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C OPYRIGHT 2008

BY

T HE J OURNAL

OF

B ONE

AND J OINT

S URGERY, I NCORPORATED

Electrical Stimulation for Long-Bone

Fracture-Healing: A Meta-Analysis of
Randomized Controlled Trials
By Brent Mollon, BHSc, Vitor da Silva, BMSc, Jason W. Busse, DC, MSc, Thomas A. Einhorn, MD, and Mohit Bhandari, MD, MSc
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

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.

onunion and delayed union remain major complications in the treatment of fractures1, and they affect 5%
to 10% of the approximately 7.9 million fractures that
occur annually in the United States2. The socioeconomic burden associated with fracture-healing, including direct healthcare costs and lost wages, is substantial3,4. The complications
and associated costs of fracture management support the need

for innovative approaches to optimize fracture-healing. An

ideal therapy is one with important benefits and limited risk.
Electromagnetic stimulation is a noninvasive technology
that may improve fracture-healing5-7. The use of electric stimulation in the treatment of ununited fractures dates back to the
mid-1800s8,9. In 1957, Fukada and Yasuda10 demonstrated a
relationship between electricity and callus formation3. Recent

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.

J Bone Joint Surg Am. 2008;90:2322-30

doi:10.2106/JBJS.H.00111

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studies have suggested that electromagnetic stimulation impacts many cellular pathways, including growth factor synthesis11-13, proteoglycan and collagen regulation14,15, and cytokine
production16. These pathways may enable bone to respond to
changing environments, ultimately stimulating the calciumcalmodulin pathway and thus enhancing bone-healing3,17.
Several randomized trials have evaluated the effect of
electromagnetic stimulation on bone-healing, but the clinical
results have been mixed18-21. We therefore conducted a systematic
review of randomized controlled trials to determine the effect
of electromagnetic stimulation on fracture-healing of long bones.
We hypothesized that electromagnetic stimulation would improve the rates of union. We conducted meta-analyses, when
possible, to provide the best estimate of the effect of electromagnetic stimulation to inform patient care and guide future
research in the area.
Materials and Methods
Search Strategy
wo reviewers independently 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). The electronic search was individually
tailored to each database in an attempt to maximize the sensitivity
of the search when identifying studies having terms relevant to
both electromagnetic fields and fracture-healing (see Appendix).
In addition, we reviewed the bibliographies of all retrieved
studies and other relevant publications, including reviews and
meta-analyses, to identify additional articles. The following seven
journals were hand-searched for citations published between
1980 and April 16, 2008, except in noted instances when journals
were created or discontinued within this time frame: Journal of
Bone and Joint Surgery (American and British Volumes), Clinical
Orthopaedics and Related Research, the Journal of Orthopaedic
Trauma, the Journal of Bioelectricity (1982-1991), Electro- and
Magnetobiology (1992-2001), and Electromagnetic Biology and
Medicine (2002-April 2008).

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sessed the quality of each eligible study. Queries pertaining to

methodology (i.e., randomization) were directed to the authors of the study if clarification was required.
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 protocol22. This approach classifies studies as
providing evidence that is of high, moderate, low, or very low
quality. The reviewers obtained consensus, with any discrepancies resolved by discussion or through the input of a third
reviewer.
Data Abstraction
Two reviewers extracted data 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. Authors of four trials18,20,23,24 were contacted
for additional clarification, with additional data provided for
two studies20,23.

Eligibility Criteria
Two reviewers independently applied eligibility criteria to the
methods section of each potentially eligible trial. Eligible trials met
the following criteria: (1) use of a random allocation of treatments;
(2) inclusion of patients presenting with a long-bone lesion; (3)
inclusion of a treatment arm receiving electromagnetism of any
waveform to impact bone-healing; (4) inclusion of a treatment
arm receiving no active intervention; and (5) report of the effect of
electromagnetic stimulation on direct bone-healing. Interim and/
or subset analyses of final trials published in full were excluded.
The reviewers obtained consensus on inclusion status,
with any discrepancies resolved by discussion or through the
input of a third reviewer.

