Skip to content

Biomedical subjects

H H Handoll

Publications and source records attributed to H H Handoll.

At least 19 recordsLinked to original sources

PubMed2003

Closed reduction methods for treating distal radial fractures in adults.

BACKGROUND: Fracture of the distal radius is a common clinical problem, particularly in older white women with osteoporosis. Displaced fractures are usually reduced using closed reduction methods, which are non-surgical and generally comprise traction and manipulation, and the resulting position stabilised by external means, typically plaster cast immobilisation. OBJECTIVES: To examine the evidence for the relative effectiveness of different methods of closed reduction for displaced fractures of the distal radius in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (to July 2002), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 3, 2002), MEDLINE (1966 to July week 4 2002), EMBASE (1988 to 2002 week 31), CINAHL (1982 to June week 4 2002), the UK National Research Register (Issue 2, 2002) and reference lists of articles. We also handsearched the British Volume of the Journal of Bone and Joint Surgery supplements (1996 onwards), and abstracts of the American Orthopaedic Trauma Association annual meetings. SELECTION CRITERIA: Randomised or quasi-randomised clinical trials evaluating different methods of closed reduction. We also included trials in which the use (or not) of anaesthesia could be classed as a co-intervention. DATA COLLECTION AND ANALYSIS: All trials judged as fitting the selection criteria by both reviewers were independently assessed by both reviewers for methodological quality. Data were extracted independently by one reviewer and checked by the other. Quantitative data are presented using relative risks or mean differences together with 95 per cent confidence limits. No pooling was possible. MAIN RESULTS: Three trials involving a total of 404, mainly female and older, patients with displaced fractures of the distal radius were included. These failed to assess functional outcome, and only one trial reported on complications. One trial found no statistically significant differences between mechanical reduction using finger trap traction and manual reduction in anatomical outcomes. One trial compared a novel method of manual reduction where the non-anaesthetised patient actively provided counter-traction versus traditional manual reduction under intravenous regional anaesthesia. While patients of the novel method group suffered more, yet not intolerable, pain during the reduction procedure, the latter was shorter in duration. No differences in anatomical outcome were detected. The third study compared mechanical reduction involving a special device without anaesthesia versus manual reduction under haematoma block (local anaesthesia). Less pain during the reduction procedure was recorded for the mechanical traction group. Both methods yielded similar radiological results. Fewer patients in the mechanical traction group had signs of neurological impairment, mainly finger numbness, at five weeks but this difference was not statistically significant by one year. REVIEWER'S CONCLUSIONS: There was insufficient evidence from comparisons tested within randomised trials to establish the relative effectiveness of different methods of closed reduction used in the treatment of displaced fractures of the distal radius in adults. Given the many unresolved questions over the management of these fractures, we suggest an integrated programme of research, which includes consideration of reduction methods, is the way forward.

Adult↗

PubMed2002

Physiotherapist-led programmes and interventions for rehabilitation of anterior cruciate ligament, medial collateral ligament and meniscal injuries of the knee in adults.

BACKGROUND: Soft-tissue injuries of the knee, mainly involving the anterior cruciate ligament (ACL), the medial collateral ligament (MCL) and menisci, are common and their rehabilitation after non-surgical or surgical treatment often involves intensive and prolonged physiotherapy. OBJECTIVES: To examine the evidence for effectiveness of various physiotherapist-led (or 'directed') rehabilitation programmes, and of various interventions used within these programmes, for rehabilitation of acute or chronic ACL, MCL or meniscal injuries of the knee in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group's specialised register (to June 2001), MEDLINE (from 1966 to August 1999), EMBASE (from 1980 to February 1997), CINAHL (1982 to April 1999), CURRENT CONTENTS (up to March 1999) and reference lists of relevant articles, and consulted colleagues. Date of the most recent search: June 2001. SELECTION CRITERIA: Randomised or quasi-randomised clinical trials evaluating physiotherapist-led rehabilitation programmes, or components of rehabilitation programmes, for the treatment or post-surgical rehabilitation of ACL, MCL or knee meniscal injuries. Excluded were trials investigating electrical stimulation, or various interventions such as cryotherapy, immobilisation braces and continuous passive motion when used in initial or early treatment. Laboratory based trials reporting intermediate outcomes were also excluded. DATA COLLECTION AND ANALYSIS: All trials, judged as fitting the selection criteria by two reviewers, were independently assessed by two reviewers for methodological quality by use of an 11 item checklist. Data were independently extracted by two reviewers. Any disagreement was resolved by discussion. Although quantitative data from most trials are presented, using relative risks or mean differences together with 95 per cent confidence intervals, trial heterogeneity and lack of outcome data prevented meaningful pooling of results from comparable trials. MAIN RESULTS: Thirty-one trials, involving 1545 mainly young and male patients, met the inclusion criteria of the review. Methodological quality was highly variable: allocation concealment and / or assessor blinding were rare, and assessment of outcome was often incomplete and short-term. ACL injury and /or deficiency was the main focus of 18 trials, MCL injury of two trials, meniscal injury of nine trials and a mixture of soft-tissue injuries in the other two trials. The trial comparisons fell into five main categories: rehabilitation programme versus control (6 trials); one rehabilitation programme versus another (6 trials); different timing of rehabilitation (4 trials); one component of a programme versus another (6 trials); supplementary interventions to a programme versus none (9 trials). No trial provided sufficient evidence to establish the relative effectiveness of the intervention(s) under investigation. REVIEWER'S CONCLUSIONS: The available evidence for physiotherapist-led rehabilitation of ACL, MCL and meniscal injuries is wide ranging in terms of scope but insufficient to establish the relative effectiveness of the various approaches and methods in current use. There is a need for further research involving good quality, large scale randomised trials with sufficiently long follow-up to fully assess knee function and recovery.

