Orthopedics

The articles prior to January 2013 are part of the back file collection and are not available with a current paid subscription. To access the article, you may purchase it or purchase the complete back file collection here

Review 

TREATMENT OF UNUNITED TIBIAL FRACTURES: A COMPARISON OF SURGERY AND PULSED ELECTROMAGNETIC FIELDS (PEMF)

Harry R Gossling, MD; Richard A Bernstein, MD; Joan Abbott, PhD

Abstract

ABSTRACT

The use of pulsed electromagnetic fields (PEMF) is gaining acceptance for the treatment of ununited fractures. The results of 44 articles published in the English language literature have been compiled to assess the effectiveness of PEMF vs surgical therapy. For ununited tibial fractures, 81% of reported cases healed with PEMF vs 82% with surgery. After multiple failed surgeries, the success rate of PEMF is reported to be greater than with surgery; this discrepancy increases with additional numbers of prior surgeries. In infected nonunions, the results of surgical treatment decreased by 21% and were less than the results utilizing PEMF (69% vs 81%). In open fractures, surgical healing exceeded PEMF (89% vs 78%), whereas in closed injuries PEMF cases healed more frequently (85% vs 79%). In general, PEMF treatment of ununited fractures has proved to be more successful than noninvasive traditional management and at least as effective as surgical therapies. Given the costs and potential dangers of surgery, PEMF should be considered an effective alternative. Experience supports its role as a successful method of treatment for ununited fractures of the tibia.

Abstract

ABSTRACT

The use of pulsed electromagnetic fields (PEMF) is gaining acceptance for the treatment of ununited fractures. The results of 44 articles published in the English language literature have been compiled to assess the effectiveness of PEMF vs surgical therapy. For ununited tibial fractures, 81% of reported cases healed with PEMF vs 82% with surgery. After multiple failed surgeries, the success rate of PEMF is reported to be greater than with surgery; this discrepancy increases with additional numbers of prior surgeries. In infected nonunions, the results of surgical treatment decreased by 21% and were less than the results utilizing PEMF (69% vs 81%). In open fractures, surgical healing exceeded PEMF (89% vs 78%), whereas in closed injuries PEMF cases healed more frequently (85% vs 79%). In general, PEMF treatment of ununited fractures has proved to be more successful than noninvasive traditional management and at least as effective as surgical therapies. Given the costs and potential dangers of surgery, PEMF should be considered an effective alternative. Experience supports its role as a successful method of treatment for ununited fractures of the tibia.

It has been estimated that of the 2 million cases of long bone fractures each year in the United States, 100 000 nonunions and an even larger number of delayed union fractures are generated.' The classical treatment for nonunions has been bone grafting, usually in some combination with internal fixation.

Only Within the last 10 years has electricity become an orthopedic option as an adjunct or an alternative to surgery in the treatment of ununited fractures.2"6 The early pioneering work of Fukada and Yasuda7 demonstrated the piezoelectric nature of bone and the relationship between electricity and callus formation. These discoveries went largely unnoticed until independently confirmed by Bassett and Becker,8 who demonstrated the presence of stress-generated potentials in bone. In vitro studies also confirmed that osteogenesis could be modulated biomechanically,9·10 suggesting that Wolffs law operated through an electrical mechanism.

Further evidence of the piezoelectric properties of bone was reported by Shamos et al," and direct current stimulation of bone growth in vivo in controlled experiments was reported by Bassett et al.'2 Friedenberg and Brighton13 were the first to demonstrate endogenous bioelectric potentials in unstressed bone which when fractured showed an electronegative peak at the fracture site.

It can be simply stated that during normal fracture repair there is an intermediate step prior to bony union in which fibrocartilage bridges the fracture gap. This tissue must be calcified before vascular invasion and trabecular bridging can occur.14 In the absence of calcification, the healing process stalls in this fibrocartilaginous stage and a nonunion results. Several different conditions can lead to this state: a large fracture gap, inadequate immobilization, malaligned fracture ends, infection, or lack of appropriate vascular resources. Any successful therapeutic method must stimulate a calcification of the fibrocartilage. Once this is accomplished the final healing stages can take place. When distraction or wide separation is present the fracture gap may be filled with fibrous tissue.

