Immediate mobilization compared with conventional immobilization for the impacted nonoperatively treated proximal humeral fracture. A randomized controlled trial. Independent exercises versus physiotherapy in nondisplaced proximal humeral fractures. Are polyaxially locked screws advantageous in the plate osteosynthesis of proximal humeral fractures in the elderly? A prospective randomized clinical observational study. Water exercise versus instruction for self-training following a shoulder fracture. Transcutaneous reduction and external fixation of displaced fractures of the proximal humerus. A controlled clinical trial. Functional results following fractures of the proximal humerus. A controlled clinical study comparing two periods of immobilization. Early versus late mobilization after hemiarthroplasty for proximal humeral fractures. Primary hemiarthroplasty in four-part fractures of the proximal humerus: randomized trial of two different implant systems. [Conservative treatment of subcapital humerus fractures. A comparative study of the classical Desault bandage and the new Gilchrist bandage]. Locking intramedullary nails and locking plates in the treatment of two-part proximal humeral surgical neck fractures: a prospective randomized trial with a minimum of three years of follow-up. Monoaxial versus polyaxial screw insertion in angular stable plate fixation of proximal humeral fractures: radiographic analysis of a prospective randomized study. Electrotherapy and the management of minimally displaced fracture of the neck of the humerus. [Prosthetic humeral head replacement in dislocated humerus multi-fragment fracture in the elderly--an alternative to minimal osteosynthesis?]. Four-part fractures of the neck of the humerus. Treatment of displaced proximal humeral fractures in elderly patients. [Surgical treatment for proximal humerus fracture]. Health and cost consequences of surgical versus conservative treatment for a comminuted proximal humeral fracture in elderly patients. Physiotherapy after fracture of the proximal end of the humerus. Comparison between two methods. Rehabilitation after two-part fractures of the neck of the humerus. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial. Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial. The clinical benefit of medial support screws in locking plating of proximal humerus fractures: a prospective randomized study.
There have been few randomized controlled trials evaluating nonoperative treatment of proximal humeral fractures. To investigate shortening the period of dependence, we assessed the feasibility and efficacy of early mobilization of the shoulder (within three days after the fracture) in comparison with those of conventional three-week immobilization followed by physiotherapy.
                We randomly assigned seventy-four patients with an impacted proximal humeral fracture to receive early passive mobilization or conventional treatment. The primary outcome was the overall shoulder functional status (as measured with the Constant score) at three months. The secondary outcomes were the Constant score at six weeks and at six months, the change in pain (on a visual analog scale), and the active and passive range of motion.
                At three months and at six weeks, the early mobilization group had a significantly better Constant score than did the conventional-treatment group (between-group difference, 9.9 [95% confidence interval, 1.9 to 17.8] [p = 0.02] and 10.1 [95% confidence interval, 2.0 to 18.1] [p = 0.02], respectively) and better active mobility in forward elevation (between-group difference, 12.0 [95% confidence interval, 1.7 to 22.4] [p = 0.02] and 28.1 [95% confidence interval, 7.1 to 49.1] [p = 0.01], respectively). At three months, the early mobilization group had significantly reduced pain compared with the conventional-treatment group (between-group difference, 15.7 [95% confidence interval, 0.52 to 30.8] [p = 0.04]). No complications in displacement or nonhealing were noted.
                Early mobilization for impacted nonoperatively treated proximal humeral fractures is safe and is more effective for quickly restoring the physical capability and performance of the injured arm than is conventional immobilization followed by physiotherapy. 42 patients with undisplaced, proximal humeral fractures were randomly assigned into two groups in order to compare the results of instruction to the patient for independent exercises and conventional physiotherapy. No differences appeared between the groups subjectively or as regards functional parameters at 1 as well as at 3 months after the fracture and at a follow up more than 1 year later. As no disadvantage could be found instructions to the patients should in these cases be regarded as a satisfactory after-treatment. To evaluate the results of plate osteosynthesis using either polyaxial or nonpolyaxially locked screw-plate systems in proximal humeral fractures in the elderly.
                Prospective, randomized.
                Level I trauma center.
