Guideline 56 - Supporting Material

Prevention and management of hip fracture in older people

Searches were carried out in the following areas:

Preoperative care

Searches were carried out on Embase, Healthstar, Medline, and the Cochrane Library. The following strategy was used for Healthstar and Medline. The Cochrane Library and Embase strategies were broadly similar, but differed in detail.

Known limitations of this strategy.

None of these topics is easy to define precisely. Revisiting the search with additional terms would probably be worthwhile in the case of undiagnosed hip fracture and radiography.

Very little was found on fast tracking.

In view of the limited amount of material retrieved, no attempt was made to limit the search output to particular study types.

Prevention

A search of the Cochrane Library was carried out using the following terms:

The following Internet sites were checked for existing guidelines:

CPG Infobase
http://mdm.ca/cpgsnew/cpgs/index.asp

HTA Web Site (University of Southampton)
http://www.hta.nhsweb.nhs.uk/main.htm

National Guideline Clearinghouse
http://www.guidelines.gov

NZ Guidelines Project
http://www.nzgg.org.nz/

Acute Care

The following search was carried out on the Cochrane Library, Healthstar, and Medline. Coverage was limited to 1985 onwards.

Standard filters for reviews and RCTs added at this point.

The Embase strategy used was:

Standard filters for reviews and RCTs were added at this stage.

Known limitations of this strategy:

Subsequent to this search, a BMJ study that had not been retrieved by the search was identified by a guideline group member. A look at the Medline record concerned (Sinclair et al, 1998) showed that it had been indexed using the broader term Femoral fractures/surgery. Femoral fractures had been excluded at an earlier discussion. However, to check on the use of this MeSH term a search of Medline was carried out from 1990 to 1999 looking for reviews or RCTs indexed as Femoral fractures/surgery. Papers using the hip fracture terms listed above, or relating to children or animal studies were excluded. The remaining papers were forwarded to the development.

Postoperative care

The following search was carried out on CINAHL, the Cochrane Library, Healthstar, and Medline.

1. Explode hip fractures/
2. hip fracture$.tw.
3. hip pain.tw.
4. painful hip$1.tw.
5. or/1-4
6. supported discharge.tw.
7. Explode patient discharge/
8. Explode nursing homes/
9. after care/
10. podiatry/
11. chiropod$.tw.
12. podiatr$.tw.
13. Shoes/
14. orthopedic shoes.tw.
15. orthopaedic shoes.tw.
16. accidental falls/
17. fall prevention.tw.
18. Explode dementia/
19. confusion/
20. acute confusion$.tw.
21. or/6-20
22. 5 and 21
23. Limit set 22 to patients aged 45 or over

Standard filters for the identification of reviews, RCTs, or observational studies were added at this point.

The equivalent Embase strategy used was:

1. hip-fracture#.mj.
2. (supported adj discharge).ti,ab.
3. aftercare.mj.
4. (podiatr$ or chiropod$).ti,ab.
5. shoe.de,ti,ab.
6. footwear.ti,ab.
7. falling.de.
8. home-accident
9. (fall prevention).ti,ab.
10. dementia#.mj.
11. confusion.de.
12. (acute adj confus$).ti,ab.
13. 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12
14. 1 and 13
15. Limit set 14 to adults

Standard filters to identify reviews, RCTs, and observational studies were applied here.

In addition, ASSIA, and Sociological Abstracts were searched for

HIP-REPLACEMENT
(Hip adj fracture$).ti,ab.
(Fractured adj hip).ti,ab.

Psychological Abstracts were searched using the same terms, plus HIPS as a descriptor, linked with the following terms:

Dementia
Presenile-Dementia
Senile-Dementia
Mental-Confusion
(Acute adj confus$).ti,ab.

This strategy turned up a large number of references that were also of interest to the prevention subgroup. These references were forwarded to them on 20 August.

A search on the use of physiotherapy for hip fracture patients was carried out on the Cochrane Library, Embase, Healthstar, Medline, and Cinahl. The following strategy was used for all databases other than Embase:

1. Explode Hip fractures/
2. Hip fracture$1.tw.
3. Fractured hip$1.tw.
4. Painful hip$1.tw.
5. Hip pain.tw.
6. Or/1-5
7. Explode physical therapy/
8. Physiotherapy.tw.
9. Exercise.tw.
10. Or/7-9
11. 6 and 10

Set 11 was limited to people aged 45 and over. No attempt was made to restrict the output to trials.

