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Efficacy of Electrical Stimulators for Os Healing: A Meta-Analysis of Randomized Sham-Controlled Trials

Ilyas Southward. Aleem,^{a, 1, 2, 3} Idris Aleem,⁴ Nathan Evaniew,^{i, 2} Jason W. Busse,^{ii, five, 6} Michael Yaszemski,^seven Arnav Agarwal,^eight Thomas Einhorn,⁹ and Mohit Bhandari^{1, 2}

Ilyas S. Aleem

^anePartitioning of Orthopaedics, Department of Surgery, McMaster University, Hamilton, ON, Canada

²Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada

³Department of Orthopaedic Surgery, Academy of Michigan, Ann Arbor, MI, USA

Idris Aleem

⁴Thalmic Labs, Kitchener, ON, Canada

Nathan Evaniew

¹Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, ON, Canada

²Department of Clinical Epidemiology and Biostatistics, McMaster Academy, Hamilton, ON, Canada

Jason Westward. Busse

ⁱⁱDepartment of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada

^vThe Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada

⁶Section of Anesthesia, McMaster Academy, Hamilton, ON, Canada

Michael Yaszemski

^viiDepartment of Orthopaedics, Mayo Clinic, Rochester, MN, United states

Arnav Agarwal

^viiiAcademy of Toronto Faculty of Medicine, Toronto, ON, Canada

Thomas Einhorn

^nineSection of Orthopaedic Surgery, New York University Langone Medical Middle, New York, NY, USA

Mohit Bhandari

¹Partition of Orthopaedics, Section of Surgery, McMaster University, Hamilton, ON, Canada

²Department of Clinical Epidemiology and Biostatistics, McMaster Academy, Hamilton, ON, Canada

Received 2016 Mar 22; Accustomed 2016 Jul 22.

Abstract

Electrical stimulation is a common adjunct used to promote bone healing; its efficacy, all the same, remains uncertain. We conducted a meta-analysis of randomized sham-controlled trials to establish the efficacy of electrical stimulation for os healing. Nosotros identified all trials randomizing patients to electric or sham stimulation for bone healing. Outcomes were hurting relief, functional improvement, and radiographic nonunion. Two reviewers assessed eligibility and risk of bias, performed data extraction, and rated the quality of the evidence. Fifteen trials met our inclusion criteria. Moderate quality evidence from 4 trials found that stimulation produced a significant improvement in pain (mean difference (MD) on 100-millimeter visual counterpart calibration = −vii.7 mm; 95% CI −13.92 to −1.43; p = 0.02). Two trials found no divergence in functional outcome (MD = −0.88; 95% CI −6.63 to 4.87; p = 0.76). Moderate quality evidence from 15 trials establish that stimulation reduced radiographic nonunion rates by 35% (95% CI nineteen% to 47%; number needed to care for = seven; p < 0.01). Patients treated with electric stimulation as an adjunct for bone healing take less pain and are at reduced risk for radiographic nonunion; functional consequence information are express and requires increased focus in time to come trials.

Os healing is a complex physiological procedure and is the end goal in the treatment of patients with fractures, surgical osteotomies and spinal fusion procedures. Failure or delays in bone healing often require further intervention and may result in serious morbidity such as increased pain and functional limitations¹. Secondary procedures to promote bone healing may be invasive, expensive, and consequence in significant patient morbidity. The socioeconomic brunt associated with bone healing complications such as delayed union or nonunion is substantial and includes direct treatment costs as well equally personal and societal costs, such as lost wages, decreased productivity and delays returning to work^{ii ,3 ,iv}.

Electrical stimulation is a popular adjunctive therapy used to promote bone healing across a range of indications^{5 ,6}. Basic science research suggests that electrical stimulation enhances the process of bone healing by stimulating the calcium-calmodulin pathway secondary to the upregulation of os morphogenetic proteins, transforming growth cistron-β and other cytokines^{iii ,7 ,viii ,nine ,ten ,eleven}. Clinical evidence to back up the use of electrical stimulators for bone healing has been inconclusive. Prior systematic reviews of electric stimulation have been express by narrow telescopic, poor methodologic quality, and a focus on radiographic healing over patient-important outcomes^{12 ,13 ,14 ,15 ,16 ,17 ,18 ,19}. Nosotros performed a meta-analysis of randomized sham-controlled trials to determine the result of electrical stimulation on os healing, focusing on patient-important outcomes.

Methods

We report this study according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement²⁰ and the protocol for reviews outlined in the Cochrane Handbook for Systematic Reviews of Interventions ²¹.

Identification of Studies

Nosotros systematically searched MEDLINE, EMBASE, CINAHL, and the Cochrane Library from inception of the database to March 6, 2016. We used MeSH and EMTREE headings in various combinations and supplemented with gratis text to increase sensitivity (Appendix 1). Manual searches of the reference lists of included trials were conducted to identify any additional articles. We hand-searched major orthopaedic conference proceedings from March 2013 to March 2016 to identify unpublished studies that were potentially eligible.

Assessment of eligibility

2 authors independently screened all titles and abstracts and applied eligibility criteria to the methods section of potentially eligible trials using an electronic screening form. All discrepancies were resolved by consensus.

We included all studies fulfilling the following criteria:

one) Adult patients >16 years of any sex undergoing operative or nonoperative treatment for a fresh fracture, nonunion, delayed union, osteotomy, or symptomatic spinal instability requiring fusion.

two) Trials comparing direct current (DC), capacitive coupling (CC), or pulsed electromagnetic field therapy (PEMF).