                Fifty-six patients (older than 60 years) with isolated, displaced three- and four-part fractures were included. Twenty-five patients (median age, 75.5 years) were randomized to a polyaxial locking screw plate (Group 1), whereas 31 patients (median age, 72 years) were treated with a locking screw plate (Group 2). Follow-up evaluations were performed 3, 6, and 12 months postoperatively using the Simple Shoulder Test, Disabilities of the Arm, Shoulder and Hand score, and Constant score as well as radiographs. The results and the complications were compared between both groups.
                Forty-eight patients were available for follow-up (Group 1, 20 of 25; Group 2, 28 of 31). The Simple Shoulder Test, Disabilities of the Arm, Shoulder and Hand, and Constant score improved significantly from 3 to 12 months and did not differ between groups. Twelve months after the index procedure, the Simple Shoulder Test score was 8.6 ± 3.2 points in Group 1 and 9.7 ± 1.8 points in Group 2. The Disabilities of the Arm, Shoulder and Hand score was 17.8 ± 16.2 in Group 1 and 15.7 ± 11.8 in Group 2. The mean Constant score amounted to 73% ± 17% in Group 1 and 81% ± 13% in Group 2. There were six complications in Group 1 and eight in Group 2.
                Both the functional outcomes and the rate of complications after polyaxial locked plate osteosynthesis of proximal humeral fractures in elderly patients were comparable to those treated with nonpolyaxial implants. Despite the theoretical advantages of polyaxial locked plating in proximal humerus fractures, this study could not show a verifiable clinical advantage of these plates. nan A consecutive series of 31 displaced fractures of the proximal humerus were randomly selected for treatment either by closed manipulation or by transcutaneous reduction and external fixation. Follow-up assessed the quality of reduction and healing as well as the functional outcome. The external fixation method gave better reduction, safer healing and superior function. In order to compare 1 and 3 weeks of immobilization following proximal humeral fractures a prospective controlled trial was performed in 85 patients. Clinical follow-up according to the Neer assessment system was done after 1, 3, 6, 12, and 24 months. One week of immobilization resulted in a better total score due to less pain during the first 3 months. After 6 months no difference in pain, function, or mobility was found and no further recovery of shoulder function was seen after 12 and 24 months. This randomized controlled trial compares 2 mobilization regimens after shoulder hemiarthroplasty for acute 3- and 4-part fractures. The aim was to establish whether the length of immobilization plays a role in the functional outcome, tuberosity healing, and subsequent range of motion. The same prosthesis and surgical technique were used. We recruited 59 patients into the study; 31 were randomized to early (2 weeks) mobilization and 28 to late (6 weeks) mobilization. Greater tuberosity migration was assessed with a series of radiographs, and the functional outcome was assessed with the Constant Shoulder Assessment and Oxford shoulder scores. Of the patients, 49 (mean age, 70 years) met the inclusion criteria and were followed up for 12 months. Greater tuberosity migration occurred in 3 cases in the early mobilization group and once in the late mobilization group (P > .10). There was no significant difference in the Constant Shoulder Assessment and Oxford scores between the 2 groups. Although there was a decreased incidence of tuberosity migration in the group undergoing late mobilization, this was not statistically significant. The objective of this study was to determine the effect of different prosthetic systems on the functional and radiographic outcomes after shoulder arthroplasty for fractures. This study comprised 35 patients (28 women and 7 men) with a mean age of 74 years (range, 56-88 years) who sustained 4-part fractures of the proximal humerus and were randomly allocated to 2 different groups regarding the type of prosthesis. The 2 systems used differ mainly in the type of fixation of the tuberosities. In group 1 (EPOCA), the fixation was achieved with wire cables through a medial and a lateral hole in the stem, whereas in group 2 (HAS), the fixation was performed by use of transosseous braided sutures. After a follow-up of 1 year, the functional and radiographic outcomes were evaluated. The retrieved data demonstrate that rigid fixation and anatomic positioning of the tuberosities (group 1) increase the rate of bony healing superior to all other factors. There was a statistically significant difference regarding the relative individual Constant score (P = .001) and the mean active range of motion (flexion, P < .001; abduction, P = .001; external rotation in adduction, P = .01; and external rotation in 90 degrees abduction, P = .001) when both groups were compared, showing a better outcome in the EPOCA group for all parameters. Radiologic findings, like heterotopic ossification, glenoid erosion, or subluxation, had no significant influence on the outcome in this study. Accurate placement of the tuberosities and healing at the bone-bone interface of the rotator cuff seem to be the most important factors influencing the outcome in prosthetic care of fractures. In a randomized prospective comparative study, we treated 28 patients with a fresh fracture of the proximal humerus alternating with a classical Desault-bandage or with the new Gilchrist-bandage. The two different bandages had no influence on the fracture healing or the functional end results. The Gilchrist-bandage was clearly superior to the Desault-bandage in a subjective and objective appreciation: the patients had less complaints in applying the bandage, had less skin irritations and felt less pain during the whole immobilisation period. locking intramedullary nails and locking plates specially designed for proximal humeral fractures are widely used. The purpose of our study was to compare the outcomes between these two types of implants in patients with a two-part surgical neck fracture. The advantages and shortcomings of each method were analyzed.