The Embase strategy was broadly the same, the main difference being the use of physiotherapyt as a descriptor, and physical therapy being searched as a phrase.

A search looking for a link between oxygenation during surgery and subsequent cognitive problems was requested. The following strategy was searched in the Cochrane Library, Healthstar and Medline.

1. Oxygen Saturation.tw.
2. Anoxia/
3. Hypoxia/
4. Anoxemia/
5. Anoxemia.tw.
6. Anoxaemia.tw.
7. Hypoxaemia.tw.
8. Hypoxemia.tw.
9. Supplemental Oxygen.tw.
10. Oxygen/blood
11. Blood oxygen.tw.
12. Or/1-11
13. Postoperative-Complications/
14. Postoperative-Period/
15. Cognitive.tw.
16. Explode Cognition disorders
17. Dementia/
18. Or/11-16
19. 12 and 19
20. Explode Orthopedic-Procedures/

Standard strategy for identifying reviews, RCTs, and observational studies added at this point.

In view of the limited amount of material retrieved, the full range of orthopedic procedures was searched rather than limiting results to hip fracture. Two of the reviews identified reported a lack of evidence in this area, so no further searches were carried out on these databases or on Embase.

A search on the relationship between HRT and hip fracture or falls was requested. The following strategy was used on Cochrane, Healthstar, and Medline.

1. Explode hip fractures/
2. Hip fracture$1.tw.
3. Fractured hip$1.tw.
4. Accidental falls/
5. Fall prevention.tw.
6. Falling.tw.
7. Or/1-6
8. Explode hormone replacement therapy/
9. Hormone replacement.tw.
10. Estrogen replacement.tw.
11. Oestrogen replacement.tw.
12. HRT.tw.
13. Or/8-12

Standard strategies for the identification of reviews, RCTs, and observational studies were added here.

Broadly similar strategies were used in Cinahl and Embase.

A search of NEED, Embase, Healthstar, and Medline was carried out for Luke Vale, looking at economic issues related to hip fracture. This search focused on economic evaluations concerned with risk reduction or fracture prevention. The general strategy used was:

1. exp Hip fractures/
2. Fractured hip$.tw.
3. Hip fracture$.tw.
4. Or/1-3
5. Hip protect$.tw.
6. Calcium, dietary/
7. Exp Vitamin D/
8. Exp Hormone replacement therapy/
9. (Biophosphate$ or Biophosfate$).tw.
10. Alendronate.tw.
11. HRT.tw.
12. Fracture prevention.tw.
13. Risk reduc$.tw.
14. Risk modif$.tw.
15. Or/5-14
16. 4 and 15
17. exp "Costs and cost analysis"/
18. Cost utility.tw.
19. Qaly.tw.
20. Resource implicat$.tw.
21. Or/17-20
22. 16 and 21

An attempt was made to broaden coverage by looking at fracture prevention related to osteoporosis. The results significantly increased the number of records retrieved, but the proportion of irrelevant material was felt to be too great.

A supplementary search on chest physiotherapy following surgery was requested. Searches were carried out on the Cochrane Library, Medline (1991-2000), and Embase (1980- 2000) using the following strategy:

1. Chest physiotherapy.tw.
2. Cystic-fibrosis
3. Cystic fibrosis.tw.
4. 2 or 3
5. 1 not 4

Results were limited to adults. No attempt was made to limit the results by study type. Attempts were made to limit results to fractures, or orthopaedics, but failed to find any papers. The search was also extended using the term Physical-therapy linked to Postoperative-care or Postoperative-complications. No useful results were obtained.

An additional search was carried out covering hospital acquired urinary infections and constipation linked to hip fracture surgery. Searches were carried out on the Cochrane Library, Embase, Healthstar, and Medline (all covering 1990-2000). The general strategy used was:

1. exp hip fractures/
2. fractured hip$.tw.
3. hip fracture$.tw.
4. painful hip$.tw.
5. hip pain.tw.
6. or/1-5
7. exp Urinary tract infections/
8. uti.tw.
9. urinary catheterization/
10. catheteri?ation.tw.
11. hospital acquired infection$.tw.
12. or/7-11
13. Constipation/
14. 6 and (12 or 13)