| BackgroundScaphoid fractures is a very common orthopaedic fracture, accounts for about2%～7%of the generale fracture and about51%～90%of the carpal bone fracture. A recent American study found that, the average age of the scaphoid bone fracture is25-35years, more common in males than in females,and the scaphoid fracture most easily caused by the sports are the basketball, biking and skateboarding.Before Roent Gen (1895) found the X-ray, CaUender (1866) and Destor (1889) have been described scaphoid fracture.They found that the scaphoid fracture occurs most frequently in young and rarely occurs in the children and the old. Codman (1905) and Destot (1921) had discussed the diagnosis and the therapeutic of the scaphoid fracture.Gradually people realized the characteristics of the scaphoid fracture.The mechanism of the injury mostly is the palm hit the ground, with the wrist hyperextension and mild radial deviation.The surface of the scaphoid has80%covered by cartilage and a branch of the radial artery supply the distal portion of scaphoid. The proximal portion of scaphoid is very similar to the femoral head, almost all are covered with cartilage, which has no direct blood sources, only has small amounts of blood supply from the radioscapholunate.Therefore proximal pole or waist scaphoid fracture is easily causes to nonunion, delayed healing, avascular necrosis and post traumatic arthritis, so it should be properly diagnosed and treated.Although people has nearly100years of experience in the scaphoid fractures and have reported many literatures, however there are still a lot of controversy in the treatment. Displaced scaphoid fractures needs surgery, which is almost less controversial. But the treatment of acute nondisplaced and minimally displaced scaphoid fractures is still controversial. They can be managed either operatively (percutaneous or ORIF) or non-operatively. For acute nondisplaced and minimally displaced scaphoid fractures, the traditional plaster fixation is the main treatment and the rate of bone union is reported as between85%and95%. Recent reports have advocated surgical treatment and indicated that surgical treatment can avoide the joint stiffness, earlier return to work. In2001, Adolfsson, Saeden, Bond reported the RCT about the surgical versus nonsurgical treatment of nondisplaced scaphoid fractures.Later many scholars have reported the randomized controlled trials in this regard, but the relevant RCTs has less consistent findings and it is difficult to carry out the multicenter, large sample and perspective clinical trials.Therefore it is necessary to conducting systematic reviews about the RCTs of surgical versus nonsurgical treatment of acute nondisplaced and minimally displaced scaphoid fractures. In addition, there are still a lot of controversy in the plaster type and fixed position for acute scaphoid fractures.In this paper we address these issues by conducting an up-to-date meta-analysis of RCTs published up to Oct2011.The purpose is to evaluate the clinical outcomes comparing surgical versus nonsurgical treatment including the rate of non-union,the time taken before returning to work, the time of union, the rate of osteoarthritis of the scaphotrapezial joint and the radiocarpal joint, the grip strength, the wrist motion, the DASH-score and the PRWE-score.We also evaluate the clinical outcomes comparing different types of cast immobilization. It is hoped that the findings will improve our understanding of the treatment for acute scaphoid fractures.Objective1. To compare the clinical therapeutic effects between surgical and nonsurgical treatment for acute nondisplaced or minimally displaced scaphoid fractures, providing the best evidence for the clinical decision.2. To compare the clinical therapeutic effects for nonoperative treatment for acute scaphoid fractures.Methods1.After put forward a question,an detailed inclusion and exclusion criteria were established according to PICO steps,and then comprehensive search strategy of literature were made to search the relevantRandomized Controlled Trials(RCTs).2.According to Cochrane systematic review, Cochrane library, Medline, Embase, CNKI, and Chinese Biomedical Database were retrieved for randomized controlled trials(RCTs) comparing relevant interventions for the treatment of displaced femoral neck fractures in elder patients before the end of October2011.Furthermore,we also handsearched relevant reference and some Chinese orthopedic journals. Finally, RCTs which met the specific inclusion and exclusion criteria were included.These RCTs were associated with the therapeutic effects of acute nondisplaced and minimally displaced scaphoid fractures.3.The methodology quality of each inclusion study was critically assessed according to the quality criteria of RCT which include four items:randomization, allocation concealment, blindness and follow-up. The validity of each trail was referred to as A, B or C scale according to Cochrane handbook for systematic reviews.4. After critical appraisal, data of each RCT on relevant outcome parameter were extracted.Software Revman5.1the Cochrane Collaboration provided were used for meta-analysis. For each study,relative risk(RR) and95%confidence