                a prospective randomized study was performed. Fifty-one consecutive patients with a fresh two-part surgical neck fracture were randomized to be treated with a locking intramedullary nail (n = 25) or a locking plate (n = 26). Clinical and radiographic assessments were conducted at one year and three years after the surgery. A visual analog scale (VAS) was used to assess shoulder pain. The American Shoulder and Elbow Surgeons (ASES) scores and Constant-Murley scores were recorded to evaluate shoulder function.
                fracture union was achieved in all patients within three months after the surgery. At one year postoperatively, a significant difference (p = 0.024) was found with regard to the complication rate between the locking plate group (31%) and the locking nail group (4%). The average ASES score, median VAS score, and average strength of the supraspinatus were significantly better in the locking plate group (90.8 compared with 83.6 points [p = 0.021], 1.0 compared with 0.5 point [p = 0.042], and 77.4% compared with 64.3% [p = 0.032]). At three years postoperatively, no significant difference could be found in terms of any parameter between the two groups. Significant improvement in the VAS pain scores, ASES scores, and Constant-Murley scores were found between the one-year and three-year follow-up examinations in each group.
                satisfactory results can be achieved with either implant in the treatment of two-part proximal humeral surgical neck fractures. There was no difference regarding the ASES scores between these two implants at the time of the final, three-year follow-up. The complication rate was lower in the locking intramedullary nail group, while fixation with a locking plate had the advantage of a better one-year outcome.
                therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence. Monoaxial and polyaxial screw insertion are used in angular stable plating of displaced proximal humeral fractures. Aim of the study was to compare both fixation techniques by radiographic evaluation.
                Prospective randomized treatment with monoaxial or polyaxial screw insertion in angular stable anatomic preshaped plates of displaced proximal humeral fractures. Analysis of standardized true anterior-posterior (true a.p.) and outlet-view radiographs at 1 day, 6 weeks, 3 months, and 6 months after surgery by two radiologists with respect to radiographic evidence of secondary varus displacement, cut out of screws, osteonecrosis, and hardware failure. Secondary varus displacement was defined as a varus decrease of the humeral head-shaft angle of > 10 degree in true a.p. radiographs.
                Sixty-six consecutive patients (48 women, [72.7%]; 18 men, [27.3%]; mean age 67.7 years [95% CI, 63.9-71.6]) with displaced proximal humeral fractures were evaluated in this study. Nineteen patients (29%) showed secondary varus displacement of > 10-degree angle. In 6 cases (9%), intra-articular cut out of screws was found. Furthermore, 1 case (2%) of nonunion was observed. No relationship between monoaxial and polyaxial screw insertion was found regarding occurrence of secondary varus displacement (monoaxial, 11/polyaxial, 8; p = 0.91) or screw cut out (monoaxial, 4/polyaxial, 2; p = 0.64). Prevalence of secondary varus displacement and hardware cut out was related to patients age (p = 0.02) and fracture pattern, according to Neer- and AO/OTA-classification (p < 0.001). The average immediate postoperative head-shaft angle was 135.2 degrees (CI, 132.3-138.1) in the group without radiographic complication, compared with 126.7-degree angle (CI, 123.6-129.7) among those with secondary varus displacement of > 10-degree angle and screw cut out (p < 0.001). Furthermore, in cases of an immediate postoperative head-shaft angle of < 130 degrees, there was a 48% incidence of secondary varus dislocation (n = 13) versus 15% in cases with a head-shaft angle > 130 degrees (n = 6, p = 0.004).