Statistical Analysis
We determined interobserver agreement for the screening and
selection of articles and assessment of quality, with kappa coefficients. Landis and Koch25 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.
For each study describing bone union results, we calculated
the relative risk using the program RevMan26 and a continuity
correction factor of 0.25 to account for zero event rates. The effect
estimates were combined with use of the random effects method
of DerSimonian and Laird27, which is conservative in that they
consider both within-study and between-study differences in calculating the error term used in the analysis28. We examined heterogeneity using both the Cochran chi-square test (Cochran Q)
and the I2 statistic. Cochran Q is associated with a heterogeneity
p value, and values of 0.10 suggest that there is sufficient heterogeneity of treatment effects to preclude meaningful pooling
of trials. I2 represents the percentage of between-study variability
that is due to true differences between studies (heterogeneity)
rather than to sampling error (chance)29. We considered an I2
value of >50% to reflect substantial heterogeneity30. On the basis
of the results of previous research31, we hypothesized a priori that
variability between studies may be due to different technical
specifications of electromagnetic stimulation devices, varying
lengths of treatment, type of bone, or type of bone lesion treated.
To test this, we utilized a sensitivity analysis, which removes
studies with potentially unique characteristics from the metaanalysis to examine the effect on heterogeneity.

Assessment of Study Quality

Potentially eligible studies were obtained and read in full by
two independent reviewers who confirmed eligibility and as-

Results
e identified 2546 potentially eligible studies; thirty articles were retrieved in full text, and ten met our inclusion

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criteria. Two additional studies were identified through a

previously published systematic review32, and one of them was
found to be a duplicate publication33. Thus, eleven studies were
included in the final review (Fig. 1)18-21,24,34-39.
The chance-adjusted between-reviewer agreement (kappa)
on the application of study inclusion criteria to study titles and
abstracts was 0.57 (95% confidence interval, 0.51 to 0.63), reflecting the difficulty encountered in interpreting non-Englishlanguage abstracts. Good agreement was noted for inclusion after
full-text evaluation (kappa = 0.80; 95% confidence interval, 0.58
to 1.00) and for methodological assessment of included studies
(kappa = 0.80; 95% confidence interval, 0.71 to 0.88).
Three notable studies40-42 were excluded from our systematic review. Fourie and Bowerbank40 found no benefit of interferential currents on time to union in patients with fresh tibial
fractures relative to placebo. This intervention, which produces
muscle contractions, was sufficiently different from electromagnetic stimulation to warrant this studys exclusion. Livesley et al.41
found no benefit of high-frequency electromagnetic therapy over
placebo with regard to pain, strength, or shoulder range of
motion in patients with a minimally displaced humeral neck
fracture. Cheing et al.42 found that short-term ice and pulsed
electromagnetic stimulation therapy reduced pain and improved

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range of motion in patients with a distal radial fracture. Both of

these studies41,42 were excluded as they did not describe outcomes
directly related to bone-healing.
Description of Studies
The eleven included studies utilized electromagnetic stimulation
in a variety of long-bone lesions, including fracture nonunions18,19,34,
delayed fracture unions35, tibial stress fractures39, congenital
pseudarthroses36, fresh fractures20,21, limb-lengthening procedures38, and osteotomies24,37. A summary of these studies can be
found in a table in the Appendix. Electromagnetic stimulation
was preceded by surgery in six studies20,24,34,36-38, three of which
listed progression to weight-bearing in the treatment protocol24,36,37. The five studies in which electromagnetic stimulation
was used alongside nonoperative treatment all required full
immobilization of the limb. Six studies described results with
regard to the rate of bone union18-20,34,35,37.
Technical specifications and application of trial devices
varied. While most electromagnetic stimulation devices19,20,34-37
utilized dual external coils situated over the site of bone-healing
to generate an electromagnetic field, two studies21,24 used a single
coil placed perpendicular to the axis of the bone, one18 used a
single coil placed around the surface of the cast over the fracture

Fig. 1

Flow diagram for identification of randomized controlled trials (RCT) evaluating the effect of
electromagnetic (EM) stimulation on long-bone healing.

