Interventions for treating proximal humeral fractures in adults (Review)

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R E S U L T S Description of studies See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of ongoing studies. On extension of the search for trials, from May 2003 to September 2006, six new studies were identified and, where appropriate, requests for further information dispatched to the contacts of the studies. Requests for updated information were also sent to the contacts of the four trials already in the ’Ongoing’ trials category. On the receipt of information, one newly identified trial (Fjalestad 2007) was placed in the ’Ongoing’ trials category and another newly identified trial (Flannery 2006) was excluded. Further details of the four new studies in ’Studies awaiting assessment’ are presented at the end of this section. Summaries of the trial populations of past and the present versions of this review as well as the changes between updates are presented in Table 2. In all, 12 trials are now included, five trials are listed as ongoing, 12 trials are excluded (see ’Characteristics of excluded studies’ table) and four are in ’Studies awaiting assessment’. Table 2. Numbers and status of studies in the published versions of the review Version Trial status Changes Ist version Issue 1, 2001 2nd version (substantive update) Issue 2, 2002 3rd version (minor update) Issue 3, 2002 The original review had 9 included studies, 4 excluded studies and 6 studies listed as ongoing. The first substantive update had 10 included studies, 9 excluded studies, 3 studies listed as ongoing and 1 study awaiting assessment. Interventions for treating proximal humeral fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Of the four newly identified studies, one ( Stableforth 1984) was included, one (Warnecke 1999) was excluded, one (Dias 2001) listed as ongoing, and the other (Martin 2000) placed in Studies Awaiting Assessment. Further information obtained from trialists resulted in the exclusion of four trials that had been previously listed as ongoing studies. Three (Brownson 2001; Hems 2000; Wallace 2000) of these had been set up as a multicentre study to test the Halder nail (Halder 2001), and one (Welsh 2000) had been set up to compare surgical with conservative treatment. As above Note: this update included some changes to the Discussion in response to comments received from an external reviewer. 7
Table 2. Numbers and status of studies in the published versions of the review (Continued) 4th version (substantive update) Issue 4, 2003 5th version (minor update) Issue 2, 2007 All 12 included trials were published as articles in journals; one (Zyto 1997) was initially identified in conference proceedings and a pre-publication report obtained from the authors. Two trials published in German were translated into English (Hoellen 1997; Rommens 1993). Seven trials were originally identified via MED- LINE, two trials (Revay 1992; Wirbel 1999) via The Cochrane Library, one (Zyto 1997) by handsearching of conference abstracts, one (Hodgson 2003) via the UK National Research Register, and two trials (Lundberg 1979; Stableforth 1984) were listed in the references of journal articles. Three ongoing trials were located in the UK National Research Register, the fourth was found opportunistically through discussion with a trialist, and the fifth was referred to in a published report of a cohort study; further details of these are presented in the ’Characteristics of ongoing studies’ table. The 12 included trials, involving a total of 578 patients, were single centre studies conducted in five different countries: Belgium (1 trial); Denmark (2); Germany (2); Sweden (4) and UK (3). (Though essentially a single centred trial, the interventions in Hodgson 2003 were undertaken at two centres within an NHS Trust in the UK.) The majority of participants in each trial were women (70-88%). Most participants were aged 60 and above; two trials (Livesley 1992; Wirbel 1999) included a small number of children, whilst another (Hoellen 1997) only included people who were 65 years or over. Five trials (Bertoft 1984; Hodgson 2003; Livesley 1992; Lundberg 1979; Revay 1992) included only The second substantive update had 12 included studies, 11 excluded studies, and 4 studies listed as ongoing. This update had 12 included studies, 12 excluded studies, 4 studies listed as ongoing and 5 pending assessment. Of four newly identified studies, one (Wirbel 1999) was included, one (de Boer 2003) excluded, and two (Frostick 2003; Shah 2003) are listed as ongoing. The other newly included trial (Hodgson 2003) was formerly listed as an ongoing trial. A trial (Martin 2000), previously in ’Studies awaiting assessment’, was excluded. Limited additional findings from newly identified trial reports were included for Hoellen 1997. Of six new studies were identified, one ( Fjalestad 2007) is listed as ongoing, one (Flannery 2006) was excluded and the other four were placed in ’Studies awaiting assessment’, pending further information. non or minimally displaced fractures, whereas five (Hoellen 1997; Kristiansen 1988; Stableforth 1984; Wirbel 1999; Zyto 1997) selected only people with displaced fractures. Fractures were graded using the Neer classification system (Neer 1970) in nine trials, a modification of the AO classification system as described in Wirbel 1999, and were without reference to a specific classification system in the remaining two trials (Bertoft 1984; Rommens 1993). Further details of individual trials are given in the ’Characteristics of included studies’ table. Eight trials evaluated conservative treatment, though this was postoperative treatment in one of these. Three trials compared surgical with conservative treatment and one compared two methods of surgery. A list of the comparisons, patient numbers and associated trials grouped according to the objectives presented in the ’Objectives’ is given below: (1) Methods of conservative management (including rehabilitation) (a) Initial treatment Interventions for treating proximal humeral fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. • “Immediate” physiotherapy within one week of fracture versus delayed physiotherapy after three weeks of immobilisation in a collar and cuff sling: Hodgson 2003 (86 participants). 8
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