A substantial body of literature has been published concerning the effects of pulsed electromagnetic fields (PEMF) on calcium metabolism and bone healing.5,15 Studies have shown that electromagnetic fields influence vascularization of fibrocartilage, cell proliferation, and enzyme, hormone, and matrix production. Cellular responsiveness to PEMF has been traced to the influence on me nuclear production of mRNA, the governing messenger of protein synthesis and cellular metabolism.16,17 The primary cellular location for transduction of this very low level electrical energy is not known, although there is increasing evidence that the cell membrane plays an important role in some responses.18"23

Stimulation of bone growth using electrically induced fields has steadily evolved since its inception. Four methods have been developed for applying electricity for the treatment of ununited fractures:

* Semi-invasive direct current in which cathodes are inserted percutaneously into the fracture gap with the anode in contact with the skin,3,4,24

* Invasive direct current in which the generator and anode are both implanted,25,26

* A non-invasive capacitively coupled electric field in which two conductive plates are in contact with the skin,27 and

* Another noninvasive method using PEMF that are generated by pulsed asymmetric currents driven through an externally attached coil, which induces low level currents in the fracture site.2,3

While each method is distinct, they have in common the production of low level electrical currents in tissue. The current review focuses on the fourth methodology using non-invasive PEMF.

MATERIALS AND METHODS

A thorough search of the English literature from 1977 to 1987 was performed using the Medline (MESH/MS81) system. Key descriptor words used in the Medline search were: delayed, nonunion, nonunion, electromag, electrostim, electric, direct current, ununited, and stimulate. From the larger number of studies reviewed, a subset of papers with data on tibias were selected for inclusion if adequate data were retrievable for analysis. Tb our knowledge, they are all inclusive, and are not biased by any one clinical condition or surgical procedure.

Data on the following parameters were used in the study: number of fractures, age of fracture, number of previous surgical procedures, number of fractures that healed, time to heal, infection, and whether the original fracture was open or closed.

No consensus exists about what constitutes an "ununited fracture" as compared to a "nonunion." In this review the classification depends on the judgment of the physician reporting the study. As a result, the age of the fracture from initial injury as described for delayed unions will overlap considerably with that for nonunions. In our terminology, the use of "ununited fracture" refers to both delayed and nonunion fractures.

RESULTS

Tibial Ununited Fractures. Fourteen articles reported on primary surgical treatment and 28 on PEMF treatment of tibial ununited fractures. Data from each article are presented in Tables 1 and 2 and summarized in Table 3. The overall success rate for surgical treatment of 569 ununited tibial fractures was 82% (range: 70% to 100%). When separated according to the authors' definitions, 90% (range: 77% to 100%) of nonunions healed, 79% (range: 70% to 94%) of delayed unions healed, and 75% healed of those whose fractures were not defined as either delayed or nonunion.

In nonunions treated surgically, the age of the fracture ranged from 4 months to 5 years, with successful healing occurring from 2 to 18 months. For delayed unions, fracture age ranged from 4 to 18 months and the healing time from 1.5 to 16 months.

In the absence of further surgery, the overall success rate for PEMF treatment of 1718 tibial ununited fractures was 81% (range: 13% to 100%). The average success rate was 80% (range: 67% to 96%) for 817 nonunions alone; 90% (range: 86% to 100%) for delayed unions; and 81% (range: 13% to 82%) for the 843 fractures not specified as either delayed or nonunions. The disability times of the PEMF healed tibial nonunions ranged from 4 months to 37 years and the time to heal from 2 to 20 months. The age of delayed unions ranged from 6 to 14 months and the time to heal from 2 to 20 months. Most patients had more than one failed surgical procedure prior to PEMF treatment (Tables 1-2).

Successive Surgical Procedures. Although the success rate for primary surgery on ununited fractures is high, the heal rates drop dramatically as successive surgeries are performed (Table 4). Boyd et al,28 reporting on 842 nonunions of long bones, showed that the initial success rate of 88% dropped to 66%, 64%, and 50% for the second, third, and fourth surgeries respectively. ZumBrunnen and Brindley29 reported that 123 nonunions of long bones showed a successive drop in healing from 85% to 70% to 33% for the first, second, and third respective surgical procedures. Showing similar results, Brodersen and Sim30 reviewed 163 tibial nonunions and reported that the first three surgical attempts gave 70%, 67%, and 71% success rates, respectively, with a drop to 39%, 50%, 25%, and 33% for the fourth, fifth, sixth, and seventii surgeries. In contrast to the drop in success rates for successive surgical procedures, die studies of Bassett et al,31 Rinaldi et al,32 and Sedei et al33 strongly suggest that the number of previous surgeries does not significantly affect the success rate of PEMF to heal tibial nonunions.

