SUPPLEMENT ARTICLE
Electrical Stimulation for Fracture Healing:
Current Evidence
Christina Goldstein, MD,* Sheila Sprague, MSc,*† and Bradley A. Petrisor, MSc, MD, FRCSC*
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Summary: This article provides an overview of the biology behind
the use of electrical stimulation in fracture healing and discusses the
current methods of electrical bone growth stimulation. In addition, we
review the best available clinical evidence for the use of electrical
stimulation in the treatment of delayed and nonunions of fractures.
Our search identified 4 meta-analyses on the use of electrical
stimulation on fracture healing. The most methodologically rigorous
and recent meta-analysis suggests that the current evidence 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. The other 3 meta-analyses
that we identified suggested a more significant treatment effect from
electrical stimulation. Although the evidence supporting electrical
stimulation does trend in favor of its use to help achieve bony union,
further large, multicenter, randomized, controlled trials are required
to resolve the current uncertainty surrounding the use of electrical
stimulation and fracture healing.
Key Words: electrical stimulation, bone growth stimulators, fracture
healing, nonunion
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INTRODUCTION
In the management of fractures, nonunions and delayed
unions present challenging clinical scenarios for surgeons and
patients alike. Of the approximately 7.9 million fractures
occurring annually in the United States, 5%–10% will be
complicated by delayed union or nonunion, resulting in up to
1.58 million delayed unions or nonunions annually.1 Nonunion
or delayed union may then result in further surgery with
subsequent prolonged or repeat hospitalization, disability, and
delays in returning to the workforce.2–7 The costs associated
with this are not insignificant, and they include both personal
and societal costs such as lost wages and productivity, as well
as direct health care costs.6,8
Accepted for publication December 3, 2009.
From the *Division of Orthopaedics, Department of Surgery; and
†Department of Clinical Epidemiology and Biostatistics, McMaster
University, Hamilton, Ontario, Canada.
No funding was received for the preparation of this article.
Reprints: Christina Goldstein, MD, Division Orthopaedics, Department of
Surgery, McMaster University, Hamilton Health Sciences—General Site,
6 North Trauma, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada
(e-mail: clgoldstein@cogeco.ca).
Copyright Ó 2010 by Lippincott Williams & Wilkins
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Electrical bone growth stimulation represents an in-
novative modality for acceleration of bone healing and it has
become a $500 million dollar market in the United States.9 In
the past 25 years, more than 400,000 fracture nonunions and
delayed unions having been treated by physical fields.8 The
aim of this article is to review the biology behind the use of
electrical stimulation in fracture healing, current methods of
electrical bone growth stimulation, and the best available
clinical evidence for the use of electrical stimulation in the
treatment of delayed and nonunions of fractures.
ELECTRICAL FIELDS AND BONE FORMATION
In 1957, Fukada and Yasuda10 described the ‘‘piezo-
electric effect of bone,’’ the generation of electrical potentials
in response to compression and tension. During the next
decade, further investigations using moist bone demonstrated
the production of electrical potentials known as ‘‘streaming
potentials’’ during mechanical deformation.11,12 This pioneer-
ing work led to the hypothesis that electrical potentials induced
by mechanical force could potentially regulate the process of
bone formation.8 Subsequent in vitro studies using osteopro-
genitor cells, osteoblasts, and rat calvarium have measured cell
proliferation, synthesis of extracellular matrix, and calcifica-
tion in response to applied electrical fields with increases in
bone formation, particularly endochondral bone, being
observed.13 In vivo studies using different animal models of
nonunion have suggested that electrical stimulation has the
capacity to increase callous volume and increase mechanical
strength of healing bone as compared with controls.14–16
These fundamental basic science investigations have
lead to the development of electrical bone growth stimulators
for clinical application and a dramatic increase in investigation
into their mechanism of action and efficacy in the treatment of
delayed unions and nonunions.
ELECTRICAL AND ELECTROMAGNETIC BONE
GROWTH STIMULATORS
Electric and electromagnetic fields can be generated and
applied to bones affected by delayed union or nonunion
through 1 of 4 currently used methods: direct current (DC),
pulsed electromagnetic field (PEMF), combined magnetic
fields (CMFs), or capacitive coupling (CC).12 Each method is
associated with different advantages and disadvantages and
has its own specific clinical indications.