Anterior Cruciate Ligament Injuries↗

PubMed2002

Anaesthesia for treating distal radial fracture in adults.

BACKGROUND: Fracture of the distal radius is a common clinical problem, particularly in older white women with osteoporosis. Anaesthesia is usually provided during manipulation of displaced fractures or during surgical treatment. OBJECTIVES: To examine the evidence for the relative effectiveness of the main methods of anaesthesia (haematoma block, intravenous regional anaesthesia (IVRA), regional nerve blocks, sedation and general anaesthesia) as well as associated physical techniques and drug adjuncts used during the management of distal radial fractures in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (January 2002), the Cochrane Controlled Trials Register (The Cochrane Library Issue 4, 2001), MEDLINE (1966 to October 2001), EMBASE (1988 to 2001 Week 48), Current Controlled Trials (December 2001) and reference lists of articles. SELECTION CRITERIA: Randomised or quasi-randomised clinical trials evaluating relevant interventions for these injuries (see Objectives). We excluded pharmacological trials comparing drug dosages and, with one exception, different drugs in the same class. Also excluded were trials reporting only pharmacokinetic and/or physiological outcomes. DATA COLLECTION AND ANALYSIS: All trials meeting the selection criteria were independently assessed by the three reviewers for methodological quality. Data were extracted independently by two reviewers. Quantitative data are presented using relative risks or mean differences together with 95 per cent confidence limits. Only very limited pooling of results from comparable trials was possible. MAIN RESULTS: The 18 included studies involved at least 1200, mainly female and older, patients with fractures of the distal radius. All studies had serious methodological limitations, notably in the frequent failure to assess clinically important and longer-term outcomes. Five trials provided evidence that, when compared with haematoma block, IVRA provided better analgesia during fracture manipulation and enabled better and easier reduction of the fracture, with some indication of a reduced risk of later redislocation or need for re-reduction. In contrast, haematoma block was quicker and easier to perform and less resource intensive. There was inadequate evidence of relative effectiveness of different methods of anaesthesia only examined within single trials: nerve block versus haematoma block; intravenous sedation versus haematoma block; general anaesthesia versus haematoma block; general anaesthesia versus sedation; and general anaesthesia versus haematoma block and sedation. None of the three trials evaluating three different physical aspects of anaesthesia (injection site of, or extra tourniquet, for IVRA; and technique for brachial plexus block) provided conclusive evidence for the effectiveness and safety of the novel technique. Six trials examined the use of drug adjuncts. The addition of two different muscle relaxants and one analgesic was tested for IVRA; one sedative and hyaluronidase for haematoma block; and clonidine for brachial plexus block. All trials evaluating adjuncts failed to provide evidence on eventual clinical outcome. A seriously flawed study comparing bupivacaine with prilocaine for IVRA gave some insight on the potential confounding effects of treatment by different doctors on patient outcome. REVIEWER'S CONCLUSIONS: There was insufficient robust evidence from randomised trials to establish the relative effectiveness of different methods of anaesthesia, different associated physical techniques or the use of drug adjuncts in the treatment of distal radial fractures. There is, however, some indication that haematoma block provides poorer analgesia than IVRA, and can compromise reduction. Given the many unresolved questions over the management of these fractures, we suggest an integrated programme of research, which includes consideration of anaesthesia options, is the way forward.