Table

Table 1SURGICAL TREATMENT OF TIBIAL UNUNITED FRACTURES

Table 1

SURGICAL TREATMENT OF TIBIAL UNUNITED FRACTURES

"Controlled" Studies with PEMF. Five studies on tibial fractures attempted to establish control groups to compare dieir results using PEMF to other modalities (Table 5). The most convincing evidence for PEMF efficacy comes from Sharrard's34 double blind study on 45 difficult tibial delayed unions. Both placebo and PEMF treated groups were carefully matched for age, sex, weeks from injury, and fracture status (infection, open fracture, comminution, etc). After 12 weeks of treatment, healing was assessed radiologically and clinically. Significandy more PEMF treated fractures had progressed toward healing (45%) tiian placebo treated fractures (12%). This was statistically significant at P =.04, using a 3 X 2 chi-squared test.

In contrast, an earlier double blind trial35 reported finding no efficacy in PEMF treatment of nonunion fractures. However, in this study there were only 16 patients with an uneven distribution of difficult fractures. Furthermore, the placebo group possessed a small but potentially active PEMF signal generated by the placebo apparatus.36,37 Even Sharrard,36 a coinvestigator in this trial, agreed that the trial was not adequate to prove PEMF ineffective.

In the four otiier "controlled" studies described in Table 5, PEMF showed a beneficial effect when compared to, or combined with, surgery or cast immobilization. In a study of 40 nonunions, DeHaas et al38 reported that the healing rate of the PEMF treated group (88%) was equal to if not better than the heal rate of bone grafted (83%) fractures. In another study, Bassett et al31 claimed that whereas cast immobilization treatment for 4 months showed no progress with 22 highly recalcitrant tibial nonunions, PEMF subsequently healed 1 8 of them in 4 to 10 months, with signs of healing appearing within the first month of treatment.

Table

Table 2PEMF TREATMENT OF TIBIAL UNUNITED FRACTURES

Table 2

PEMF TREATMENT OF TIBIAL UNUNITED FRACTURES

Infection. Results available on heal rates of infected ununited tibial fractures are limited to 10 studies using PEMF treatment and eight using surgical techniques (Table 6). In surgically treated ununited fractures, the heal rate in the infected population is 21% lower than the heal rate in the non-infected population (69% vs 90%), whereas in PEMF-treated fractures the infected heal rate was only 6% lower than the non-infected rate (81% vs 87%). These data indicate that treatment of infected ununited tibial fractures with PEMF yields results at least equivalent to, if not better than, results of treatment by surgery.

Closed vs Open Fractures. Only 10 studies were available that presented data on open and closed tibial ununited fractures - four with surgical treatment and six with PEMF (Table 7). The rate of healing for open fractures was 89% for surgery and 78% for PEMF In closed fractures, PEMF stimulated 85% healing vs 79% in surgically treated cases. It should be noted that all surgical results were derived from primary surgeries on ununited fractures, whereas most PEMF-exposed patients had had multiple surgeries prior to initiation of treatment.

Fracture Location. There was insufficient data in the literature to discuss the implication of fracture location on healing rates for ununited tibial fractures.

DISCUSSION

Bone is a tissue that has osteolytic and osteogenic potential and is subject to regulatory mechanisms which will modify bone mass and local bone response to a variety of conditions (eg, increase or decrease in mechanical stress patterns by Wolffs law). A widely held hypothesis - for which there is considerable evidence - is that small electric currents in bone, generated in response to mechanical stress, initiate changes in the local bone environment, causing osteoblasts and osteoclasts to increase or decrease their activity.5 Although little is understood about how this electrical energy is transduced at the cellular level, there is increasing information that one location of action may be at the cell membrane.

Parathyroid hormone (PTH) is a well known osteoclastic stimulator. Luben and Cain23 have shown that the PEMF signal used to heal nonunions blocks the PTH-stimuIated calcium loss from mouse calvariae in vitro. It also appears to block the rise in cyclic adenosine mono-phosphate (cAMP) normally associated with PTH-stimulation of osteoblasts.22

The rise in cellular cAMP stimulated by PTH depends on the interaction between three elements of a membrane complex - -a receptor protein, the N-protein, and the enzyme adenylate cyclase. As the result of a series of elegant experiments, Luben, Cain, and others19,21,23 suggest that a likely target for PEMF action is at the N-protein level, affecting its interaction with adenylate cyclase. Luben21 demonstrated that PEMF induces the reduction of a specific molecular moiety making up part of the membrane receptor for PTH. This could potentially prevent the transmission of the hormone stimulatory activity across the membrane.

