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Biomedical subjects

H H G Handoll

Publications and source records attributed to H H G Handoll.

At least 19 recordsLinked to original sources
PubMed2006

Nutritional supplementation for hip fracture aftercare in older people.

BACKGROUND: Older people with hip fractures are often malnourished at the time of fracture, and have poor food intake subsequently. OBJECTIVES: To review the effects of nutritional interventions in older people recovering from hip fracture. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 1), MEDLINE, six other databases and reference lists. We contacted investigators and handsearched journals. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials of nutritional interventions for people aged over 65 years with hip fracture. DATA COLLECTION AND ANALYSIS: Both authors independently selected trials, extracted data and assessed trial quality. We sought additional information from trialists, and pooled data for primary outcomes. MAIN RESULTS: Twenty-one randomised trials involving 1727 participants were included. Overall trial quality was poor, specifically regarding allocation concealment, assessor blinding and intention-to-treat analysis, and limited availability of outcome data. Eight trials evaluated oral multinutrient feeds: providing non-protein energy, protein, some vitamins and minerals. Oral feeds had no statistically significant effect on mortality (15/161 versus 17/176; relative risk (RR) 0.89, 95% confidence interval (CI) 0.47 to 1.68) but may reduce 'unfavourable outcome' (combined outcome of mortality and survivors with medical complications) (14/66 versus 26/73; RR 0.52, 95% CI 0.32 to 0.84). Four trials examining nasogastric multinutrient feeding showed no evidence of an effect on mortality (RR 0.99, 95% CI 0.50 to 1.97) but the studies were heterogeneous regarding case mix. Nasogastric feeding was poorly tolerated. There was insufficient information for other outcomes. Increasing protein intake in an oral feed was tested in four trials. There was no evidence for an effect on mortality (RR 1.42, 95% CI 0.85 to 2.37). Protein supplementation may have reduced the number of long term medical complications. Two trials, testing intravenous vitamin B1 and other water soluble vitamins, or 1-alpha-hydroxycholecalciferol (an active form of vitamin D) respectively, produced no evidence of effect for either supplement. One trial, evaluating dietetic assistants to help with feeding, showed a trend for a reduction in mortality (RR 0.57, 99% CI 0.29 to 1.11). AUTHORS' CONCLUSIONS: Some evidence exists for the effectiveness of oral protein and energy feeds, but overall the evidence for the effectiveness of nutritional supplementation remains weak. Adequately sized trials are required which overcome the methodological defects of the reviewed studies. In particular, the role of dietetic assistants requires further evaluation.

Aftercare↗
PubMed2006

Pre-operative traction for fractures of the proximal femur in adults.

BACKGROUND: Following a hip fracture, traction may be applied to the injured limb before surgery. OBJECTIVES: To evaluate the effects of traction applied to the injured limb prior to surgery for a fractured hip. Different methods of applying traction (skin or skeletal) were considered. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2006), MEDLINE (1966 to March 2006), EMBASE (1988 to 2006 Week 11), CINAHL (1982 to March 2006), the UK National Research Register (Issue 1, 2006), conference proceedings and reference lists of articles. SELECTION CRITERIA: All randomised or quasi-randomised trials comparing either skin or skeletal traction with no traction, or skin with skeletal traction for patients with an acute hip fracture prior to surgery. DATA COLLECTION AND ANALYSIS: Both authors independently assessed trial quality and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, data were pooled. MAIN RESULTS: Ten randomised trials, mainly of moderate quality, involving a total of 1546 predominantly elderly patients with hip fractures, were identified and included in the review. Nine trials compared traction with no traction. Although limited data pooling was possible, overall this provided no evidence of benefit from traction, either in the relief of pain before surgery or ease of fracture reduction or quality of fracture reduction at time of surgery. One of these trials included both skin and skeletal traction groups. This trial and one other compared skeletal traction with skin traction and found no important differences between these two methods, although the initial application of skeletal traction was noted as being more painful and more costly. AUTHORS' CONCLUSIONS: From the evidence available, the routine use of traction (either skin or skeletal) prior to surgery for a hip fracture does not appear to have any benefit. However, the evidence is also insufficient to rule out the potential advantages for traction, in particular for specific fracture types, or to confirm additional complications due to traction use. Further, high quality trials would be required to confirm or refute the absence of benefits of traction.

Adult↗
PubMed2006

Rehabilitation for distal radial fractures in adults.

