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Electrical
Stimulation And Fracture Healing
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Satter S.A., Islam M.S.,
Rabbani K.S., and Talukder M.S. (1999) Pulsed electromagnetic fields for the
treatment of bone fractures. Bangladesh Med. Res. Counc. Bull. 25, 6-10.
Abstract: The effectiveness of electrical stimulation and Pulsed Electro
Magnetic Field (PEMF) stimulation for enhancement of bone healing has been
reported by many workers. The mechanism of osteogenesis is not clear, therefore,
studies look for empirical evidence. The present study involved a clinical trial
using low amplitude PEMF on 19 patients with non-union or delayed union of the
long bones. The pulse system used was similar in shape to Bassett's single pulse
system where the electric voltage pulse was 0.3 mSec wide repeating every 12
mSec making a frequency of about 80 Hz. The peak magnetic fields were of the
order of 0.01 to 0.1 m Tesla, hundred to thousand times smaller than that of
Bassett. Among the 13 who completed this treatment schedule the history of
non-union was an average of 41.3 weeks. Within an average treatment period of 14
weeks, 11 of the 13 patients had successful bone healing. The two unsuccessful
cases had bone gaps greater than 1 cm following removal of dead bone after
infection. However, use of such a low field negates Bassett's claim for a narrow
window for shape and amplitude of wave form, and justifies further experimental
study and an attempt to understand the underlying mechanism
Abeed R.I., Naseer M., and Abel
E.W. (1998) Capacitively coupled electrical stimulation treatment: results from
patients with failed long bone fracture unions. J. Orthop. Trauma 12,
510-513.
Abstract: OBJECTIVE: To determine the extent to which capacitively coupled
electrical stimulation (CCEST) at a long bone fracture site can promote healing
of nonunited fractures. DESIGN: Sixteen patients with nonunited fractures of
nine to seventy-six months were treated with CCEST. Thirteen patients had
previously undergone one or more surgical procedures, and the other three had
been given plaster casts. A sixty- three-kilohertz, six-volt peak-to-peak sine
wave signal was applied across two forty-millimeter-diameter stainless steel
plates placed on the skin at opposite sides of the fracture site. The device was
used for up to thirty weeks until either healing occurred or it was removed
after this period and considered to have failed. RESULTS: Eleven of the
nonunions achieved union at an average of fifteen weeks of stimulation. The only
significant factor determining the success of healing was the distance between
the plates; a distance of eighty millimeters or less resulted in healing in all
cases. Healing was not affected significantly by any of the following factors:
whether or not the nonunion had been treated surgically prior to stimulation,
whether or not it had been infected, whether or not the patient bore weight
after treatment, or by the presence or absence of metal at the fracture site
from previous surgery. CONCLUSIONS: These findings confirm those of previous
studies that CCEST promotes bone healing of fracture nonunions. The dependence
of healing on the interplate distance suggests that maintaining sufficient
current across the plates is necessary to allow healing, which for larger bones
may be achieved by increasing the area of the plates, the applied voltage, or
the excitation frequency of the stimulation signal
Zamora-Navas P., Borras V.A.,
Antelo L.R., Saras A., Jr., and Pena Reina M.C. (1995) Electrical stimulation of
bone nonunion with the presence of a gap. Acta Orthop. Belg. 61, 169-176.
Abstract: A total of 22 established nonunions was treated with a capacitively-
coupled electrical signal. A gap of 0.5 cm or more between the fragments was
present in all of these nonunions. After an average of 26 weeks of treatment
with capacitive coupling, radiographic assessment showed solid bone union in
72.7% of the cases. The results were better when the fracture site was
metaphyseal. When the site was diaphyseal, bone healing was mainly achieved by
bone trabeculae invading the gap. When the site was metaphyseal, healing
occurred by the formation of a peripheral callus. The results were not affected
by the presence of infection. In 8 of the cases osteomyelitis occurred, but all
healed
MacGinitie L.A., Wu D.D., and
Cochran G.V. (1993) Streaming potentials in healing, remodeling, and intact
cortical bone. J. Bone Miner. Res. 8, 1323-1335.
Abstract: Electrical fields have been implicated in accelerated bone healing and
as a transduction mechanism for mechanically driven bone remodeling. Applied
mechanical or electrical stimulation of bone remodeling suggests that this
depends on the magnitude, frequency, and duration of the stimulus. The magnitude
of endogenous electrical fields, manifest by streaming potentials (SPs) across
canine cortical bone, were measured as a function of bending frequency in vivo
and then in vitro at healing drill holes and at remodeling (ipsilateral) and
normal, intact (contralateral) control sites in canine tibia. SP magnitudes
normalized to periosteal strain were smaller for drill holes at 2 and 4 weeks
postsurgery relative to either remodeling (P < 0.05 at 10 Hz) or normal intact
(P < 0.001 at 10 Hz) controls both in vivo and in vitro. SPs of 12 week drill
holes were similar to SPs of remodeling controls and tended to be smaller than
SPs of normal intact controls. Mean SP normalized to bone impedance was
approximately the same for all sites, suggesting that the smaller SPs during
healing and remodeling relate to smaller bone impedance and/or larger porosity.