Aged↗

PubMed2002

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 evidence for effectiveness of rehabilitation intervention(s) for adults with conservatively or surgically treated distal radial fractures. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (January 2002), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), the Cochrane Rehabilitation and Related Therapies Field database, MEDLINE (1966 to January 2002), EMBASE (1988 to 2001 Week 50), CINAHL (1982 to December Week 2 2001), Current Controlled Trials (December 2001), AMED, PEDro, conference proceedings and reference lists of articles. SELECTION CRITERIA: Randomised or quasi-randomised clinical trials evaluating rehabilitation as part of the management of fractures of the distal radius sustained by skeletally mature patients. 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: All trials meeting the selection criteria were independently assessed by all three reviewers for methodological quality. Data were extracted independently by two reviewers. The trials were grouped into categories relating to the main comparisons, and to when the intervention(s) commenced (for example, during or after plaster cast immobilisation). Quantitative data are presented using relative risks or mean differences together with 95 per cent confidence limits. MAIN RESULTS: Twelve trials, involving 601 mainly female and older patients, were included. Initial treatment was conservative, involving plaster cast immobilisation, in all but 20 patients whose fractures were fixed surgically. Though some trials were well conducted, others were methodologically compromised. No trial provided definitive evidence. Only very limited pooling of results from comparable trials was possible. During immobilisation, there was weak evidence of improved hand function in the short term, but not in the longer term, for early occupational therapy (1 trial), and of a lack of differences in outcome between supervised and unsupervised exercises (1 trial). Post-immobilisation, there was weak evidence of a lack of clinically significant differences in outcome in patients receiving formal rehabilitation therapy (3 trials), passive mobilisation (2 trials) or whirlpool immersion (1 trial) compared with no intervention. There was weak evidence of a short-term benefit of continuous passive motion (post external fixation) (1 trial), intermittent pneumatic compression (1 trial) and ultrasound (1 trial). There was weak evidence of better short-term hand function in patients given physiotherapy than in those given instructions for home exercises by a surgeon (1 trial). REVIEWER'S CONCLUSIONS: The available evidence from randomised 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↗

PubMed2001

Interventions for treating acute and chronic Achilles tendinitis.

BACKGROUND: Achilles tendinitis is one of the most common of all sports injuries. There is no consensus on treatment. OBJECTIVES: To assess the effectiveness of various treatment interventions for acute and chronic Achilles tendinitis in adults. SEARCH STRATEGY: The Cochrane Musculoskeletal Injuries Group specialised register (December 2000), Cochrane Controlled Trials Register (The Cochrane Library Issue 4, 2000), MEDLINE (1966 to December 2000), EMBASE (1980 to 2001 wk 04), CINAHL (1982 to December 2000), and reference lists of identified trials were searched. SELECTION CRITERIA: Randomised or quasi-randomised trials of treatment interventions for acute and chronic Achilles tendinitis in adults. Studies focusing on pathological tendinitis were excluded. Excluded were those trials that compared different dosages of the same drug or drugs within the same class of drugs, for example different non-steroidal anti-inflammatory drugs (NSAIDs). DATA COLLECTION AND ANALYSIS: Three reviewers independently assessed trial quality, by use of a ten item check list, and extracted data. Requests were sent for separate data for Achilles tendinitis patients in studies within trials of mixed patient populations. Where possible, quantitative analysis and limited pooling of data were undertaken. MAIN RESULTS: Nine trials, involving 697 patients, met the inclusion criteria of the review. Methodological quality was adequate in most of the trials with regards to blinding but the assessment of outcome was incomplete and short-term. There was weak but not robust evidence from three trials of a modest benefit of NSAIDs for the alleviation of acute symptoms. There was some weak evidence of no difference compared with no treatment of low dose heparin, heel pads, topical laser therapy and peritendonous steroid injection, but this could not be fully evaluated from the reports of four trials. The results of an experimental preparation of a calf-derived deproteinized haemodialysate, Actovegin, were promising but the severity of patient symptoms was questionable in the single small trial testing this comparison. The results of a comparison of glycosaminoglycan sulfate with a NSAID were inconclusive. REVIEWER'S CONCLUSIONS: There is insufficient evidence from randomised controlled trials to determine which method of treatment is the most appropriate for the treatment of acute or chronic Achilles tendinitis. Further research is warranted.

Achilles Tendon↗

PubMed2001

Interventions for treating proximal humeral fractures in adults.

BACKGROUND: Proximal humeral fractures are common yet management varies widely. In particular, the role and timing of any surgical intervention have not been clearly defined. OBJECTIVES: To collate and evaluate the scientific evidence supporting the various methods used for treating proximal humeral fractures. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, MEDLINE, PubMed, the Cochrane Controlled Trials Register, CINAHL, the National Research Register and bibliographies of trial reports. The search was completed in July 2000. SELECTION CRITERIA: All randomised studies pertinent to the treatment of proximal humeral fractures were selected. DATA COLLECTION AND ANALYSIS: Independent quality assessment and data extraction were performed by two reviewers. Although quantitative data from trials are presented, trial heterogeneity prevented pooling of results. MAIN RESULTS: Nine randomised trials were included. All were small trials; the largest study involved only 85 patients. Bias in these trials could not be ruled out. Six trials evaluated conservative treatment, two compared surgery with conservative treatment and one compared two surgical techniques. In the 'conservative' group there was very limited evidence indicating that the type of bandage used made any difference in terms of time to fracture union and the functional end result. However, an arm sling was generally more comfortable than a body bandage. There was some evidence that mobilisation at one week instead of three weeks alleviated pain in the short term without compromising long term outcome. Two trials provided some evidence that patients, when given sufficient instruction to pursue an adequate physiotherapy programme, could generally achieve a satisfactory outcome if allowed to exercise without supervision. Operative reduction improved fracture alignment in two trials. However, in one trial, surgery was associated with a greater risk of complication, and did not result in improved shoulder function. Fracture fixation of severe injuries was associated with a high rate of re-operation in one trial, comparing tension-band wiring fixation with hemi-arthroplasty. REVIEWER'S CONCLUSIONS: Only tentative conclusions can be drawn from the available randomised trials, which do not provide robust evidence for many of the decisions which need to be made in contemporary fracture management. It is unclear whether operative intervention, even for specific fracture types, will produce consistently better long term outcomes. There is a need for good quality evidence for the management of these fractures.