BACKGROUND: Fracture of the distal radius is a common clinical problem, particularly in older white women with osteoporosis. OBJECTIVES: To examine the effects of rehabilitation interventions in adults with conservatively or surgically treated distal radial fractures. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE, EMBASE, CINAHL, AMED, PEDro, OTseeker and other databases, conference proceedings and reference lists of articles. No language restrictions were applied. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials evaluating rehabilitation as part of the management of fractures of the distal radius sustained by adults. Rehabilitation interventions such as active and passive mobilisation exercises, and training for activities of daily living, could be used on their own or in combination, and be applied in various ways by various clinicians. DATA COLLECTION AND ANALYSIS: The authors independently selected and reviewed trials. Study authors were contacted for additional information. No data pooling was done. MAIN RESULTS: Fifteen trials, involving 746 mainly female and older patients, were included. Initial treatment was conservative, involving plaster cast immobilisation, in all but 27 participants whose fractures were fixed surgically. Though some trials were well conducted, others were methodologically compromised. For interventions started during immobilisation, there was weak evidence of improved hand function for hand therapy in the days after plaster cast removal, with some beneficial effects continuing one month later (one trial). There was weak evidence of improved hand function in the short term, but not in the longer term (three months), for early occupational therapy (one trial), and of a lack of differences in outcome between supervised and unsupervised exercises (one trial). For interventions started post-immobilisation, there was weak evidence of a lack of clinically significant differences in outcome in patients receiving formal rehabilitation therapy (four trials), passive mobilisation (two trials), ice or pulsed electromagnetic field (one trial), or whirlpool immersion (one trial) compared with no intervention. There was weak evidence of a short-term benefit of continuous passive motion (post external fixation) (one trial), intermittent pneumatic compression (one trial) and ultrasound (one trial). There was weak evidence of better short-term hand function in participants given physiotherapy than in those given instructions for home exercises by a surgeon (one trial). AUTHORS' CONCLUSIONS: The available evidence from randomised controlled trials is insufficient to establish the relative effectiveness of the various interventions used in the rehabilitation of adults with fractures of the distal radius.

Adult↗
PubMed2006

Intramedullary nails for extracapsular hip fractures in adults.

BACKGROUND: Intramedullary nails may be used for the surgical fixation of extracapsular hip fractures in adults. They may be inserted from the top (cephalocondylic) or from the bottom (condylocephalic) end of the femur. OBJECTIVES: To compare different types or design modifications of intramedullary nails used in the fixation of extracapsular hip fractures. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2006), MEDLINE, EMBASE, the UK National Research Register, several orthopaedic journals, conference proceedings and reference lists of articles. SELECTION CRITERIA: All randomised or quasi-randomised trials comparing different types of intramedullary nails or modifications to the design of intramedullary nails in the treatment of extracapsular hip fractures in adults. DATA COLLECTION AND ANALYSIS: Both authors independently assessed trial quality and extracted data. Additional information was sought from all trialists. MAIN RESULTS: Six studies, involving a total of 1071 predominantly female and older people with mainly unstable trochanteric fractures, were included. Allocation concealment was likely in one trial, not described in three and not done in the other two trials. Four studies, with 910 participants, compared the proximal femoral nail with the Gamma nail. Though there was increased risk of comminution (fragmentation) at the fracture site when inserting a Gamma nail, there was no statistically significant difference in operative fracture of the femur (1/455 versus 5/455; relative risk 0.33, 95% confidence interval 0.07 to 1.63). No notable differences were seen between implants for fracture healing complications, reoperations and other post-operative complications. Pooled data showed no significant difference between implants for mortality (relative risk 1.08, 95% confidence interval 0.82 to 1.41) or function assessment outcomes. One study, with 80 participants, found no differences between a gliding nail versus a standard Gamma nail. Another study, with 81 participants, found no difference between a dynamically versus a statically locked intramedullary hip screw. AUTHORS' CONCLUSIONS: The limited evidence from the randomised trials undertaken to date is insufficient to determine whether there are important differences in outcome between different designs of intramedullary nails used in the internal fixation of extracapsular hip fractures. Given the evidence of superiority of the sliding hip screw compared with intramedullary nails for extracapsular hip fractures, further studies comparing different designs of intramedullary nails are not a priority. Any new design should be evaluated in a randomised comparison with the sliding hip screw.

Aged↗
PubMed2006

Replacement arthroplasty versus internal fixation for extracapsular hip fractures in adults.

BACKGROUND: Internal fixation, commonly used for extracapsular hip fractures, may fail particularly in unstable fractures. Replacement of the hip using arthroplasty, often used for intracapsular fractures, has been used as an alternative. OBJECTIVES: To compare replacement arthroplasty with internal fixation for the treatment of extracapsular hip fractures in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE, EMBASE, the UK National Research Register, several orthopaedic journals, conference proceedings and reference lists of articles. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing replacement arthroplasty with an internal fixation implant for adults with an extracapsular hip fracture. DATA COLLECTION AND ANALYSIS: Both review authors independently assessed 10 aspects of trial quality and extracted data. We requested additional information from trial investigators. Where appropriate, limited pooling of data was performed. MAIN RESULTS: Two randomised controlled trials including a total of 148 people aged 70 years or over with unstable extracapsular hip fractures in the trochanteric region were identified and included in this review. Both had methodological limitations, including inadequate assessment of longer-term outcome. One trial compared a cemented arthroplasty with a sliding hip screw. This found no significant differences between the two methods of treatment for operating time, local wound complications, mechanical complications, reoperation, mortality or loss of independence of previously independent patients at one year. There was, however, a higher blood transfusion need in the arthroplasty group. The other trial compared a cementless arthroplasty versus a proximal femoral nail. It also found a higher blood transfusion need in the arthroplasty group, together with a greater operative blood loss, and a longer length of surgery. There were no significant differences between the two interventions for mechanical complications, local wound complications, reoperation, general complications, mortality at one year or long-term function. None of the pooled outcome data yielded statistically significant differences between the arthroplasty and internal fixation, with the exception of the significantly higher numbers of participants in the arthroplasty group requiring blood transfusion (relative risk 1.71, 95% confidence interval 1.05 to 2.77). AUTHORS' CONCLUSIONS: There is insufficient evidence from randomised trials to determine whether replacement arthroplasty has any advantage over internal fixation for extracapsular hip fractures. Further larger well-designed randomised trials comparing arthroplasty versus internal fixation for the treatment of unstable fractures are required.

