Cochrane Reviews - Jas Daurka 16/10/2008

Title

RCTs

No of patients

Results

Notes

Anaesthesia for hip fracture surgery in adults

22

2567

Regional – less confusion and reduced DVT vs general

No real difference except DVT/confusion

Anaesthesia for treating distal radial fracture in adults

18

1200

Haematoma block poorer analgesia and reduction than regional(IVRA)

Haematoma block not great

Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures

22

8307

Single dose antibiotic prophylaxis significantly reduced deep wound infection,superficial wound infections, urinary infections, and respiratory tract infections

multi dose has similar effects

Economic modelling using data from one large trial indicates that single dose prophylaxis with ceftriaxone is a cost-effective intervention

Use ceftriaxone single dose

Antibiotics for preventing infection in open limb fractures

7

913

The use of antibiotics had a protective effect against early infection compared with no antibiotics or placebo

There were insufficient data in the included studies to evaluate other outcomes

Use antibiotics

Arthroplasties (with and without bone cement) for proximal femoral fractures in adults

6unvs cem hemi)

7 bip vshm

5 (hemi vs thr)

549

857

608

Not enough evidence from randomised trials to show which arthroplasty is best

There is some evidence that people with arthroplasties that are cemented in place may have less pain and better mobility after the operation than those, which are inserted as a press fit.

No difference between uni and   bipolar

A trend to better functional outcomes after total hip replacement, but firm conclusions could not be made because of the lack of patient numbers.

Cemented hemis give less pain/better mobility

No difference in uni/bipolar

THR better functional outcomes

Autologous cartilage implantation for full thickness articular cartilage defects of the knee

4

266

no evidence of significant difference between ACI and other interventions.

no statistically significant difference in outcomes at two years in a trial comparing ACI with microfracture. In addition, one trial of matrix-guided ACI versus microfracture did not contain enough long-term results to reach definitive conclusions.

No difference – stick with microfracture

Biopsychosocial rehabilitation for upper limb RSI

2

there appears to be little scientific evidence for the effectiveness of biopsychosocial rehabilitation on repetitive strain injuries

No evidence to support

Bioresorbable fixation devices for musculoskeletal injuries in adults

31

No significant difference between the bioresorbable and other implants could be demonstrated with respect to functional outcome, infections and other complications. Reoperation rates were lower in some of the groups of people treated with bioresorbable implants.

No difference except lower reop rates

Bone grafts and bone substitutes for treating distal radial fractures in adults

10

874

that while bone scaffolding may improve anatomical outcome compared with plaster cast immobilisation alone, there is insufficient evidence to conclude on function and safety; or on outcome for other comparisons.(vs ex fix)

Better anatomy – no difference in function

Closed reduction methods for treating distal radial fractures in adults

3

404

that there was not enough evidence to decide whether there was any difference between the various methods tested.

Mechanical (finger trap)/manual/reduction device

No difference

Closed suction surgical wound drainage after orthopaedic surgery

36

5464

no statistically significant difference in the incidence of wound infection, haematoma, dehiscence or re-operations

Blood transfusion was required more frequently in those who received drains. The need for reinforcement of wound dressings and the occurrence of bruising were more common in the group without drains.

No difference in infection, haematoma, dehiscence, re ops

Co-ordinated multidisciplinary for rehab patients with proximal femoral #

9

1887

Combined outcome measures (e.g. death or institutional care) tended to be better for patients receiving co-ordinated inpatient rehabilitation, but the results were heterogeneous and not statistically significant.

No statistical difference

Condylocephalic nails versus extramedullary implants for extracapsular hip fractures

11

1667

only advantages of condylocephalic nails were a reduced deep wound sepsis rate (0.9% versus 4.2% length of surgery and operative blood loss

increased risk of reoperation (20.9% versus 5.5%

and later fracture of the femur when compared with extramedullary implants.

There was an increased risk of cut-out of the implant from the femoral head for Ender nails compared with the sliding hip screw

Ender nails 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, predominantly 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.

Don’t use nails

Conservative interventions for treating distal radial fractures in adults

37

4215

insufficient evidence from randomised controlled trials to determine which methods of conservative treatment are the most appropriate for the more common types of distal radial fractures in adults

not enough evidence from trials to determine whether, and if so when, moderately displaced fractures should be manipulated back into position. Nor was there enough evidence to determine the best method and duration of immobilisation.

Do what you are happy with

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

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.

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

No difference, do whatever

Conservative Rx for closed fifth   metacarpal neck fractures

5

252

No included studies reported our primary outcome measure of interest, validated hand function. There was heterogeneity between the studies, which were of limited quality and size.

No guidance

Conservative versus operative treatment for hip fractures in adults

5

428

One small and potentially biased trial of 23 patients with undisplaced intracapsular fracture provided limited evidence that surgical fixation increased the chances of the fracture healing. The four trials on extracapsular fractures tested a variety of surgical techniques and implant devices and only one trial involving 106 patients can be considered to test current practice. This trial found no major difference between surgery and traction for people with extracapsular fractures.

However, people who had surgery had better anatomical outcomes, tended to leave hospital sooner, and seemed less likely to lose their independence.

Prefer operative Rx

Different functional treatment strategies for acute lateral ankle ligament injuries in adults

9

892

The use of an elastic bandage has fewer complications than taping but appears to be associated with a slower return to work and sport, and more reported instability than a semi-rigid ankle support. Lace-up ankle support appears to be effective in reducing swelling in the short-term compared with semi-rigid ankle support, elastic bandage and tape. However, definitive conclusions are hampered by the variety of treatments used, and the inconsistency of reported follow-up times. The most effective treatment, both clinically and in costs, is unclear from currently available randomised trials.

Pros and cons

Different methods of external fixation for treating distal radial fractures in adults

9

510

2 comparing a bridging   external fixator versus pins and plaster external fixation found no statistically significant differences in function or deformity.

1 trial found tendencies for more serious complications but less subsequent discomfort and deformity in the fixator group.