3) Randomized sham-controlled trials (RCT) only²².

No restrictions were made for publication date, language, presence or absence of co-interventions, or length of follow-up. Studies using multiple basic in the same patients as the unit of randomization, rather than patients were excluded due to lack of independence²³.

Assessment of risk of bias

Two reviewers independently performed outcome-specific cess of risk of bias using the Cochrane Collaboration's tool for risk-of-bias assessment²¹. Attempts were made to contact study authors to resolve whatever uncertainties when required. When the issues bearing on the take a chance of bias were identical across outcomes within a study, a unmarried risk of bias assessment was reported²⁴.

Data extraction

Two reviewers independently extracted data using a piloted electronic data extraction form. Extracted data included author names, journal names and publication year, funding source, sample size, hateful ages and proportion of each sex in handling and control groups, descriptions of the interventions in each group, all reported outcomes and follow-up times, and loss to follow-up. We attempted to contact report authors for clarification if important data were unclear or not reported.

Radiographic healing was adamant according to the methods implemented in each trial. When multiple criteria for union were described, nosotros recorded the virtually conservative judge of marriage. For each trial we determined whether radiographic cess was blinded or independently assessed and judged by consensus whether the determination of wedlock was reasonable or non reasonable. We converted radiographic union rates to the number of nonunions past subtracting from the total number of patients in each group. For patients already presenting with a nonunion or delayed wedlock, we recorded the number of patients with persistent or on-going nonunions. In trials that reported union based on CT-scan and manifestly radiographs, we recorded apparently moving-picture show radiographic healing for consistency.

Statistical Analyses

We calculated agreement for reviewers' assessments of study eligibility with the Cohen's kappa coefficient and agreement for assessments of risk of bias using the intraclass correlation coefficient (ICC). Kappa values ≥0.65 were considered adequate²⁵.

Among eligible trials we found substantial diversity in the types of bone lesions targeted for handling. Although baseline os healing time differs by size of bone and the site of lesion, the biologic process of healing is consequent across all os lesions^{26 ,27 ,28 ,29} and the effect of electrical stimulation compared with control on the time to bone healing is therefore likely to be similar. Nosotros reasoned that pooling trials exploring the result of electrical stimulation for different bone lesions would increase the generalizability of our results³⁰. We explored the validity of this assumption. We further anticipated that different forms of electrical stimulation may produce different effects, and explored this issue.

Nosotros utilized the conservative random-furnishings model of DerSimonian and Laird to pool effect estimates^{21 ,31}. Our primary meta-analysis was an intention-to-treat analysis in which all patients were analysed in the groups to which they were originally randomized. We reported pooled estimates as risk ratios (RR) with 95% confidence intervals (CIs). The Absolute Risk Reduction (ARR) was used to calculate the Number Needed to Care for (NNT) when applicable to assistance interpretability^{32 ,33}. Continuous outcome instruments measuring the same constructs were summarized using hateful differences (MDs) with 95% CIs²¹. If standard deviations were not bachelor, they were estimated from trials with similar outcomes^{21 ,34}. We transformed pain scores expressed in different units to the 0 to 100 mm visual analogue scale to facilitate pooling as a weighted mean deviation. When there were at least x studies in a particular meta-analysis, we examined publication bias by using funnel plots comparing sample size versus treatment effect across the included trials²¹. All tests of significance were two-tailed and p-values of <0.05 were considered significant.

Evaluation of heterogeneity

We quantified heterogeneity using the Χ ² exam for heterogeneity and the I ² statistic²¹. I ² values were interpreted according to the Cochrane Handbook²¹ equally: 0–30% might non exist important, 30–60% may represent moderate heterogeneity, fifty–xc% substantial heterogeneity and 75–100% considerable heterogeneity. We prespecified the post-obit two subgroup hypotheses to explain potential heterogeneity³⁵.

1. Clinical indication: fresh fractures, delayed union or nonunion, spinal fusion, or surgical osteotomy.

2. Type of stimulation: direct current (DC), capacitive coupling (CC), or pulsed electromagnetic fields (PEMF).

For each subgroup, we performed tests for interaction using a chi-square significance test³⁶.

Sensitivity Analyses

Our main reported assay is a complete instance analysis in which participants with missing data were excluded from both the numerator and denominator. To explore the effects of missing outcome information, we performed sensitivity analyses. For the control group, we assumed the event rate to exist the aforementioned for patients with missing information and those successfully followed; for the handling grouping nosotros assumed plausible ratios of result rates in patients with missing information compared with those who were successfully followed at ratios of: i.5:1, 2:1, and 2.v:one³⁷. Equally such, nosotros tested the robustness of the results of the chief meta-analysis under relatively farthermost assumptions with variable degrees of plausibility^{37 ,38}. When only total losses to follow-upwardly were reported and non specific numbers of losses in each arm, we assumed that losses in each arm were equal.

Given potential variability in the methods used to evaluate radiographic union^{39 ,40 ,41} we performed three farther sensitivity analyses: (1) including only trials in which an independent assessor was used to determine radiographic union; (2) including but trials in which consensus judgment was reasonable with regards to overall determination of marriage; (three) including only trials that defined union as >seventy% of bony continuity, or three of four cortices, as the nigh conservative estimate of bony union.

GRADE quality cess and summary of findings

We utilized the Class approach to summarize the quality of the evidence for or against the use of electrical stimulation by each event. Information from randomized controlled trials were considered loftier-quality evidence, only could accept been rated down according to risk of bias, imprecision, inconsistency, indirectness, or publication bias⁴².

