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M J Parker

Publications and source records attributed to M J Parker.

At least 19 recordsLinked to original sources
PubMed2001

A kinetic folding intermediate probed by native state hydrogen exchange.

Stopped-flow fluorescence studies on the N-terminal domain of rat CD2 (CD2.d1) have demonstrated that folding from the fully denatured state (U) proceeds via the transient accumulation of an apparent intermediate (I) in a so-called burst phase that precedes the rate-limiting transition leading to the native state (N). A previous pH-dependent equilibrium hydrogen exchange (HX) study identified a subset of amides in CD2.d1 which, under EX2 conditions, exchange from N with free energies greater than or equal to the free energy difference between the N and I states calculated from the stopped-flow data. Under EX1 conditions the rates of HX for these amides tend towards an asymptote that matches the global unfolding rate calculated from the stopped-flow data, suggesting that exchange for these amides requires traversing the N-to-I transition state barrier. Exchange for these amides presumably occurs from exchange-competent forms comprising the kinetic burst phase therefore. To explore this idea further, native state HX (NHX) data have been collected for CD2.d1 under EX2 conditions using denaturant concentrations which span either side of the denaturant concentration where, according to the stopped-flow data, the apparent U and I states are iso-energetic. The data fit to a two-component, sub-global (sg)/global (g) NHX mechanism, yielding Delta G and m value parameters (where the m value is a measure of hydrocarbon solvation). Regression analysis demonstrates that the (m(sg), Delta G(sg)) and (m(g), Delta G(g)) values calculated for this subset of amides correspond with those describing the kinetic burst phase transition. This result confirms the ability of the NHX technique to explore the structural and energetic properties of kinetic folding intermediates.

Animals↗
PubMed2001

Internal fixation implants for intracapsular proximal femoral fractures in adults.

BACKGROUND: Numerous different implants with screws, pins and side plates have been used for the internal fixation of intracapsular hip fractures. OBJECTIVES: To determine from randomised trials which implant is superior for the internal fixation of intracapsular proximal femoral fractures. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register. The date of the most recent search was December 2000. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing different implants for the internal fixation of intracapsular hip fractures in adults. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality, by use of a ten item scale, and extracted data. Additional information was sought from trialists. After grouping by implant type, comparable groups of trials were subgrouped and where appropriate, data were pooled using the fixed effects model. MAIN RESULTS: Twenty-seven studies involving 5269 participants (5274 fractures) were included in the study. Considerable variation in the quality of methodology between studies was found and biases due to familiarity with some of the implants were noted. None of the implants tested were found to be significantly superior for any of the outcome measures related to fracture healing complications or mortality. 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. REVIEWER'S CONCLUSIONS: No clear conclusions can be made on the choice of implant for internal fixation of intracapsular fractures from the available evidence within randomised trials.

Bone Nails↗
PubMed2001

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

BACKGROUND: Numerous types of arthroplasties may be used in the surgical treatment of a hip fracture (proximal femoral fracture). The main differences between the implants are the design of the stems, whether the stem is fixed in place with or without cement, whether a second articulating joint is included within the prosthesis (bipolar prosthesis) or whether the whole hip joint is replaced. OBJECTIVES: To review all randomised trials that have compared different arthroplasties for the treatment of hip fractures in adults. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register. Additional trials were identified by searching reference lists of relevant articles, conference proceedings, and contact with trialists. Date of most recent search: January 2001. SELECTION CRITERIA: All randomised and quasi-randomised trials comparing different arthroplasties (and or cement), for the treatment of hip fractures. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality, by use of a ten-item checklist and extracted data. MAIN RESULTS: Thirteen trials involving 1464 patients were included. One trial investigated two comparisons. Cemented prostheses, when compared with uncemented (four trials, 391 participants) were associated with a lower risk of failure to regain mobility (relative risk (RR) 0.60, 95% confidence interval (CI) 0.44, 0.82) and of post-operation pain at a year or later (RR 0.51, 95% CI 0.31, 0.81). For this comparison, there were no significant differences in any other outcome. Comparison of unipolar hemiarthroplasty with bipolar hemiarthroplasty (six trials, 742 participants) showed no significant differences between the two types of implant. Two trials of 269 patients compared different types of hemiarthroplasty with a total hip replacement and two trials of 151 patients compared either different types of prosthesis head or different bipolar prostheses. Because of the limited number of cases and the use of different prostheses, no definite conclusions could be made from these four studies. REVIEWER'S CONCLUSIONS: Cementing prostheses in place seems to reduce pain post-operatively and results in better mobility, but because of the under-reporting of outcomes and the small number of patients involved, no definite conclusions can be made. The role of bipolar prostheses and total hip replacement is uncertain. Further well-conducted randomised trials are required.

Adult↗
PubMed2001

Closed suction surgical wound drainage after orthopaedic surgery.