Another hormone, osteoclast activating factor (OAF), acts first on osteoblasts which in turn affect the activity of adjacent osteoclasts, resulting in increased osteolytic activity. OAF activity is transduced via increased c AMP production, and PEMF also blocks this stimulation22 presumably via the same membrane mechanism as for the PTH stimulation of cAMP. There are several other hormones and growth factors known to affect bone metabolism, with estrogen being the best known. Effects of PEMF on their action have not, as yet, been explored.

Table

Table 3SUMMARY OF SUCCESS RATES FOR SURGICAL AND PEMF TREATMENT OF UNUNITED FRACTURES OF THE TIBIA*

Table 3

SUMMARY OF SUCCESS RATES FOR SURGICAL AND PEMF TREATMENT OF UNUNITED FRACTURES OF THE TIBIA*

Farndale et al2ü reviewed ion transport in the cell membrane and the direct and indirect effects of PEMF on ionic flow. Whereas others have felt that PEMF acts di reedy on these channels, Farndale concluded that the effect of ion flow is secondary. In summary, it can be fairly stated that PEMF does induce a biological effect in bone tissue. Although this effect is not yet completely understood, recorded clinical experience supports a positive role in stimulating fracture healing.

The data presented in this article suggest that the success rates of primary surgery and PEMF treatment of ununited tibial fractures are essentially equivalent (Table 3). These findings are even more significant when one considers that in the past PEMF was most often used to treat highly recalcitrant nonunions after multiple failed surgeries. Several large studies in which 75% to 80% of the ununited fractures had had one or more failed surgical procedures reported an overall heal rate of 70% to 80% (Garland DE, Salyer W, Zoltan J. Treatment of nonunions with electromagnetic stimulation (PEMF). Submitted for publication j.39"4'

Whereas the success rate for surgeries for nonunions and delayed unions declines with each surgery, the effectiveness of PEMF still remains high. Even when PEMF-treated fractures at all sites are analyzed, the overall success rates range from 70% to 80% (Garland DE, Salyer W, Zoltan J. Treatment of nonunions with electromagnetic stimulation (PEMF). Submitted for publication).39"43 There is preliminary evidence to suggest that the success rate of bone grafted ununited fractures can be enhanced when combined with PEMF treatment.44"46 Being a non-invasive technique, PEMF spares the significant associated risks from anesthesia, wound hematoma, infection, bone length loss, or skin breakdown. After multiple operations in the same anatomic location, especially in the distal tibia, the potential of soft tissue complications increases. Reconstructing and grafting of nonunions are formidable surgical challenges often requiring prolonged operative times and potentially lengthy hospital stays.

Table

Table 4HEAL RATES OF SURGERY AND PEMF AFTER SUCCESSIVE PROCEDURES ON UNUNITED FRACTURES

Table 4

HEAL RATES OF SURGERY AND PEMF AFTER SUCCESSIVE PROCEDURES ON UNUNITED FRACTURES

Table

Table 5CONTROLLED CLINICAL STUDIES OF PEMF STIMULATION OF UNUNITED FRACTURES

Table 5

CONTROLLED CLINICAL STUDIES OF PEMF STIMULATION OF UNUNITED FRACTURES

In addition to the two reports of double-blind trials using PEMF to treat ununited fractures, there have been other double-blind studies reporting effects of PEMF in the treatment of intertrochanteric osteotomies,47 rotator cuff tendonitis,48 humeral epicondylitis,49 and skin lesions.50 All of these show statistically significant positive effects associated with PEMF (/><.05 or less).

Nonunions in the strictest sense are fractures in which me processes of repair are arrested, as in a synovial pseudarthrosis or when tissue in the fracture region no longer manifests biochemical characteristics associated with repair. From clinical experience, it is clear that PEMF is not effective in healing nonunions when a synovial pseudarthrosis is present, the fracture exceeds 5 mm, or when the fracture is not adequately immobilized.3 Even when these patterns are absent, there are still some fractures that remain unresponsive to PEMF but which cannot be distinguished radiographically from those competent to respond.

Gossling et al51 investigated the cellular basis for responsiveness to PEMF by analyzing biopsies of the fracture gap tissue. They have found drat the presence of fibrocartUage (glycosaminoglycan or fibrous stroma with alkaline phosphatase present) is correlated with responsiveness to PEMF leading to bony union. Presence in the fracture gap of dense fibrous tissue lacking these osteogenic biochemical markers is correlated with unresponsiveness to PEMF. Although biopsy of ununited fractures is not general medical practice, there could be difficult surgical situations when it would be appropriate to determine whether a fracture had a good chance of responding to the non-invasive PEMF treatment.