SP as a function of bending frequency for normal sites was similar to that
observed previously. SP versus frequency for drill holes and remodeling controls
was more variable, probably because of variations in bone microstructure, and
displayed a higher frequency content. The observed differences in SP magnitude
and frequency response to loading associated with stages of healing indicate
that endogenous electrical fields do indeed respond to the structural changes in
healing and remodeling and are therefore capable of providing structural
feedback information for the repair and remodeling process
Sisken B.F., Walker J., and
Orgel M. (1993) Prospects on clinical applications of electrical stimulation for
nerve regeneration. J. Cell Biochem. 51, 404-409.
Abstract: Regenerative capability is limited in higher vertebrates but present
in organ systems such as skin, liver, bone, and to some extent, the nervous
system. Peripheral nerves in particular have a relatively high potential for
regeneration following injury. However, delay in regrowth or growth, blockage,
or misdirection at the injury site, and growth to inappropriate end organs may
compromise successful regeneration, leading to poor clinical results. Recent
studies indicate that low- intensity electrical stimulation is equivalent to
various growth factors, offering avenues to improve these outcomes. We present a
review of studies using electric and electromagnetic fields that provide
evidence for the enhancement of regeneration following nerve injury. Electric
and electromagnetic fields (EMFs) have been used to heal fracture non-unions.
This technology emerged as a consequence of basic studies [Yasuda, 1953; Fukada
and Yasuda, 1957] demonstrating the piezoelectric properties of (dry) bone. The
principle for using electrical stimulation for bone healing originated from the
work of Bassett and Becker [1962], who described asymmetric voltage waveforms
from mechanically deformed live bone. These changes were presumed to occur in
bone during normal physical activity as a result of mechanical forces, and it
was postulated that these forces were linked to modifications in bone structure.
Endogenous currents present in normal tissue and those that occur after injury
were proposed to modify bone structure [Bassett, 1989]. These investigators
proposed that tissue integrity and function could be restored by applying
electrical and/or mechanical energy to the area of injury. They successfully
applied electrical currents to nonhealing fractures (using surgically implanted
electrodes or pulsed currents using surface electrodes) to aid endogenous
currents in the healing process.(ABSTRACT TRUNCATED AT 250 WORDS)
Albert S.F. and Wong E. (1991)
Electrical stimulation of bone repair. Clin. Podiatr. Med. Surg. 8,
923-935.
Abstract: Interest in methods of accelerating bone healing persists. Electrical
stimulation has demonstrated consistently high success rates in recalcitrant,
complicated nonunions. The promise of successful noninvasive alternatives for
treating nonunions continues to be realized. Given the rapidity of advances in
this field, it appears likely that acceleration of fracture repair by electrical
stimulation will become more widespread in the future
Barden R.M. and Sinkora G.L.
(1991) Bone stimulators for fusions and fractures. Nurs. Clin. North Am.
26, 89-103.
Abstract: Even though a complete understanding of electrical responses of bone
has not been fully obtained, useful data toward this end have been gathered. The
development of devices that use what is known about the bone's
electrophysiologic properties has impacted patient care. Many health care
professionals remain skeptical about the effects of electrical stimulation in
bone healing. Therefore, further research is needed to help the practitioner
formulate a more educated opinion on this form of therapy
Gupta T.D., Jain V.K., and
Tandon P.N. (1991) Comparative study of bone growth by pulsed electromagnetic
fields. Med. Biol. Eng Comput. 29, 113-120.
Abstract: Pulsed electromagnetic fields have been widely used for treatment of
non-united fractures and congenital pseudarthrosis. Several electrical
stimulation systems such as air-cored and iron-cored coils and solenoids have
been used the world over and claimed to be effective. Electrical parameters such
as pulse shape, magnitude and frequency differ widely, and the exact
bone-healing mechanism is still not clearly understood. The study attempts to
analytically investigate the effectiveness of various parameters and suggests an
optimal stimulation waveform. Mathematical analysis of electric fields inside
the bone together with Fourier analysis of induced voltage waveforms produced by
commonly used electrical stimulation wave-forms has been performed. A hypothesis
based on assigning different weightings to different frequencies for osteogenic
response has been proposed. Using this hypothesis astonishingly similar
effective values of electric fields have been found in different systems. It is
shown that effective electric field rather than peak electric field is the main
parameter responsible for osteogenesis. The results are in agreement with
experimental findings made on human beings by different investigators
Uhl R.L. (1989) The use of
electricity in bone healing. Orthop. Rev. 18, 1045-1050.