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Direct Current
DC electrical stimulation involves the surgical implan-
tation of a cathode at the fracture site and an anode in the
nearby subcutaneous tissue, with the production of an electric
current between them (Fig. 1).17 Implantable techniques have
the benefits of providing constant stimulation of the bone at the
nonunion or fracture site, increasing patient compliance and
optimizing electrode positioning. However, drawbacks include
the risk of the surgical procedures for implantation and
removal, the possibility of infection, prominent or painful
implants, and the potential for lead breakage or electrode
dislodgement.18
Pulsed Electromagnetic Fields
PEMF therapy is a noninvasive mode of bone growth
stimulation involving placement of a wire coil over the fracture
site (Fig. 1).17 Bursts of electric pulses repeated many times
per second create an electrical field, which is thought to be
similar to the endogenous fields produced in bone in response
to mechanical stress.8 The primary advantage of PEMF bone
stimulators is their noninvasive application. However, patient
compliance may be a limiting factor in the success of PEMF
treatment as healing rates in nonunions treated with PEMF
have been shown to be dose dependent.19
Capacitive Coupling
CC bone stimulation is a second method of applying
time-varied electrical stimulation to delayed unions or non-
unions. Though, unlike the electromagnetic field produced by
PEMF therapy, the electrical field is created by an oscillating
electric current produced between 2 capacitor plates placed
on the skin on opposite sides of the fracture (Fig. 1).17 Bone
FIGURE 1. Methods of electrical
bone growth stimulation: DC (A),
PEMF (B), and CC (C).17
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Electrical Stimulation
growth stimulation with CC devices also has the advantage of
being noninvasive, although the device must be worn 24 hours
a day, creating the potential for decreased compliance and skin
irritation from the electrode pads.8
Combined Magnetic Fields
CMF electrical stimulation is the newest method of bone
growth stimulation. CMFs are produced through the combi-
nation of alternating and DCs and produce a constant
sinusoidal wave pattern of electric stimulation.20 The electro-
magnetic field is delivered by an external pair of coils applied
over the fracture site and is worn by patients for 30 minutes
a day. In addition to being a noninvasive method of bone
growth stimulation, the daily length of time the CMF unit must
be worn is significantly less than those delivering CC or PEMF
stimulation, potentially increasing patient compliance and
treatment success.8
CURRENT CLINICAL EVIDENCE
In the hierarchy of evidence, randomized controlled
trials and meta-analyses of randomized controlled trials are
considered level I evidence or the best quality evidence
available. A number of systematic reviews and meta-analyses
of randomized trials assessing electrical stimulation and bone
healing have been conducted.21–24
The most recent meta-analysis was conducted by Mollon
et al24 in 2008. This study included 11 articles using electrical
stimulation in a variety of long-bone lesions, including
fracture, nonunion or delayed union; stress fractures; limb
lengthening procedures; and osteotomies. Eight of the trials
used PEMF treatment, whereas the other trials used
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Goldstein et al
a capacitance coupled field. These trials were considered
variable in their methodological quality, some having very
serious methodological limitations.24 Data pooled for 4 studies
assessing 106 delayed unions suggested a pooled relative risk
of 1.76 (95% confidence interval, 0.81–3.81) (Fig. 2). This
suggests a trend favoring the use of electrical stimulation to
stimulate bony union. However, the confidence intervals were
wide. In addition, there was significant heterogeneity between
these trials, which may be due, in part, to the different
electrical impulses delivered and differing treatment times
ranging from 3 to 24 hours.24
Regarding fresh fractures, only one trial was included,
which assessed union rates in those patients sustaining a
femoral neck fracture and having been treated with 3 screws.25
This trial suggested a nonstatistically significant relative risk of
1.26 (95% confidence interval, 0.99–1.6) in favor of electrical
stimulation.25
Mollon et al24 further examined trials reporting on
clinical outcomes such as pain or tenderness. Two trials
showed no benefit with the use of electrical stimulation when
used to treat tibial shaft nonunions. However, 1 trial found a
reduction in pain at all time points in those fractures of the
femoral neck treated with cannulated screws and electrical
stimulation.24
This meta-analysis suggests that the current evidence
from randomized controlled trials is not sufficient to conclude
if a benefit exists for electromagnetic stimulation in either
improving rates of union in patients with fresh fractures or
treating delayed union. However, the authors did find that
FIGURE 2. Meta-analysis forest plot of trials comparing electromagnetic stimulation and sham devices on the rates of long-bone
union.24
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J Orthop Trauma  Volume 24, Number 3 Supplement, March 2010
trends were in favor of electrical stimulation as an adjunct to
potentially increase union rates.24 They also suggest that
current evidence is insufficient to attribute a reduction in pain
to electromagnetic stimulation in patients with fractures.
Previous meta-analyses have suggested that there is
a more significant treatment effect from electrical stimula-
tion.21–23 For example, Akai et al,21 included 12 trials of
varying methodological quality in their meta-analysis and have
suggested that after pooling data from 765 cases, a treatment
effect in favor of electromagnetic stimulation was found. They
found a pooled difference of 0.26 (95% confidence interval,
0.16–0.36), which was statistically significant and favorable
with respect to the effect of electromagnetic stimulation on
bony union. This meta-analysis, however, included trials
related to spinal fusion and tibial osteotomy, which tended to
drive the treatment effect more than trials dealing with fracture
union.21
Another systematic review by Griffin et al, as well as
descriptively assessing randomized controlled trials, also
included nonrandomized trials in a descriptive fashion.22 In
those prospective observational studies, there was a collective
healing rate of 61%–90% with the use of electromagnetic
stimulation in the treatment of established nonunions of long
bones.22 However, all these trials had no comparison group
and were of variable methodological quality.
As compared with the other meta-analyses, that by
Mollon et al24 was rigorous in its methodology and they
contacted authors for reanalysis of original data and to judge
inclusion and exclusion criteria of some trials where necessary.
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CONCLUSIONS
Four meta-analyses have been conducted that have
highlighted the fact that small methodologically limited trials
make up the best available evidence on the use of electrical
stimulation and fracture healing. The most methodologically
rigorous and recent meta-analysis suggests that this evidence
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.’’24
A recent survey of 250 Canadian orthopaedic surgeons found
that 45% were using some form of bone stimulator when
managing certain tibial shaft fractures.26 With delayed union
and nonunion being a significant clinical entity, it behooves
us as orthopaedic trauma surgeons to use everything in our
armamentarium to obtain union. If this can be done outside of
the operating room, this may be beneficial from both an
economic and patient perspective. Although the evidence
supporting electrical stimulation does trend in favor of its use
to help achieve bony union, further large-scale randomized
trials are needed to resolve the current uncertainty surrounding
the use of electrical stimulation and fracture healing.
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