Fracture Fixation, Internal↗
PubMed2006

Extramedullary fixation implants and external fixators for extracapsular hip fractures in adults.

BACKGROUND: Extramedullary fixation of hip fractures involves the application of a plate and screws to the lateral side of the proximal femur. In external fixators, the stabilising component is held outside the thigh by pins or screws driven into the bone. OBJECTIVES: To compare different types of extramedullary fixation implants and external fixators for fixing extracapsular hip fracture in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2005), various other databases, conference proceedings and reference lists. SELECTION CRITERIA: All randomised or quasi-randomised controlled trials comparing extramedullary implants or external fixators for fixing extracapsular hip fracture in adults. DATA COLLECTION AND ANALYSIS: Two authors independently selected trials, assessed trial quality and extracted data. Data were pooled where appropriate. MAIN RESULTS: The 14 included trials tested seven comparisons in a total of 2222 mainly female and older participants. All trials had methodological flaws that may affect the validity of their results. Three trials comparing a fixed nail plate (Jewett or McLaughlin) with the sliding hip screw (SHS) found an increased risk of fixation failure for fixed nail plates. The two trials comparing the Resistance Augmented Bateaux (RAB) plate with the SHS had contrasting results, notably in terms of operative complications, fixation failure and anatomical restoration. One trial comparing the Pugh nail and the SHS found no significant difference between implants. Two trials compared the Medoff plate with the SHS. One trial reported higher blood losses and longer operation times for the Medoff plate. There was a lower risk of fixation failure with the Medoff plate for unstable trochanteric fractures. Two trials compared the Medoff plate with three different screw-plate systems. There were no statistically significant differences in outcome for trochanteric fractures. For subtrochanteric fractures, there was a lower fixation failure rate for the Medoff plate, but no evidence for differences in longer-term outcomes. Two trials comparing the Gotfried percutaneous plate with a SHS found a reduced blood loss with the Gotfried plate. A higher intra-operative fixation failure rate of the Gotfried plate may indicate some restriction to its use. Two trials found less operative trauma for external fixation when compared with the SHS. Final outcome appeared similar. AUTHORS' CONCLUSIONS: The markedly increased fixation failure rate of fixed nail plates compared with the SHS is a major consideration and thus the SHS appears preferable. There was insufficient evidence from other comparisons to draw definite conclusions.

Bone Plates↗
PubMed2006

Single, double or multiple injection techniques for axillary brachial plexus block for hand, wrist or forearm surgery.

BACKGROUND: Regional anaesthesia comprising axillary block of the brachial plexus is a common anaesthetic technique for distal upper extremity surgery. OBJECTIVES: To compare the relative effects of anaesthetic techniques using either single, double or multiple injections for axillary block of the brachial plexus for distal upper extremity surgery. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, as well as reference lists of trials. We contacted trial authors and the medical industry. Date of last search: August 2004. SELECTION CRITERIA: We included randomized controlled trials that compared double with single injection techniques, multiple with single injection techniques, or multiple with double injection techniques for axillary block in adults undergoing surgery of the distal upper extremity. DATA COLLECTION AND ANALYSIS: We performed independent study selection, quality assessment and data extraction. We undertook meta-analysis, including exploratory analyses according to the method of nerve location and definition of primary anaesthesia failure. MAIN RESULTS: The 12 included trials involved a total of 981 participants who received regional anaesthesia for hand, wrist, forearm or elbow surgery. Trial design and conduct was generally adequate although several trials failed to monitor longer-term effects and to provide sufficient description of their study populations. Substantial heterogeneity precluded the pooling of data for primary anaesthesia failure from the five trials comparing double versus single injections. However, double injections were significantly more effective than single injections in the three trials where electrolocation was used throughout (relative risk (RR) 0.31, 95% confidence interval (CI) 0.31 to 0.74). Five trials compared multiple with single injections. These showed a statistically significant decrease in primary anaesthesia failure (RR 0.24, 95% CI 0.13 to 0.46) and incomplete motor block (RR 0.61, 95% CI 0.39 to 0.96) in the multiple injection group. Six trials compared multiple with double injections. These showed a statistically significant decrease in primary anaesthesia failure (RR 0.23, 95% CI 0.14 to 0.38) and incomplete motor block (RR 0.55, 95% CI 0.36 to 0.85) in the multiple injection group.Generally, none of the differences between the two groups of any of the three comparisons in secondary analgesia failure, complications and patient discomfort were statistically significant. The time for block performance was significantly shorter for single and double injections compared with multiple injections, but the requirement for supplementary blocks in these groups tended to increase the time to readiness for surgery. AUTHORS' CONCLUSIONS: This review provided some evidence that multiple injection techniques using nerve stimulation for axillary plexus block provide more effective anaesthesia than either double or single injection techniques. However, there was insufficient evidence for other outcomes, including safety.

Anesthetics, Local↗
PubMed2006

Conservative management following closed reduction of traumatic anterior dislocation of the shoulder.

