 2010 Jun;92(6):1534-44. doi: 10.2106/JBJS.I.01214.
There is a current trend in orthopaedic practice to treat nondisplaced or minimally displaced fractures with early open reduction and internal fixation instead of cast immobilization. This trend is not evidence-based. In this systematic review and meta-analysis, we pool data from trials comparing surgical and conservative treatment for acute nondisplaced and minimally displaced scaphoid fractures, thus aiming to summarize the best available evidence.
A systematic literature search of the medical literature from 1966 to 2009 was performed. We selected eight randomized controlled trials comparing surgical with conservative treatment for acute nondisplaced or minimally displaced scaphoid fractures in adults. Data from included studies were pooled with use of fixed-effects and random-effects models with standard mean differences and risk ratios for continuous and dichotomous variables, respectively. Heterogeneity across studies was assessed with calculation of the I(2) statistic.
Four hundred and nineteen patients from eight trials were included. Two hundred and seven patients were treated surgically, and 212 were treated conservatively. Most trials lacked scientific rigor. Our primary outcome parameter, standardized functional outcome, which was assessed for 247 patients enrolled in four trials, significantly favored surgical treatment (p < 0.01). With regard to our secondary parameters, we found heterogeneous results that favored surgical treatment in terms of satisfaction (assessed in one study), grip strength (six studies), time to union (three studies), and time off work (five studies). In contrast, we found no significant differences between surgical and conservative treatment with regard to pain (two studies), range of motion (six studies), the rates of nonunion (six studies) and malunion (seven studies), and total treatment costs (two studies). The rate of complications was higher in the surgical treatment group (23.7%) than in the conservative group (9.1%), although this difference was not significant (p = 0.13). There was a nearly significantly higher rate of scaphotrapezial osteoarthritis in the surgical treatment group (p = 0.05).
Based on primary studies with limited methodological quality, this study suggests that surgical treatment is favorable for acute nondisplaced and minimally displaced scaphoid fractures with regard to functional outcome and time off work; however, surgical treatment engenders more complications. Thus, the long-term risks and short-term benefits of surgery should be carefully weighed in clinical decision-making.
在矫形外科实践中，目前存在一种趋势，即用早期切开复位内固定治疗无移位或轻度移位的骨折，而不是用石膏固定。这种趋势没有循证医学的依据。在这项系统回顾和荟萃分析中，我们汇集了比较手术和保守治疗急性无移位和轻度移位舟状骨骨折的试验数据，从而旨在总结最佳的现有证据。
对 1966 年至 2009 年的医学文献进行了系统的文献检索。我们选择了 8 项比较成人急性无移位或轻度移位舟状骨骨折手术与保守治疗的随机对照试验。使用固定效应和随机效应模型，对纳入研究的数据进行了汇总，分别用标准均数差和风险比表示连续和二分类变量。用 I(2)统计量评估研究之间的异质性。
纳入了 8 项试验的 419 名患者。207 名患者接受手术治疗，212 名患者接受保守治疗。大多数试验缺乏科学严谨性。我们的主要结局参数，即评估了 4 项试验中的 247 名患者的标准化功能结局，显著倾向于手术治疗（p < 0.01）。关于我们的次要参数，我们发现了不一致的结果，即手术治疗在满意度（一项研究评估）、握力（6 项研究）、愈合时间（3 项研究）和停工时间（5 项研究）方面有优势。相比之下，我们发现手术和保守治疗在疼痛（2 项研究）、活动范围（6 项研究）、不愈合率（6 项研究）和畸形愈合率（7 项研究）以及总治疗费用（2 项研究）方面没有显著差异。手术组的并发症发生率（23.7%）高于保守组（9.1%），尽管差异无统计学意义（p = 0.13）。手术组舟状骨大多角骨关节病的发生率几乎显著升高（p = 0.05）。
基于方法学质量有限的初步研究，本研究表明，在功能结局和停工时间方面，手术治疗对急性无移位和轻度移位的舟状骨骨折有利；然而，手术治疗会产生更多的并发症。因此，在临床决策中，应仔细权衡手术的长期风险和短期益处。