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TABLE I Assessment of Methodological Quality in Randomized Controlled Trials Evaluating the Effect of Electromagnetic Stimulation
on Long-Bone Healing
Blinding
Randomization
Method

Study

Allocation
Concealment

Patients

Surgeons

Outcome
Assessors

Intentionto-Treat
Analysis

Follow-up (%)

Additional
Study Limitations?

Delayed or
ununited
fractures
Barker
18
et al. (1984)

Minimization
procedure

Not described

Yes

Yes

Yes

No

Simonis
34
et al. (2003)

Random-number
table

Independent
team
member holding
randomization
list

Yes

Yes

Yes
(surgeon)

Not described

Scott and
19
King (1994)

Not described

Manufacturer
holding
randomization
list

Yes

Yes

Yes
(surgeon)

No

91%

None evident

Not described

Not described

Yes

Yes

Yes
(surgeon
and
radiologist)

No

88%

Younger patients in
active group (mean
age difference,
10.7 yr)

Not described

None

No

No

No

Not described

Random-number
table

None

No

No

No

Computer random
number list

Not described

Yes

Unclear

Sequential
distribution of
electromagnetic
stimulation with
randomly allocated
activity status

Manufacturer
holding
randomization list

Yes

Borsalino
24
et al. (1988)

Blocked
randomization table

Not described

Mammi
37
et al. (1993)

Computer
random-number
generator

Eyres
38
et al. (1996)

Not described

Sharrard
(1990)

35

94%

100%

Evidence
that control exposed
to some weak
electromagnetic fields
More smokers in
control group (81%)
than in intervention
group (44%)

Congenital
pseudarthrosis
Poli et al.
(1985)

36

100%

None evident

No

94%

None evident

Unclear

No

84%

Most outcomes
only reported for
subset of compliant
patients

Not
described

Yes

No

86%

None evident

Yes

Yes

Yes

No

97%

None evident

Not described

Yes

Yes

Yes
(surgeon)

No

93%

None evident

Not described

Yes

Yes

Yes
(surgeon)

Not described

Fresh fractures
Wahlstrom
(1984)
Betti et al.
(1999)

21

20

Stress fractures
Beck
39
et al. (2008)

Osteotomies

site, another38 used a saddle-shaped coil fitted around the limb,

and one39 delivered a capacitively coupled electric field with use
of two water-based electrodes. Eight trial devices produced

100%

Multiple limbs
analyzed for some
individually
randomized patients

pulsed electromagnetic fields with a reported frequency range of

15 to 75 Hz and a reported electromagnetic force of 0.0025 to
150 V, with one study21 that described an extremely low range,

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Fig. 2

Meta-analysis Forest plot of trials comparing electromagnetic stimulation and sham devices on the rates of long-bone union.

pulsed electromagnetic field frequency output (1 to 1000 Hz)