BACKGROUND: Closed suction drainage systems are frequently used to drain fluids, particularly blood, from surgical wounds. The aim of these systems is to reduce the occurrence of wound haematomas and infection. OBJECTIVES: To evaluate the effectiveness of closed suction drainage systems for orthopaedic surgery. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (May 2001), MEDLINE (1996-May 2001) and references from articles. SELECTION CRITERIA: All randomised or quasi-randomised trials comparing the use of closed suction drainage systems with no drainage systems for all types of elective and emergency orthopaedic surgery. DATA COLLECTION AND ANALYSIS: Both reviewers independently assessed trial quality, using a nine item scale, and extracted data. Wherever appropriate and possible, the data are presented graphically. MAIN RESULTS: Twenty-one studies involving 2772 patients with 2971 wounds were included in the analysis. The types of surgery involved were hip and knee replacement, shoulder surgery, hip fracture surgery, spinal surgery, cruciate ligament reconstruction, open meniscectomy and fracture fixation surgery. Many of the studies had poor methodology and reporting of outcomes. Pooling of results indicated no difference in the incidence of wound infection, haematoma or dehiscence between those allocated to drains and the un-drained wounds. There was a tendency to an increased risk of re-operation for wound complications in the group with drains (relative risk (RR) 2.25, 95% confidence intervals (CI) 0.95 to 5.33), but due to the small numbers of cases involved definite conclusions cannot be made for this outcome. Blood transfusion was required more frequently in those who received drains (RR 1.41, 95% CI 1.10 to 1.80). The need for reinforcement of wound dressings (RR 0.22, 95% CI 0.13 to 0.40) and bruising around the operation site was more common in the group without drains. REVIEWER'S CONCLUSIONS: There is insufficient evidence from randomised trials to support or refute the routine use of closed suction drainage in orthopaedic surgery. Further randomised trials are required before definite conclusions can be made.

Hematoma↗
PubMed2001

Current concepts in the treatment of hip fracture.

Clinicians involved in the care of hip fracture patients should move away from using treatments based on historical practices or local preferences, to those that are derived from careful evaluations and summaries of all previous medical research on that topic. For the busy clinician the use of summary articles, reviews and guidelines that are evidenced based are necessary to provide the best treatment available for the patient. Current practice indicates that the majority of hip fractures should be treated surgically, mobilised without restriction as soon as able and discharged home as soon a practicable. Given modern technology this should be possible for all patients.

Aged↗
PubMed2001

Does the level of an intracapsular femoral fracture influence fracture healing after internal fixation? A study of 411 patients.

The aim of the study was to determine if the level of an intracapsular femoral fracture influences the risk of non-union or avascular necrosis occurring after internal fixation. An observer blinded to the outcome of the treatment (fracture union, non-union or avascular necrosis) reviewed the radiographs of 411 patients with an intracapsular fracture, which had been treated by internal fixation. The level of the fracture was determined by two methods, a direct distance measurement and a ratio method. In addition, the diameter of the femoral head was measured. Results indicated that none of the methods for determining the fracture level had any relationship to the risk of non-union or avascular necrosis occurring. Undisplaced fractures were found to be more proximally located than displaced fractures. We conclude that the level of an intracapsular fracture should not be used as a method of deciding if the femoral head should be preserved or replaced. The level of an intracapsular fracture may determine if the fracture displaces at the time of injury.

Aged↗
PubMed2001

Results of the long Gamma nail for complex proximal femoral fractures.

The results for a series of 35 patients with complex proximal femoral fractures treated with the long Gamma nail are presented. Fracture healing occurred in all surviving patients, but there were four technical problems associated with the implant. Two nails broke associated with delayed union of the fracture necessitating revision of the implant, one fracture of femur at the site of distal locking occurred during surgery and there was one later fracture at the tip of the nail. All but one failures of fixation were revised with another Gamma nail and healed uneventfully. Overall the number of fracture healing complications compares favourably to contemporary implants and improvements in the design and strength of the nail may further improve results.

Adult↗
PubMed2001

Determinants of agonist binding affinity on neuronal nicotinic receptor beta subunits.

The alpha and beta subunits of heteromeric neuronal nicotinic acetylcholine receptors (nAChRs) are thought to contribute "principal" and "complementary" components to the agonist binding site, respectively. At least six loops of amino acid sequence (A, B, and C from alpha; D, E, and F from beta) are involved. We demonstrated previously that receptors containing the beta2 subunit had consistently higher affinities for a variety of agonists than beta4-containing receptors. For example, the affinity of the alpha2beta2 receptor for epibatidine, ACh, nicotine, and dimethylphenylpiperazinium (DMPP) exceeds that of alpha2beta4 by 9-, 61-, 87-, and 120-fold, respectively. Using saturation and competition analysis of receptors formed by chimeric beta subunits coexpressed with alpha2 in Xenopus laevis oocytes, we have now identified sequence segment 54-63 (corresponding to loop D) as a major determinant of affinity for epibatidine, ACh, nicotine, and DMPP. We then analyzed a series of mutant beta2 subunits in which each residue that differs between beta2 and beta4 in this region was changed from what occurs in beta2 to what occurs in beta4. The N55S, V56I, and E63T mutations each resulted in a loss of affinity for ACh and nicotine of 3- to 4-fold, whereas the T59K mutation resulted in a 7-fold loss of ACh and nicotine affinity. These mutations had little or no effect on epibatidine and DMPP affinity. The positive charge introduced by the T59K mutation does not appear to underlie loss of agonist affinity, because a similar loss of affinity was observed when a negative charge (T59D) was introduced at this position.

