Joseph J. Dias

Aims: The association between scaphoid fractures and ligament injuries is uncertain, and the clinical relevance is not well established. The aim of this study was to undertake a secondary analysis of data from the Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) to evaluate the incidence of concurrent ligament injuries in patients with a scaphoid waist fracture displaced by ≤ 2 mm, explore the radiological changes between one and five years after the injury, and assess whether there is an association between the characteristics of the fracture and ligament injury. Methods: All 439 patients from the SWIFFT had baseline measurements available from plain radiographs and CT scans. Further follow-up measurements were undertaken from CT scans in 292 patients at 52 weeks and 239 patients at five years. A total of 345 patients had radiographs suitable for assessment of the scapholunate (SL) and lunotriquetral (LT) intervals at 52 weeks and/or five years. Results: Only 12 patients (2.8%) had widening of the SL gap by > 3 mm on initial imaging. There was no progression of these gaps at five years, and no patient had widening of the LT gap. Conclusion: Injury to the interosseous intercarpal ligaments causing diastasis of carpal bones is rare in patients with a scaphoid waist fracture displaced by ≤ 2 mm. Treatment of the fracture with a cast or surgical fixation, without additional imaging or intervention for a potential ligament injury, appears adequate for most fractures. If there are ligament injuries not identified with standard imaging, they do not seem to progress. Cite this article: Bone Joint J 2026;108-B(4):538–543.

Aims: In the Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT), surgical fixation was compared with cast immobilization, with the primary endpoint being the outcomes at one year. The aim of the current study was to assess the radiological outcomes (union and the development of osteoarthritis (OA)) of the two forms of treatment at five years. Methods: Patients who remained in the trial at five years after randomization were invited to have plain radiographs and a CT scan of the injured wrist, and a posterior-anterior radiograph of the contralateral wrist. This imaging was reviewed by three observers independently for union of the fracture and the distribution and severity of OA. This analysis followed a pre-specified statistical analysis plan. The relationship between OA and the Patient-Rated Wrist Evaluation (PRWE) scores at five years was assessed. Results: Of the 439 patients who were randomized, 267 (60.8%) provided imaging at five years. Their characteristics were similar to those of the original cohort. A total of 182 patients (68.2%) (n = 92 fixation, n = 90 cast) had complete union and seven had a nonunion (2.6%; n = 3 fixation, n = 4 cast). Fractures with a minimum of 20% union at one year consolidated with the passage of time without intervention. Progression of OA in the joints around the scaphoid was seen in both groups from baseline to five years. By five years, 140 patients (52.4% of those with imaging at five years) had OA in at least one joint with similar prevalences in both groups. The prevalence of OA, the number of arthritic joints and the maximum severity of OA, was similar in the two groups. A total of 344 of the initial cohort of 439 patients (78.4%) provided a valid PRWE score at five years and the mean score was higher in those with more severe OA, indicating worse pain and function. Conclusion: Between one and five years after randomization, union consolidated in those with > 20% bridging without intervention. The proportion of patients with full, almost full, partial, slight, and nonunion for the two forms of treatment remained similar at five years. The prevalence and severity of OA increased during the five years but was similar in both groups. Cite this article: Bone Joint J 2026;108-B(1):87–95.

Aims: In the Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT), surgical fixation was compared with cast immobilization using the Patient-Rated Wrist Evaluation (PRWE) score at one year as the primary endpoint. The aim of this longer-term study was to assess the clinical effectiveness of the two treatment pathways at a five-year follow-up. Methods: Patients who had not withdrawn from the trial were invited for a clinical assessment at five years after randomization and asked to complete a patient-reported questionnaire in the clinic, or by post or telephone. The PRWE was collected along with the grip strength, range of motion (ROM), imaging data, EuroQol five-dimension three-level questionnaire (EQ-5D-3L) score, and the use of health resources. The repeated measures analysis model used at one year was repeated to include the five-year timepoint. Results: A total of 344 patients provided a valid PRWE score at five years (78.4% of the original cohort). There was no significant difference between the groups at five years (mean difference 0.6 (95% CI -2.4 to 3.6); p = 0.709). These results were robust to sensitivity analyses, restricting data collection windows. Neither the pain and function subscales of the PRWE score nor the overall estimate of the treatment effect showed a significant difference between the groups. Neither non-compliance with allocation of treatment, the displacement of the fracture, nor the patient’s preferred treatment at baseline had an effect on the PRWE scores between groups. Only seven patients for whom imaging was collected at five years had a nonunion, three of 146 (2.1%) in the fixation group and four of 121 (3.3%) in the immobilization group. Grip strength and ROM were similar between the groups. Conclusion: The clinical effectiveness of the two forms of treatment remained similar at five years. The recommendation that adult patients with a fracture of the waist of the scaphoid which is displaced by ≤ 2 mm should be treated inially with immobilization in a cast, followed by early fixation of a nonunion, is further corroborated by these findings. Cite this article: Bone Joint J 2026;108-B(1):70–78.

