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Scientific Articles   |    
Electrical Stimulation for Long-Bone Fracture-Healing: A Meta-Analysis of Randomized Controlled Trials
Brent Mollon, BHSc1; Vitor da Silva, BMSc2; Jason W. Busse, DC, MSc3; Thomas A. Einhorn, MD4; Mohit Bhandari, MD, MSc3
1 37 Perkinsfield Street, Whitby, ON L1N 8J5, Canada
2 28-410 Ambleside Drive, London, ON N6G 4Y3, Canada
3 CLARITY Research Group, Department of Surgery, McMaster University, 293 Wellington Street North, Suite 110, Hamilton, ON L8L 8E7, Canada. E-mail address for M. Bhandari: bhandam@mcmaster.ca
4 Boston University Orthopaedic Surgical Associates, 720 Harrison Avenue, Suite 805, Boston, MA 02118
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario; the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario; the Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada; and the Department of Orthopaedic Surgery, Boston University, Boston, Massachusetts

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Nov 01;90(11):2322-2330. doi: 10.2106/JBJS.H.00111
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Abstract

Background: Bone stimulation represents a $500 million market in the United States. The use of electromagnetic stimulation in the treatment of fractures is common; however, the efficacy of this modality remains uncertain. We conducted a systematic review and meta-analysis of randomized controlled trials to evaluate the effect of electromagnetic stimulation on long-bone fracture-healing.

Methods: We searched four electronic databases (MEDLINE, EMBASE, CINAHL, and all Evidence-Based Medicine Reviews) for trials of electromagnetic stimulation and bone repair, in any language, published from the inception of the database to April 2008. In addition, we searched by hand seven relevant journals published between 1980 and April 2008 and the bibliographies of eligible trials. Eligible trials enrolled patients with long-bone lesions, randomly assigned them to electromagnetic stimulation or a control group, and reported on bone-healing. Information on the methodological quality, stimulation device, duration of treatment, patient demographics, and all clinical outcomes were independently extracted by two reviewers.

Results: Of 2546 citations obtained in the literature search, eleven articles met the inclusion criteria. Evidence from four trials reporting on 106 delayed or ununited fractures demonstrated an overall nonsignificant pooled relative risk of 1.76 (95% confidence interval, 0.8 to 3.8; p = 0.15; I2 = 60.4%) in favor of electromagnetic stimulation. Single studies found a positive benefit of electromagnetic stimulation on callus formation in femoral intertrochanteric osteotomies, a limited benefit for conservatively managed Colles fracture or for lower limb-lengthening, and no benefit on limb-length imbalance and need for reoperation in surgically managed pseudarthroses or on time to clinical healing in tibial stress fractures. Pain was reduced in one of the four trials assessing this outcome.

Conclusions: While our pooled analysis does not show a significant impact of electromagnetic stimulation on delayed unions or ununited long-bone fractures, methodological limitations and high between-study heterogeneity leave the impact of electromagnetic stimulation on fracture-healing uncertain.

Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Mohit Bhandari, MD, FRCSC
    Posted on February 18, 2009
    Dr. Bhandari and colleagues respond to Dr. Pienkowski
    CLARITY Research Group, Division of Orthopaedic Surgery, McMaster University

    We thank Dr. Pienkowski for his letter and interest in our study (1). One of our stated eligibility criteria was “inclusion of a treatment arm receiving electromagnetism of any waveform to impact bone-healing” and, as such, both studies by Scott and King (2) and Beck et al. (3) were eligible for our review.

    In our methods section we advanced, a priori, that one source of variability between studies may by due to different technical specification of trial devices; however, given the small number of diverse trials available we felt unable to conduct meaningful subgroup analyses according to this parameter.

    If we remove the trial by Scott and King from our meta-analysis of rates of long bone union, our pooled relative risk changes from 1.76 (95% CI 0.81, 3.80), with an associated I2 of 60%, to 1.57 (95% CI 0.76, 3.25), with an associated I2 of 64%. Thus, the removal of this trial does not appreciably modify our results or the associated heterogeneity.

    On their own, neither trial that applied electrical capacitive coupling to enhance bone healing demonstratred a statistically significant effect (2, 3).

    Further trials are required to establish if electromagnetic stimulation or electrical capacitively-coupled stimulation are effective in accelerating fracture healing.

    References

    1. Mollon B, et al. Electrical stimulation for long-bone fracture- healing: a meta-analysis of randomized controlled trials. J Bone Joint Surg Am, 2008. 90(11): p. 2322-30.

    2. Scott, G and JB King, A prospective, double-blind trial of electrical capacitive coupling in the treatment of non-union of long bones. J Bone Joint Surg Am, 1994. 76(6): p. 820-6.

    3. Beck BR, et al. Do capacitively coupled electric fields accelerate tibial stress fracture healing? A randomized controlled trial. Am J Sports Med, 2008. 36(3): p. 545-53.

    David Pienkowski, PhD
    Posted on January 28, 2009
    Capacitive Coupled Stimulation is Different From Electromagnetic Stimulaltion
    University of Kentucky

    To the Editor:

    Mollon et al. state in their article “Electrical Stimulation for Long-Bone Fracture-Healing: A Meta-Analysis of Randomized Controlled Trials” that their analysis was restricted to publications involving electromagnetic stimulation(1).

    However,two of the eleven studies included in their meta-analysis, i.e., Scott and King [2] and Beck et al [3] used capacitive-coupled stimulation exclusively. The term “capacitive-coupling” was clearly denoted in the titles, abstracts, and methods of these two publications.

    Electromagnetic stimulation and capacitively-coupled stimulation both involve electrical and magnetic fields, but the means by which stimulation is applied, the tissue-level distribution of applied magnetic and induced electrical fields, and the mechanisms of action differ between these stimulation modalities. Electromagnetic stimulation and capacitively-coupled stimulation are distinct, non interchangeable, and should not be mixed in a meta-analysis restricted to electromagnetic stimulation only.

    Mollon et al.(1) noted that two reviewers “read in full” each publication. It is therefore puzzling how these two studies,(2,3) were included in a meta-analysis intended to be restricted to electromagnetic stimulation.

    Electrical stimulation is a third modality. It differs from the other two in its means of application, tissue-level field distribution, and mechanism of action. Use of this modifier in the title of the article by Mollon et al.(1) was inaccurate given the restriction of their study to electromagnetic fields. Furthermore, repetitive use of the expression “electromagnetic force” by Mollon et al.(1) was incorrect. This term refers to one of the four fundamental forces in nature, but not to the magnitude of the electrical potential induced in conducting media by a time-varying applied electromagnetic field.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    References

    1. Mollon, B., et al., Electrical stimulation for long-bone fracture-healing: a meta-analysis of randomized controlled trials. J Bone Joint Surg Am, 2008. 90(11): p. 2322-30.

    2. Scott, G. and J.B. King, A prospective, double-blind trial of electrical capacitive coupling in the treatment of non-union of long bones. J Bone Joint Surg Am, 1994. 76(6): p. 820-6.

    3. Beck, B.R., et al., Do capacitively coupled electric fields accelerate tibial stress fracture healing? A randomized controlled trial. Am J Sports Med, 2008. 36(3): p. 545-53.

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