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Poor Citation of Prior Evidence in Hip Fracture Trials
Ujash Sheth, BHSc; Nicole Simunovic, MSc; Paul Tornetta, III, MD; Thomas A. Einhorn, MD; Mohit Bhandari, MD, PhD, FRCSC
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Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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Center for Evidence-Based Orthopaedics, Division of Orthopaedic Surgery, McMaster University, 293 Wellington Street North, Suite 110, Hamilton, ON L8L 8E7, Canada. E-mail address for U. Sheth: usheth@qmed.ca. E-mail address for M. Bhandari: bhandam@mcmaster.ca
Boston Medical Center, 850 Harrison Avenue, Dowling 2 North, Boston, MA 02118
Investigation performed at the Center for Evidence-Based Orthopaedics, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
A commentary by Charles L. Cox, MD, MPH, is linked to the online version of this article at jbjs.org.

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Nov 16;93(22):2079-2086. doi: 10.2106/JBJS.J.01274
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Failure to cite prior evidence in the medical literature may result in publication redundancy and inefficient use of research funding. We evaluated trials in which internal fixation was compared with arthroplasty for the treatment of hip fractures in order to determine the extent to which these randomized trials cited all relevant previous trials.


We searched MEDLINE and Embase for all relevant articles on four topics: internal fixation compared with arthroplasty, total hip arthroplasty compared with hemiarthroplasty, sliding hip screws compared with other fixation devices, and surgical delay of hip fracture treatment. We determined the proportion of previous studies that were cited in comparison with the total number of previous studies that were citable (i.e., the citation rate) as well as the proportion of times that a study was cited in comparison with the total number of times that it could have been cited (i.e., the hit rate). A cumulative meta-analysis was performed for the “internal fixation compared with arthroplasty” topic to determine whether compelling evidence favoring one intervention existed at an earlier time.


In total, sixty studies were assessed and yielded an overall citation rate of 48%. All “highly cited” studies reported a positive result (favoring arthroplasty), and 60% were published in The Journal of Bone and Joint Surgery (American or British volume). The results of a study and the journal of publication significantly affected the hit rate (p < 0.05).


Our review of studies of hip fracture treatment suggests poor citation of the previous literature. Studies in higher-impact journals with positive results are more likely to be cited in subsequent studies. Therefore, redundancy in publication and unnecessary surgical trials often occur.

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    Jan Tidermark, Hans Törnkvist, Sari Ponzer
    Posted on December 07, 2011
    Some previous research may be outdated; further studies are necessary
    Karolinska Institutet, Stockholm, SWEDEN

    Having been involved in hip fracture research for the last 15 years, we have read the paper by Sheth et al.[1] with great interest. We definitely share the authors’ opinion that a critical appraisal of prior evidence is mandatory before starting a new trial. However, we are not convinced that the low citation rate reported in some of the included studies is a good indicator of insufficient review of previous research. For example, in our study comparing internal fixation (IF) with primary total hip arthroplasty (THA) published in 2003,[2] we cited all contemporary relevant RCTs comparing IF and THA as well as those comparing IF with HA and THA, but we intentionally opted not to cite previous studies that compared IF with hemiarthroplasty (HA) even though they were well known to us. That decision, supported by the journal, was solely based on the fact that the main focus of the paper was on a comparison of IF vs. THA. Moreover, we do not share the authors’ opinion that the debate as to whether internal fixation or arthroplasty is better for patients with displaced femoral neck fractures could have been resolved as early as a decade ago and that later studies may have been unnecessary. The issue regarding the optimal treatment for patients with this injury cannot be simplified into an evaluation of reoperation rates. Considering the varying complications and long-term outcome for the available treatment modalities (IF, HA, and THA) and the heterogeneous elderly fracture population with different functional demands, life expectancies and risk factors, the outcome analysis needs to be much more sophisticated and, among other things, also include patient-reported outcome measures. Fortunately, outcome analyses have indeed improved in modern studies and, today, there is good evidence for selecting an arthroplasty instead of IF for most elderly patients with a displaced fracture of the femoral neck. There are still controversies, however. For example, we still do not know the optimal lower age limit for arthroplasty and the patient selection criteria for when to use a THA instead of an HA are not fully clarified. Furthermore, surgical and anesthesiological methods continuously improve and the results of studies conducted more than 20 years ago, sometimes using now-outdated implants, may become less valid in the course of time. In our opinion, in order to optimize the treatment for patients with femoral neck fractures, further studies are indeed necessary. This opinion is also shared by the latest Cochrane review[3] (assessed as up-to-date: Nov 4th, 2010), which concludes: “There is still a need for studies to define which patient groups are better served by the different treatment methods.” REFERENCES: [1] Sheth U, Simunovic N, Tornetta P, Einhorn T, Bhandari M. Poor citation of prior evidencein hip fracture trials. J Bone Joint Surg Am. 2011;93:2079-2086. [2] Tidermark J, Ponzer S, Svensson O, Söderqvist A, Törnkvist H. Internal fixation compared with total hip replacement for displaced femoral neck fractures in the elderly. A randomised, controlled trial. J Bone Joint Surg Br. 2003;85:380-8. [3] Parker MJ, Gurusamy KS. Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD001708.

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