Results

Eligible and Included Studies

Of 2025 potentially eligible manufactures, 1664 titles and abstracts were screened and 17 were eligible for our review. However, the authors of one trial⁴³ clarified that the same patients were included in a more recent manuscript⁴⁴ and Anderson et al. reported different outcomes of the same patient population in ii separate publications^{45 ,46}. Thus 15 trials that were reported in 16 manuscripts^{44 ,45 ,46 ,47 ,48 ,49 ,fifty ,51 ,52 ,53 ,54 ,55 ,56 ,57 ,58 ,59} with a total of 1247 patients were included (Fig. one). No additional trials from conference proceedings were identified. Agreement between the reviewers for eligibility based on championship and abstruse screening was very loftier (kappa = 0.85, 95% CI 0.78–0.93).

Flow of manufactures included in the study.

Study characteristics

Mean age of study participants was 45 years in the experimental and command arm. The proportion of male patients in the experimental and control arm was 58.3% and 56.3%, respectively. Hateful follow-up was 8.2 (SD iii.4) months for radiographic outcomes and 8.6 (SD 3.7) months for pain and function (Appendix 2).

Four trials included patients undergoing a spinal fusion^{45 ,46 ,49 ,52 ,55}, 5 trials evaluated fresh fracture handling^{44 ,47 ,50 ,51 ,54 ,60}, v trials examined treatment of delayed or nonunions^{48 ,56 ,57 ,58 ,59} and i study included patients undergoing surgical osteotomy⁵³. Trials of the appendicular skeleton assessed patients with tibial or femoral fractures^{47 ,48 ,53 ,54 ,57 ,59}, femoral cervix⁴⁴, scaphoid fractures^{50 ,51}, and other long-bone fractures^{56 ,58}.

Twelve trials reported employ of pulsed electromagnetic field (PEMF) therapy, one trial reported direct current (DC) stimulation and 2 trials reported continuous current (CC) stimulation. Details with regards to specific stimulator blazon, frequency and treatment elapsing for each study are reported in Appendix 3.

Radiographic union was described in all 15 of the included trials (Appendix iv). Consensus judgment with regards to the overall determination of wedlock was deemed to exist reasonable in all but 4 studies^{48 ,54 ,56 ,59}. Sharrard⁵⁷ reported results of radiographic union read by both orthopaedic surgeons and radiologists separately.

Pain was reported in 4 trials using either the Visual Counterpart Calibration (VAS)⁴⁴, Dallas Pain Questionnaire (DPQ)⁴⁶ or a categorical pain calibration^{48 ,57}. The lower and upper limits of the categorical hurting calibration reported in one study⁵⁷ (with demised single author) was assumed to exist 0 to v based on the reported mean and standard deviations and a statistical simulation. Functional outcome was reported using components of the Brusque Class 36 (SF-36) health survey in 2 trials^{46 ,47}.

Gamble of bias

Risk of bias assessments are presented in Fig. ii. The funnel plot for radiographic nonunion at last follow-up was symmetric and did non suggest publication bias (Fig. 3)²¹.

Risk of bias summary: review authors' judgments nigh each risk of bias particular for included trials.

Greenish circles indicate low gamble of bias and red circles indicate high risk of bias.

Funnel plot of Standard Mistake (log(relative take chances)) against relative risk to assess for publication bias.

Pain and function

Hurting was reported across four trials^{44 ,46 ,48 ,57} including a total of 195 patients. The pooled estimate of effect between electrical stimulation and sham control showed a statistically significant difference in pain (Doc on the 100 mm visual analogue scale = −7.67 mm, 95% CI −xiii.92 to −1.43; p = 0.02; I² = 0%; Fig. 4). In the GRADE quality assessment (Table 1) pain was rated as moderate quality due for imprecision given that the 95% CI includes values beneath and in a higher place the minimal important divergence (MID) of 10 mm⁶¹. We found no evidence to support a difference in treatment effect due to treatment indication (interaction p = 0.41) or stimulator type (interaction p = 0.19).

Pooled hurting score (mean difference).

Tabular array 1

Combined Form and summary of findings table.

Quality assessment							Number of patients		Outcome		Quality
# of trials	Outcome	Take a chance of bias	Inconsistency	Indirectness	Imprecision	Other considerations	E-stim	Placebo	Relative	Absolute
									(95% CI)	(95% CI)
15	Radiographic nonunion	Not serious	Non serious	Seriousfour	Not serious	None	162/625 (25.nine%)	255/622 (41.0%)	RR 0.65 (0.53 to 0.81)	143 fewer per grand (from 78 fewer to 193 fewer)	⊕⊕⊕⊖ MODERATE
								35.0%		123 fewer per 1000 (from 73 fewer to 163 fewer)
4	Pain	Not serious	Not serious	Not serious	Serious3	Not serious	307	305	—	SMD 0.34 lower (0.62 lower to 0.05 lower)	⊕⊕⊕⊖ MODERATE
2	Functional outcome	Serious1	Seriousii	Not serious	Non serious	None	161	155	—	SMD 0.07 college (0.33 lower to 0.48 college)	⊕⊕⊖⊖ LOW

Functional outcomes were compared in two trials that reported SF-36 scores (due north = 316 patients). The pooled estimate of outcome between electrical stimulation and control was non statistically significant (MD −0.88, 95% CI −6.63 to four.87, p = 0.76) (Fig. 5). In the Class quality cess, functional outcome was rated every bit low quality evidence due to adventure of bias (high losses to follow-upward in both studies^{46 ,47}) and inconsistency due to unexplained heterogeneity (I² = 57%)⁶².