Aims: The conclusion of the one-year analysis of the Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) was that initial cast immobilization with surgical fixation for nonunion was the optimal treatment for patients with a fracture of the waist of the scaphoid. However, there remained significant uncertainty about the medium-term outcomes and how these could influence the patient’s health-related quality of life (HRQoL), care requirements, and costs. The aim of this study was to explore how additional data from the five-year follow-up influenced the cost-effectiveness of the treatment of these fractures. Methods: The analysis presents the patient-reported HRQoL, measured with the EuroQol five-dimension three-level health questionnaire, and the use of healthcare resources at five years after randomization, and considers which factors influenced the results. The original analytical model, in which the implications of the different forms of treatment throughout the patient’s life were estimated, was also updated. Results: Five years after randomization, most patients in both groups returned to the HRQoL level which is consistent with age-adjusted norms and did not require further healthcare. In contrast, those who continued to have clinically relevant adverse events at five years reported significantly worse HRQoL scores and greater care needs. It was also confirmed in the updated model that initial cast immobilization was the most cost-effective strategy, with a mean cost to the health system of £1,606 less per eligible patient compared with those who initially underwent surgery, an annual saving of £7.5 million. Conclusion: Most patients had no long-term impact from the injury regardless of the form of treatment. However, the few who had clinically defined adverse events at five years had poor HRQoL and greater care needs. The limited difference in these clinical outcomes between the two groups informed the findings of the decision model that, over the patient’s lifetime, the small quality-adjusted life year gains for those who underwent surgery initially were not sufficient to justify the higher costs. These findings confirm that initial immobilization in a cast with fixation for nonunion is the optimal form of treatment for these patients. Cite this article: Bone Joint J 2026;108-B(1):79–86.

Introduction: Shoulder osteoarthritis most commonly affects older adults, causing pain, reduced function and quality of life. Total shoulder replacements (TSRs) are indicated once other non-surgical options no longer provide adequate pain relief. Two main types of TSRs are widely used: anatomic TSR (aTSR) and reverse TSR (rTSR). It is not clear whether one TSR type provides better short- or long-term outcomes for patients, and which, if either, is more cost-effective for the National Health Service (NHS). Methods and analysis: RAPSODI-UK is a multi-centre, pragmatic, two-parallel arm, superiority randomised controlled trial comparing the clinical- and cost-effectiveness of aTSR versus rTSR for adults aged 60+ with a primary diagnosis of osteoarthritis, an intact rotator cuff and bone stock suitable for TSR. Participants in both arms of the trial will receive usual post-operative rehabilitation. We aim to recruit 430 participants from approximately 28 NHS sites across the UK. The primary outcome is the Shoulder Pain and Disability Index (SPADI) at 2 years post-randomisation. Outcomes will be collected at 3, 6, 12, 18 and 24 months after randomisation. Secondary outcomes include the pain and function subscales of the SPADI, the Oxford Shoulder Score, health-related quality of life (EQ-5D-5L), complications, range of movement and strength, revisions and mortality. The between-group difference in the primary outcome will be derived from a constrained longitudinal data analysis model. We will also undertake a full health economic evaluation and conduct qualitative interviews to explore perceptions of acceptability of the two types of TSR and experiences of recovery with a sample of participants. Ethics and dissemination: Ethics committee approval for this trial was obtained (London - Queen Square Research Ethics Committee, Rec Reference 22/LO/0617) on 4 October 2022. The results of the main trial will be submitted for publication in a peer-reviewed journal and using other professional and media outlets. Trial registration number: ISRCTN12216466 .