intervals (95%CI) were calculated for dichotomous outcomes and weighted mean differences (WMD) and95%confidence intervals (95%CI) were calculated for dichotomous outcomes. Before outcome measures of each trial were pooled, clinical heterogeneity should be considered. If interventions of each trial were different, subgroup analysis should be applied. The results of individually randomized trials were pooled whenever possible, with use of the fixed effects model of Mantel-Haenszel. Heterogeneity between comparable studies was tested, with the use of a standard chi·square test. The random—effects model of DerSimonian and Laird was used when there was statistical evidence of heterogeneity (P<0.1).Results1. Search results1.1A total of519papers were retrieved, but only9published randomized controlled trials including559patients met the criteria of the present study about the therapeutic effects of acute nondisplaced and minimally displaced scaphoid fractures.1.2A total of103papers were retrieved, but only5published randomized controlled trials including676patients met the criteria of the present study about the nonoperative treatment methods for acute scaphoid fractures.2.Meta-analysis results2.1Surgical Versus Nonsurgical Treatment of Acute Nondisplaced and Minimally Displaced Scaphoid Fractures2.1.1The rate of nonunionSeven reports, on a total of383patients, provided the rate of non-union. A meta-analysis showed there was no statistically significant differences between two groups in the rate of nonunion.[RR=0.60,95%CI (0.22,1.66), P=0.33] 2.1.2The time taken before returning to workFour reports, on a total of165patients, provided the time taken before returning to work. We found that it had significant difference between two groups in the time taken before returning to work[SMD=-2.06,95%CI (-3.46,-0.67), P=0.004].2.1.3The time o f unionTwo reports, on a total of69patients, provided the time of union. We found that it had significant difference between two groups in the time of union.[SMD=-5.88,95%CI (-9.23,-2.54), P=0.0006]2.1.4The grip strengthThree reports, on a total of143patients, provided the grip strength. A meta-analysis showed there was no statistically significant differences between two groups in the grip strength [WMD=1.44,95%CI (-3.78,6.66), P=0.59]2.1.5The Wrist palmar flexion and dorsal extension angleTwo reports, on a total of119patients, provided the wrist palmar flexion and dorsal extension angle. A meta-analysis showed there was no statistically significant differences between two groups in the wrist palmar flexion and dorsal extension angle [WMD=-3.09,95%CI (-7.22,1.04), P=0.14; WMD=-2.51,95%CI (-5.46,0.43), P=0.09].2.1.6The DASH-scoreTwo reports, on a total of119patients, provided the DASH-score. A meta-analysis showed there was no statistically significant differences between two groups in the DASH-score [WMD=-4.66,95%CI (-12.47,3.15), P=0.24].2.1.7The PRWE-scoreTwo reports, on a total of146patients, provided the PRWE-score. A meta-analysis showed there was no statistically significant differences between two groups in the PRWE-score [WMD=-0.53,95%CI (-3.81,2.75), P=0.75] 2.1.8The rate of osteoarthritis of the scaphotrapezial joint and the radiocarpal jointTwo reports, on a total of113patients, provided the rate of osteoarthritis of the scaphotrapezial joint. We found that it had significant difference between two groups in the rate of osteoarthritis of the scaphotrapezial joint [RR=3.72,95%CI (1.61,8.63), P=0.002]. A meta-analysis showed there was no statistically significant differences between two groups in the rate of osteoarthritis of the radiocarpal joint [RR=1.41,95%CI (0.67,2.69), P=0.36]2.2The therapeutic effects of the nonoperative treatment methods for acute scaphoid fracturesWrist extension was significantly more limited in patients that were immobilized in flexion and there were no significant differences comparing nonoperative treatment methods for acute scaphoid fractures in the rate of nonunion, pain, grip strength, AVN, immobilization time.Conclusion1. Compared with conservative treatment for adult nondisplaced or minimally displaced scaphoid fractures, the time taken before returning to work and the time of union was shorter in the surgical treatment group,but the rate of osteoarthritis of the scaphotrapezial joint was higher than the conservative treatment group.2. Compared with conservative treatment for adult nondisplaced or minimally displaced scaphoid fractures, the rate of osteoarthritis of the the radiocarpal joint, the grip strength, the wrist motion, the DASH-score and the PRWE-score, the rate of non-union was no significant difference in the surgical treatment group.3. Wrist extension was significantly more limited in patients that were immobilized in flexion and there were no significant differences comparing nonoperative treatment methods for acute scaphoid fractures in the rate of nonunion, pain, grip strength, AVN, immobilization time.4. Because of the small sample size, this conclusion should further tested using well-designed, large scale RCTs and more high quality, large-scale randomized controlled trials are required for accurate conclusion. |
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