Dr.

Andreas SpOT
Jacky Junaedi

Introduction
Nonunion and delayed union remain major complications in
the treatment of fractures (5% - 10% of the approximately 7.9
million fractures that occur in the United States )
Electromagnetic stimulation is a noninvasive technology that
may improve fracture-healing
Electromagnetic stimulation impacts many cellular pathways,
including growth factor synthesis, proteoglycan and collagen
regulation, and cytokine production
Changing
environments,
ultimately
stimulating
the
calciumcalmodulin pathway and thus enhancing bone-healing

Materials and Method

Search Strategy
Identified relevant randomized controlled trials, in any
language, by a systematic search of the following
databases from inception to April 16, 2008: MEDLINE,
EMBASE, CINAHL, and all Evidence-Based Medicine
Reviews (EBMR)
Reviewed the bibliographies of all retrieved studies and
other relevant publications, including reviews and metaanalyses, to identify additional articles

Materials and Method

Eligibility Criteria
Eligible trials met the following criteria
(1) use of a random allocation of treatments
(2) inclusion of patients presenting with a longbone lesion;
(3) inclusion of a
electromagnetism of
bone-healing

treatment arm receiving

any waveform to impact

(4) inclusion of a treatment arm receiving no

active intervention; and (5) report of the effect of

Materials and Method

Assessment of Study Quality
Methodological quality was gauged by noting the
specifics of randomization, concealment of allocation,
blinding, the management of study withdrawals, and the
extent of follow-up. These data were used to determine
study quality with the welldescribed GRADE protocol

Data Abstraction
Data extracted independently and in duplicate from
each eligible study.
Information on the electromagnetic stimulation device,
the duration of treatment, patient inclusion and/or
exclusion criteria, patient demographics, and all clinical
outcomes were inputted into a standardized electronic
data collection form

 Determined inter observer agreement for the screening and selection of

articles and assessment of quality, with kappa coefficients. Landis and Koch
suggest a kappa of 0 to 0.2 represents slight agreement; 0.21 to 0.40, fair
agreement; 0.41 to 0.60, moderate agreement; and 0.61 to 0.80, substantial
agreement. A value of >0.80 is considered almost perfect agreement.
bone union results, we calculated the relative risk using the program RevMan
and a continuity correction factor of 0.25 to account for zero event rates
Examined heterogeneity using both the Cochran chi-square test (Cochran Q)
and the I statistic. Cochran Q is associated with a heterogeneity p value, and
values of0.10 suggest that there is sufficient heterogeneity of treatment
effects to preclude meaningful pooling of trials

Result

Result

Result

Result

Discussion
suggests that
(1) current evidence from randomized trials is insufficient to conclude a benefit of
electromagnetic stimulation in improving the rate of union in patients with a fresh
fracture, osteotomy, delayed union, or nonunion
(2) current evidence is insufficient to conclude a benefit of electromagnetic
stimulation on time to healing in tibial stress fractures
(3) current evidence is insufficient to attribute a reduction in pain to
electromagnetic stimulation in patients with a fracture or osteotomy
(4) electromagnetic stimulation results in short but not long-term (i.e., four weeks
or more) increases in scintimetric healing activity with no impact on fracture
redisplacement rates in nonoperatively treated Colles fractures in women
(5) bone density is improved in patients undergoing femoral intertrochanteric
osteotomy and is variably impacted in lengthening procedures of the lower limb,
although the clinical importance of these findings is unclear

 These findings were inconsistent with our initial

hypothesis and with three previous systematic reviews
on the effect of electromagnetic stimulation on fracturehealing each of which suggested a favorable impact on
bone-healing with adjuvant electromagnetic stimulation
therapy.
A major difference in one review was the pooling of
spinal fusion data along with long-bone data. It is likely
that the favorable impact was driven not by efficacy in
long-bone lesions but rather with spinal fusions

Relevance of Our Findings

Our data suggest that despite the widespread use of
electromagnetic stimulation in orthopaedics, there are no
definitive clinical data to support its use in long-bone
fractures
In conclusion, small, methodologically limited trials with
wide confidence intervals leave the impact of
electromagnetic stimulation of fracture-healing uncertain.
The current evidence justifies neither enthusiastic
dissemination nor confident rejection of this therapeutic
modality. Appropriately sized and methodologically sound
trials are needed to resolve the current uncertainty.