Adult↗

PubMed2001

Surgical interventions for treating 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 determine when, and if so what type of, surgical intervention is the most appropriate treatment for fractures of the distal radius in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group's specialised register, Cochrane Controlled Trials Register (The Cochrane Library Issue 4, 2000), MEDLINE, EMBASE, CINAHL, the National Research Register (Issues 2 to 4, 2000) and bibliographies of trial reports. The full search was concluded in December 2000. SELECTION CRITERIA: Randomised or quasi-randomised clinical trials involving skeletally mature patients with a fracture of the distal radius, which compared surgical treatment with conservative treatment, different types of surgical intervention or the duration of immobilisation after surgery. The main categories of surgical intervention were external fixation, percutaneous pinning, open reduction and internal fixation, and the insertion of bone scaffolding materials. DATA COLLECTION AND ANALYSIS: All trials, meeting the selection criteria, were independently assessed by both reviewers for methodological quality. Data were extracted for anatomical, functional and clinical outcomes (including complications). The trials were grouped into categories relating to the main comparisons and types of surgical intervention. Despite clear heterogeneity in the characteristics of comparable trials, pooling of data was undertaken where possible and appropriate. MAIN RESULTS: Forty four trials, examining 23 treatment comparisons, met the inclusion criteria of this review. These involved a total of 3193 mainly female and older patients with generally displaced, often comminuted and potentially or evidently unstable fractures. Half of the trials compared surgery with plaster cast immobilisation. Summarising the outcomes was hampered by the variation between the studies in participant characteristics, interventions, quality of trial methodology and reporting, and methods of outcome measurement. Surgical methods were usually associated with better anatomical appearance after fracture healing, but there was inadequate evidence to confirm that these had resulted in better functional and clinical outcomes for the patients. REVIEWER'S CONCLUSIONS: The 44 randomised trials do not provide robust evidence for most of the decisions necessary in the management of these fractures. Although, in particular, there is some evidence to support the use of external fixation or percutaneous pinning, their precise role and methods are not established. It is also unclear whether surgical intervention of most fracture types will produce consistently better long-term outcomes. There is a need for good quality evidence for the surgical management of these fractures.

Adult↗

PubMed2001

Lessons for search strategies from a systematic review, in The Cochrane Library, of nutritional supplementation trials in patients after hip fracture.

BACKGROUND: A key aim when conducting systematic reviews of randomized controlled trials (RCTs) is to include all of the evidence, if possible. Serious bias may result if trials are missed through inadequate search strategies. OBJECTIVE: The objective was to evaluate the search plan for identifying RCTs in nutrition as part of a systematic review, in The Cochrane Library, of nutritional supplementation trials in patients after hip fracture. DESIGN: We identified potential studies by searching the electronic databases BIOSIS, CABNAR, CINAHL, EMBASE, HEALTHSTAR, and MEDLINE; reference lists in trial reports; and other relevant articles. We also contacted investigators and other experts for information and searched 4 nutrition journals by hand. RESULTS: We identified 15 RCTs that met the predefined inclusion criteria. The search plan identified 8 trials each in EMBASE, HEALTHSTAR, and MEDLINE and 7 in BIOSIS and CABNAR. BIOSIS was the only electronic database source of 2 trials. Eleven trials were identified by searching electronic databases and 2 unpublished trials were identified via experts in the field. We found one trial, published only as a conference abstract, by searching nutrition journals by hand. After publication of the protocol for the review in The Cochrane Library, we were informed of another unpublished trial. CONCLUSIONS: We found that a limited search plan based on only MEDLINE or one of the other commonly available databases would have failed to locate nearly one-half of the studies. To protect against bias, the search plan for a systematic review of nutritional interventions should be comprehensive.

Bias↗

PubMed2000

Interventions for preventing ankle ligament injuries.