BACKGROUND: Acute anterior dislocation is the commonest type of shoulder dislocation and usually results from an injury. Subsequently, the shoulder is less stable and more susceptible to redislocation, especially in active young adults. OBJECTIVES: To compare methods of conservative (non-surgical) management versus no treatment or different methods of conservative management after closed reduction of traumatic anterior dislocation of the shoulder. Interventions include methods of postreduction immobilisation and rehabilitation. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2005), MEDLINE, EMBASE, the National Research Register (UK), conference proceedings and reference lists of articles. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials comparing various conservative interventions versus control (no or sham treatment) or other conservative interventions applied after closed reduction of traumatic anterior dislocation of the shoulder. DATA COLLECTION AND ANALYSIS: All authors selected trials, assessed methodological quality and extracted data. Study authors were contacted for additional information. MAIN RESULTS: One flawed quasi-randomised trial was included. A "preliminary report" gave the results for 40 adults with primary traumatic anterior dislocation of the shoulder treated by post-reduction immobilisation with the arm in either external or internal rotation. There was no statistically significant difference between the two groups in the failure to return to pre-injury sports by previously active athletes, in redislocation or shoulder instability. Similar numbers of participants of the two groups removed their immobiliser before one week had passed. AUTHORS' CONCLUSIONS: There is a lack of evidence from randomised controlled trials to inform the choices for conservative management following closed reduction of traumatic anterior dislocation of the shoulder. Sufficiently powered, good quality, well reported randomised controlled trials with long-term surveillance of conservative management are required. In particular, trials examining the type and duration of immobilisation would be useful.

Humans↗
PubMed2005

Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults.

BACKGROUND: Two types of implants used for the surgical fixation of extracapsular hip fractures are cephalocondylic intramedullary nails, which are inserted into the femoral canal proximally to distally across the fracture, and extramedullary implants. OBJECTIVES: To compare cephalocondylic intramedullary nails with extramedullary implants (e.g. the sliding hip screw) for extracapsular hip fractures in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (June 2005), the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, the UK National Research Register, orthopaedic journals, conference proceedings and reference lists of articles. SELECTION CRITERIA: All randomised and quasi-randomised controlled trials comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures. DATA COLLECTION AND ANALYSIS: Both authors independently assessed trial quality and extracted data. Wherever appropriate, results were pooled. MAIN RESULTS: Predominantly older people with mainly trochanteric fractures were treated in the 32 included trials. Twenty trials, involving 3646 people, compared the Gamma nail with the sliding hip screw (SHS). The Gamma nail was associated with an increased risk of operative and later fracture of the femur and an increased reoperation rate. There were no major differences between implants in the wound infection, mortality or medical complications. Data were inadequate for other outcomes. Five trials, involving 623 people, compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group: all cases of operative and later fracture of the femur occurred in this group. Results for post-operative complications, mortality and functional outcomes were similar in the two groups. Two trials involving 314 people showed no difference in fracture fixation complications, reoperation, wound infection and length of hospital stay for proximal femoral nail (PFN) compared with the SHS. Single trial comparisons (experimental mini-invasive static intramedullary nail compared with the SHS: 60 participants; Kuntscher-Y nail with the SHS: 230 participants; Gamma nail and the Medoff sliding plate: 217 participants) failed to provide sufficient evidence to establish differences between implants in outcome. Two trials, involving 65 people with reverse and transverse fractures at the level of the lesser trochanter, found intramedullary nails (Gamma nail or PFN) were associated with better intra-operative results and fewer fracture fixation complications than extramedullary implants (a 90-degree blade plate or dynamic condylar plate) for these fractures. AUTHORS' CONCLUSIONS: Given the lower complication rate of the SHS in comparison with intramedullary nails, SHS appears superior for trochanteric fractures. Further studies are required to determine if different types of intramedullary nail produce similar results, or if intramedullary nails have advantages for selected fracture types (for example, subtrochanteric fractures).

Adult↗
PubMed2005

Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults.

BACKGROUND: Stress reaction in bone, which may proceed to a fracture, is a significant problem in military recruits and in athletes, particularly long distance runners. OBJECTIVES: To evaluate the evidence from randomised controlled trials of interventions for prevention or management of lower-limb stress fractures and stress reactions of bone in active young adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group Specialised Register (April 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to September week 1, 2004), EMBASE, CINAHL, Index to UK Theses, reference lists of relevant articles and contacted trialists. SELECTION CRITERIA: Any randomised or quasi-randomised trials evaluating interventions for preventing or treating lower limb stress reactions of bone or stress fractures in active young adults. DATA COLLECTION AND ANALYSIS: We independently selected trials for inclusion, assessed trial quality and extracted data. Only limited data pooling was undertaken. MAIN RESULTS: We included 16 trials. All 13 prevention trials involved military recruits undergoing training. Participants of two of the three treatment trials were military personnel. Ten prevention trials tested the effects of various foot inserts and other footwear modifications. While pooling of data was not possible, the four trials evaluating the use of "shock-absorbing" boot inserts versus control found fewer stress injuries of the bone in their intervention groups. However, the only trial showing a significant benefit lacked important information about trial design. A key issue in several trials was the acceptability, in terms of practicality and comfort, of the boot inserts. Two cluster-randomised prevention trials found no significant effect of leg muscle stretching during warm up before exercise. Pooled data from three small but very different trials testing the use of pneumatic braces in the rehabilitation of tibial stress fractures showed a significant reduction in the time to recommencing full activity (weighted mean difference -33.39 days, 95% confidence interval -44.18 to -22.59 days). These results were highly heterogeneous (I squared = 90%), which is likely to reflect the underlying differences of the trials, including differences in the control group interventions and definitions of outcomes. AUTHORS' CONCLUSIONS: The use of shock absorbing inserts in footwear probably reduces the incidence of stress fractures in military personnel. There is insufficient evidence to determine the best design of such inserts but comfort and tolerability should be considered. Rehabilitation after tibial stress fracture may be aided by the use of pneumatic bracing but more evidence is required to confirm this.

