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Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial

Dias, Joseph J; Brealey, Stephen D; Fairhurst, Caroline; Amirfeyz, Rouin; Bhowal, Bhaskar; Blewitt, Neil; Brewser, Mark; Brown, Daniel; Choudhary, Surabhi; Coapes, Christopher; Cook, Liz; Costa, Matthew; Davis, Timothy; DisMascio, Livio; Giddins, Grey; Hedley, Helen; Hewitt, Catherine; Hinde, Sebastian; Hobby, Jonathan; Hodgson, Stephen; Jefferson, Laura; Jeyapalan, Kanagaratnam; Jeyapalan, Phillip; Jones, Jonathon; Keding, Ada; Leighton, Paul; Logan, Andrew; Mason, Will; McAndrew, Andrew; McNab, Ian; Muir, Lindsay; Nicholl, James; Northgraves, Matthew; Palmer, Jared; Poulter, Rob; Jeyapalan, Zulfi; Rangan, Amar; Richards, Simon; Richardson, Gerry; Stuart, Paul; Taub, Nicholas; Tavakkolizadeh, Adel; Tew, Garry; Thompson, John; Torgerson, David; Warwick, David

Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial Thumbnail


Authors

Joseph J Dias

Stephen D Brealey

Caroline Fairhurst

Rouin Amirfeyz

Bhaskar Bhowal

Neil Blewitt

Mark Brewser

Daniel Brown

Surabhi Choudhary

Christopher Coapes

Liz Cook

Matthew Costa

Timothy Davis

Livio DisMascio

Grey Giddins

Helen Hedley

Catherine Hewitt

Sebastian Hinde

Jonathan Hobby

Stephen Hodgson

Laura Jefferson

Kanagaratnam Jeyapalan

Phillip Jeyapalan

Jonathon Jones

Ada Keding

PAUL LEIGHTON PAUL.LEIGHTON@NOTTINGHAM.AC.UK
Associate Professor of Applied Health Services Research

Andrew Logan

Will Mason

Andrew McAndrew

Ian McNab

Lindsay Muir

James Nicholl

Matthew Northgraves

Jared Palmer

Rob Poulter

Zulfi Jeyapalan

Amar Rangan

Simon Richards

Gerry Richardson

Paul Stuart

Nicholas Taub

Adel Tavakkolizadeh

Garry Tew

John Thompson

David Torgerson

David Warwick



Abstract

Background
Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. Immediate surgical fixation of this fracture has increased, in spite of insufficient evidence of improved outcomes over non-surgical management. We compared the clinical effectiveness of surgical fixation with cast immobilization and early fixation of those that fail to unite, for ≤2 mm displaced scaphoid waist fractures in adults.
Methods
This pragmatic, multicentre, open-label, parallel-group, two-arm randomised clinical trial included adults who presented to orthopaedic departments of 31 hospitals in England and Wales with a clear, bicortical fracture of the scaphoid waist on radiographs. Participants were randomly assigned to early surgical fixation or below-elbow cast immobilization followed by urgent fixation of confirmed non-union. The primary outcome was the Patient Rated Wrist Evaluation (PRWE) total score at 52 weeks post-randomisation. Registration ISRCTN67901257.
Findings
Of 439 randomised patients (mean age 33 years, 363 [83%] men), 408 (93%) were included in the primary analyses. There was no difference in PRWE score at 52 weeks (adjusted mean difference -2·1 points, 95% CI -5·8 to 1·6, p=0·27). There were no differences at 52 weeks for the PRWE pain or function subscales, the SF-12 mental component score, grip strength, or range of movement. Fewer participants in the surgery group (4, 1·8%) compared with cast immobilization (9, 4·1%), had non- or slight union at 52 weeks. Participants in the surgery group were more likely to experience a potentially serious complication. Time off work was similar.
Interpretation
Adult patients with ≤2 mm displaced scaphoid waist fracture should have initial cast immobilization and suspected non-unions immediately confirmed and urgently fixed. This will help avoid risks of surgery and mostly limit its use to fixing non-union.

Citation

Dias, J. J., Brealey, S. D., Fairhurst, C., Amirfeyz, R., Bhowal, B., Blewitt, N., …Warwick, D. (2020). Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial. Lancet, 396(10248), 390-401. https://doi.org/10.1016/S0140-6736%2820%2930931-4

Journal Article Type Article
Acceptance Date Apr 22, 2020
Online Publication Date Aug 8, 2020
Publication Date Aug 8, 2020
Deposit Date Mar 6, 2020
Publicly Available Date Mar 28, 2024
Journal Lancet
Print ISSN 0140-6736
Electronic ISSN 1474-547X
Publisher Elsevier
Peer Reviewed Peer Reviewed
Volume 396
Issue 10248
Pages 390-401
DOI https://doi.org/10.1016/S0140-6736%2820%2930931-4
Public URL https://nottingham-repository.worktribe.com/output/4096908
Publisher URL https://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2820%2930931-4/fulltext#seccestitle10

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