with a magnetic flux density of 4 G. Two devices delivered a
continuous sinusoidal wave at 60,000 Hz, with one19 having an
electromagnetic force of 5 to 10 V and another39 having an
electromagnetic force of 3 to 6 V and a current of 5 to 10 mA.
The trials had a wide variation in the duration that the electromagnetic stimulation was administered, ranging from four
to twenty-four hours a day over treatment periods of four to
seventy-six weeks.
Methodologically, the studies were of variable quality
(Table I). Nine studies18-20,24,34,35,37-39 described adequate blinding of patients and outcome assessors through the use of a
sham device in the placebo group, while two studies were unblinded21,36. All six studies18-20,34,35,37 that described the primary
outcome of bone union had blinded the patients to their allocation status. Two studies34,35 had imbalances within trials
that could favor the intervention, with one study34 having
more patients who smoked in the control group (81% in the
control group compared with 44% in the intervention group),
and the other35 having younger patients in the intervention
group. In one study18, there was some evidence that the control
group was exposed to small doses of pulsed electromagnetic
fields43, thus not truly representing placebo management. One
study 38 included multiple limbs from individual patients, resulting in the inappropriate use of multiple observations from
single individuals and potentially biasing the results44. One
study 20 described results only for a subset of compliant patients. Sample sizes in all of the included trials were modest.
No study appeared to describe or use an intention-to-treat
analysis; however, the rate of follow-up was typically high, with
84% to 100% of randomized patients included in all final
analyses.

Bone Union (Radiographic Outcomes)

Four studies18,19,34,35 that described 106 delayed unions or nonunions demonstrated an overall pooled relative risk of 1.76 (95%
confidence interval, 0.81 to 3.81; I2 = 60%; heterogeneity, p =
0.06) in favor of electromagnetic stimulation (Fig. 2, Table II).
However, as evidenced by the associated confidence interval,
which crosses 1, this effect failed to reach significance (p = 0.15).
Sensitivity analyses by type of bone (isolated tibia compared with
other) and lesion (nonunion compared with delayed union)
failed to explain heterogeneity (I2 = 64% and 62%, respectively).
Mammi et al.37 reported a nonsignificant relative risk of
2.81 (95% confidence interval, 0.88 to 8.98; p = 0.08) in favor of
electromagnetic stimulation in a comparison of union rates in
patients undergoing tibial reduction osteotomies. Betti et al.20
reported a nonsignificant relative risk of 1.26 (95% confidence
interval, 0.99 to 1.60; p = 0.06) in favor of electromagnetic stimulation in a comparison of union rates in patients with a femoral
neck fracture treated with osteosynthesis with three screws.
Clinical Outcomes
Barker et al.18 reported no differences in pain or tenderness
scores following twenty-four weeks of treatment with electromagnetic stimulation or a sham device for nonoperatively
managed tibial shaft nonunions. Sharrard35 also failed to show
a reduction in pain (p = 0.29) or tenderness (p = 0.18) in tibial
shaft nonunions treated only with electromagnetic stimulation
or a sham device. Betti et al.20 noted a significant reduction in
pain at day 30, 60, and 90 in patients with a femoral neck
fracture treated with three screw fixations (p < 0.01, 0.05, and
0.05, respectively), but these findings were based on a subgroup analysis of sixteen compliant intervention patients
who used the active device for more than six hours per day

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22

TABLE II GRADE Quality Assessment of Trials Comparing Electromagnetic Stimulation with Sham Devices to Impact Long-Bone Union
Rates in Delayed or Ununited Fractures
Summary of Findings
Treatment
(no. of patients)

Effect

Quality Assessment
Long-Bone
Fracture Union
(Measured as a
Binary Outcome)
Nonunion (three
18,19,34
)
studies
and delayed union
35
(one study )

Design

Quality

Consistency

Directness

Other
Modifying
Factors

Randomized,
controlled trials

Very
serious
limitations

Serious
limitations

Serious
limitations

Imprecise
data#

Electrom
agnetic
Stimulati
on

Sham Device

57

59

Relative
Risk* (95%
Confidence
Interval)
1.757
(0.812
to 3.805)

Quality
Very
low

Import
ance
Critical

*A 10.25 correction was added to account for a zero cell. Despite adequate blinding, studies had small sample sizes, lacked intention-to-treat
analysis, and had baseline differences in two studies, which could favor the intervention group, and evidence that the control group was exposed
43
to some electromagnetic stimulation in another study . There was an issue with consistency, as only three studies tended to favor intervention
and only two had significant differences. There was uncertainty about the directness of the study because of the heterogeneity of technical
specifications of the electromagnetic stimulator and the duration of stimulator use. #The data were considered imprecise because of wide
confidence intervals in two of the four studies.