Adult↗
PubMed2005

Nutritional supplementation for hip fracture aftercare in older people.

BACKGROUND: Fractures of the hip are an important cause of later ill health and mortality in older people. People with hip fractures are often malnourished at the time of fracture, and have poor food intake in hospital. OBJECTIVES: This review assesses the effects of nutritional interventions in older people recovering from hip fracture. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 3, 2004), MEDLINE (1966 to October week 1 2004), Nutrition Abstracts and Reviews, EMBASE, BIOSIS, CINAHL, HEALTHSTAR, the National Research Register and reference lists. We contacted investigators and handsearched four nutrition journals. SELECTION CRITERIA: Randomised and quasi-randomised trials of nutritional interventions for mainly older people (aged over 65 years) with hip fracture. DATA COLLECTION AND ANALYSIS: Both authors independently selected trials, extracted data and assessed trial quality. We sought additional information from all trialists, and pooled data for primary outcomes. MAIN RESULTS: Eighteen randomised trials involving 1306 participants were included. Overall trial quality was poor; specifically in terms of allocation concealment, assessor blinding and intention-to-treat analysis. This, and the limited availability of outcome data, mean that the following results must be interpreted with caution. Eight trials evaluated oral multinutrient feeds: these provided non-protein energy, protein, some vitamins and minerals. Oral feeds had no statistically significant effect on mortality (15/161 versus 17/176; relative risk (RR) 0.89, 95% confidence interval (CI) 0.47 to 1.68) but may reduce 'unfavourable outcome' (combined outcome of mortality and survivors with complications) (14/66 versus 26/73; RR 0.52, 95% CI 0.32 to 0.84). Four trials examining nasogastric multinutrient feeding showed no evidence of an effect on mortality (RR 0.99, 95% CI 0.50 to 1.97), but the studies were heterogeneous regarding case mix. There was insufficient information for other outcomes. The specific effect of protein given in an oral feed was tested in three trials. There was no evidence for an effect on mortality (RR 1.38, 95% CI 0.82 to 2.34). Protein supplementation may have reduced the number of long term complications and days spent in rehabilitation wards. Two trials, testing intravenous thiamin (vitamin B1) and other water soluble vitamins, or 1-alpha-hydroxycholecalciferol (an active form of vitamin D) respectively, produced no evidence of effect for either vitamin supplement. AUTHORS' CONCLUSIONS: While some evidence exists for the effectiveness of oral protein and energy feeds, overall the evidence for the effectiveness of nutritional supplementation remains weak. Future trials are required which overcome the defects of the reviewed studies, particularly inadequate size, methodology and outcome assessment.

Aftercare↗
PubMed2005

Intramedullary nails for extracapsular hip fractures in adults.

BACKGROUND: Intramedullary nails may be used for the surgical fixation of extracapsular hip fractures in adults. They may be inserted from the top (cephalocondylic) or from the bottom (condylocephalic) end of the femur. OBJECTIVES: To compare different types or design modifications of intramedullary nails used in the fixation of extracapsular hip fractures. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (September 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2004), MEDLINE (1966 to September week 1 2004), EMBASE (1988 to 2004 Week 37), the UK National Research Register Issue 2, 2004, several orthopaedic journals, conference proceedings and reference lists of articles. SELECTION CRITERIA: All randomised or quasi-randomised trials comparing different types of intramedullary nails or modifications to the design of intramedullary nails in the treatment of extracapsular hip fractures in adults. DATA COLLECTION AND ANALYSIS: Both authors independently assessed trial quality and extracted data. Additional information was sought from all trialists. MAIN RESULTS: Four studies, involving a total of 834 predominantly female and older patients with mainly unstable trochanteric fractures, were included. All trials compared different designs of cephalocondylic nail. Allocation concealment was likely in one trial, not described in two and not done in the fourth. Two studies, with 674 participants, compared the proximal femoral nail versus the Gamma nail. Blood transfusion was greater for the proximal femoral nail group in one trial, yet blood loss was less in this group in the other trial. Pooled data for re-operation (relative risk 1.08, 95% confidence interval 0.65 to 1.81) and mortality (relative risk 1.24, 95% confidence interval 0.90 to 1.71) showed no statistically significant differences between the two groups. Limited data for long term function also showed no statistically significant differences. The two other studies, with 80 participants each, found respectively no differences between a gliding nail versus a Gamma nail; and a dynamically versus a statically locked intramedullary hip screw. AUTHORS' CONCLUSIONS: The limited evidence from the randomised trials undertaken to date is insufficient to determine if there are important differences in outcome between different designs of intramedullary nails used in the internal fixation of extracapsular hip fractures. Given the evidence of superiority of the sliding hip screw compared with intramedullary nails for extracapsular hip fractures, further studies comparing different designs of intramedullary nails are not a priority. Any new design should be evaluated in a randomised comparison with the sliding hip screw.