3 trials compared non-bridging versus bridging fixation, using external fixators. Two trials tested similar non-bridging fixators: one found no significant differences in functional or clinical outcomes, whereas the other found non-bridging fixation significantly improved grip strength, wrist flexion and anatomical outcome. The third trial found no significant findings in favour of multi-planar non-bridging fixation of complex fractures

One trial using a bridging external fixator found that fixing the distal fracture fragment with an extra external fixator pin gave superior functional and anatomical results.

One trial found no evidence of differences in clinical outcomes for hydroxyapatite coated pins compared with standard uncoated pins.

Two trials compared dynamic versus static external fixation. One trial found no significant effects from the early 'dynamism' of an external fixator. The poor quality of the other trial undermines its findings of poorer results for dynamic fixation

Insufficient evidence

Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults

21

limited evidence for the effectiveness of keyboards with an alternative force-displacement of the keys or an alternative geometry, and limited evidence for the effectiveness of exercises compared to massage; breaks during computer work compared to no breaks; massage as an add-on treatment to manual therapy; and manual therapy as an add-on treatment to exercises.

?

Exercise for improving balance in older people

34

2883

Exercise appears to have statistically significant beneficial effects on balance ability in the short term but the strength of evidence contained within these trials is limited

Probably beneficial

Exercise for treating anterior cruciate ligament injuries in combination with collateral ligament and meniscal damage of the knee in adults

6

343

This review found no evidence to support one form of exercise programme over another in managing recovery from the injury looking at return to daily activities, work and sporting activities.

No particular regime better

Exercise for treating isolated anterior cruciate ligament injuries in adults

9

391

This finding was based on 9 randomised controlled trials, involving 391 mainly male people aged 15 to 49 years and followed up from 12 weeks to one year. Two trials used conservative treatment and seven trials, involving 315 participants, evaluated rehabilitation following reconstruction surgery.

No real conclusions

Exercise therapy for patellofemoral pain syndrome

12

The evidence that exercise therapy is more effective in treating PFPS than no exercise was limited with respect to pain reduction, and conflicting with respect to functional improvement. There is strong evidence that open and closed kinetic chain exercise are equally effective.

Exercise reduces pain but reduces functional ability.open/closed chain about the same

External fixation versus conservative treatment for distal radial fractures in adults

15

1022

The review found that external fixation reduced fracture redisplacement that prompted further treatment and generally improved final anatomical outcome. It appears to improve function too but this needs to be confirmed. The complications, such a pin tract infection, associated with external fixation were many but were generally minor. Serious complications occurred in both groups. The review concludes that there is some evidence to support the use of external fixation for these fractures.

supports ex fix

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

14

2222

We concluded that the sliding hip screw seems preferable to older types of fixed nail plates given their high rate of implant and fixation failure. However, there was not enough evidence to draw conclusions for other comparisons of extramedullary implants or on the use of external fixators

DHS works

  im nails versus em implants for extracapsular hip fractures in adults

22gamvsdhs

5imhs vsdhs

3pfn vs dhs

1 targon vs dhs

3871

623

394

50

given the lower complication rate of the sliding hip screw in comparison with intramedullary nails, the sliding hip screw appears to be a better implant for fixing the more common types of extracapsular hip fractures.

Supports DHS

Heparin,LMWH and physical methods for preventing DVT and PE following surgery for hip fractures

31

2958

U and LMW heparins protect against lower limb DVT. There is insufficient evidence to confirm either protection against pulmonary embolism or an 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.

Heparin prevents DVT – prob not PE

Foot/calf pumps work but compliance problems

Hip protectors for preventing hip fractures in older people

15

3(5135)

marginally statistically significant reduction in hip fracture incidence. Pooling of data from three individually randomised trials involving 5135 community dwelling participants, showed no reduction in hip fracture incidence from the provision of hip protectors (RR 1.16, 95% CI 0.85 to 1.59).

There was no evidence of any significant effect of hip protectors on incidence of pelvic or other fractures. No important adverse effects of the hip protectors were reported but compliance, particularly in the long term, was poor

Overall reduction in #s

Good studies – no difference

Hyperbaric oxygen therapy for delayed onset muscle soreness and closed soft tissue injury

9

219

There was insufficient evidence from comparisons tested within randomised controlled trials to establish the effects of HBOT on ankle sprain or acute knee ligament injury, or on experimentally induced DOMS(delayed onset muscle soreness). There was some evidence that HBOT may increase interim pain in DOMS. Any future use of HBOT for these injuries would need to have been preceded by carefully conducted randomised controlled trials which have demonstrated effectiveness.

Insufficient evidence, don’t use

Hyperbaric oxygen therapy for promoting fracture healing and treating fracture non-union

0

No randomised trials found

No evidence

Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults

21

2184

Statistically significant differences in favour of functional treatment when compared with immobilisation were found for seven outcome measures: more patients returned to sport in the long term,the time taken to return to sport was shorter,more patients had returned to work at short term follow-up, the time taken to return to work was shorter,fewer patients suffered from persistent swelling at short term follow-up ,fewer patients suffered from objective instability as tested by stress X-ray ,and patients treated functionally were more satisfied with their treatment

A separate analysis of trials that scored 50 per cent or more in quality assessment found a similar result for time to return to work only (WMD (days) 12.89, 95% CI 7.10 to 18.67). No significant differences between varying types of immobilisation, immobilisation and physiotherapy or no treatment were found, apart from one trial where patients returned to work sooner after treatment with a soft cast. In all analyses performed, no results were significantly in favour of immobilisation.

Functional Rx probably better –return to work earlier

Internal fixation implants for intracapsular proximal femoral fractures in adults

28

5547

The sliding hip screw was found to take longer to insert and to have an increased operative blood loss compared with multiple screws or pins .

Overall no clear conclusion but DHS takes longer

Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults

17

2694

2 ^nd op 36% vs 11% (fixation vs hemi)

length of surgery, operative blood loss, need for blood transfusion and risk of deep wound infection were significantly less for internal fixation compared with arthroplasty.

No definite differences for hospital stay, mortality, or regain of same residential state were found. Limited information from some studies suggested pain was less and function was better for a cemented arthroplasty in comparison to fixation.