and thirty-five control patients; no benefit of electromagnetic

stimulation was found on osteonecrosis rates or the need for
arthroplasty20. Beck et al.39 found no overall impact of electromagnetic stimulation on clinical (i.e., pain) or radiographic
injury severity in a group of patients with tibial stress fractures.
Poli et al.36 found no benefit of adjunctive care with electromagnetic stimulation for surgically managed pseudarthroses
on limb-length imbalance (relative risk, 0.43; 95% confidence
interval, 0.09 to 2.12; p = 0.30) or the need for reoperation
(relative risk, 0.14; 95% confidence interval, 0.01 to 2.28; p =
0.16). Wahlstrom21 found no benefit of electromagnetic stimulation on redisplacement rates in extra-articular Colles fractures in women compared with unblinded controls (53.3% for
active stimulation group and 46.7% for unblinded control
group; relative risk, 0.88; 95% confidence interval, 0.43 to 1.78;
p = 0.72).
Bone Densitometry
Eyres et al.38 explored the use of electromagnetic stimulation in
lengthening procedures in the lower limb and reported a statistical improvement in bone density within the intervention
group at twelve months in segments proximal to the osteotomy
relative to baseline values; however, this effect was not found to
differ significantly when we recalculated the standard error of
the mean as a standard deviation and compared both groups at
twelve months (118% 18.5% in patients treated with active
coils and 100% 22.0% in control subjects; p = 0.14). While
bone loss in the distal segment at twelve months was significantly reduced in the intervention group relative to the control
(mean and standard deviation, 13% 10.6% for intervention
and 46% 12.2% for control; p < 0.01), electromagnetic
stimulation had no significant impact on the quality of bone in
the distraction site (106% 25.9% of original bone mineral
density in the intervention group and 95% 36.7% of original

bone mineral density in the control group; p = 0.54), or on the

ratio of time until fixator removal to length achieved (mean
and standard deviation, 39 10.6 days/cm in the intervention
group and 44 14.7 days/cm in the control group; p = 0.49).
Borsalino et al.24 reported an increase in callus and trabecular bridging with electromagnetic stimulation in both the
medial and the lateral cortex at forty and ninety days, as well as
improved bone callus density at ninety days in patients undergoing a femoral intertrochanteric osteotomy. Wahlstrom21
utilized electromagnetic stimulation to supplement treatment
of extra-articular Colles fractures in women and noted a significant increase in the Q-ratio of scintimetric healing activity
at week 1 (mean and standard deviation, 23.9 6.4 in the
intervention group and 18.5 6.5 in the control group; p =
0.03) and week 2 (mean, 52.1 12.7 and 38.6 12.7, respectively; p < 0.01) of fracture-healing. This result, however,
was not significant at weeks 4 or 8.
Discussion
ur systematic review 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; and (5) bone density is
improved in patients undergoing femoral intertrochanteric
osteotomy and is variably impacted in lengthening procedures