SUMMARY

Tibia fractures are common injuries mat are prone to proceed to delayed or nonunion. The usual approach to treatment has been surgical intervention with stabilization and/or bone graft. The advent of electrical stimulation of ununited fractures has opened new opportunities for treatment. Various types of electrical stimulation have been shown to be successful in achieving bony union. The most popular modality to induce an electrical stimulation at die fracture gap has been PEMF. This review compares reported success of surgical vs PEMF treatment of ununited fractures of die tibia. PEMF appears equal to or more effective than surgery in achieving union of delayed and nonunion tibial fractures.

The designation of an ununited fracture as a delayed nonunion is usually made on the basis of radiographic evidence and time from fracture, and there is considerable variation in the way the terms are used. PEMF therapy is not indicated for ununited fractures in which the repair tissues are absent, as in synovial pseudarthrosis. The biological activity of a fracture gap may be defined by biopsy. When biochemical markers for osteogenesis are lacking in the fracture gap tissue, surgical tiierapies are indicated to obtain union.

Experience with PEMF has been established as an effective non-invasive technique for fracture treatment. Given the absence of reported complications and high efficacy in both tibial and scaphoid fractures, PEMF should be considered an appropriate treatment option for ununited fractures.

Table

Table 6INFECTED UNUNITED TIBIAL FRACTURES: PEMF VS SURGICAL TREATMENT

Table 6

INFECTED UNUNITED TIBIAL FRACTURES: PEMF VS SURGICAL TREATMENT

Table

Table 7CLOSED AND OPEN UNUNITED TIBIAL FRACTURES: PEMF VS SURGICAL TREATMENT

Table 7

CLOSED AND OPEN UNUNITED TIBIAL FRACTURES: PEMF VS SURGICAL TREATMENT

REFERENCES

1. Heppeostcll RB. cd. Fracture Treatment and Healing. Philadelphia, Pa: W.B. Saunders Co; 1980.

2. Bassen CAL. The development and application of pulsed electromagnetic fields (PEMF) for ununited fractures and arthrodeses. Orthop Clin North Am. 1984; 15(l):61-87.

3. Bassett CAL. The electrical management of ununited fracturcs. In: Gossling HR. Pillsbury SL, eds. Complications tf Fracture Management. New York. NY: J.B. Lippincott Co; 1984:9-39.

4. Brighton CT. The semi-invasive method of treating nonunion with direct current. Orthop Clin North Am. 1984: 15(1 ): 33-45.

5. Brighton CT. McCluskey WP. Cellular response and mechanisms of action of electrically induced osteogenesis. In: Peck WA, ed. Bone and Mineral Research, New York. NY: Elsevier Science Publishers; 1986:213.

6. Singh S. Katz JL. Scientific basis of electro-stimulation. J Bioeieciricity 1986; 5:285.

7. Fukada E. Yasuda I. On the piezoelectric effect in bone. J Phys Soc Japan. 1957; 12:1158.

8. Bassett CAL, Becker RO. Generation of electric potentials by bone in response to mechanical stress. Science. 1962: 137:1063.

9. Bassett CAL. Hermann I. Influence of oxygen concentration and mechanical factors on differentiation of connective tissues in vitro. Nature. 1961: 190:460.

10. Bassett CAL. Electrical effects in bone. Scientific American. 1965; 213:18.

11. Shamos MH, Lavine LS, Shamos Ml. Piezoelectric effect in bone. Nature. 1963; 197:81.

12. Bassett CAL. Pawluk RJ, Becker RO. Effects of electric currents on bone formation in vivo. Nature, 1964; 204:652.

13. Friedenberg ZB, Brighton CT. Bioelectric potentials in bone. J Bone Joint Surg. 1966; 48A-.9I5.

14. Bassett CAL. Biology of fracture repair, nonunion and pseudarthrosis. In: Gossling HR, Pillsbury SL, eds. Complications tf Franare Management. New York. NY: IB. Lippincort Co; 1984:18.

15. Black J. Electrical Stimulation. New York. NY: Pracger; 1987.

16. Goodman R, Henderson A. Exposure of salivary glands to low-frequency electromagnetic fields alters polypeptide synthesis. Prov Natl Acad Sci USA. 1988; 85:3928-3932.

17. Goodman R. Bassett CAL. Henderson AS. Pulsing electromagnetic fields induced cellular transcription. Science. 1 983; 220: 1 283.

18. Cain CD, Luben RA. Pulsed electromagnetic field effects on PTTLstimulated cAMP accumulation and bone resorption in mouse calvaría. In: Anderson LE. Kelman BJ, Weigcl RJ. eds. Interaction of Biological Systems with Static and ELF Electric and Magnetic Fields. Proceedings of 23rd Han ford Life Sciences Symposium, October 2-4. 1984. Conf. 84. pp 269-278.