BACKGROUND: Some sports, for example basketball and soccer, have a very high incidence of ankle injuries, mainly sprains. This contributes to ankle sprains being one of the most commonly treated injuries. OBJECTIVES: To assess the effects of interventions used for the prevention of ankle ligament injuries or sprains in physically active individuals from adolescence to middle age. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, MEDLINE (1966 to July 1996), EMBASE (1980 to September 1996), CINAHL (1982 to June 1996), and bibliographies of study reports. We also contacted colleagues and some trialists. Date of the most recent search: March 1997. SELECTION CRITERIA: Randomised or quasi-randomised trials of interventions for the prevention of ankle sprains in physically active individuals from adolescence to middle age were included provided ankle sprains were recorded. Interventions include use of modified footwear and associated supports, adapted training programmes and health education. DATA COLLECTION AND ANALYSIS: At least four reviewers independently assessed methodological quality and extracted data. Wherever possible, results of outcome measures were pooled and sub-grouped by history of previous sprain. MAIN RESULTS: Five randomised trials with data for 3954 participants were included. All trials involved young, active, mostly male adults participating in high-risk, usually sporting, activities. With the exception of ankle disc training, all prophylactic interventions entailed the application of an external ankle support in the form of a semi-rigid orthosis, air-cast brace or high top shoes. There was a significant reduction in the number of ankle sprains in people allocated external ankle support (Peto odds ratio 0.49; 95% confidence interval 0.37 to 0.66). This reduction was greater for those with a previous history of ankle sprain, but still possible for those without prior sprain. There was no apparent difference in the degree of severity of the ankle sprain prevented nor any change to the incidence of other leg injuries. The protective effect of 'high-top' shoes remains to be established. There was limited evidence for reduction in ankle sprain for those with previous ankle sprains who did ankle disc training exercises. REVIEWER'S CONCLUSIONS: This review provides good evidence for the beneficial effect of ankle supports in the form of semi-rigid orthoses or air-cast braces to prevent ankle sprain during high-risk sporting activities (e.g. soccer, basketball). Participants with a history of previous sprain can be advised that wearing such supports may reduce the risk of incurring a future sprain. However, any potential prophylactic effect should be balanced against the baseline risk of the activity, the supply and cost of the particular device, and for some, the possible or perceived loss of performance. Further research is indicated principally to investigate other prophylactic interventions and general applicability.

Adolescent↗

PubMed2000

Replacement arthroplasty versus internal fixation for extracapsular hip fractures.

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 Musculoskeletal Injuries Group's trials register and bibliographies of published papers, and contacted colleagues. Date of the most recent search: August 1999. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing replacement arthroplasty with an internal fixation implant for skeletally mature patients with an extracapsular hip fracture. DATA COLLECTION AND ANALYSIS: Both reviewers independently assessed trial quality, using a ten item scale, and extracted data. Additional information was sought from trialists. Odds ratios and 99% confidence intervals were calculated for relevant dichotomous outcomes and presented graphically. MAIN RESULTS: Only one randomised trial of 90 patients with unstable extracapsular hip femoral fractures in the trochanteric region was identified and included in this review. This compared arthroplasty with a sliding hip screw and was of poor methodological quality. From the limited data available for this trial, there were no significant differences between the two methods of treatment for operating time, local wound complications, mortality rate or mobility of previously independent patients. There was however a reportedly higher blood transfusion need in the arthroplasty group. REVIEWER'S CONCLUSIONS: There is insufficient evidence from randomised trials to determine whether replacement arthroplasty has any advantage over the sliding hip screw for extracapsular hip fractures. Further well designed randomised trials for the treatment of these fractures for this comparison are required.

Fracture Fixation, Internal↗

PubMed2000

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 update and expand our review comparing the Gamma nail with the sliding hip screw (SHS) by comparing all cephalocondylic intramedullary nails with extramedullary implants for the surgical treatment of extracapsular hip fractures in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline, select orthopaedic journals and conference proceedings, and reference lists of relevant articles. We contacted trialists, colleagues and implant manufacturers. Date of the most recent search: June 1998. 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: The one trial of 230 patients comparing the Kuntscher-Y nail with the SHS, reported no major difference the 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. Fourteen trials comparing the Gamma nail with the SHS were included, with data available for 1977 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 to determine if there were differences for other outcomes. Two trials involving 231 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 and haematoma occurred in this group. Results for post-operative complications, mortality and functional outcomes were similar in the two groups. REVIEWER'S CONCLUSIONS: Further evidence is required before any conclusions can be drawn on the relative merits of the Kuntscher-Y nail and the SHS. Given the lower complication rate of the SHS in comparison with the Gamma nail, it appears that for trochanteric fractures the SHS is superior. Further evidence is still required to confirm this, as well as to determine if the Gamma nail, or modifications of the Gamma nail, have advantages for selected fracture types (for example, subtrochanteric fractures). From the limited evidence available, IMHS appears to have the same problems as the Gamma nail, but other theoretical advantages of the IHMS can not be ruled out.

Bone Nails↗

PubMed2000

Co-ordinated multidisciplinary approaches for inpatient rehabilitation of older patients with proximal femoral fractures.

