A Review of Bone Growth Stimulation for Fracture Treatment

Steve B. Behrens; Matthew E. Deren; Keith O. Monchik

Disclosures

Curr Orthop Pract. 2013;24(1):84-91. 

In This Article

Inductive Coupling

Much literature regarding bone growth stimulators involves inductive coupling, or PEMF. Based on the lack of highquality Level I data and preponderance of Level IV data, the use of PEMF for delayed unions and nonunions has a Grade C recommendation.

The early investigator, Bassett et al.[63] first published the acceleration of fracture repair using electromagnetic fields, and the first clinical trial using this surgically noninvasive method was conducted in 1977.[64] In 1982, the confirmed final results of 1007 ununited fractures and 71 failed arthrodeses treated with PEMF by over 500 surgeons worldwide were published.[65] Seventy-five percent of 332 patients were effectively treated with PEMF, averaging 4.7 years disability,[3.4] previous operative failures, and with a 35% infection rate.

A meta-analysis of four randomized, controlled trials for electromagnetic field stimulation for treatment of long-bone delayed unions and nonunions concluded that the effect of bone stimulation was small, not statistically significant, and provided insufficient evidence to make a definitive practice recommendation.[66] The heterogeneity of study designs and lack of functional outcome measures limited conclusions.

Sharrard[67] published the results of 45 tibial shaft nonunions after initial conservative management in a multicenter, double-blinded trial.[67] After 12 weeks of PEMF or placebo stimulation, the authors found a statistically significant number of healed fractures by PEMF compared with controls after radiographic evaluation. The mean age of the treatment group was significantly lower than the control group (34.7–45.4 years), a possible cofounder in the results.

A randomized, double-blinded, controlled trial by Borsalino et al.[68] was completed by 31 patients undergoing femoral intertrochanteric osteotomy for degenerative hip arthritis. At 90 days, increases in bone callus, callus density, and trabecular bridging were all statistically significant in the stimulated group.

Barker[69] reported the results of 17 adults with tibial shaft nonunions treated with either PEMF or a control stimulator, reporting no significant differences between groups at 24 weeks. This study excluded a significant group of patients with sepsis, internal or external fixation, fracture gap greater than 0.5 cm, or operative procedure within 6 months.

Heckman et al.[70] published a report on 149 patients treated with PEMF, noting a 64.4% success rate and the importance of anatomic location and patient compliance. Gossling et al.[71] published a comparison of surgery and PEMF for tibial fracture nonunion in 1992. After reviewing 44 articles, the authors concluded that PEMF treatment of nonunited tibial fractures is more successful than noninvasive management, and at least equally effective as surgery.

Copious Level IV evidence exists for the use of PEMF in delayed and nonunited fractures. Meskens et al.[72] reported 67.7% successful unions in a case series with the use of PEMF in patients with nonunions, but reported unfavorable results in patients with atrophic nonunions or fractures of the humerus. In 57 tibial pseudarthroses treated with intramedullary nailing, PEMF increased the union rate from 83 to 91%, and decreased the time to union from 4.9 to 3.3 months.[73] The authors concluded that neither value was statistically significant. The results were clinically significant by a relative risk of 0.53, which confers a 47% reduction in the appearance of events. In a case series of proximal fifth metatarsal fractures treated with nonweightbearing cast immobilization and PEMF, all fractures healed within 3 months.[74] A follow-up study for scaphoid nonunions treated with PEMF showed a decreased successful union rate from the initially reported 80 to 69%, with only 50% of proximal pole fractures uniting, and decreased success in nonunions associated with avascular necrosis.[75] The authors concluded that PEMF should be a secondary alternative to traditional bone grafting.

Colson et al.[76] published a prospective cohort of 33 longbone nonunions treated with either PEMF alone or combined with surgery, resulting in 83% and 100% unions, respectively. The authors noted the regimen of PEMF was simpler than prior studies but equally efficacious. PEMF used greater than 3 hours per day was 80% successful in 139 nonunions, compared with 35.7% successful unions in patients who used PEMF less than 3 hours per day.[77] Most recently, Assiotis et al.[76] reported a 77.3% fracture union rate in a prospective cohort of 44 tibial delayed unions or nonunions without infection.

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