Integrated approach is needed

EDITOR—As Cochrane reviewers appraising randomised controlled trials on surgical interventions for orthopaedic trauma and through our involvement with the promotion of evidence based orthopaedic surgery in Teesside, we would like to endorse and extend the observations of McCulloch et al on randomised controlled trials in surgery.1

Although issues specific to surgical trials mentioned by McCulloch et al also apply, most of the trials we have reviewed have methodological defects that could have been avoided. For example, concealment of study allocation is always possible, yet this was confirmed in just two of the 44 trials included in a review of surgical treatment of wrist fractures in adults.2

Tackling any “lack of education in clinical epidemiology,” and various other measures proposed by McCulloch et al will go some way …