BACKGROUND: Hip fracture is a major cause of morbidity in older people and its impact, both on the individual and to society, is substantial. OBJECTIVES: To examine the effects of co-ordinated multidisciplinary inpatient rehabilitation, compared with usual orthopaedic care, for older patients with hip fracture. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline (up to April 1998), and reference lists of published papers and books. We also contacted colleagues and trialists. SELECTION CRITERIA: Randomised and quasi-randomised trials of postsurgical care using specialised rehabilitation of mainly older patients (aged 65 years or over) with hip fracture. DATA COLLECTION AND ANALYSIS: Trial assignment to included, excluded and awaiting assessment categories, was by consensus. Two reviewers independently assessed trial quality and extracted data. Limited additional information was sought from most trialists. As well as pooling of data from primary outcomes, supplementary analyses were performed to combine clinically relevant outcomes and investigate possible explanatory factors. MAIN RESULTS: In this minor update, one new trial is identified and has been placed in "studies awaiting assessment". Of another three trials previously pending assessment, one has now been excluded. The five included trials involved 1068 patients. The combined outcomes of death or requiring institutional care at final follow-up showed no significant difference between intervention and control groups (Peto odds ratio 0.92; 95% confidence interval 0.71 to 1.18). There was considerable heterogeneity in length of stay and cost data. Using death and deterioration in function as a further combined outcome variable yielded a Peto odds ratio of 0.83 (95% confidence interval 0.64 to 1. 07). This should be interpreted with caution due to heterogeneity. No quality of life measures were reported and the two trials investigating carer burden showed no detrimental effect from the intervention. The review update did not result in any new data for these outcomes. REVIEWER'S CONCLUSIONS: The trials reviewed had different aims, interventions and outcomes. As a consequence, results were heterogeneous and the question of effectiveness of different types of co-ordinated inpatient rehabilitation after hip fracture cannot be answered conclusively. There is a trend to effectiveness when combined outcome variables (death and institutional care, death and deterioration in function) are considered. Future trials of postsurgical care involving inpatient rehabilitation, or other models such as 'early supported discharge' and 'hospital at home' schemes, should aim to establish both effectiveness and cost effectiveness of multidisciplinary rehabilitation overall, rather than attempt to evaluate its components.

Aged↗

PubMed2000

Pre-operative traction for fractures of the proximal femur.

BACKGROUND: Pre-operative traction following an acute hip fracture remains standard practice in some hospitals. 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 Musculoskeletal Injuries Group trials register, MEDLINE (1983 to August 1999), CINAHL (1982 to July 1999), EMBASE (1980 to September 1999), CENTRAL (Issue 4, 1999 of The Cochrane Library) and bibliographies of trial reports. Date of the most recent search: September 1999. 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 reviewers independently assessed trial quality, using a nine item scale, and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, the data are presented graphically. MAIN RESULTS: Five randomised trials, mainly of moderate quality, involving a total of 635 predominantly elderly patients, were identified and included in the review. The review has been updated twice to include additional and new data from two of the studies. The availability of this additional data resulted in no important change in the results nor conclusions. The four trials which compared traction with no traction found no evidence of benefit from traction, either in the relief of pain, 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 which compared skeletal traction with skin traction found no important differences between these two methods, although the initial application of skeletal traction was noted as being more painful and most costly. REVIEWER'S 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. Where a policy of general or selective application of traction exists, the choice of method must remain a decision based on evaluation of the individual patient. Further, high quality trials would be required to confirm or refute the absence of benefits of traction.

Femoral Fractures↗

PubMed2000

Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures.

BACKGROUND: Hip fracture patients have a high risk of thromboembolic complications following surgical management. OBJECTIVES: To examine the effects of heparin (unfractionated (U), and low molecular weight (LMW) heparins), and physical methods (compression stockings, calf or foot pumps) for prevention of deep venous thrombosis (DVT) and pulmonary embolism after surgery for hip fracture in the elderly. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline, Embase, and reference lists of published papers and books. We contacted trialists and other workers in the field. Date of most recent search: September 1996. SELECTION CRITERIA: Randomised and quasi-randomised trials evaluating the use of heparins and physical agents for prevention of DVT and pulmonary embolism in patients undergoing surgery for hip fracture. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed methodological quality and extracted data. Trials were grouped into four categories (heparin versus control, mechanical versus control, LMW heparin versus U heparin, and miscellaneous) and results pooled where possible. MAIN RESULTS: The 26 included trials involved 2600 predominantly female and elderly patients. Overall, trial quality was disappointing. Ten trials involving 826 patients which compared U heparin with control, and four trials of 471 patients which compared LMW heparin with control, showed a reduction in the incidence of lower limb DVT (121/511 (24%) versus 203/519 (39%); Peto odds ratio 0.41; 95% confidence interval 0.31 to 0.55). There were insufficient data to confirm the efficacy of either agent in the prevention of pulmonary embolism. There was a non significant increase in overall mortality in the heparin group (46/420 (11%) versus 35/423 (8%); Peto odds ratio 1.39; 95% confidence interval 0. 86 to 2.23). Data were inadequate for all other outcomes including wound complications. There is insufficient evidence from five trials, involving 644 patients, to establish if LMW heparin was superior to U heparin. Most trials evaluating heparins had methodological defects. Four trials, involving 442 patients, testing mechanical pumping devices were also methodologically flawed, and so pooled results need to be viewed cautiously. Mechanical pumping devices may protect against DVT (12/202 (6%) versus 42/212 (19%); Peto odds ratio 0.24; 95% confidence interval 0.13 to 0.44). Although the limited data indicated a potential benefit, they were inadequate to establish any effect on the incidence of pulmonary embolism and overall mortality. Problems with skin abrasion and compliance were reported. REVIEWER'S CONCLUSIONS: U and LMW heparins protect against lower limb DVT. There is insufficient evidence to confirm either protection against pulmonary embolism or overall benefit, or to distinguish between various applications of heparin. Foot and calf pumping devices appear to prevent DVT, may protect against pulmonary embolism, and reduce mortality, but compliance remains a problem. Good quality trials of mechanical methods as well as direct comparisons with heparin should be considered.