Pooled functional outcome data (mean divergence).

Radiographic nonunion

Radiographic nonunion was compared across 15 trials with 1247 patients. The pooled estimate of result betwixt electrical stimulation and sham controls at last reported follow-upwards upwards to 12 months found that electrical stimulation reduced the relative risk for nonunion or persistent nonunion past 35% (RR 0.65, 95% CI 0.53 to 0.81, p < 0.01, moderate certainty) and the absolute chance by 15%. Overall between-study heterogeneity was moderate (Iⁱⁱ = 46%; p = 0.02) (Fig. 6). Interpreted another manner, for every 7 patients treated with electrical stimulation, 1 nonunion or persistent nonunion could exist averted (NNT = vii). In the GRADE quality cess radiographic nonunion was rated equally moderate quality evidence due to indirectness (Table one). We establish no evidence to support a divergence in treatment outcome due to treatment indication (interaction p = 0.75) or stimulator type (interaction p = 0.05) (Appendices 5 and half dozen). An analysis conducted with the spine studies removed nevertheless showed a significant pooled treatment effect in favor of electrical stimulation for acute fracture, nonunion or delayed union, and osteotomy (RR 0.68, 95% CI 0.50 to 0.91, p = 0.01).

Radiographic nonunion at last reported follow-upwardly to 12 months with subgroups past indication.

Sensitivity Analyses

Our consummate case analysis showed a significant difference (RR 0.66, 95% CI 0.55 to 0.80) that remained robust when assumed nonunion rates in patients with missing data were ane.5:ane and two:1. When the assumed nonunion rates in patients with missing information went up to 2.v:1 the pooled gauge of issue was no longer pregnant (Appendix 7).

In only trials in which an independent assessor was used to determine union, a significant difference in favor of electrical stimulation was found (RR 0.69, 95% CI 0.54 to 0.87, p < 0.01). Trials in which consensus judgment deemed the definition and assessment as reasonable showed a pregnant departure in favor of electrical stimulation (RR 0.68, 95% CI 0.55 to 0.85, p < 0.01). Finally, the most bourgeois gauge in simply those trials^{44 ,47 ,50 ,51 ,52 ,53 ,57 ,58} explicitly defining wedlock as >75% of bony continuity also favored electrical stimulation (RR 0.73, 95% CI 0.58 to 0.91, p < 0.01).

Discussion

Our systematic review and meta-analysis of eligible randomized controlled trials plant moderate quality evidence for electrical stimulation in reducing patient-reported hurting and radiographic nonunion or persistent nonunion. Low-quality functional issue data showed no divergence with electric stimulation compared to sham handling.

Our findings are strengthened by our comprehensive search and broad clinical eligibility criteria, and past including just randomized sham-controlled trials. We hypothesized the effect of electric stimulation on bone healing would be similar across different types of stimulation and different clinical lesions, and our subgroup analyses back up this assumption. We found no evidence to support a divergence in handling consequence due to treatment indication (interaction p = 0.75). In keeping with other orthopaedic trials of os healing, nigh trials reported but surrogate end points. Express reporting of patient-important outcomes is highlighted in this review and has been identified as a significant trouble in the surgical literature^{63 ,64}. The calculation of Minimally Important Differences (MIDs) can further aid the estimation of treatment effects, only they are oft context- or musical instrument- specific and may accept limited generalizability beyond clinical indications or varying pain measures^{65 ,66}. Although we found the mean difference in pain statistically pregnant, information technology is possible that this may not represent a departure important to patients⁶⁷.

A Cochrane review published in 2011 reported non-meaning differences for electrical stimulation in improving union rates in four trials involving 125 patients^xv. 2 reviews done in 2014 too showed an inconclusive benefit of electrical stimulation. Hannemann et al.^{51 ,60} performed a systematic review evaluating the effects of low-intensity pulsed ultrasound (LIPUS) and electric stimulation specifically in acute fractures; results for LIPUS and electrical stimulation, nevertheless, were pooled together and not reported separately. In 2013, Tian et al. conducted a meta-analysis looking at the efficacy of various types of electric stimulation on spinal fusion¹⁸. Randomized trials and observational trials were, nevertheless, combined to provide a pooled estimate and no cess of methodological quality or gamble of bias was performed.

A previous review performed by our grouping in 2008¹⁶ specifically assessed long-bone fracture healing and failed to prove a significant affect of electric stimulation on radiographic healing, and inconsistent results for pain relief. In 2014¹⁴, we performed a systematic review and network meta-analysis to indirectly comparing low-intensity pulsed ultrasonography (LIPUS) and electrical stimulation. Results were pooled separately by three, 6 and 12-month time points and a deadline significant effect in improving wedlock rates in nonunions or delayed unions at 3 months with electrical stimulation merely non at half dozen or 12 months was seen. 2 trials included in that review, however, were found to have used the same patient groups on contact with the authors^{43 ,44}. The present review's results differ given that our interpretation of the testify is based upon the addition of 6 recent trials (424 patients) relating to fresh fractures, nonunions/delayed unions and osteotomies^{44 ,47 ,50 ,51 ,54 ,58} (Table 2). Moreover, we restricted eligible trials to only sham-controlled randomized trials and assessed both patient-important and radiographic outcomes. Finally, we broadened our eligibility criteria to include bone healing in spinal fusions and tested the supposition regarding similarity of treatment effect using a formal test of interaction. The addition of this data suggests that electric stimulation for bone healing may improve rates of radiographic union and produce minor but clinically significant improvements in pain relief.