Fixation less trauma etc, hemi prob better function

Interventions for isolated diaphyseal fractures of the ulna in adults

3

135

One trial compared short arm pre-fabricated functional braces with long arm plaster casts. It found no statistically significant difference between the two groups in the time taken for the fracture to heal. However, significantly more people in the brace group were satisfied with their treatment and significantly more returned to work during their treatment. One 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. The third trial found no significant differences in anatomical or functional outcomes nor complications between the two types of plates used for surgical fixation of the fracture.

Overall, there was not enough evidence from randomised controlled trials to show which methods of treatment are better for these injuries.

Insufficient evidence

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

16

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.

Shock absorbing foot wear   prob reduces stress #s

Rehab post stress # - use pneumatic brace

Interventions for preventing ankle ligament injuries

14

8279

Twelve trials involved active, predominantly young, adults participating in organised, generally high-risk, activities. The other two trials involved injured patients who had been active in sports before their injury. The prophylactic interventions under test included the application of an external ankle support in the form of a semi-rigid orthosis (three trials), air-cast brace (one trial) or high top shoes (one trial); ankle disk training; taping; muscle stretching; boot inserts; health education programme and controlled rehabilitation.

The main finding was a significant reduction in the number of ankle sprains in people allocated external ankle support (RR 0.53, 95% CI 0.40 to 0.69). 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 severity of ankle sprains or 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 disk training exercises. Various problems with data reporting limited the interpretation of the results for many of the other interventions.

good evidence for the beneficial effect of ankle supports in the form of semi-rigid orthoses or air-cast braces to prevent ankle sprains during high-risk sporting activities (e.g. soccer, basketball).

Ankle supports prevent ankle sprain

Interventions for preventing falls in elderly people

62

21668

Interventions likely to be beneficial :

Multidisciplinary, multifactorial, health/environmental risk factor screening/intervention programmes in the community both for an unselected population of older people   and for older people with a history of falling or selected because of known risk factors and in residential care

A programme of muscle strengthening and balance retraining, individually prescribed at home by a trained health professional

Home hazard assessment and modification that is professionally prescribed for older people with a history of falling

Withdrawal of psychotropic medication

Cardiac pacing for fallers with cardioinhibitory carotid sinus hypersensitivity A 15 week Tai Chi group exercise intervention

Interventions of unknown effectiveness:

Group-delivered exercise interventions (9 trials, 1387 participants)

Individual lower limb strength training (1 trial, 222 participants)

Nutritional supplementation (1 trial, 46 participants)

Vitamin D supplementation, with or without calcium (3 trials, 461 participants)

Home hazard modification in association with advice on optimising medication (1 trial, 658 participants), or in association with an education package on exercise and reducing fall risk (1 trial, 3182 participants)

Pharmacological therapy (raubasine-dihydroergocristine, 1 trial, 95 participants)

Interventions using a cognitive/behavioural approach alone (2 trials, 145 participants)

Home hazard modification for older people without a history of falling (1 trial, 530 participants)

Hormone replacement therapy (1 trial, 116 participants)

Correction of visual deficiency (1 trial, 276 participants).

Interventions unlikely to be beneficial :

Brisk walking in women with an upper limb fracture in the previous two years (1 trial, 165 participants).

Interventions for preventing lower limb soft-tissue injuries in runners

12

8806

Twelve trials with 8,806 participants were included. In one trial, a single control group was matched to three different included intervention groups. The effectiveness of stretching exercises (5 trials, 1944 participants in the intervention groups, 3159 controls), and of insoles and footwear modification (5 trials, 903 participants in the intervention groups, 3006 controls) in the prevention of lower extremity soft tissue injuries associated with running is unknown. Reducing the distance, frequency and duration of running may be effective in the prevention of lower extremity soft tissue injuries associated with running (3 trials, 514 participants in intervention groups, 1663 controls). Wearing a knee brace with a patellar support ring may be effective in the prevention of running-associated anterior knee pain (1 trial, 27 participants in the intervention group, 33 controls).

Run less=less injuries

Interventions for tears of the rotator cuff in adults

8

455

Only results from two studies comparing open repair to arthroscopic debridement could be pooled. There is weak evidence for the superiority of open repair of rotator cuff tears compared with arthroscopic debridement.

Little evidence, no real comparison possible

Interventions for treating acute and chronic Achilles tendinitis

9

697

weak but not robust evidence from three trials of a modest benefit of NSAIDs for the alleviation of acute symptoms. 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.

Insufficient evidence

Interventions for treating calcaneal fractures

6

Three trials, involving 134 patients, compared open reduction and internal fixation with non-operative management of displaced intra-articular fractures. Pooled results showed no apparent difference in residual pain (24/40 versus 24/42)but a lower proportion of the operative group was unable to return to the same work (11/45 versus 23/45)and was unable to wear the same shoes as before (12/52 versus 24/54).

One trial, involving 23 patients, evaluated impulse compression therapy. At one year there was a mean difference of 1.40 pain units on a visual analogue score (scale 0-10) in favour of the treated group. The impulse compression group had greater subtalar movement (mean difference 14.0 degrees, at three months. On average, patients in the impulse compression group returned to work three months earlier than those in the control group.

No clear guidance

Some evidence for surgery and compression therapy

Interventions for treating chronic ankle instability

7

Surgical interventions (four studies): one study showed more complications after the Chrisman-Snook procedure compared to an anatomical reconstruction, whereas another study showed greater mean talar tilt after an anatomical reconstruction. Subjective instability and hindfoot inversion was greater after a dynamic than after a static tenodesis in a third study. The fourth study showed that the operating time for anatomical reconstructions was shorter for the reinsertion technique than for the imbrication method. Rehabilitation after surgical interventions (two studies): both studies provided evidence that early functional mobilization leads to an earlier return to work and sports than immobilisation. Conservative interventions: the only study in this group showed better proprioception and functional outcome with the bi-directional than with the uni-directional pedal technique on a cyclo-ergometer.

No support for particular intervention

Post surgery functional rx do better than 6/52 immobilisation

Interventions for treating hallux valgus (abductovalgus) and bunions

21

The methodological quality of the 21 included trials was generally poor and trial sizes were small.