Aged↗
PubMed2004

Anaesthesia for hip fracture surgery in adults.

BACKGROUND: The majority of people with hip fracture are treated surgically, requiring anaesthesia. OBJECTIVES: To compare different types of anaesthesia for surgical repair of hip fractures (proximal femoral fractures) in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (November 2003), MEDLINE (1996 to February week 2 2004), EMBASE (1988 to 2004 week 10) and reference lists of relevant articles. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing different methods of anaesthesia for hip fracture surgery in adults. The primary focus of this review was the comparison of regional (spinal or epidural) anaesthesia versus general anaesthesia. The use of nerve blocks preoperatively or in conjunction with general anaesthesia is evaluated in another review. The primary outcome was mortality. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. MAIN RESULTS: Twenty two trials, involving 2567 predominantly female and elderly patients, comparing regional anaesthesia with general anaesthesia were included. All trials had methodological flaws and many do not reflect current anaesthetic practice. Pooled results from eight trials showed regional anaesthesia to be associated with a decreased mortality at one month (56/811 (6.9%) versus 86/857 (10.0%)); however, this was of borderline statistical significance (relative risk (RR) 0.69, 95% confidence interval (CI) 0.50 to 0.95). The results from six trials for three month mortality were not statistically significant, although the confidence interval does not exclude the possibility of a clinically relevant reduction (86/726 (11.8%) versus 98/765 (12.8%), RR 0.92, 95% CI 0.71 to 1.21). The reduced numbers of trial participants at one year, coming exclusively from two trials, preclude any useful conclusions for long-term mortality (80/354 (22.6%) versus 78/372 (21.0%), RR 1.07, 95% CI 0.82 to 1.41).Regional anaesthesia was associated with a reduced risk of deep venous thrombosis (39/129 (30%) versus 61/130 (47%); RR 0.64, 95% CI 0.48 to 0.86). However, this finding is insecure due to possible selection bias in the subgroups in whom this outcome was measured. Regional anaesthesia was also associated with a reduced risk of acute postoperative confusion (11/117 (9.4%) versus 23/120 (19.2%), RR 0.50, 95% CI 0.26 to 0.95). There was insufficient evidence to draw any conclusions from a further four included trials, involving a total of 179 participants, which compared other methods of anaesthesia (a 'light' general with spinal anaesthesia; intravenous ketamine; nerve blocks). REVIEWERS' CONCLUSIONS: Overall, there was insufficient evidence available from trials comparing regional versus general anaesthesia to rule out clinically important differences. Regional anaesthesia may reduce acute postoperative confusion but no conclusions can be drawn for mortality or other outcomes.

Aged↗
PubMed2004

Mobilisation strategies after hip fracture surgery in adults.

BACKGROUND: Hip fracture, which happens in predominantly elderly populations, often results in a reduction in mobility. Care programmes after hip fracture surgery include strategies for mobilisation, such as early weight bearing and gait retraining. Other mobilisation strategies, such as exercises and physical training, are used at various stages in rehabilitation including after discharge from hospital. OBJECTIVES: To evaluate the effects of different mobilisation strategies and programmes after hip fracture surgery. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group Specialised Register (May 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2004), MEDLINE and other databases, conference proceedings and reference lists of articles. SELECTION CRITERIA: All randomised or quasi-randomised trials comparing different mobilisation strategies/programmes after hip fracture surgery. DATA COLLECTION AND ANALYSIS: The reviewers independently assessed trial quality and extracted data. MAIN RESULTS: Our third update, which extended the review scope to cover the whole rehabilitation period, included four new trials. Most of the 10 included trials were small and all had methodological limitations, including inadequate follow up. Seven trials evaluated mobilisation strategies started soon after hip fracture surgery. One trial (273 participants) found no statistically significant differences in unfavourable outcomes for weight bearing started at two versus 12 weeks after internal fixation of a displaced intracapsular fracture. Of two trials (188 participants) comparing a more with a less intensive regimen of physiotherapy, one reported a lack of demonstrable difference in recovery of the two patient groups, and the other found a higher level of drop-out in the more intensive group with no difference in length of hospital stay. One trial (80 participants) comparing two-week programmes of weight-bearing versus non-weight-bearing exercise found some short-term improvement in mobility and balance in the weight-bearing exercise group. One trial (80 participants) found improved mobility, leg extension power and Barthel score in those given a quadriceps muscle strengthening exercise programme. One trial (40 participants) found no statistically significant difference in recovery of mobility and time to hospital discharge after a treadmill versus conventional gait retraining programme. One trial (27 participants) comparing neuromuscular stimulation of the quadriceps muscle with placebo found a greater recovery of pre-fracture mobility in the stimulation group. The interventions tested by the three remaining trials started after hospital discharge. One trial (28 participants) found improved outcome after 12 weeks of intensive physical training. One trial (120 participants) found improved outcome after home-based exercises started around 22 weeks from injury. One trial (44 participants) found home-based weight-bearing exercises starting at seven months produced no statistically significant differences aside, perhaps, for greater quadriceps strength. REVIEWERS' CONCLUSIONS: There is insufficient evidence from randomised trials to determine the effectiveness of the various mobilisation strategies examined in this review that start either in the early post-operative period or during the later rehabilitation period. Further research is required to establish the possible benefits of the additional provision of interventions primarily aimed at enhancing mobility.