Table two

Trials included in previous meta-analyses and the present study.

Meta-Analysis Study	1	2	3	4	5	vi	vii	8	nine	10	11	12	thirteen	14	fifteen	sixteen	17	18	19	20	21	22
Akai et al.13	X	X	X	10	10	10	X	Ten	X	Ten	Ten
Mollon et al.xvi	X			Ten	10			X				X		X
Griffin et al.fifteen	X			Ten				10						X
Ebrahim et al.14	X			X				X						10			X	X	X	10
Hannemann et al.51 ,threescore																	X	X	Ten
Aleem et al.	X		X	X	X			10			X		X	Ten	10	X	X	X	X	Ten	X	X

Implications for clinical practice and inquiry

A survey of 450 Canadian trauma surgeons in 2008 (response rate 79%) demonstrated that 23% of surgeons used electrical bone stimulators to advance bone healing⁶⁸. Our findings back up electrical stimulation as an adjunctive modality for radiographic os healing and reduction in hurting. Large trials of high methodological quality focusing on patient important outcomes are needed to establish the effectiveness of electric stimulation on functional outcomes⁶⁹.

Conclusions

This systematic review and meta-analysis plant that patients treated with electrical stimulation equally an adjunct for bone healing have significantly less pain and experience lower rates of radiographic nonunion or persistent nonunion. No departure was seen with regards to functional outcomes in a limited number of trials. Time to come trials focusing on functional outcomes to place appropriate indications and ideal patient selection are warranted.

Additional Information

How to cite this article: Aleem, I. S. et al. Efficacy of Electrical Stimulators for Os Healing: A Meta-Analysis of Randomized Sham-Controlled Trials. Sci. Rep. 6, 31724; doi: x.1038/srep31724 (2016).

Supplementary Cloth

Supplementary Data:

Footnotes

MB has received honorariums from Smith & Nephew, Stryker, Amgen, Zimmer, Moximed, Bioventus, Merck, Eli Lilly, Sanofi and research grants from Smith & Nephew, DePuy, Eli Lily, Bioventus, Stryker, Zimmer, Amgen; JWB was a co-principal investigator for a recently completed trial of a competing device (low intensity pulsed ultrasound) that received funding from an industry sponsor (Smith & Nephew); no other relationships or activities have influenced the submitted work.

Author Contributions I.S.A. and M.B. were involved in the written report pattern and concept. I.S.A., I.A., Due north.Eastward. and A.A. nerveless the data. I.S.A., I.A., Northward.Due east., J.W.B. and M.B. analyzed and interpreted the data. I.South.A., I.A., North.Due east. and Yard.B. drafted the initial manuscript. All authors made critical revisions of the manuscript for important intellectual content and approved the last version. I.S.A. is the guarantor.

