Electrical stimulation for bone healing reduced pain and risk of nonunion vs. sham control

Study Type: Meta analysis
OE Level of Evidence: 1
Journal Level of Evidence: 1
15 randomized controlled trials comparing electrical stimulation to sham treatment in adults with a fresh fracture, nonunion, delayed union, osteotomy, or symptomatic spinal instability requiring fusion were included. The purpose of this meta-analysis was to quantitatively assess the efficacy of bone stimulation in terms of pain relief, functional improvements, and radiographic nonunion. The results indicated Please login to view the rest of this report. Please login to view the rest of this report.
Funding: Non-funded
Conflicts: None disclosed
Why was this study needed now?
Failure or delay in bone healing may result in increased pain and reduced function, subsequently reducing the quality of life of the patient. Secondary procedures may be required to promote healing which can be associated with significantly increased costs and patient morbidity. Less invasive adjunct procedures that promote bone healing, such as electrical stimulation, have increased in popularity. However, the body of clinical evidence on this topic has been far from conclusive. Thus, the present study sought to assess the efficacy of electrical stimulation on bone healing by conducting a meta-analysis of available evidence in order to guide clinical practice.
What was the principal research question?
Is bone stimulation efficacious in terms of pain relief, functional improvement, and radiographic nonunion in comparison to sham stimulation?
Data Source: A computerized database search was conducted using MEDLINE, EMBASE, CINAHL, and the Cochrane Library from inception to February 2, 2015. As well manual searches of reference lists of included trials and major orthopaedic conference proceedings (from Feb 2013-Feb 2015) were also conducted.
Index Terms: Full search strategy and index terms available in appendix of publication. MeSH terms and EMTREE headings were used in various combinations.
Study Selection: Studies with adult patients (over 16 years of age), presenting with a fresh fracture, nonunion, delayed union, osteotomy, or symptomatic spinal instability requiring fusion, randomly allocated to receive electrical or sham stimulation, were included. Two independent reviewers assessed articles for adherence to inclusion criteria using an electronic form, all disagreements were resolved via consensus. 15 randomized controlled trials were selected for inclusion (n=1247). Electrical stimulation methods included pulsed electromagnetic field (PEMF) therapy (n=12 studies), direct current (DC) stimulation (n=1 study), and continuous current (CC) stimulation (n=2 studies).
Data Extraction: Two reviewers independently extracted data using an electronic form. The primary outcomes were pain relief and functional improvement; the secondary outcome was radiographic nonunion.
Data Synthesis: Meta-analyses were conducted using a random-effects model. Pooled estimates were represented as Risk Ratios (RR) with 95% confidence intervals (CIs) and the Absolute Risk Reduction (ARR) was used to calculate the number needed to treat (NNT). Continuous outcomes were reported with mean differences (MDs) and corresponding 95% CIs. Publication bias was assessed using funnel plots and heterogeneity was assessed using the X2 test and the I2 statistic. Significance was tested using two-tailed tests with p-values of <0.05 considered significant. Subgroup analyses were conducted by clinical indication (fresh fractures, delayed union or nonunion, spinal fusion, surgical osteotomy) and type of simulation, and sensitivity analyses were performed to explore the effects of missing outcome data.
What were the important findings?
What should I remember most?
How will this affect the care of my patients?
The authors responsible for this critical appraisal and ACE Report indicate no potential conflicts of interest relating to the content in the original publication.