Adult↗
PubMed2004

Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures.

BACKGROUND: Cephalocondylic intramedullary nails, which are inserted proximally to distally (cephalocondylic), have been used for the surgical treatment of extracapsular hip fractures. OBJECTIVES: To compare all cephalocondylic intramedullary nails with extramedullary implants for the surgical treatment of extracapsular hip fractures in adults. This is the fourth substantive update of our original review which compared the Gamma nail with the sliding hip screw (SHS). SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, MEDLINE, several orthopaedic journals and conference proceedings, and reference lists of relevant articles. We contacted trialists, colleagues and implant manufacturers. Date of the most recent search: May 2003. SELECTION CRITERIA: All randomised and quasi-randomised trials comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures. DATA COLLECTION AND ANALYSIS: Both reviewers independently assessed trial quality and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, results were pooled. MAIN RESULTS: Eighteen trials comparing the Gamma nail with the SHS were included, with data available for 2575 patients. The Gamma nail was associated with an increased risk of operative and later fracture of the femur and an increased re-operation rate. There were no major differences in the incidence of wound infection, mortality or medical complications between implants. Data were inadequate for other outcomes. Five trials involving 623 patients compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group: all cases of operative and later fracture of the femur occurred in this group. Results for post-operative complications, mortality and functional outcomes were similar in the two groups. One trial of 206 patients with a trochanteric fracture showed no advantages for proximal femoral nail (PFN) compared with the SHS. One trial of 60 patients reported favourable preliminary results for an experimental mini-invasive static intramedullary nail compared with the SHS. One trial of 230 patients, which compared the Kuntscher-Y nail with the SHS, reported no major difference in outcome aside from a significantly increased number of patients with leg shortening, and a tendency for poorer recovery of mobility in the Kuntscher-Y nail group. Two trials, involving 65 patients with reverse and transverse fractures at the level of the lesser trochanter, compared an intramedullary nail (Gamma or PFN nail) with an extramedullary implant (a 90-degree blade plate or dynamic condylar plate). The intramedullary nails were associated with better intra-operative results and fewer fracture fixation complications for these rare fractures. REVIEWER'S CONCLUSIONS: Given the lower complication rate of the SHS in comparison with intramedullary nails, it appears that the SHS is superior for trochanteric fractures. Further studies are required to determine if different types of intramedullary nail produce similar results, or if intramedullary nails have advantages for selected fracture types (for example, reversed fracture lines and subtrochanteric fractures).

Adult↗
PubMed2004

Interventions for isolated diaphyseal fractures of the ulna in adults.

BACKGROUND: Isolated fractures of the shaft of the ulna, which are often sustained when the forearm is raised to shield against a blow, are generally treated on an out-patient basis. OBJECTIVES: To assess the effects of various forms of treatment for isolated fractures of the ulnar shaft in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (November 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2003), MEDLINE (1966 to November week 2 2003), EMBASE (1981 to 2003 week 51) and CINAHL (1982 to December week 2 2003), Current Controlled Trials (accessed November 2003), the UK National Research Register (up to Issue 4, 2003 ), various conference proceedings and bibliographies of relevant articles. Date of the most recent search: December 2003. SELECTION CRITERIA: Randomised or quasi-randomised trials of conservative and surgical treatment of isolated fractures of the ulnar shaft in adults. Excluded were fractures of the proximal ulna and Monteggia fracture dislocations. DATA COLLECTION AND ANALYSIS: Independent quality assessment and data extraction were performed by the reviewers. Requests for more information were sent to trialists. Given the limited and generally poor quality evidence available, quantitative analysis was kept to a minimum. MAIN RESULTS: One new trial comparing two types of plates used for the surgical fixation of these fractures was included in the fifth update of this review. Thus there are now three trials, involving a total of 135 patients. All three trials were methodologically flawed, particularly the two trials of conservative treatment. One of these compared short arm pre-fabricated functional braces with long arm plaster casts. There was no statistically significant difference in the time it took for fracture union. Patient satisfaction and return to work were better in the brace group. The other, a quasi-randomised trial, compared Ace Wrap elastic bandage, short arm plaster cast and long arm plaster cast. The large loss to follow-up in this trial makes any data analysis tentative. However the need for replacement of the Ace wrap by other methods due to pain does indicate the potential for a serious problem with this intervention. There were no statistically significant differences in anatomical or functional outcomes nor complications between the two plate groups in the surgical trial. REVIEWERS' CONCLUSIONS: There is insufficient evidence from randomised trials to determine which method of treatment is the most appropriate for isolated fractures of the ulnar shaft in adults. There is a need to establish the incidence of this injury and the outcome and associated costs of the various forms of treatment. Well designed randomised trials of current forms of conservative treatment are recommended.

Adult↗
PubMed2004

Nutritional supplementation for hip fracture aftercare in the elderly.