Three trials involving 332 participants evaluated conservative treatments versus no treatment. There was no evidence of a difference in outcomes between treatment and no treatment.

One good quality trial involving 140 participants compared surgery to conservative treatment. Evidence was shown of an improvement in all outcomes in patients receiving chevron osteotomy compared with those receiving orthoses. The same trial also compared surgery to no treatment in 140 participants. Evidence was shown of an improvement in all outcomes in patients receiving chevron osteotomy compared with those receiving no treatment.

Two trials involving 133 people with hallux valgus compared Keller's arthroplasty with other surgical techniques. In general, there was no advantage or disadvantage using Keller's over the other techniques. When the distal osteotomy was compared to Keller's arthroplasty, the osteotomy showed evidence of improving the intermetatarsal angle and preserving joint range of motion. The arthroplasty was found to have less of an impact on walking ability compared to the arthrodesis.

Six trials involving 309 participants compared chevron (and chevron-type) osteotomy with other techniques. The chevron osteotomy offered no advantages in these trials. For some outcomes, other techniques gave better results. Two of these trials (94 participants) compared a type of proximal osteotomy to a proximal chevron osteotomy and found no evidence of a difference in outcomes between techniques.

Three trials involving 157 participants compared outcomes between original operations and surgeon's adaptations. There was no advantage found for any of the adaptations.

Three trials involving 71 people with hallux valgus compared new methods of fixation to traditional methods. There was no evidence that the new methods of fixation were detrimental to the outcome of the patients.

Four trials involving 162 participants evaluated methods of post-operative rehabilitation. The use of continuous passive motion appeared to give an improved range of motion and earlier recovery following surgery. Early weightbearing or the use of a crepe bandage were not found to be detrimental to final outcome.

Conservative rx – doesn’t work

Osteotomy better than nothing

?Which osteotomy

Osteotomy better than arthroplasty

Updated

Interventions for treating mallet finger injuries

4

278

Four trials were included. These involved a total of 278, mainly adult, participants with 283 mallet finger injuries..

Three trials compared different types of finger splints versus a standard Stack splint. One trial found a lower incidence of treatment failure in participants treated with a perforated custom-made splint. One trial found there were fewer complications in participants treated with a padded aluminium-alloy malleable finger splint; however, the incidence of treatment failure was similar in the two treatment groups. One trial evaluating the Abouna splint found a similar incidence of treatment failure in the two groups. However, the Abouna splint often needed replacing due to disintegration of its rubber cover and rusting of the exposed wires and was also less popular with participants.

The fourth trial found no statistically significant differences between participants whose mallet finger was treated with Kirschner wire fixation and those with a Pryor and Howard splint. Similar numbers had complications in the two groups.

insufficient evidence

custom-made vs off-the-shelf   finger splints

prolonged immobilisation should be robust enough for everyday use

  compliance important

? when is surgery indicated – no answers

Interventions for treating plantar heel pain

19

1626

Nineteen randomised trials involving 1626 participants were included. Trial quality was generally poor – hence no pooling. All trials measured heel pain as the primary outcome. Seven trials evaluated interventions against placebo/dummy or no treatment. There was limited evidence for the effectiveness of topical corticosteroid administered by iontophoresis, i.e. using an electric current, in reducing pain. There was some evidence for the effectiveness of injected corticosteroid providing temporary relief of pain. There was conflicting evidence for the effectiveness of low energy extracorporeal shock wave therapy in reducing night pain, resting pain and pressure pain in the short term (6 and 12 weeks) and therefore its effectiveness remains equivocal. In individuals with chronic pain (longer than six months), there was limited evidence for the effectiveness of dorsiflexion night splints in reducing pain. There was no evidence to support the effectiveness of therapeutic ultrasound, low-intensity laser therapy, exposure to an electron generating device or insoles with magnetic foil. No randomised trials evaluating surgery, or radiotherapy against a randomly allocated control population were identified. There was limited evidence for the superiority of corticosteroid injections over orthotic devices.

Iontophoresis(top steroid) helps

Inj steroid help in short term

ESWT – equivocal

Chronic pain (>6/12) night splints work

US, laser, magnet foil -   no evidence

Injections better than orthotics

No surgery evidence(compared to control)

Stretching/heel pads better than custom orthoses(pts who stand for >8hrs day

Interventions for treating posterior cruciate ligament injuries of the knee in adults

Main results

No randomized or quasi-randomized controlled studies meeting the selection criteria were identified.

Authors' conclusions

Future research should include randomized controlled trials of acute isolated PCL injuries, or PCL injuries when combined with other ligament injuries of the knee, treated operatively and conservatively. Adequate numbers of patients and an objective methodology for patient evaluation must be used in future studies of these interventions to determine the long-term results.

Nil out there

Interventions for treating proximal humeral fractures in adults

12

578

Seven trials evaluated conservative treatment. There was very limited evidence that the type of bandage used had any influence on the 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 'immediate' physiotherapy compared with that delayed until after three weeks immobilisation resulted in less pain and faster and potentially better recovery in people with undisplaced two-part fractures. Similarly, there was evidence that mobilisation at one week instead of three weeks alleviated short term pain without compromising long term outcome. Two trials provided some evidence that unsupervised patients could generally achieve a satisfactory outcome when given sufficient instruction to pursue an adequate physiotherapy programme.

Operative reduction compared with conservative treatment improved fracture alignment in two trials. However, in one trial, surgery was associated with more complications, and did not result in improved shoulder function. In one trial, hemi-arthroplasty resulted in better short-term function with less pain and disability when compared with conservative treatment for severe injuries. Compared with hemi-arthroplasty, tension-band wiring fixation of severe injuries was associated with a high rate of re-operation in one trial.

One trial provided very limited evidence of similar outcomes resulting from mobilisation at one week instead of three weeks after surgical fixation.

