Lesley D Gillespie

Effectiveness of hip protectors for preventing hip fractures in elderly people: systematic review

Abstract Objectives To present the updated results of systematic review of the current evidence for the effectiveness of hip protectors from reports of completed randomised trials, and to explore the evolution of that evidence. Design Systematic review with meta-analysis. Data sources Cochrane Bone, Joint, and Muscle Trauma Group trials register (January 2005), Cochrane central register of controlled trials (Cochrane Library Issue 1, 2005), Medline (1966 to January 2005), Embase (1988 to January 2005), and CINAHL (1982 to December 2004). Other databases and reference lists of relevant articles were searched and some trialists were contacted. Review methods Randomised or quasirandomised controlled trials reporting the incidence of hip fractures, pelvic fractures, and other fractures in elderly people offered hip protectors compared with a control group that was not. Results Outcomes for fracture were available from 14 randomised and quasirandomised trials. Pooling of data from 11 trials carried out in nursing or residential care settings, including six cluster randomised studies, showed evidence of a marginally statistically significant reduction in incidence of hip fracture (relative risk 0.77, 95% confidence interval 0.62 to 0.97). Pooling of data from three individually randomised trials of 5135 community dwelling participants showed no reduction in hip fracture incidence with provision of hip protectors (1.16, 0.85 to 1.59). No evidence was found of any significant effect of hip protectors on incidence of pelvic or other fractures. No important adverse effects of hip protectors were reported, but compliance, particularly in the long term, was poor. Conclusions On the basis of early reports of randomised trials, hip protectors were advocated. Accumulating evidence indicates that hip protectors are an ineffective intervention for those living at home and that their effectiveness in an institutional setting is uncertain.

Moving towards evidence-based healthcare for musculoskeletal injuries: featuring the work of the Cochrane Bone, Joint and Muscle Trauma Group

Due to their high incidence and associated morbidity and mortality, musculoskeletal injuries place an enormous burden on society. For example, in the 2004 to 2005 period 62,000 people with hip fracture accounted for 2.9% of the total number of hospital bed days in England. Between 12% and 37% of people with hip fracture die in the first year. Of the survivors, most are less mobile and many lose their independence. Soft-tissue joint injuries during sports and exercise-related activities in young adults constitute another important group. Of these, ankle sprain is the most common single injury and it predisposes people to further recurrence. Members of the Cochrane Bone, Joint and Muscle Trauma Group prepare systematic reviews (Cochrane Reviews) of the evidence for interventions used in the prevention and management of musculoskeletal injuries. These reviews serve to facilitate evidence-based decision making by policy makers, healthcare professionals and consumers, and to guide future research. This article focuses on two major groups of injuries: osteoporotic fractures and soft-tissue joint injuries, and discusses some of the fundamental issues and questions associated with the prevention and management of these. Drawing insights from relevant Cochrane Reviews, this article examines the different approaches used for preventing, and the role of surgery and immobilisation for treating, these injuries. Brief illustrations of the inherent complexity of rehabilitation are also provided. This article also gives examples of how these reviews are helping to inform healthcare choices and practice, and guide research in this area.

The Cochrane Collaboration: a leading role in producing reliable evidence to inform healthcare decisions in musculoskeletal trauma and disorders.

Systematic reviews are a key component of evidence-based practice. A valuable and accessible source of good quality systematic reviews on topics in musculoskeletal trauma and disorders is the Cochrane Database of Systematic Reviews, published in The Cochrane Library. These reviews are produced by members of The Cochrane Collaboration, an international not-for-profit organization that aims to make up-to-date, accurate information about the effects of healthcare readily available worldwide. Contributions from orthopedic specialists in India and neighboring countries are required to make the Cochrane Database an even more useful and comprehensive resource of reliable evidence. Linked with this is the opportunity for orthopedic specialists to take a leading role in generating the evidence to inform their practice.

Systematic Reviews, Meta-Analyses, and Methodology

To The Editor: We have been encouraged by the explicit emphasis on evidence-based orthopaedics in The Journal, and we read with great interest “Meta-Analyses in Orthopaedic Surgery. A Systematic Review of Their Methodologies” (83-A: 15-24, Jan. 2001), by Bhandari et al. This article raised some important points, one being that adherence to strict scientific methodology can limit bias and improve the validity of meta-analyses. However, we would like to comment on the methodology and consequent findings of their study. The first issue is their omission of relevant studies published in the Cochrane Database of Systematic Reviews. As Bhandari et al. stated, they consulted this database in their search for meta-analyses, yet some thirty to fifty systematic reviews available in this database in 1999 were not included, which we find puzzling. Omission of these reviews, which, if included, would have more than doubled the number of reviews of fracture treatment, results in a distorted picture of the information that is available to the orthopaedic specialist. Moreover, as acknowledged by Bhandari et al., there is evidence that these reviews have higher scientific quality than …