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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 fracture-healing32,45,46, each of
which suggested a favorable impact on bone-healing with adjuvant electromagnetic stimulation therapy. A major difference
in one review 32 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 fusions47. Another review46 erroneously excluded the negative trial
by Barker et al.18 after assuming it was an interim report of a
study later published by Sharrard35. Contact with the author of
the first trial18 confirmed that these are two different studies
with two unique patient groups. Lastly, inconsistencies between
the findings of another review45 and our data are thought to be
due to our inclusion of additional studies as well as the recalculation and reinterpretation of original data. For example,
of the six trials that noted rates of union, five19,20,34,35,37 described
outcomes favoring electromagnetic stimulation in their original publication. However, we determined the results of three
studies19,20,37 to be not significant when we recalculated relative
risks (and 95% confidence intervals). For one study19, this was
explained through differing statistical analyses (i.e., the Fisher
exact test compared with relative risk). For another20, this was
explained by an intention-to-treat analysis utilized in our reanalysis but not in the original analysis. The third study 37 utilized
a four-tier measure of bone-healing (i.e., the osteotomy line
was clearly evident on anteroposterior and lateromedial radiographs; cortical bridging in <50% of the osteotomy line;
cortical bridging over >50% of the osteotomy line; and complete
union), which we converted into a binary measure of bone
union prior to recalculating the relative risk.
A recent survey of 450 Canadian trauma surgeons (with
a response rate of 60%) found that 45% were currently making
use of bone growth stimulators as part of their management
strategy for at least some tibial shaft fractures48. Of these, the proportion endorsing electromagnetic stimulation and low-intensity
pulsed ultrasound was equivalent. Although electromagnetic
stimulation has been evaluated in multiple randomized trials
of delayed unions and nonunions, our analysis indicates that
current evidence provides little justification for the relatively
high clinical use of electromagnetic stimulation for fracturehealing.
Strengths and Limitations
Our study is strengthened by a comprehensive search of articles in any language, duplicate assessment of study quality, and
inclusion of only randomized trials. Nonetheless, the analysis
has limitations. Our data pooling was based on low-quality
evidence, and the associated heterogeneity was not explained
by our sensitivity analyses. We believe that this heterogeneity
might be explained by the diverse technical specifications of
electromagnetic stimulation devices used in trials and/or the
differing durations of treatment. This diversity of technological
specifications within clinical trials of electromagnetic stimu-

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lation has been identified by other researchers31 and within

other systematic reviews32,47. Because of the small number of
diverse trials, we were unable to explore these potential sources
of heterogeneity through a sensitivity analysis. Our findings
do, however, echo the call for greater standardization of devices
and treatment protocols within studies evaluating electromagnetic stimulation.
Relevance of Our Findings
Bone growth stimulators in the management of fresh fractures,
long-bone nonunions, and spinal fusions represent a market of
$500 million per year in the United States49. Current estimates
suggest that low-intensity ultrasound and electrical stimulation
maintain an equal market share47. In an era of evidence-based
orthopaedics, health-care providers should base patient care
on the best available evidence, maintaining sensitivity to the
costs and consequences of adjunctive fracture-healing therapies.
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. Both
researchers and bone-stimulation device manufacturers should
direct appropriate research funding to better inform the potential role of electromagnetic stimulation in fracture-healing
with appropriately powered, well-designed clinical trials with
use of important patient outcomes such as functional improvement and the need for revision surgery.
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.
Appendix
Details of the search strategy and a table summarizing the
trials evaluated in this study are available with the electronic versions of this article, on our web site at jbjs.org (go to
the article citation and click on Supplementary Material)
and on our quarterly CD/DVD (call our subscription department, at 781-449-9780, to order the CD or DVD). n
NOTE: The authors thank Dr. Erhard W. Busse, Alisa Eichelberger, Michael Lau, Joseph Catapano,
and Sharka Joskova for their aid in article translation. They also thank Drs. Ruggero Cadossi,
Andrew A. Marino, and Anthony T. Barker for responding to our queries or providing us with raw data
for use in this review.

Brent Mollon, BHSc

37 Perkinsfield Street, Whitby, ON L1N 8J5, Canada
Vitor da Silva, BMSc
28-410 Ambleside Drive, London, ON N6G 4Y3, Canada
Jason W. Busse, DC, MSc
Mohit Bhandari, MD, MSc
CLARITY Research Group, Department of Surgery,
McMaster University, 293 Wellington Street North,

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Suite 110, Hamilton, ON L8L 8E7, Canada.

E-mail address for M. Bhandari:
bhandam@mcmaster.ca

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Thomas A. Einhorn, MD
Boston University Orthopaedic Surgical Associates, 720 Harrison Avenue,
Suite 805, Boston, MA 02118

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