Anticoagulants↗

PubMed2000

Conservative interventions for treating distal radial fractures in adults.

BACKGROUND: Fracture of the distal radius is a common clinical problem particularly in elderly white women with osteoporosis, in whom the lifetime risk of this injury has been estimated as 15 per cent. OBJECTIVES: To determine the most appropriate conservative treatment for fractures (such as Colles') of the distal radius in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline and reference lists of trials. Date of the most recent search: April 1998. SELECTION CRITERIA: Randomised or quasi-randomised clinical trials involving skeletally mature patients with a fracture of the distal radius, which compared commonly applied conservative interventions for fracture fixation. These included the application of an external support (plaster cast or brace) and fracture manipulation. DATA COLLECTION AND ANALYSIS: All trials, judged as fitting the selection criteria by both reviewers, were independently assessed by both reviewers for methodological quality. Data were extracted for anatomical, functional and clinical, including complications, outcomes. The trials were grouped into categories relating to cast position, extent and duration of immobilisation, use of braces, cast material and fracture manipulation. Although quantitative data from some trials are presented, the lack of good quality trials and trial heterogeneity inhibited pooling of results. MAIN RESULTS: Over 50 randomised trials comparing treatment options for distal radial fractures were identified. Twenty nine trials of these, involving a total of 3199 mainly female and older patients, met the inclusion criteria for this review. Comprehensive details of the individual trials are provided in tabular form, and their results, grouped as indicated above, have been presented in text and analyses tables. The poor quality and heterogeneity in terms of patient characteristics, interventions compared and outcome measurement, of the included trials meant that no meta-analyses were undertaken. REVIEWER'S CONCLUSIONS: There is insufficient evidence from randomised trials to determine which methods of conservative treatment are the most appropriate for the more common types of distal radial fractures in adults. Therefore, at present, practitioners applying conservative management should use an accepted technique with which they are familiar, and which is cost-effective from the perspective of their provider unit. Whilst tempting, any call for further research to clarify the most appropriate conservative treatment for this common fracture must be resisted for now. Instead it is important to reflect on the issues raised in this review, to ascertain patient preferences, prioritise researchable questions and undertake a systematic programme of research after agreeing a core data set for classification of fractures and outcomes.

Adult↗

PubMed2000

Conservative versus operative treatment for extracapsular hip fractures.

BACKGROUND: Until operative treatment involving the use of various implants was introduced in the 1950s, hip fractures were managed using conservative methods based on traction and bed rest. OBJECTIVES: To compare conservative with operative treatment for extracapsular fractures of the proximal femur (hip) in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register and bibliographies of published papers, and contacted trialists. Date of the most recent search: August 1999. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing these two treatment methods in adults with hip fracture. Outcomes sought fell into four categories: a) fracture fixation complications, b) post-operative or clinical complications, c) final outcome measures including mortality and d) anatomical restoration. DATA COLLECTION AND ANALYSIS: Both reviewers independently assessed trial quality, by use of an eleven item scale, and extracted data. Additional information was sought from trialists. Comparable groups of trials were subgrouped by implant type (fixed nail plate or sliding hip screw) and where appropriate, data were pooled using the fixed effects model. MAIN RESULTS: The four randomised trials identified involved only 402 elderly patients. These tested a variety of surgical techniques and implant devices and only one trial involving 106 patients can be considered to test current practice. In this trial, no differences were found in medical complications, mortality and long-term pain. However, operative treatment was more likely to result in the fracture healing without leg shortening, a shorter hospital stay and a statistically non-significant increase in the return of patients back to their original residence. REVIEWER'S CONCLUSIONS: The limited available evidence from randomised trials does not suggest major differences in outcome between conservative and operative management programmes for extracapsular femoral fractures, but operative treatment appears to be associated with a reduced length of hospital stay and improved rehabilitation. However these results are derived mainly from one study. Conservative treatment will be acceptable where modern surgical facilities are unavailable, and will result in a reduction in complications associated with surgery, but rehabilitation is likely to be slower and limb deformity more common. Although further randomised trials would provide more robust data, they may be difficult to mount.