Arm sling more comfortable than body bandage, but delay in # union/functional result

Immediate physio better than delayed (3/52) for undisplaced 2 part #s

Move at 1/52 reduced pain compared to 3/52 – no diff in outcome

Op =better alignment but also = complications/ similar functional result

Hemi –better short term function

Interventions for treating wrist fractures in children

10

827

Four trials compared removable splintage versus the traditional below-elbow cast in children with buckle fractures. There was no short-term deformity recorded in all four trials and, in one trial, no refracture at six months. The Futura splint was cheaper to use; a removable plaster splint was less restrictive to wear enabling more children to bathe and participate in other activities, and the option preferred by children and parents; the soft bandage was more comfortable, convenient and less painful to wear; home-removable plaster casts removed by parents did not result in significant differences in outcome but were strongly favoured by parents.

Two trials found below-elbow versus above-elbow casts did not increase redisplacement of reduced fractures or cast-related complications, were less restrictive during use and avoided elbow stiffness.

One trial evaluating the effect of arm position in above-elbow casts found no effect on deformity.

Three trials found that percutaneous wiring significantly reduced redisplacement and remanipulation but one of these found no advantage in function at three months.

Use removable splints in buckle #s

Below elbow as effective as above following reduction of displaced #s

Wiring reduces redisplacement - ?no functional difference

Intramedullary nails for extracapsular hip fractures in adults

6

1071

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.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   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.

DHS still best

Authors comment –“we should be comparing with dhs rather than nail vs nail.

No nail stands out

Mobilisation strategies after hip fracture surgery in adults

13

1065

Seven trials evaluated mobilisation strategies started soon after hip fracture surgery. One historic trial found no significant differences in unfavourable outcomes for weight bearing started at two versus 12 weeks after internal fixation of a displaced intracapsular fracture. Two trials compared a more with a less intensive regimen of physiotherapy: one found no difference in recovery, the other found a higher level of drop-out in the more intensive group with no difference in length of hospital stay. One trial found short-term improvement in mobility and balance for a two-week programme of weight-bearing versus non-weight-bearing exercise. One trial found improved mobility in those given a quadriceps muscle strengthening exercise programme. One trial found no significant difference in recovery of mobility after a treadmill versus conventional gait retraining programme. One trial found a greater recovery of pre-fracture mobility after neuromuscular stimulation of the quadriceps muscle.

Six trials evaluated strategies started after hospital discharge. Started soon after discharge, two trials found improved outcome after 12 weeks of intensive physical training and a home-based physical therapy programme respectively. Begun after completion of standard physical therapy, one trial found improved outcome after six months of intensive physical training whereas another trial found no significant effects of home-based resistance or aerobic training. One trial found improved outcome after home-based exercises started around 22 weeks from injury. One trial found home-based weight-bearing exercises starting at seven months produced no statistically significant differences aside for greater quadriceps strength.

Insufficient evidence

Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures

8

328

Eight randomised or quasi-randomised trials involving 328 patients were included. Three trials related to insertion of a nerve block pre-operatively and the remaining five to peri-operative insertion.

Nerve blocks resulted in a reduction of the quantity of parenteral or oral analgesia administered to control pain from the fracture/operation or during surgery and/or a reduction in reported pain levels. It was not possible to demonstrate if this reduction in analgesia use was associated with any other clinical benefit.

Nerve blocks reduce painkiller use – no other clinical benefit

Small no.s different blocks – hence cant say whether they are better than other analgesics

Non-steroidal anti-inflammatory drugs for preventing heterotopic bone formation after hip arthroplasty

16

4763

Overall, in 17 trials that examined the effects of medium to high doses of NSAIDs, there was a reduced risk of developing HBF after hip surgery (59% reduction, 95% confidence interval 54% to 64% reduction). In contrast, one large trial examining low-dose aspirin, demonstrated no effect on the risk of HBF (2% reduction, 95% confidence interval 15% reduction to 12% increase). There was strong evidence of differences in the size of the treatment effects observed between the trials examining medium to high doses of NSAIDs, but reasons were not clearly identified.

There was a non-significant one third increased risk of gastro-intestinal side effects among patients assigned NSAIDs (29% increase, 95% confidence interval 0% to 76% increase). Most of this increase was due to an increased risk of minor gastro-intestinal complications. Data on the late post-operative outcomes of pain, impaired physical function and range of joint movement were few and no formal overviews of the effects of NSAIDs on these outcomes were possible.

1/2 to 2/3   reduction in the risk of HBF. With routine use, such agents may be able to prevent 15-20 cases of HBF among every 100 total hip replacements performed.

Cant comment on complications, long term pain etc

Nutritional supplementation for hip fracture aftercare in older people

21

1727

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.

Weak evidence – it helps

Operative versus non-operative treatment for thoracolumbar burst fractures without neurological deficit

1

53

We included one trial comparing operative with non-operative treatment (53 participants).

There was no statistically significant difference in pain and function-related outcomes, rates of return to work, radiographic findings or average length of hospitalization at final follow up. The rate of complications was higher for the patients treated operatively. The degree of kyphosis or the percentage of correction lost did not correlate with any clinical symptoms at the time of the final follow up. Average costs related to hospitalization and treatment in the operative group appeared to be more than in the non-operative group.

No difference in functional outcome

Orthotic devices for treating patellofemoral pain syndrome

5

362

Five other trials await possible inclusion if further information can be obtained and one awaits further assessment. Due to clinical heterogeneity, we refrained from statistical pooling and conducted analysis by grading the strength of scientific evidence. The level of obtained research-based evidence was graded as limited as all trials were of low methodological quality.

This limited research-based evidence showed the Protonics orthosis at six week follow-up was significantly more effective for decrease in pain (weighted mean difference (WMD) between groups 3.2; 95% confidence interval (CI) 2.8 to 3.6), functional improvement on the Kujala score (WMD 45.6; 95% CI 43.4 to 47.7) and change in patellofemoral congruence angle (WMD 17.2; 95% CI 14.1 to 20.3) when compared to no treatment. A comprehensive programme including tape application was significantly superior to a monitored exercise programme without tape application for decrease in worst pain (WMD 1.6; 95% CI 0.4 to 2.8) and usual pain (WMD 1.2; 95% CI 0.2 to 2.1), and clinical change and functional improvement questionnaire scores (WMD 10, 95% CI 2.07 to 17.93) at four weeks follow-up. The trials reported statistically significant differences in patient satisfaction after applied therapy (WMD 3.3; 95% CI 0.5 to 6.1) in favour of the McConnell regimen compared with the Coumans bandage at six weeks follow-up

No definitive conclusions

Osteotomy, compression and reaming techniques for internal fixation of extracapsular hip fractures

8

824

One trial of 65 patients undergoing fixation with a fixed nail-plate compared osteotomy versus anatomical reduction. There was a tendency to a reduced fixation failure rate after osteotomy. Four trials involving 465 patients undergoing fixation with a sliding hip screw (SHS) compared osteotomy versus anatomical reduction. Osteotomy was associated with an increased operative blood loss and length of surgery. There was also a tendency to an increased length of hospital stay and limb shortening for the osteotomy group.