                Monoaxial and polyaxial screw insertion allow for mechanical stabilization in angular stable plating of unstable proximal humerus fractures. Radiographic evidence of secondary varus displacement of > 10-degree angle and screw cut out was seen similarly often in both fixation techniques. To avoid secondary varus displacement and screw cut out, restoration of a humeral head-shaft angle of > 130 degrees seems to be important in monoaxial and polyaxial fixation of proximal humeral fractures. A poor outcome arising from a minimally displaced fracture of the neck of the humerus may be the result of a contracture of the capsule of the glenohumoral joint. Pulsed high frequency electromagnetic energy (PHFE) is an electrotherapy to reduce pain and swelling and to enhance healing. If PHFE is effective, early mobilization of the injured shoulder will be possible, reducing the risk of joint capsule contracture. We therefore conducted a double-blind trial of PHFE in minimally displaced fractures of the neck of the humerus. Early physiotherapy produced an excellent outcome in all cases. The functional outcome depended on age rather than time of starting treatment, although a relationship was found between the time of starting treatment and the duration of therapy required. The use of PHFE did not improve the result further. In a prospective randomised study, comprising 30 aged patients with fractures of the proximal humerus (4-fragment fractures according to Neer) minimal osteosynthesis was compared to primary endoprosthetic replacement. The Constant score was used for evaluation during follow-up. After one year the results were similar in both groups. There were two complications necessitating revision surgery among the patients with minimal osteosynthesis and in four cases the implants had to be removed. In the group with primary endoprosthetic repair neither complications nor revision surgery occurred. Primary endoprosthetic replacement for the treatment of proximal humeral fractures appears as a therapeutic option with a low complication rate and a satisfying functional outcome. In older patients we need a safe mode of therapy permitting early mobilization and quick discharge from the hospital back to the patient's home. Endoprosthetic replacement fulfils these demands since it resembles a "one time surgery" without the risk of revision surgery for implant loosening, pseudarthrosis or ischemic necrosis of the humeral head. Four-part fractures of the upper end of the humerus are uncommon injuries and there is still dispute about the best form of management. A retrospective study of 32 patients with these injuries has shown that non-operative management is frequently followed by persistent pain, stiffness and dysfunction of the shoulder. A prospective study of 49 patients with this injury presenting at the Bristol Royal Infirmary has shown that reconstruction of the upper end of the humerus with insertion of a Neer prosthesis will usually restore comfort and function. Whichever regimen is employed, disability is prolonged and dedicated physiotherapy is essential in their management. We randomised 40 elderly patients of mean age 74 years with displaced three- or four-part fractures of the humerus to either conservative treatment or tension-band osteosynthesis. At one year and after three to five years, clinical follow-up showed no functional differences between the two groups of patients, with optimal function achieved within one year. There were major complications only in the surgically-treated group. Radiological review showed that surgery had improved the position of the fractured humeral head, but this was not reflected in improved function. Semi-rigid fixation with tension-band wiring of displaced multifragment fractures of the proximal humerus in the elderly did not improve the functional outcome when compared with conservative treatment. The aim of the study was to compare the medical aspects of alternative surgical methods for treatment of proximal humerus fractures in specific indications (two- and three- fragment fractures).
                A prospective randomised study on surgical treatment of two- and three-fragment fractures of the proximal humerus was carried out at the Department of Surgery, University Hospital in Hradec Králové, from January 2006 till January 2010. The study comprised patients with proximal humerus fractures indicated for surgical treatment. Study inclusion criteria were as follows: informed consent, AO fracture types A2, A3, B1 or C1, age between 18 and 80 years, and patient compliance. Exclusion criteria included open fracture, associated injury (AIS . 2), open growth plates, or such state of the patient's health that would limit the extent of surgery. Two groups were compared. One included patients treated by the Zifko method of minimally invasive osteosynthesis with intramedullary K-wire insertion (MIO group) and the other (ORIF group) consisted of patients undergoing open reduction with angle-stable osteosynthesis using a Philos plate (Synthes, Switzerland). The patients were randomised to the groups by a computer programme which facilitates the maintenance of homogeneity of the groups compared. The procedure in each patient was based on the sealed-envelope method.