References

• Cook J. J., Summers North. J. & Cook E. A. Healing in the new millennium: bone stimulators: an overview of where we've been and where we may be heading. Clinics in podiatric medicine and surgery 32, 45–59, 10.1016/j.cpm.2014.09.003 (2015). [PubMed] [CrossRef] [Google Scholar]
• Goldstein C., Sprague Southward. & Petrisor B. A. Electrical stimulation for fracture healing: current evidence. Journal of orthopaedic trauma 24 Suppl 1, S62–S65, 10.1097/BOT.0b013e3181cdde1b (2010). [PubMed] [CrossRef] [Google Scholar]
• Heckman J. D. & Sarasohn-Kahn J. The economic science of treating tibia fractures. The cost of delayed unions. Bulletin (Hospital for Joint Diseases (New York, N.Y.)) 56, 63–72 (1997). [PubMed] [Google Scholar]
• Busse J. W. et al.. Low intensity pulsed ultrasonography for fractures: systematic review of randomised controlled trials. BMJ (Clinical research ed.) 338, b351, ten.1136/bmj.b351 (2009). [PMC free commodity] [PubMed] [CrossRef] [Google Scholar]
• Anglen J. The clinical use of bone stimulators. J South Orthop Assoc 12, 46–54 (2003). [PubMed] [Google Scholar]
• Einhorn T. A. Enhancement of fracture-healing. J Bone Joint Surg Am 77, 940–956 (1995). [PubMed] [Google Scholar]
• Aaron R. Chiliad., Boyan B. D., Ciombor D. Chiliad., Schwartz Z. & Simon B. J. Stimulation of growth cistron synthesis by electrical and electromagnetic fields. Clinical orthopaedics and related inquiry, thirty–37 (2004). [PubMed] [Google Scholar]
• Boden Due south. D., Schimandle J. H. & Hutton W. C. An experimental lumbar intertransverse process spinal fusion model. Radiographic, histologic, and biomechanical healing characteristics. Spine (Phila Pa 1976) 20, 412–420 (1995). [PubMed] [Google Scholar]
• Ciombor D. M. & Aaron R. 1000. The part of electrical stimulation in bone repair. Foot and ankle clinics ten, 579–593, vii, 10.1016/j.fcl.2005.06.006 (2005). [PubMed] [CrossRef] [Google Scholar]
• France J. C., Norman T. L., Santrock R. D., McGrath B. & Simon B. J. The efficacy of straight electric current stimulation for lumbar intertransverse process fusions in an animal model. Spine (Phila Pa 1976) 26, 1002–1008 (2001). [PubMed] [Google Scholar]
• Haddad J. B., Obolensky A. Yard. & Shinnick P. The biologic effects and the therapeutic mechanism of activity of electrical and electromagnetic field stimulation on bone and cartilage: new findings and a review of earlier work. J Altern Complement Med thirteen, 485–490, 10.1089/acm.2007.5270 (2007). [PubMed] [CrossRef] [Google Scholar]
• Akai Thou. & Hayashi Thou. Effect of electrical stimulation on musculoskeletal systems; a meta-analysis of controlled clinical trials. Bioelectromagnetics 23, 132–143 (2002). [PubMed] [Google Scholar]
• Akai Yard., Kawashima North., Kimura T. & Hayashi Grand. Electrical stimulation every bit an adjunct to spinal fusion: a meta-analysis of controlled clinical trials. Bioelectromagnetics 23, 496–504, 10.1002/bem.10041 (2002). [PubMed] [CrossRef] [Google Scholar]
• Ebrahim South., Mollon B., Bance S., Busse J. W. & Bhandari M. Depression-intensity pulsed ultrasonography versus electric stimulation for fracture healing: a systematic review and network meta-analysis. Canadian journal of surgery. Periodical canadien de chirurgie 57, E105–E118 (2014). [PMC free commodity] [PubMed] [Google Scholar]
• Griffin Xavier L., Costa Matthew L., Parsons Nick & Smith Nick Electromagnetic field stimulation for treating delayed spousal relationship or non-matrimony of long bone fractures in adults. Cochrane Database of Systematic Reviews (2011). < http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008471.pub2/abstract>. [PubMed]
• Mollon B., da Silva V., Busse J. W., Einhorn T. A. & Bhandari M. Electric stimulation for long-bone fracture-healing: a meta-analysis of randomized controlled trials. Journal of Bone & Joint Surgery-American Volume ninety, 2322–2330 (2008). [PubMed] [Google Scholar]
• Park P., Lau D., Brodt Due east. D. & Dettori J. R. Electrical stimulation to raise spinal fusion: a systematic review. Evidence-based spine-care periodical 5, 87–94, 10.1055/southward-0034-1386752 (2014). [PMC free article] [PubMed] [CrossRef] [Google Scholar]
• Tian Northward. F. et al.. Efficacy of electrical stimulation for spinal fusion: a meta-analysis of fusion rate. Spine J thirteen, 1238–1243, 10.1016/j.spinee.2013.06.056 (2013). [PubMed] [CrossRef] [Google Scholar]
• Walker N. A., Denegar C. R. & Preische J. Low-intensity pulsed ultrasound and pulsed electromagnetic field in the handling of tibial fractures: a systematic review. Journal of able-bodied training 42, 530–535 (2007). [PMC free article] [PubMed] [Google Scholar]
• Moher D., Liberati A., Tetzlaff J. & Altman D. Grand. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA argument. Int J Surg eight, 336–341, 310.1016/j.ijsu.2010.1002.1007. Epub 2010 February 1018 (2010). [PubMed] [Google Scholar]
• Higgins JPT G. S. editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0, 2011).
• Kaptchuk T. J., Goldman P., Stone D. A. & Stason W. B. Exercise medical devices accept enhanced placebo effects? Journal of clinical epidemiology 53, 786–792 (2000). [PubMed] [Google Scholar]
• Bryant D., Havey T. C., Roberts R. & Guyatt G. How many patients? How many limbs? Analysis of patients or limbs in the orthopaedic literature: a systematic review. J Bone Joint Surg Am 88, 41–45, x.2106/jbjs.e.00272 (2006). [PubMed] [CrossRef] [Google Scholar]
• Guyatt G. H. et al.. Class guidelines: 4. Rating the quality of evidence–study limitations (hazard of bias). Journal of clinical epidemiology 64, 407–415, x.1016/j.jclinepi.2010.07.017 (2011). [PubMed] [CrossRef] [Google Scholar]