19. Cain CD, Luben RA. Pulsed electromagnetic field modifies cAMP metabolism and ornithine decarboxylase activity in primary bone cells. In: International Conference on Electric and Magnetic Fields in Medicine and Biology Conf. Pubi. No. 257. Institute of Electrical Engineers. London and New York. 1985:9-13.

20. Pamdale RW, Maraudas A. Marsland TP. Effects of lowamplitude pulsed magnetic fields on cellular ion transpon. Bioelectromagnelics. 1987:8:119.

21. Luben RA. Gene Expression of Parathyroid Hormone (PTHI Receptors and Functionally Related Antigens in Bone Cells: Desensitiztaion with Hormones and Electromagnetic Fields (EF). The Bioelectromagnetie Society Tenth Annual Meeting Abstracts. June 19-23, Stanford, Conn. 1988:20-21.

22. Luben RA. Cain CD. Chen MC. Rosen DM, Adey WR. Effects of electromagnetic stimuli on bone and bone cells in vitro: inhibition of responses to parathyroid hormone by low-energy, low frequency fields. Proc Natl Acad Sci. 1982: 79:4180.

23. Luben RA. Cain CD. Use of bone cell hormone response systems to investigate bioelectromagnetic effects of membranes in vitro. In: Adey WR. Lawrence AE eds. Non-Linear Electrodynamics in Biological' Systems. New York. NY: Plenum Press; 1984:23-33.

24. Forsted DL. Murray KD, Mitchell E. Brighton CT. Alavi A. Radiologic évaluation of the treatment of nonunion of fractures by electrical stimulation. Radiology. 1978; 128:629.

25. Dwyer AF. Wickam GG. Direct current stimulation in spinal fusion. Med J Ausi. 1974; 1:73.

26. Paterson DC. Lewis GN. Cass CA. Treatment of delayed union and nonunion with an implanted direct current stimulator. Clin Orthop 1980: 148:117-128.

27. Brighton CT. Pollack SR. Treatment of recalcitrant non-union with a capacilively coupled electrical field. A preliminary report. J Bone Joint Surg. 198S; 67A:577-585.

28. Boyd HB, Lipinski SW. Wiley JH. Observations of nonunion of the shafts of the long bones, with a statistical analysis of 842 patients. J Bone Joint Surg. I%! : 43A: 159-168.

29. ZumBrunnen JL. Brindley HH. Nonunion of the shafts of the long bones. A review and analysis of 140 cases. JAMA. 1968; 203:121-124.

30. Brodersen MP. Sim FH. Surgical management of delayed union and nonunion of the tibia. Orthopedics. 1981: 4:1361-1368.

31. Bassett CAL. Mitchell SN. Gaston SR. Treatment of ununited tibial diaphyseal fractures with pulsing electromagnetic fields. J Bone Joint Surg. 1 98 1 : 63 A:5 1 1 -523.

32. Rinaldi E. Negri V, Marenghi P. Braggion M. Treatment of infected pseudarthrosis of me inferior limb with low-frequency pulsing electromagnetic fields: report of 16 cases. J Bioeieclricity. 1985:4:251-264.

33. Sedei L, Christel P. Duriez R. et al. Results of nonunion treated by pulsed electromagnetic field stimulation. Acta Orthop Scand. 1982: I96(suppl):8l.

34. Sharrard WJW. A double blind trial of pulsed electromagnetic fields for delayed union of tibial fractures. J Bone Joint Surg. 1990; 72B:347-355.

35. Barker AT, Dixon RA, Sharrard WJW, Sutcliffe ML. Pulsed magnetic field therapy for tibial nonunion. Interim results. Lancet. 1984:8384:994-996.

36. Sharrard WJW. Reply to O'Connor and Leavay. Lancet, 1984;8395:171-172.

37. O'Connor BT. Pulsed magnetic field therapy for tibial nonunion (letter). Lancet. 1984; 2(8395): 17 1-172.

38. DeHaas WG. Watson J. Morrison DM. Noninvasive treatment of ununited fractures of the tibia using electrical stimulation. J Bone Joint Surg. 1980; 62B:465-470.

39. Bassen CAL. Mitchell SN. Gaston SR. Pulsing electromagnetic field treatment in ununited fractures and failed arthrodeses. JAMA. l982;247(5):623-628.