This review examines whether randomised controlled trials (RCTs) of surgery in orthopaedics are inclusive of their target populations, including under-served populations. The BMJ, Journal of the American Medical Association, The Lancet, and The New England Journal of Medicine were electronically searched in February 2022 for eligible RCTs published from 1 January 2014. Screening, key baseline patient characteristics, the inclusion of under-served groups and whether patient recruitment was pragmatic in design were key data extracted. The findings were tabulated and reported narratively. There were 26 RCTs included that were parallel in design and conducted across a range of countries in different hospital settings. Four RCTs did not report the complete CONSORT statement. There was variation in the percentage of the screened population who were randomised into the studies ranging from 5.8% to 74.7%. Most RCTs were pragmatic in design regarding patient selection but this did not necessarily translate to an inclusive trial population. Only two RCTs reported the age and gender of all screened patients. All 26 RCTs reported the age and gender of randomised patients but only four studies reported ethnicity. Reporting about the consideration and inclusion of under-served populations was limited. There is variation in the exclusion of patients of the target population. Reporting of key patient characteristics during screening and attention given to under-served populations in the design, conduct and reporting of these trials is limited. Training and education on inclusivity is required along with practical guidance about how to implement this. To improve inclusivity in the screening and recruitment of patients there should be a focus on (i) screening and eligibility criteria, (ii) collection and reporting on attributes to ensure no section of the eligible population is inadvertently excluded, and (iii) embedding mechanisms to allow all eligible patients the opportunity to participate.

Background This review examines whether randomised controlled trials (RCTs) of surgery in orthopaedics are inclusive of their target populations, including under-served populations. Methods The BMJ, Journal of the American Medical Association, The Lancet, and The New England Journal of Medicine were electronically searched in February 2022 for eligible RCTs published from 1 January 2014. Screening, key baseline patient characteristics, the inclusion of under-served groups and whether patient recruitment was pragmatic in design were key data extracted. The findings were tabulated and reported narratively. Results There were 26 RCTs included that were parallel in design and conducted across a range of countries in different hospital settings. Four RCTs did not report the complete CONSORT statement. There was variation in the percentage of the screened population who were randomised into the studies ranging from 5.8% to 74.7%. Most RCTs were pragmatic in design regarding patient selection but this did not necessarily translate to an inclusive trial population. Only two RCTs reported the age and gender of all screened patients. All 26 RCTs reported the age and gender of randomised patients but only four studies reported ethnicity. Reporting about the consideration and inclusion of under-served populations was limited. Conclusions There is variation in the exclusion of patients of the target population. Reporting of key patient characteristics during screening and attention given to under-served populations in the design, conduct and reporting of these trials is limited. Training and education on inclusivity is required along with practical guidance about how to implement this. To improve inclusivity in the screening and recruitment of patients there should be a focus on (i) screening and eligibility criteria, (ii) collection and reporting on attributes to ensure no section of the eligible population is inadvertently excluded, and (iii) embedding mechanisms to allow all eligible patients the opportunity to participate.

Aims: To evaluate the diagnostic characteristics and reliability of radiological methods used to assess scaphoid fracture union through a systematic review and meta-analysis.Methods: MEDLINE, Embase, and the Cochrane Library were searched from inception to June 2022. Any study reporting data on the diagnostic characteristics and/or the reliability of radiological methods assessing scaphoid union was included. Data were extracted and checked for accuracy and completeness by pairs of reviewers. Methodological quality was assessed using the QUADAS-2 tool.Results: A total of 13 studies were included, which were three assessed radiographs alone, six CT alone, and four radiographs + CT. Diagnostic sensitivity was assessed by CT in three studies (0.78, 0.78, and 0.73) and by radiographs in two studies (0.65, 0.75). Diagnostic specificity was assessed by CT in three studies (0.96, 0.8, 0.4) and by radiographs in two studies (0.67, 0.4). Interobserver reliability was assessed for radiographs by seven studies (two fair, four moderate, and one substantial) and for CT in nine studies (one fair, one moderate, six substantial, and one almost perfect).Conclusion: There is evidence to support both the use of CT and radiographs in assessing scaphoid fracture union. Although CT appears superior in terms of both its diagnostic characteristics and reliability, further research is necessary to better define the optimal clinical pathways for patients.Cite this article: Bone Jt Open 2025;6(3):246–253.