                The ORIF group comprised 28 patients. It took them an average of 27.2 weeks (9-72) to regain normal upper limb function. The final CM score was 86.6% (64-100%) as compared with the healthy limb. Excellent and good results were achieved in 89% of the patients; complications were recorded in 39% of them. The MIO group included 27 patients. The fractures healed in all of them. Normal upper limb function was regained at an average of 21.4 weeks (13-36). The final CM score was 87.5% (52-100%) in comparison with the healthy limb. Excellent and good results were achieved in 89% and complications developed in 33% of the patients.
                The statistical evaluation of the results, using the unpaired t-test, did not show any significant differences either in functional outcomes or the number of complications between the two groups. The only significant difference was found in operative times (117 min and 72 min in ORIF and MIO groups, respectively). The difference in time needed to regain limb function (27 and 21 weeks) was at a marginal level of statistical significance. With both methods 89% of excellent and good results were achieved, and a similar number of patients had complications (11 and 9). This study aims to evaluate the costs and health outcome for surgical and conservative treatment of displaced proximal humeral fractures.
                This study is a randomised controlled trial.
                This study included 50 patients aged 60 or older admitted to hospital with a severely displaced three- or four-part fracture.
                The patients were treated surgically with an angular stable interlocking implant (25 patients) or conservative treatment (25 patients).
                The outcomes measured included quality-adjusted life years (QALYs) and societal costs.
                At 12 months' follow-up, the mean difference in the number of QALYs was 0.027 (95% confidence interval (CI)=-0.025, 0.078) while the mean difference in total health-care costs was 597 euro in favour of surgery (95% CI=-5291, 3777).
                There was no significant difference in QALYs or costs between surgical and conservative treatment of severe displaced proximal humeral fractures.
                Copyright 2009 Elsevier Ltd. All rights reserved. Two methods of physiotherapy after fracture of the proximal end of the humerus were compared. The study was designed as a randomized, controlled and single-blind trial. Twenty patients were assigned to two groups 10-12 days after the injury. One group was treated conventionally, the other received instructions in self-training with follow-up control of results. Objective examination and subjective assessment were made at five intervals, up to one year after the injury. The greatest improvement in function was shown in both groups between 3 and 8 weeks. The patients deemed their daily life functions to be normal 8 weeks after the injury. The objective assessment was normal at later stages. No significant differences were found between the two groups in any of the tests. Instruction in self-training with control of results including objective assessments are therefore an adequate method in the rehabilitation of these patients. We undertook a prospective, controlled trial which compared two rehabilitation programmes for 86 patients who sustained two-part fractures of the proximal humerus. Patients were randomised either to receive immediate physiotherapy within one week (group A) or delayed physiotherapy after three weeks of immobilisation in a collar and cuff sling (group B). At 16 weeks after the fracture, patients in group A had less pain (p < 0.01) and had greater shoulder function (p < 0.001) than those in group B. At 52 weeks, the differences between the groups had reduced. Although group A still had greater shoulder function and less pain, there was no statistical difference when compared with group B. By analysis of the area under the curve, an overall measure up to the 52-week period, group A experienced less pain as measured by the SF36 general health questionnaire and had improved shoulder function. Our results show that patients with two-part fractures of the proximal humerus who begin immediate physiotherapy, experience less pain. The gains in shoulder function persist at 52 weeks which suggests that patients do not benefit from immobilisation before beginning physiotherapy. The aim of the study was to report the 2-year outcome after a displaced 3-part fracture of the proximal humerus in elderly patients randomized to treatment with a locking plate or nonoperative treatment.
                We included 60 patients, mean age 74 years (range, 56-92), 81% being women. The main outcome measures were the Constant and Disabilities of the Arm, Shoulder and Hand (DASH) scores and the health-related quality of life (HRQoL) according to the EQ-5D.
                At the final 2-year follow-up, the results for range of motion (ROM), function and HRQoL were all in favor of the locking plate group. The mean flexion in the locking plate group was 120° compared to 111° in the nonoperative group (P = .36) and the mean abduction was 114° compared to 106° (P = .28). The corresponding values for the Constant score were 61 versus 58 (P = .64), for DASH 26 versus 35 (P = .19), and the mean EQ-5D (index) score was 0.70 compared to 0.59 (P = .26). In spite of good primary reduction in 86% of the fractures in the locking plate group, 13% of the patients had a fracture complication requiring a major reoperation and 17% had a minor reoperation.