40. Mcskens M. Stuyck J. Mulicr JC. Treatment of delayed union and nonunion ?? the tibia by pulsed electromagnetic fields. A retrospective follow up. Bull Hasp Jt Dis. 1988: 48:170-175.

41. Bassett CAL. Pilla AA. Mitchell SN. Norton L. Repair ?G nonunions by pulsing electromagnetic fields. Acta Orthop BeIg. 1978;44:706.

42. Hinsenkamp M. Ryaby J. Burny F. Treatment of nonunion by pulsing electromagnetic field: European muldcenter study of 308 cases. Reconstr Surg Traumatol. 1985; 19:147.

43. Goldberg AAJ. Gaston SR. Ryaby JP. Transactions ?G the Second Annual Meeting of the Bioelectrical Repair and Growth Society. Oxford. UK. Aztec Business Systems. Inc. Bala Cynwyd. Pa. September 20-22. 1 982; 2:61.

44. Fontanes) G, Giancecchi F, Rotini R. Pseudarthrosis treatment with cancellous bone grafts and low frequency pulsing electromagnetic fields. J Bioeieclricity. 1 985; 4Í I ): 1 03.

45. DeHaas WG. Beaupré A. Cameron H. English E. The Canadian experience with pulsed electromagnetic fields in the treatment of ununited tibial fractures. Clin Orthop 1986: 208:55.

46. Dunn AW, Rush GA. Electrical stimulation in treatment of delayed union and nonunion of fractures and osteotomies. South Med J. 1984:77:1530-1534.

47. Borsalino G. Bagnacani M. Bettati E, et al. Electrical stimulation of human femoral intertrochanteric osteotomies. Doubleblind study. Clin Orthop 1988; 237:256-263.

48. Binder A. Parr G, Hazelman B. Fitton-Jackson S. Pulsed electromagnetic field therapy of persistent rotator cuff tendinitis. A double-blind controlled clinical assessment. Lancet. 1984. pp 695698.

49. Devereaux MD, Hazelman BL. Thomas PP. Chronic lateral humeral epicondylitis - a double-blind controlled assessment of pulsed electromagnetic field therapy. Clin Exp Rheum. 1985; 3:333-336.

50. Jeran ME. Bagnacani J. Zaffino S. Morali A. Cadossi R. Effect of Low Frequency Pulsing Electromagnetic Fields on the Healing of Skin Lesions of Various Origin; A Double Blind Study. Transactions of the Seventh Annual Meeting of the Bioelectrical Repair and Growth Society. Toronto, Canada. Syracuse Copy Center. Syracuse. NY. October 1 1-14. 1987; 7.

51. Gossling HR. Kromplinger WJ. Broom MJ. Fracture gap biopsy as a predictor of response to PEMF. In: Current Status tf Electricity in the Clinical Sciences. Course sponsored by University of Connecticut Health Center Department of Orthopaedic Surgery, April 18-19, 1985. pp 18-19..

52. Mandt PR. Gershuni DH. Treatment of nonunion of fractures in the epiphyseal-metaphyseal region of long bones. J Orthop Trauma. 1987; 1:141-151.

53. Green SA. Daval TA. The open bone graft lor septic nonunion. Clin Orthop 1983; 180:117.

54. Clancey GJ, Winquist RA, Hansen ST. Nonunion of the tibia treated with Kuntscher intramedullary nailing. Clin Orthop 1982: 167:191-196.

55. Gershuni DH. Pinsker R. Bone grafting for nonunion of fractures of the tibia: a critical review J Trauma. 1982; 22( I );43-49.

56. DcLee JC. Heckman JD. Lewis AG. Partial fibuleetomy for ununited fractures. J Bone Joint Surg. 1 981 ; 63 A: 1 390.

57. Tauber C. Horns/.owski H, Farine 1. Delayed union and nonunion of tibial shaft fractures. Orthop Rev. 1981: 9:31-40.

58. Bernhang AM, Lazarus JL. The use of Lotte's nail in nonunion of the tibia. Orthop Rev. 1980; 9:53-56.

59. Reckling FS. Waters CH. Treatment of nonunion of fractures of the tibial diaphysis by posterolateral cortical cancellous bonegrafting. J Bone Joint Surg. 1980; 62A:936.

60. Muller ME. Thomas RJ. Treatment of nonunion in fractures of long bones. Clin Orthop 1979; 138:141.

61. Rosen H. Compression treatment of long bone pseudarthroses. CHn Orthop 1979: 138:154.

62. Freeland AE. Mutz SB. Posterior bone grafting for infected ununited fracture of the tibia. J Bone Joint Surg. 1976: 58A:653.