One trial of 200 patients undergoing fixation with a SHS compared results with or without compression across the fracture site. The only significant difference in outcomes was increased varus deformity in those fractures treated with compression. One trial of 19 patients reported reduced temperatures generated by a modified method of reaming the femoral head. Another study used oesophageal ultrasound to demonstrate reduced bone marrow intravascular embolism when a Gamma nail was inserted in 50 patients with, rather than without, a distal pressure venting hole in the femur.

Authors' conclusions

There is inadequate evidence to determine if any benefits exist for the routine use of osteotomy in conjunction with a SHS for the internal fixation of an unstable trochanteric femoral fracture. Osteotomy may be relevant if used in conjunction with a fixed nail plate. Based on the evidence of one trial only, there is inadequate evidence to support the application of compression across the fracture site of a trochanteric fracture during SHS fixation. Inadequate information exists for different reaming techniques during SHS or Gamma nail fixation to make definite conclusions.

?huh

Percutaneous pinning for treating distal radial fractures in adults

13

940

Six heterogeneous trials compared percutaneous pinning with plaster cast immobilisation. Across-fracture pinning, used in five trials, was associated with improved anatomical outcome and generally minor complications. There was some indication of similar or improved function in the pinning group. One quasi-randomised trial found an excess of complications after Kapandji pinning.

Three trials compared different methods of pinning. Two trials found a higher incidence of complications after Kapandji fixation compared with two methods of across-fracture fixation. The third trial provided inadequate evidence for modified Kapandji fixation versus Willenegger fixation.

Two small trials comparing biodegradable pins versus metal pins found a significant excess of complications associated with biodegradable material.

Two small trials compared plaster cast immobilisation for one week versus for six weeks after surgery. One trial found duration of immobilisation after trans-styloid fixation did not have a significant effect on outcome. More complications occurred in the early mobilisation group after Kapandji pinning in the second trial.

Evidence to support wires

Higher complications with kapandji and biodegradeable materials

Pharmacological interventions for treating acute heterotopic ossification

2

92

Two randomised trials comparing disodium etidronate versus placebo were included (Ono 1988; Stover 1976).

Given the absence of long term radiographic outcomes in the included studies, there is insufficient evidence to recommend the use of disodium etidronate

No supporting evidence

Pharmacotherapy for patellofemoral pain syndrome

4

163

Four trials (163 participants) studied the effect of NSAIDs. Aspirin compared to placebo in a high quality trial produced no significant differences in clinical symptoms and signs. Naproxen produced significant short term pain reduction when compared to placebo, but not when compared to diflunisal. Laser therapy to stimulate blood flow in tender areas led to more satisfied participants than tenoxicam, though not significantly.

Two high quality RCTs (84 participants) studied the effect of glycosaminoglycan polysulphate (GAGPS). Twelve intramuscular injections in six weeks led to significantly more participants with a good overall therapeutic effect after one year, and to significantly better pain reduction during one of two activities. Five weekly intra-articular injections of GAGPS and lidocaine were compared with intra-articular injections of saline and lidocaine or no injections, all with concurrent quadriceps training. Injected participants showed better function after six weeks, though only the difference between GAGPS injected participants and non-injected participants was significant. The differences had disappeared after one year.

One trial (43 participants) found that intramuscular injections of the anabolic steroid nandrolone phenylpropionate significantly improved both pain and function compared to placebo injections.

limited evidence for the effectiveness of NSAIDs for short term pain reduction in PFPS

anabolic steroid nandrolone may be effective, but is too controversial for treatment of PFPS.

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

10

1546

  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.

Not for routine use

Prescription of prosthetic ankle-foot mechanisms after lower limb amputation

26

245

In individuals with a transtibial amputation, there seems to be a small tendency towards a greater stride length when walking with the Flex-foot in comparison to the SACH (solid-ankle cushioned heel) foot. When walking speed was increased, the energy cost was lower. In high activity individuals with a transfemoral amputation, there is limited evidence for the superiority of the Flex foot during level walking compared with the SACH foot in respect of energy cost and gait efficiency.

Flex-foot better than SACH foot for greater stride length and lower energy cost – in both trans tib and fem

Progressive resistance strength training for physical disability in older people

66

3783

PRT had a large positive effect on strength (41 trials, 1955 participants), but there was statistical heterogeneity that was not explained by differences in study quality, participant characteristics or the exercise program. Some functional limitation measures showed modest improvements (i.e. gait speed, 14 trials, 798 participants, WMD 0.07 m/s, 95% CI 0.04 to 0.09). However, there was no evidence that PRT had an effect on physical disability when activity measures or health related quality of life measures (HRQOL) were assessed (10 trials, 798 participants, SMD 0.01, 95% CI -0.14 to 0.16 ). Adverse events were poorly recorded, but musculoskeletal injuries were detected in most of the studies that prospectively defined and monitored these events.

Increased strength – possible functional benefits

Cons –musculoskeletal injuries (not recorded adequately)

Rehabilitation after surgery for flexor tendon injuries in the hand

6

464

Data were not pooled. One trial compared continuous passive motion (CPM) with controlled intermittent passive motion (CIPM) and found a significant difference in mean active motion favouring CPM (WMD 19.00 degrees, 95% CI 15.11 to 22.89). One trial compared a shortened passive flexion/active extension programme with a normal passive flexion/active extension mobilisation programme, and reported (without data) a significant reduction in absence from work of 2.1 weeks in favour of the shortened programme. Other trials compared active flexion with rubber band traction, early controlled active mobilisation with early controlled passive mobilisation and dynamic splintage versus static splintage. No trials found significant differences in overall functioning or complication rate.