Adult↗

PubMed2000

Condylocephalic nails versus extramedullary implants for extracapsular hip fractures.

BACKGROUND: Condylocephalic nails are intramedullary nails which are inserted up through the femoral canal from above the knee, for example Ender and Harris nails. OBJECTIVES: To compare condylocephalic nails with alternative implants (extramedullary implants such as fixed nail plates and sliding hip screws, or other intramedullary nails) for the treatment of extracapsular hip fracture in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline (1983 to August 1999) and reference lists of relevant articles. Date of the most recent search: August 1999. SELECTION CRITERIA: Randomised or quasi-randomised trials comparing condylocephalic nails with other implants. DATA COLLECTION AND ANALYSIS: All reviewers independently assessed trial quality and extracted data. Data were pooled where relevant and possible. Ender nails and Harris nail data were presented separately. Results from fixed nail plates and sliding hip screws were sub-grouped to explore differences in these two implant types. MAIN RESULTS: Eleven trials were included. Ten compared Ender nails with either a fixed nail plate or a sliding hip screw. One compared the Harris condylocephalic nail with a sliding hip screw. The only advantages of condylocephalic nails were a reduced deep wound sepsis rate (0.9% versus 4.2%; odds ratio 0.26, 95% confidence interval 0.12 to 0.56), length of surgery and operative blood loss. However there was an increased risk of re-operation (20.9% versus 5. 5%; odds ratio 3.78, 95% confidence interval 2.67 to 5.36) and later fracture of the femur when compared with extramedullary implants. There was also an increased risk of cut-out of the implant from the femoral head for Ender nails compared with the sliding hip screw, but not for fixed nail plates. Backing out of the nail was a frequent complication (30%) of Ender nails and often resulted in revision surgery. Ender nails also had an increased risk of shortening of the leg and external rotation deformity and potentially a poorer return to previous walking ability. An increase in residual pain resulting from an excess of knee pain was also evident in patients undergoing condylocephalic nailing. There was no apparent difference in mortality between the condylocephalic nail and extramedullary implant groups. REVIEWER'S CONCLUSIONS: Any advantages in intra-operative outcomes of condylocephalic nails are outweighed by the increase in fracture healing complications, re-operation rate, residual pain and limb deformity when compared with an extramedullary implant, particularly a sliding hip screw. The use of condylocephalic nails (in particular Ender nails), for trochanteric fracture is no longer appropriate.

Bone Nails↗

PubMed2000

Extramedullary fixation implants for extracapsular hip fractures.

BACKGROUND: Extramedullary fixation of hip fractures refers to the application of a plate and screws to the lateral side of the proximal femur. OBJECTIVES: To compare different types of extramedullary fixation implants for the surgical treatment of extracapsular hip fracture in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register and reference lists of relevant articles. Date of the most recent search: March 1998. SELECTION CRITERIA: All randomised or quasi-randomised trials comparing extramedullary implants used in the fixation of extracapsular hip fracture in adults. DATA COLLECTION AND ANALYSIS: All three reviewers independently assessed trial quality, using a ten item scale, and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, results of outcome measures were pooled by comparison. MAIN RESULTS: The methodological quality of all six included trials was poor and in no trial was there clear concealment of allocation. Three trials involving 355 patients compared a fixed nail plate (Jewett or McLaughlin) with the sliding hip screw (SHS). The limited data presented indicated an increased risk of fixation failure outcomes for fixed nail plates. One trial involving 233 patients compared the RAB plate (a fixed angle blade plate with an oblique connecting strut) with the SHS. In this trial both implants had a high incidence of fixation failure. There was a tendency to a lower incidence of cut-out, re-operation, fixation failure, leg shortening, varus deformity and mortality for the RAB plate. None of the differences in these outcomes were statistically significant. One trial involving 100 patients compared the Pugh nail and the SHS. There was no significant difference between implants for the outcome measures reported. One trial involving 176 patients with 182 fractures, compared the Medoff plate with the SHS. A significantly higher mean operative blood loss and longer mean operative time were reported for the Medoff plate. There was however a tendency to a lower risk of fixation failure for unstable trochanteric fractures fixed with the Medoff plate. REVIEWER'S CONCLUSIONS: The fixed nail plate was demonstrated to have to an increased risk of implant breakage and fixation failure in comparison to the SHS. Although the lack of evidence from randomised trials for other outcomes means that a firm conclusion of overall superiority of the SHS cannot be made, the increased fixation failure rate is a major consideration and indicates that the SHS is preferable. Insufficient information is available to draw firm conclusions of the clinical significance of differences between the SHS and either the RAB plate, the Pugh nail or the Medoff plate.

Bone Plates↗