63. Sakellarides HT. Freeman PA, Grant BD. Delayed union and nonunion of tibiul-snaft fractures: a review of 100 cases. J Bone Joint Surg. 1964;46A:557-569.

64. Warren SH. McDonnell JM. Steurer PA. Healing of fracture nonunions with pulsed electromagnetic field stimulation: a clinical study. Electro Biology Internal Report, 1987.

65. Cheng N. Vanhoof H, Dclport PH, Hoogmartens MJ. Mulier JC. Treatment of nonunion, congenital pseudarthroses and benign cystic lesion using pulsed electromagnetic fields. Reconstr Surg Traumatol. 1985; 19:118.

66. Frcedman LS. Pulsating electromagnetic fields in Uie treatment of delayed and nonunion of fractures: results from a district general hospital. Injury. 1985: 16:315.

67. (to H. Sturai Y. Fujisawa H. Narita T, lnoue S. Shibazaki T. The treatment of nonunion of the tibia with a pulsing electromagnetic field, (n: Fukada el al, eds. Bioelectrical Repair and Growth. Japan: Nishimura Co: 1985:230-233.

68. Lynch AF, MacAuley P. Treatment of bone nonunion by electromagnetic therapy. UMS. 1985; 154:153-155.

69. O'Connor BT. Treatment of surgically resistant nonunions with pulsed electromagnetic fields. Recontar Surg Traumau.il. 19R5; 19:123.

70. Mareer M, Musatti G. Bassett CAL. Results of pulsed electromagnetic fields (PEMF) in ununited fractures after external skeletal fixation. Clin Orthop 1984; 190:260-265.

71. Stein GA, Anzel SH. A review of delayed unions of open tibia fractures treated with external fixation and pulsing electromagncuc fields. Orthopedics. 1984; 7:428-436.

72. Bassett CAL. Mitchell SN, Schink MM. Treatment of therapeutically resistant nonunions with bone grafts and pulsing electromagnetic fields. J Bone Joint Surg. 1982: 64A: 1 214-1220.

73. Sharrard WJW. Sutcliffe ML, Robson MJ, Maceachcm AG. The treatment of fibrous nonunion of fractures by pulsing electromagnetic stimulation. J Bone Joint Surg. 1982: 64B:I89.

74. Cheng N. Mulicr JC. Treatment of Nonunion of the Tibia with a Pulsed Electromagnetic Field. Transactions of the First Annual Meeting of the Bioelectrical Repair and Growth Society. Philadelphia. Pa, Aztec Business Systems, Inc. Bala Cynwyd. Pa, November 9-11.1981:1:41.

75. Heckman JD, ei al. The use of pulsed electromagnetic fields in ununited fractures, AAOS 48th Annual Meeting, Las Vegas, NV, February- March 1981,

76. Krempen JF, Silver RA. External electromagnetic fields in the treatment of nonunion of bones. A three-year experience in private practice. Orthop Rev. 1981; 10:33-39.

77. Dal Monte A. Fontanes! G, Cadossi R, Poli G. Giancecchi F. Pulsed electromagnetic field therapy in the treatment of congenital and acquired pseudarthrosis. In; Marino AA, ed. Modern Bioelectricity. New York, NY: Marcel Dekker, lnc; 1988:71 1-756.

78. Eisenstein SM. Freeman MJS. An improved apparatus for the generation of pulsed electromagnetic fields in the ireaiment of ununited fractures. Submitted to ElectroBiology Inc.

79. Simonis RB, Good C. Cowell TK, The treatment of nonunion by pulsed electromagnetic fields combined with a Denham external fixator. Injury. 1984: 15:255.

Table 1

SURGICAL TREATMENT OF TIBIAL UNUNITED FRACTURES

Table 2

PEMF TREATMENT OF TIBIAL UNUNITED FRACTURES

Table 3

SUMMARY OF SUCCESS RATES FOR SURGICAL AND PEMF TREATMENT OF UNUNITED FRACTURES OF THE TIBIA*

Table 4

HEAL RATES OF SURGERY AND PEMF AFTER SUCCESSIVE PROCEDURES ON UNUNITED FRACTURES

Table 5

CONTROLLED CLINICAL STUDIES OF PEMF STIMULATION OF UNUNITED FRACTURES

Table 6

INFECTED UNUNITED TIBIAL FRACTURES: PEMF VS SURGICAL TREATMENT

Table 7

CLOSED AND OPEN UNUNITED TIBIAL FRACTURES: PEMF VS SURGICAL TREATMENT

10.3928/0147-7447-19920601-08

Sign up to receive

Journal E-contents