BACKGROUND: Fractures of the hip are an important cause of later ill health and mortality in elderly people. People with hip fractures are often malnourished at the time of fracture, and have poor food intake in hospital. OBJECTIVES: This review assesses the effects of nutritional interventions in elderly people recovering from hip fracture. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register, the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 2, 2003), MEDLINE (1966 to July 2003), Nutrition Abstracts and Reviews (1984 to March 2003), EMBASE (1980 to week 29 2003), BIOSIS (1985 to July 2003), CINAHL (1982 to July 2003), HEALTHSTAR (1975 to March 2002), the National Research Register and reference lists. We contacted investigators, and handsearched the American Journal of Clinical Nutrition, Proceedings of the Nutrition Society, Clinical Nutrition and the Journal of Parenteral and Enteral Nutrition. SELECTION CRITERIA: Randomised and quasi-randomised trials of nutritional interventions of mainly older patients (aged over 65 years) with hip fracture. DATA COLLECTION AND ANALYSIS: Trial allocation to included, excluded and awaiting assessment categories, was by consensus. Both reviewers independently extracted data and assessed trial quality. Additional information was sought from all trialists. Pooling of data for primary outcomes and select exploratory analyses were undertaken. MAIN RESULTS: Seventeen randomised trials involving 1266 participants were included. Overall the quality of trials was poor; specifically in terms of allocation concealment, assessor blinding and intention to treat analysis. This, and the limited availability of outcome data, mean that the following results must be interpreted with caution. Oral multinutrient feeds (providing non-protein energy, protein, some vitamins and minerals), evaluated by seven trials, may reduce unfavourable outcome (death or complications) (14/66 versus 26/73; relative risk 0.52, 95% confidence interval 0.32 to 0.84), but did not demonstrate an effect on mortality (12/91 versus 14/97; relative risk 0.85, 95% confidence interval 0.42 to 1.70). Four trials, examining nasogastric multinutrient feeding, showed no evidence for an effect on mortality (relative risk 0.99, 95% confidence interval 0.50 to 1.97), but the studies were heterogeneous regarding case-mix. Insufficient information was provided to evaluate unfavourable outcome. The effect of protein in an oral feed, tested in three trials, showed no evidence for an effect on mortality (relative risk 1.38, 95% confidence interval 0.82 to 2.34). It may have reduced the number of long term complications and days spent in rehabilitation wards. Two trials, testing intravenous thiamin (vitamin B1) and other water soluble vitamins, or 1-alpha-hydroxycholecalciferol (an active form of vitamin D) respectively, produced no evidence of benefit for either vitamin supplement. REVIEWER'S CONCLUSIONS: The strongest evidence for the effectiveness of nutritional supplementation exists for oral protein and energy feeds, but the evidence is still very weak. Future trials are required which overcome the defects of the reviewed studies, particularly inadequate size, methodology and outcome assessment.

Aftercare↗
PubMed2004

Surgical versus non-surgical treatment for acute anterior shoulder dislocation.

BACKGROUND: Acute anterior shoulder dislocation is the commonest type of shoulder dislocation. Subsequently, the shoulder is less stable and more susceptible to re-dislocation, especially in active young adults. OBJECTIVES: We aimed to compare surgical versus non-surgical treatment for acute anterior dislocation of the shoulder. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (August 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2003), MEDLINE (1966 to September week 3 2003), EMBASE (1988 to 2003 week 39), the National Research Register (UK) (Issue 3, 2003), conference proceedings and reference lists of articles. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials comparing surgical with conservative interventions for treating acute anterior shoulder dislocation. DATA COLLECTION AND ANALYSIS: Selection of the included trials was by all three reviewers. Two reviewers independently assessed methodological quality and extracted data. Where appropriate, results of comparable studies were pooled. MAIN RESULTS: Five studies were included. These involved a total of 239 young (mainly aged around 22 years) active and mainly male people, all of whom had had a primary (first time) traumatic anterior shoulder dislocation. Methodological quality was variable, but notably there was insufficient information to judge whether allocation was effectively concealed in all five trials. Two trials, involving 115 participants, were only reported in conference abstracts.One trial involving military personnel reported that all had returned to active duty. Another trial reported similar numbers in the two intervention groups with reduced sports participation, and a third trial reported that significantly fewer people in the surgical group failed to attain previous levels of sports activity. Pooled results from all five trials showed that subsequent instability, either redislocation or subluxation, was statistically significantly less frequent in the surgical group (relative risk (RR) 0.20; 95%confidence interval (CI) 0.11 to 0.33). This result remained statistically significant (RR 0.32, 95%CI 0.17 to 0.59) for the three trials reported in full. Half (17/33) of the conservatively treated patients with shoulder instability in these three trials opted for subsequent surgery.Different, mainly patient-rated, functional assessment measures for the shoulder were recorded in the five trials. The results were more favourable, usually statistically significantly so, in the surgically treated group. Aside from a septic joint in a surgically treated patient, there were no other treatment complications reported. There was no information on shoulder pain, long-term complications such as osteoarthritis or on service utilisation and resource use. REVIEWER'S CONCLUSIONS: The limited evidence available supports primary surgery for young adults, usually male, engaged in highly demanding physical activities who have sustained their first acute traumatic shoulder dislocation. There is no evidence available to determine whether non-surgical treatment should not remain the prime treatment option for other categories of patient. Sufficiently powered, good quality and adequately reported randomised trials of good standard surgical treatment versus good standard conservative treatment for well-defined injuries are required; in particular, for patient categories at lower risk of activity-limiting recurrence. Long term surveillance of outcome, looking at shoulder disorders including osteoarthritis is also required. Reviews comparing different surgical interventions and different conservative interventions including rehabilitation are needed.

Adult↗