                The results of our study indicate an advantage in functional outcome and HRQoL in favor of the locking plate compared to nonoperative treatment in elderly patients with a displaced 3-part fracture of the proximal humerus, but at the cost of additional surgery in 30% of the patients.
                Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved. The aim of the study was to report the 2-year outcome after a displaced 4-part fracture of the proximal humerus in elderly patients randomized to treatment with a hemiarthroplasty (HA) or nonoperative treatment.
                We included 55 patients, mean age 77 (range, 58-92) years, 86% being women. Follow-up examinations were done at 4, 12, and 24 months. The main outcome measures were health-related quality of life (HRQoL) according to the EQ-5D and the DASH and Constant scores.
                At the final 2-year follow-up the HRQoL was significantly better in the HA group compared to the nonoperative group, EQ-5D (index) score 0.81 compared to 0.65 (P = .02). The results for DASH and pain assessment were both in favor of the HA group, DASH score 30 versus 37 (P = .25) and pain according to VAS 15 versus 25 (P = .17). There were no significant differences regarding the Constant score or range of motion (ROM). Both groups achieved a mean flexion of approximately 90-95° and a mean abduction of 85-90°. The need for additional surgery was low: 3 patients in the HA group and 1 patient in the nonoperative group.
                The results of the study demonstrated a significant advantage in quality of life in favor of HA, as compared to nonoperative treatment in elderly patients with a displaced 4-part fracture of the proximal humerus. The main advantage of HA appeared to be less pain while there were no differences in ROM.
                Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved. The purpose of this study was to evaluate the clinical benefit of medial support screws for locking plating of proximal humerus fractures.
                Seventy-two consecutive patients underwent prospective treatment for proximal humerus fractures with locking plates between October 2007 and September 2008. Sixty-eight patients accomplished a mean 30.8-month follow-up and were randomized into two groups: 39 patients were treated with only a locking plate and were classified in the -MSS (medial support screw) group, and 29 patients were included in the + MSS group, which were fixed with additional medial support screws. Clinical and radiological investigations were performed in both groups.
                The fractures united at an average of 13.6 weeks after final surgery. Comparably better shoulder function recovery was achieved in the +MSS group with regard to the Constant shoulder score (P = 0.01), with the respective excellent and good rates of 79% and 62%. Eleven patients developed various complications. A statistical difference (P = 0.036) was observed regarding the failure rate (23.1% in the -MSS group vs. 3.4% in the +MSS group). The early loss of fixation was related to higher age (P < 0.001) and less initial neck-shaft angle (NSA) (P = 0.011) of the patients. However, bone mineral density was not significantly associated with loss of fixation (P = 0.076). Although no difference was found in all types of the fractures between the +MSS and -MSS groups regarding immediate postoperative NSA, we observed a significantly lower final NSA in the -MSS group and greater secondary angle loss in the subgroup of Neer three-part (P = 0.033 and 0.015, respectively) and four-part fractures (P = 0.043 and 0.027).
                Anatomical reduction can substantially decrease the risk of postoperative failure in locking plating of proximal humerus fractures. Medial support for proximal humerus fractures seems to have no benefits in Neer two-part fractures. However, the additional medial support screws inserted into the medio-inferior region of the humeral head may help to enhance mechanical stability in complex fractures and allow for better maintenance of reduction.
There is insufficient evidence to inform the management of these fractures. Early physiotherapy, without immobilisation, may be sufficient for some types of undisplaced fractures. It remains unclear whether surgery, even for specific fracture types, will produce consistently better long term outcomes but it is likely to be associated with a higher risk of surgery-related complications and requirement for further surgery.
There is insufficient evidence to establish what is the best method of surgical treatment, either in terms of the use of different categories of surgical intervention (such as plate versus nail fixation, or hemiarthroplasty versus tension-wire fixation) or different methods of performing an intervention in the same category (such as different methods of plate fixation). There is insufficient evidence to say when to start mobilisation after either surgical fixation or hemiarthroplasty.