Background: Thumb carpometacarpal osteoarthritis (CMC-1 OA) is a common and debilitating condition, particularly among older adults and women. With the aging population, the prevalence of CMC-1 OA is expected to rise, emphasizing the need to find effective nonoperative strategies. So far, for determining the most effective nonoperative interventions in CMC-1 OA, two network meta-analyses (NMAs) have been published. However, these NMAs were limited to specific intervention types: one comparing multiple splints and the other comparing different intraarticular injections. Therefore, an NMA that compared all nonoperative intervention types is urgently needed. Questions/purposes: This study aimed to assess and compare the effectiveness of available nonoperative interventions (both nonpharmacologic and pharmacologic) for CMC-1 OA to establish which nonoperative options are more effective than control in terms of (1) pain, (2) function, and (3) grip strength. Methods: We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) NMA guidelines (PROSPERO: CRD2021272247) and conducted a comprehensive search across Medline, Embase, CENTRAL, and CINAHL up to March 2023. We included randomized controlled trials (RCTs) and quasi-RCTs evaluating nonoperative interventions for symptomatic CMC-1 OA, excluding inflammatory or posttraumatic arthritis. Studies comparing ≥ 2 interventions or against a control, focusing on pain reduction, functional improvement, and grip strength, were selected. We assessed methodologic quality using the modified Coleman Methodology Score, including only studies scoring > 70. Risk of bias was evaluated with the Risk of Bias 2.0 tool, and evidence quality with Confidence in Network Meta-Analysis (CINeMA). Of 29 screened studies, 22 (21 RCTs and one quasi-RCT) were included, involving 1631 women and 331 men. We analyzed eight different nonoperative interventions, including splints, hand exercises, injections, and multimodal treatment (≥ 2 nonpharmacologic interventions or nonpharmacologic with a pharmacologic intervention). Six studies had a low risk of bias, eight had a high risk, and the remainder were moderate. We extracted mean and SD scores, and NMA and pairwise analyses were performed at short- (≤ 3 months) and medium-term (> 3 to ≤ 12 months) time points. Standardized mean differences were re-expressed into common units for interpretation, which were the VAS (range 0 to 10) for pain, the DASH test (range to 100) for function, and pounds for grip strength. Clinical recommendations were considered strong if the mean differences exceeded the minimum clinically important difference—1.4 points for VAS, 10 points for DASH, and 14 pounds for grip strength—and were supported by moderate or high confidence in the evidence, as assessed using CINeMA methodology. Results: Our NMA (based on moderate or high confidence) showed a clinically important reduction in pain at the short-term time point for multimodal treatment and hand exercises versus control (mean difference VAS score -5.3 [95% confidence interval (CI) -7.6 to -3.0] and -5.0 [95% CI -8.5 to -1.5]). At the medium-term time point, only the rigid carpometacarpal-metacarpophalangeal (CMC-MCP) splint was superior to control (mean difference VAS score -1.9 [95% CI -3.1 to -0.6]) and demonstrated clinical importance. For function, only the rigid CMC-MCP splint demonstrated a clinically important improvement at the medium-term time point versus control (mean difference DASH score -11 [95% CI -21 to -1]). Hand exercises resulted in a clinically important improvement in short-term grip strength versus control (mean difference 21 pounds [95% CI 11 to 31]). Conclusion: This systematic review and NMA show that multimodal treatment and hand exercises reduce short-term pain and improve grip strength, while a rigid CMC-MCP splint enhances medium-term function. Future research should evaluate long-term efficacy. Level of Evidence: Level I, therapeutic study.

Treatments for Dupuytren's contracture include limited fasciectomy and collagenase injection. Comparisons of the effectiveness of these treatments have been limited. We performed an unblinded, multicenter, pragmatic, two-group, randomized, controlled noninferiority trial comparing collagenase injection with limited fasciectomy in persons with moderate Dupuytren's contracture. The primary outcome was the score on the Patient Evaluation Measure-Hand Health Profile (PEM), a questionnaire for assessing hand health as reported by the patient, at 1 year after treatment. Scores on the PEM range from 0 to 100, with higher scores indicating worse outcomes. The prespecified noninferiority margin was 6 points. A total of 672 persons (336 per group) were assigned to receive collagenase injection or to undergo limited fasciectomy. The primary analysis included 599 persons: 314 in the collagenase group and 285 in the limited-fasciectomy group. The mean score on the PEM at 1 year was 17.8 among the 284 patients with available data in the collagenase group and 11.9 among the 250 patients with available data in the limited-fasciectomy group (estimated difference, 5.9 points; 95% confidence interval [CI], 3.1 to 8.8; one-sided P = 0.49 for noninferiority). Among the patients with available data (229 patients in the collagenase group and 197 patients in the limited-fasciectomy group), the estimated difference in the mean score on the PEM at 2 years was 7.2 points (95% CI, 4.2 to 10.9). Moderate or severe complications of treatment occurred in 1.8% of the patients in the collagenase group and in 5.1% of those in the limited-fasciectomy group; recurrent contracture resulted in reintervention in 14.6% and 3.4%, respectively. Collagenase injection was not noninferior to limited fasciectomy with respect to the score on the PEM at 1 year after treatment. (Funded by the National Institute for Health and Care Research Health Technology Assessment Programme; DISC ISRCTN Registry number ISRCTN18254597.).