Unable to define best regime

Rehabilitation for ankle fractures in adults

31

Thirty-one studies were included. Clinical and statistical heterogeneity prevented meta-analyses in most instances. After surgical fixation, commencing exercise in a removable brace or splint significantly improved activity limitation, pain and ankle range of motion, but also led to a higher rate of adverse events. Early commencement of weight-bearing during the immobilisation period improved ankle range of motion after surgical fixation. Where it was possible to avoid ankle range of motion after surgical fixation, the use of no immobilisation compared to cast immobilisation also improved ankle range of motion. After the immobilisation period, manual therapy was beneficial in increasing ankle range of motion. There was no evidence of effect for electrotherapy, hypnosis, or stretching.

limited evidence supporting the use of a removable type of immobilisation and exercise during the immobilisation period, early commencement of weight-bearing during the immobilisation period, and no immobilisation after surgical fixation of ankle fracture

is also limited evidence for manual therapy after the immobilisation period

Rehabilitation for distal radial fractures in adults

15

746

  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).

Insufficient evidence

Rehabilitation for hamstring injuries

3

There is limited evidence to suggest that rate of recovery can be increased with an increased daily frequency of hamstring stretching exercises. Consideration should be given to the lumbar spine, sacroiliac and pelvic alignment and postural control mechanisms when managing hamstring injuries. Lumbar stability and pelvic motor control may also be factors in reducing the rate of recurrence of hamstring injury. Until further evidence is available, current practice and widely published rehabilitation protocols cannot either be supported or refuted.

stretch

Replacement arthroplasty versus internal fixation for extracapsular hip fractures in adults

2

148

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).

no advantage of arhtroplasty and they bleed

Stretching to prevent or reduce muscle soreness after exercise

10

Of the 10 included studies, nine were carried out in laboratory settings using standardised exercise protocols and one involved post-exercise stretching in footballers. All participants were young healthy adults. Three studies examined the effects of stretching before exercise and seven studies investigated the effects of stretching after exercise. Two studies, both of stretching after exercise, involved repeated stretching sessions at intervals of greater than two hours. The duration of stretching applied in a single session ranged from 40 to 600 seconds.

All studies were small (between 10 and 30 participants received the stretch condition) and of questionable quality.

The effects of stretching reported in individual studies were very small and there was a high degree of consistency of results across studies. The pooled estimate showed that pre-exercise stretching reduced soreness one day after exercise by, on average, 0.5 points on a 100-point scale (95% CI -11.3 to 10.3; 3 studies). Post-exercise stretching reduced soreness one day after exercise by, on average, 1.0 points on a 100-point scale (95% CI -6.9 to 4.8; 4 studies). Similar effects were evident between half a day and three days after exercise.

Stretching doesn’t help delayed onset muscle soreness

Surgical approaches and ancillary techniques for internal fixation of intracapsular proximal femoral fractures

One trial with 103 participants studied the effect of impaction of the fracture at the time of surgery. The only outcome measure reported was bone scintimetry. There was some evidence that impaction, particularly of displaced fractures, resulted in a reduction of blood flow to the femoral head as assessed by bone scintimetry.
One quasi-randomised trial with 220 participants compared compression of the fracture with no compression. Results for 156 individuals at one year showed a tendency to a lower incidence of non-union for those fractures treated without compression.

Two trials, one involving 102 young adults under 50 years old and the other involving 49 older people aged 65 years or over, compared open versus closed reduction of the fracture. Both found open reduction significantly increased length of surgery. None of the other differences between open and closed reduction in the outcomes reported by the two trials were statistically significant.

Insufficient evidence exists from randomised trials to confirm the relative effects of open versus closed reduction of intracapsular fractures, or the effects of intra-operative impaction or compression of an intracapsular fracture treated by internal fixation

Surgical approaches for inserting hemiarthroplasty of the hip

1

114

The trial had poor methodology (particularly in susceptibility to selection bias), inadequate follow-up of patients who withdrew, and there was limited reporting of results. Medical complications and mortality from six months to two years appeared greater in the posterior group; this difference in mortality, within the structure of the poor methodology, was statistically significant. No other differences were claimed to be significant.

No difference in approach

Surgical interventions for treating acute Achilles tendon ruptures

14

891

Fourteen trials involving 891 patients were included. Several of the studies had poor methodology and inadequate reporting of outcomes.

Open operative treatment compared with non-operative treatment (4 trials, 356 patients) was associated with a lower risk of rerupture (relative risk (RR) 0.27, 95% confidence interval (CI) 0.11 to 0.64), but a higher risk of other complications including infection, adhesions and disturbed skin sensibility (RR 10.60, 95%CI 4.82 to 23.28).

Percutaneous repair compared with open operative repair (2 studies, 94 patients) was associated with a shorter operation duration, and lower risk of infection (RR 10.52, 95% CI 1.37 to 80.52). These figures should be interpreted with caution because of the small numbers involved.

Patients splinted with a functional brace rather than a cast post-operatively (5 studies, 273 patients) tended to have a shorter in-patient stay, less time off work and a quicker return to sporting activities. There was also a lower complication rate (excluding rerupture) in the functional brace group (RR 1.88 95%CI 1.27 to 2.76).

Because of the small number of patients involved no definitive conclusions could be made regarding different operative techniques (1 study, 51 patients), different non-operative treatment regimes (2 studies, 90 patients), and different forms of post-operative cast immobilisation (1 study, 40 patients).

Open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared to non-operative treatment

  higher risk of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously. Post-operative splintage in a functional brace appears to reduce hospital stay, time off work and sports, and may lower the overall complication rate.

Surgical interventions for treating distal radial fractures in adults

48

3371

unstable fractures. Nearly 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 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.

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.

Surgical treatment for meniscal injuries of the knee in adults

3

260

Three trials, involving 260 patients, which addressed two (partial versus total meniscectomy; surgical access) comparisons were included.