Animals↗
PubMed2000

A statistical appraisal of native state hydrogen exchange data: evidence for a burst phase continuum?

For a number of proteins, folding occurs via the rapid accumulation of secondary and tertiary structural features in a so-called burst phase, preceding the relatively slow, highly activated transition leading to the native state. A fundamental question is: do these burst phase reactions comprise two phase-separated thermodynamic states or a continuum of states? Ribonuclease HI (RNase H) from Escherichia coli and phage T4 lysozyme (T4L) both exhibit such a phenomenon. Native-state hydrogen exchange (NHX) data have been collected for these proteins, providing residue-specific free energies and m-values (a measure of hydrocarbon solvation) for the manifold of partially unfolded, exchange-competent forms that are accessible from the native state (DeltaG(sg) and m(sg), where the sg subscript denotes sub-global). There is good evidence that these parameters pertain to exchange-competent species comprising the burst phase observed in the global folding kinetics. We combine the results from the global folding kinetics of these proteins with a statistical analysis of their NHX parameters to determine if the distribution of experimental (m(sg), DeltaG(sg)) values derive from a mechanism where the burst phase is two-state. For RNase H, this analysis demonstrates that the burst phase of this protein is not two-state; the results imply a distribution of states, m and DeltaG exhibiting a linear functional relationship consistent with the global folding parameters. For T4L, it is difficult to distinguish the observed distribution of m(sg), DeltaG(sg) values from that expected for a mechanism where the burst phase is two-state. The results for RNase H* lend support for the idea that the burst phase reaction of this protein comprises a continuum of states. This has important implications for how we model the process of structural acquisition in protein folding reactions.

Bacteriophage T4↗
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

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

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↗
PubMed2000

General versus spinal/epidural anaesthesia for surgery for hip fractures in adults.

BACKGROUND: The majority of hip fracture patients are treated surgically, requiring anaesthesia. OBJECTIVES: To compare different types of anaesthesia for surgical repair of hip fractures (proximal femoral fractures) in adults. This is primarily regional (spinal or epidural) anaesthesia versus inhalation general anaesthesia, but also includes ketamine anaesthesia versus inhalation general anaesthesia. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline, selected orthopaedic and anaesthetic journals and conference proceedings, and reference lists of relevant articles. Date of the most recent search: August 1998. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing different methods of anaesthesia for hip fracture surgery in skeletally mature persons. Trials comparing the use of local nerve blocks are not considered in this review. Neither are trials using different types of drugs or techniques with one type of anaesthesia. The primary outcome was mortality. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality, using a nine item scale, and extracted data. The other two reviewers independently checked these results. Wherever appropriate and possible, results were pooled. MAIN RESULTS: Fifteen trials, involving 2162 patients, which compared regional anaesthesia with general anaesthesia, were included. All trials had methodological flaws. Regional anaesthesia was associated with a decreased mortality at one month (49/766 (6.4%) versus 76/812 (9.4%)) of borderline statistical significance (Peto odds ratio 0.66, 95% confidence interval 0.46 to 0.96)). The results for three month mortality were not statistically significant, although the confidence interval does not exclude the possibility of a clinically relevant reduction (86/726 (11.8%) versus 98/765 (12.8%), Peto odds ratio 0.91, 95% confidence interval 0.67 to 1.24). The reduced numbers at one year, coming exclusively from two studies, preclude any useful conclusions for long term mortality (80/354 (22.6%) versus 78/372 (21.0%), Peto odds ratio 1.10, 95% confidence interval 0.77 to 1.57). Regional anaesthesia was associated with a tendency to a longer operation (weighted mean difference 4.8 minutes, 95% confidence interval 1.1 to 8.6 minutes), and a reduced risk of deep venous thrombosis (39/129 (30%) versus 61/37(76%); Peto odds ratio 0. 41, 95% confidence interval 0.23 to 0.72), although this conclusion is insecure due to possible selection bias in the subgroups in whom this outcome was measured. No other statistically significant differences in outcome were identified. There was insufficient evidence to draw any conclusions from a further two included trials, involving a total of 100 patients, which compared other types of anaesthesia. REVIEWER'S CONCLUSIONS: Regional anaesthesia and general anaesthesia appear to produce comparable results for most of the outcomes studied. Regional anaesthesia may reduce short-term mortality but no conclusions can be drawn for longer term mortality.

Adult↗