• Landis J. R. & Koch Chiliad. G. The measurement of observer agreement for categorical data. Biometrics 33, 159–174 (1977). [PubMed] [Google Scholar]
• Musculoskeletal injuries written report: incidence, risk factors and prevention. (Rosemont, IL).
• Khan S. N. et al.. The biology of bone grafting. J Am Acad Orthop Surg xiii, 77–86 (2005). [PubMed] [Google Scholar]
• Marsell R. & Einhorn T. A. The biology of fracture healing. Injury 42, 551–555, ten.1016/j.injury.2011.03.031 (2011). [PMC gratis article] [PubMed] [CrossRef] [Google Scholar]
• Day S. M., Ostrum R. F., Chao Eastward. Y. Due south., Rubin C. T., Aro H. T. & Einhorn T.A. Orthopaedic basic science: biology and biomechanics of the musculoskeletal organisation. two edn, 371–399 (American Academy of Orthopaedic Surgeons, 2000). [Google Scholar]
• Gotzsche P. C. Why we need a wide perspective on meta-analysis. It may be crucially important for patients. BMJ (Clinical inquiry ed.) 321, 585–586 (2000). [PMC free article] [PubMed] [Google Scholar]
• DerSimonian R. & Laird N. Meta-analysis in clinical trials. Controlled clinical trials vii, 177–188 (1986). [PubMed] [Google Scholar]
• Murad Yard. H., Montori Five. M., Walter Southward. D. & Guyatt G. H. Estimating risk difference from relative association measures in meta-assay tin infrequently pose interpretational challenges. Journal of clinical epidemiology 62, 865–867, 10.1016/j.jclinepi.2008.eleven.005 (2009). [PubMed] [CrossRef] [Google Scholar]
• Akl E. A. et al.. Using alternative statistical formats for presenting risks and risk reductions. The Cochrane database of systematic reviews, Cd006776, ten.1002/14651858.CD006776.pub2 (2011). [PMC free commodity] [PubMed] [CrossRef] [Google Scholar]
• Hozo S. P., Djulbegovic B. & Hozo I. Estimating the hateful and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5, thirteen, 10.1186/1471-2288-5-13 (2005). [PMC gratuitous article] [PubMed] [CrossRef] [Google Scholar]
• Sun Ten., Briel M., Walter S. D. & Guyatt G. H. Is a subgroup event believable? Updating criteria to evaluate the credibility of subgroup analyses. BMJ (Clinical inquiry ed.) 340, c117, 10.1136/bmj.c117 (2010). [PubMed] [CrossRef] [Google Scholar]
• Altman D. G. & Bland J. M. Interaction revisited: the difference betwixt two estimates. BMJ (Clinical research ed.) 326, 219 (2003). [PMC free article] [PubMed] [Google Scholar]
• Akl E. A. et al.. Addressing dichotomous data for participants excluded from trial analysis: a guide for systematic reviewers. PloS i eight, e57132, 10.1371/journal.pone.0057132 (2013). [PMC gratuitous commodity] [PubMed] [CrossRef] [Google Scholar]
• Johnston B. C. et al.. Probiotics for the prevention of Clostridium difficile-associated diarrhea: a systematic review and meta-analysis. Annals of internal medicine 157, 878–888 (2012). [PubMed] [Google Scholar]
• Kuurstra N., Vannabouathong C., Sprague South. & Bhandari G. Guidelines for fracture healing assessments in clinical trials. Role Two: electronic data capture and image direction systems–Global Adjudicator organization. Injury 42, 317–320, 10.1016/j.injury.2010.11.054 (2011). [PubMed] [CrossRef] [Google Scholar]
• McKee K. D. Displaced fractures of the clavicle: who should be fixed? commentary on an article by C.1000. Robinson, FRCSEd(Tr&Orth) et al.: "Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures. a multicenter, randomized, controlled trial". J Bone Articulation Surg Am 95, e1291–e1292, ten.2106/jbjs.m.00527 (2013). [PubMed] [CrossRef] [Google Scholar]
• Bhandari Chiliad., Petrisor B. & Schemitsch E. Outcome measurements in orthopedic. Indian journal of orthopaedics 41, 32–36, 10.4103/0019-5413.30523 (2007). [PMC free article] [PubMed] [CrossRef] [Google Scholar]
• Atkins D. et al.. Grading quality of evidence and forcefulness of recommendations. BMJ (Clinical inquiry ed.) 328, 1490, 10.1136/bmj.328.7454.1490 (2004). [PMC costless article] [PubMed] [CrossRef] [Google Scholar]
• Betti E. Chiliad. S., Cadossi R., Faldini C. & Faldini A. Effect of stimulation past low-frequency pulsed electromagnetic fields in subjects with fracture of the femoral neck. 853–855 (Kluwer Academic/Plenum, 1999). [Google Scholar]
• Faldini C., Cadossi K., Luciani D., Betti E., Chiarello Due east. & Giannini S. Electromagnetic os growth stimulation in patients with femoral neck fractures treated with screws: Prospective randomized double-bullheaded written report. Electric current Orthopaedic Practice 21, 282–287 (2010). [Google Scholar]
• Andersen T. et al.. The effect of electrical stimulation on lumbar spinal fusion in older patients: a randomized, controlled, multi-center trial: office ii: fusion rates. Spine (Phila Pa 1976) 34, 2248–2253, 10.1097/BRS.0b013e3181b02c59 (2009). [PubMed] [CrossRef] [Google Scholar]
• Andersen T. et al.. The effect of electrical stimulation on lumbar spinal fusion in older patients: a randomized, controlled, multi-heart trial: part 1: functional effect. Spine (Phila Pa 1976) 34, 2241–2247, x.1097/BRS.0b013e3181b02988 (2009). [PubMed] [CrossRef] [Google Scholar]
• Adie S., Harris I. A., Naylor J. Thou., Rae H., Dao A., Yong S. & Ying V. Pulsed electromagnetic field stimulation for astute tibial shaft fractures: a multicenter, double-blind, randomized trial. Journal of Os & Joint Surgery-American Volume 93, 1569–1576 (2011). [PubMed] [Google Scholar]
• Barker A. T., Dixon R. A., Sharrard W. J. W. & Sutcliffe M. L. Pulsed magnetic field therapy for tibial non-union. Interim results of a double-blind trial. Lancet 1, 994–996 (1984). [PubMed] [Google Scholar]