Partial meniscectomy may allow a slightly enhanced recovery rate as well as a potentially improved overall functional outcome including better knee stability in the long term. It is probably associated with a shorter operating time with no apparent difference in early complications or re-operation between partial and total meniscectomy. The long term advantage of partial meniscectomy indicated by the absence of symptoms (symptoms or further operation at six years or over: 14/98 versus 22/94; Peto odds ratio 0.55, 95% confidence interval 0.27 to 1.14) or radiographical outcome was not established.

The results available from the only trial comparing arthroscopic with open meniscectomy were very limited in terms of patient numbers and length of follow-up. However it is likely that partial meniscectomy via arthroscopy is associated with shorter operating times and a quicker recovery.

The lack of randomised trials means that no conclusions can be drawn on the issue of surgical versus non-surgical treatment of meniscal injuries, nor meniscal tear repair versus excision.

In randomised trials so far reported, there is no evidence of difference in radiological or long term clinical outcomes between arthroscopic and open meniscal surgery, or between total and partial meniscectomy. Partial meniscectomy seems preferable to the total removal of the meniscus in terms of recovery and overall functional outcome in the short term.

Surgical versus conservative interventions for anterior cruciate ligament ruptures in adults

2

324

Two poor quality randomised trials conducted in the early 1980s were included in the review. The two trials differed considerably and no data pooling was done for the few shared outcome measures.

One quasi-randomised trial of 167 people with a complete ACL rupture treated with repair or augmented repair versus conservative treatment found no difference in the return to sports activities between people treated surgically and those treated conservatively. Measures of knee stability and functional (Lysholm) knee scores were higher in surgically-treated participants. By the end of the follow-up period (average 55 months), three people treated with repair only and 16 treated conservatively had had ACL reconstruction.

The other trial included 157 people with ACL injury. This found that conservatively-treated participants recovered from their injury more rapidly but, at the last follow up (minimum 13 months), the functional outcome was similar in both treatment groups. A large proportion of participants experienced some temporary discomfort after surgery and there were some more serious postoperative complications. There was less knee instability in surgically-treated participants and a tendency to fewer subsequent operations in the longer term.

There is insufficient evidence from randomised trials to determine whether surgery or conservative management was best for ACL injury in the 1980s, and no evidence to inform current practice.

Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults

20

2562

  All trials had methodological weaknesses. Specifically, concealment of allocation was confirmed in only one trial. Data for pooling individual outcomes were only available for a maximum of 12 trials and under 60% of participants.

The findings of statistically significant differences in favour of the surgical treatment group for the four primary outcomes (non-return to pre-injury level of sports; ankle sprain recurrence; long-term pain; subjective or functional instability) when using the fixed-effect model were not robust when using the random-effects model, nor on the removal of one low quality (quasi-randomised) trial that had more extreme results. A corresponding drop in the I² statistics showed the remaining trials to be more homogeneous.

The functional implications of the statistically significantly higher incidence of objective instability in conservatively treated trial participants are uncertain. There was some limited evidence for longer recovery times, and higher incidences of ankle stiffness, impaired ankle mobility and complications in the surgical treatment group.

Insufficient evidence

Surgery does have a few complications –stiffness etc

Surgical versus non-surgical treatment for acute anterior shoulder dislocation

4

163

All had had a primary (first time) traumatic anterior shoulder dislocation. Methodological quality was variable.

All participants of one trial returned to active military duty. Two trials respectively reported similar numbers with reduced sports participation or non return to previous activities. The other, an inadequately reported, trial found significantly fewer people in the surgical group failed to attain previous levels of sports activity.

Pooled results from all four trials showed that subsequent instability, either redislocation or subluxation, was statistically significantly less frequent in the surgical group (relative risk 0.25; 95% confidence interval 0.14 to 0.44). This result remained statistically significant (relative risk 0.32, 95% confidence interval 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 these trials. The results were more favourable, usually statistically significantly so, in those treated surgically.

The only complication reported was a septic joint in a surgically treated patient. There was no information on shoulder pain, long-term complications or resource use.

Stabilise young active males – cant say much else about the rest of the population

Therapeutic ultrasound for acute ankle sprains

5

572

Five trials were included, involving 572 participants. Four of these trials were of modest methodological quality and one placebo-controlled trial was considered to be of good quality. None of the four placebo-controlled trials (sham ultrasound) demonstrated statistically significant differences between true and sham ultrasound therapy for any outcome measure at seven to 14 days of follow up. The pooled relative risk for general improvement was 1.04 (random-effects model, 95% confidence interval 0.92 to 1.17) for active versus sham ultrasound. The differences between intervention groups were generally small, between zero and six per cent for most dichotomous outcomes. However, one trial reported relatively large differences for pain-free status (20%) and swelling (25%) in favour of ultrasound.

Possible small effect if anything

Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis

Vitamin D alone showed no statistically significant effect on hip fracture (seven trials, 18,668 participants, RR 1.17, 95% CI 0.98 to 1.41), vertebral fracture (four trials, 5698 participants, RR (random effects) 1.13, 95% CI 0.50 to 2.55) or any new fracture (eight trials, 18,935 participants, RR 1.02, 95% CI 0.93 to 1.11).

Vitamin D with calcium marginally reduced hip fractures (seven trials, 10,376 participants, RR 0.81, 95% CI 0.68 to 0.96), non-vertebral fractures (seven trials, 10,376 participants, RR 0.87, 95% CI 0.78 to 0.97), but there was no evidence of effect of vitamin D with calcium on vertebral fractures. The effect appeared to be restricted to those living in institutional care.

Hypercalcaemia was more common when vitamin D or its analogues was given compared with placebo or calcium (14 trials, 8035 participants, RR 2.38, 95% CI 1.52 to 3.71). The risk was particularly high with calcitriol (three trials, 742 participants, RR 14.94, 95% CI 2.95 to 75.61). There was no evidence that vitamin D increased gastro-intestinal symptoms (seven trials, 10,188 participants, RR (random effects) 1.03, 95% CI 0.79 to 1.36) or renal disease (nine trials, 10,107 participants, RR 0.80, 95% CI 0.34 to 1.87).

Frail older people confined to institutions may sustain fewer hip and other non-vertebral fractures if given vitamin D with calcium supplements.