• Goodwin C. B. et al.. A double-blind report of capacitively coupled electrical stimulation as an offshoot to lumbar spinal fusions. Spine (Phila Pa 1976) 24, 1349–1356; discussion 1357 (1999). [PubMed] [Google Scholar]
• Hannemann P. F., Gottgens K. W., van Wely B. J., Kolkman Grand. A., Werre A. J., Poeze M. & Brink P. R. The clinical and radiological outcome of pulsed electromagnetic field handling for astute scaphoid fractures: a randomised double-blind placebo-controlled multicentre trial. Journal of Os & Joint Surgery-British Book 94, 1403–1408 (2012). [PubMed] [Google Scholar]
• Hannemann P. F., van Wezenbeek M. R., Kolkman K. A., Twiss E. L., Berghmans C. H., Dirven P. A., Brink P. R. & Poeze 1000. CT scan-evaluated outcome of pulsed electromagnetic fields in the treatment of acute scaphoid fractures: a randomised, multicentre, double-blind, placebo-controlled trial. Bone & Joint Journal 96-B, 1070–1076 (2014). [PubMed] [Google Scholar]
• Linovitz R. J. et al.. Combined magnetic fields advance and increase spine fusion: a double-bullheaded, randomized, placebo controlled study. Spine (Phila Pa 1976) 27, 1383–1389; discussion 1389 (2002). [PubMed] [Google Scholar]
• Mammi Thou. I., Rocchi R., Cadossi R., Massari 50. & Traina G. C. The electrical stimulation of tibial osteotomies. Double-blind study. Clinical Orthopaedics & Related Enquiry. 246–253 (1993). [PubMed] [Google Scholar]
• Martinez-Rondanelli A., Martinez J. P., Moncada One thousand. Due east., Manzi E., Pinedo C. R. & Cadavid H. Electromagnetic stimulation as coadjuvant in the healing of diaphyseal femoral fractures: A randomized controlled trial. Colombia Medica 45, 67–71 (2014). [PMC free article] [PubMed] [Google Scholar]
• Mooney V. A randomized double-blind prospective written report of the efficacy of pulsed electromagnetic fields for interbody lumbar fusions. Spine xv, 708–712 (1990). [PubMed] [Google Scholar]
• Scott G. & King J. B. A prospective, double-bullheaded trial of electrical capacitive coupling in the treatment of not-marriage of long bones. Journal of Bone & Joint Surgery-American Volume 76, 820–826 (1994). [PubMed] [Google Scholar]
• Sharrard W. J. A double-blind trial of pulsed electromagnetic fields for delayed union of tibial fractures. Journal of Bone & Articulation Surgery-British Volume 72, 347–355 (1990). [PubMed] [Google Scholar]
• Shi H. F., Xiong J., Chen Y. 10., Wang J. F., Qiu Ten. S., Wang Y. H. & Qiu Y. Early application of pulsed electromagnetic field in the handling of postoperative delayed union of long-bone fractures: a prospective randomized controlled written report. BMC Musculoskeletal Disorders 14, 35 (2013). [PMC free article] [PubMed] [Google Scholar]
• Simonis R. B., Parnell E. J., Ray P. S. & Peacock J. L. Electrical treatment of tibial not-union: a prospective, randomised, double-blind trial. Injury 34, 357–362 (2003). [PubMed] [Google Scholar]
• Hannemann P. F., Mommers Eastward. H., Schots J. P., Brink P. R. & Poeze 1000. The effects of depression-intensity pulsed ultrasound and pulsed electromagnetic fields bone growth stimulation in acute fractures: a systematic review and meta-assay of randomized controlled trials. Curvation Orthop Trauma Surg 134, 1093–1106, 10.1007/s00402-014-2014-8 (2014). [PubMed] [CrossRef] [Google Scholar]
• Guyatt Yard. H. et al.. GRADE guidelines six. Rating the quality of evidence–imprecision. Journal of clinical epidemiology 64, 1283–1293, 10.1016/j.jclinepi.2011.01.012 (2011). [PubMed] [CrossRef] [Google Scholar]
• Guyatt 1000. H. et al.. Grade guidelines: vii. Rating the quality of bear witness–inconsistency. Journal of clinical epidemiology 64, 1294–1302, 10.1016/j.jclinepi.2011.03.017 (2011). [PubMed] [CrossRef] [Google Scholar]
• Jacquier I., Boutron I., Moher D., Roy C. & Ravaud P. The reporting of randomized clinical trials using a surgical intervention is in need of immediate improvement: a systematic review. Ann Surg 244, 677–683, ten.1097/01.sla.0000242707.44007.80 (2006). [PMC gratuitous article] [PubMed] [CrossRef] [Google Scholar]
• Poolman R. W. et al.. Does a "Level I Evidence" rating imply high quality of reporting in orthopaedic randomised controlled trials? BMC Med Res Methodol half dozen, 44, x.1186/1471-2288-6-44 (2006). [PMC costless article] [PubMed] [CrossRef] [Google Scholar]
• Bannuru R. R., Vaysbrot E. E. & McIntyre Fifty. F. Did the American Academy of Orthopaedic Surgeons osteoarthritis guidelines miss the mark? Arthroscopy 30, 86–89, x.1016/j.arthro.2013.10.007 (2014). [PubMed] [CrossRef] [Google Scholar]
• Jaeschke R., Singer J. & Guyatt G. H. Measurement of wellness status. Ascertaining the minimal clinically important difference. Controlled clinical trials 10, 407–415 (1989). [PubMed] [Google Scholar]
• Busse J. W. et al.. Optimal Strategies for Reporting Pain in Clinical Trials and Systematic Reviews: Recommendations from an OMERACT 12 Workshop. J Rheumatol, 10.3899/jrheum.141440 (2015). [PubMed] [CrossRef] [Google Scholar]
• Busse J. W., Morton East., Lacchetti C., Guyatt G. H. & Bhandari M. Electric current management of tibial shaft fractures: a survey of 450 Canadian orthopedic trauma surgeons. Acta orthopaedica 79, 689–694, 10.1080/17453670810016722 (2008). [PubMed] [CrossRef] [Google Scholar]
• Chan S. & Bhandari M. The quality of reporting of orthopaedic randomized trials with utilise of a checklist for nonpharmacological therapies. J Bone Articulation Surg Am 89, 1970–1978, ten.2106/jbjs.f.01591 (2007). [PubMed] [CrossRef] [Google Scholar]

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4990885/

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