Abstract: The history of electrical bone healing and the vast amount of
laboratory and clinical data that support its efficacy are reviewed. The paper
presents guidelines for the proper use of electrical stimulation and a
description of the various systems available. The use of electrical stimulation
to treat scaphoid fractures is covered in detail. Contraindications to the use
of electrical stimulation are also addressed
Sanders-Shamis M., Bramlage L.R.,
Weisbrode S.E., and Gabel A.A. (1989) A preliminary investigation of the effect
of selected electromagnetic field devices on healing of cannon bone osteotomies
in horses. Equine Vet. J. 21, 201-205.
Abstract: The effect of electrical stimulation by means of selected
electromagnetic field devices on healing of cannon bone osteotomies in horses
was examined. The defects were created as 3 cm x 1 mm longitudinal osteotomies
through the dorsal cortices of the mid- metacarpi/metatarsi of adult horses.
This type of defect would asses bone healing in a situation similar to an acute,
stable fracture of the cortex. Three electromagnetic devices of different design
were tested in three different groups of horses. Healing was evaluated
radiographically and histologically. Results showed that osteotomies treated
with the electromagnetic devices healed similarly to untreated controls. Our
conclusion is that the electromagnetic devices studied did not have a local
effect on the repair process of an acute, stable, osseous defect
Ferrier J., Ross S.M., Kanehisa
J., and Aubin J.E. (1986) Osteoclasts and osteoblasts migrate in opposite
directions in response to a constant electrical field. J. Cell Physiol
129, 283-288.
Abstract: We have investigated in vitro the effects of the electrical field
produced by constant current on freshly isolated rabbit osteoclasts and on well
characterized clonal rat osteoblastlike cells. At field strengths of 0.1 and 1
V/mm, the osteoclasts migrated rapidly toward the positive electrode, whereas
the osteoblastlike cells migrated in the opposite direction, toward the negative
electrode. Thus, different cell types from the same tissue can respond
differently to the same electrical signal. These results have important
implications for hypotheses concerning the cellular mechanism of galvanotaxis,
and may also clarify the cellular basis of the clinical application of
electrical stimulation of bone healing
Schubert T., Kleditzsch J., and
Wolf E. (1986) [Results of fluorescence microscopy studies of bone healing by
direct stimulation with bipolar impulse currents and with the interference
current procedure in the animal experiment]. Z. Orthop. Ihre Grenzgeb.
124, 6-12.
Abstract: 42 cross-breed rabbit bastards of either sex were osteotomized on the
left proximal third of the tibia. A teflonisolated stable plating was made by
means of the polychromatically KF-AO-instrumentarium. The animals were
fluorescentlabelled in weekly intervals. Tetraverinex, alizarin complexon,
fluorexon, xylenol orange and calceine were used as colours. The animals were
stimulated in the bipolar squaretopped pulse current procedure (1 Hz and 10 Hz,
resp., +/- 25 and +/- 50 microA, resp., intensity, permanent stimulation) or in
the interference current procedure (oscillation frequency 100 Hz, intensity 1 mA,
4 hours daily). An osteotomized group served as a control. The undecalcified
bone sections were quantitatively measured in the area of the periosteal and
endoosteal accummulation seams as well as in the area of the Haversians canals
and compared by means of multiple variance analyses. A delay in the Haversian
remodelling within the first 2 weeks was found in the animals only osteotomized.
This delay could not be detected in all electrically stimulated groups. The
electrical stimulation leads to a shortening of the fracture healing period by
skipping the physiologically occurring delay of the Haversian remodelling in
fractures and osteotomies. Further on there was derived a growth function of the
osteones as a regression function r (t) = a + beta X e gamma t. For the rabbit
the concrete formula expression r (t) = 50.9 X e-0.094 X t + 17.4 for the
animals not treated and r (t) = 42.9 X e-0.067 X t + 8.5 for the electrical
stimulated animals has been found.(ABSTRACT TRUNCATED AT 250 WORDS)
Kondo J. (1985) [Experimental
histopathological studies of electrical callus formation and mechanism of bone
healing by direct micro-electrical current]. Nippon Seikeigeka Gakkai Zasshi
59, 803-817.
Abstract: In order to get better understanding of the effects of electrical
stimulation on bone healing processes, the author compared the healing processes
of the femur in dogs between two groups: a stimulation group and a control group
(non-stimulation group) which were experimentally prepared. These bone specimens
were periodically extirpated and used for pathological examinations and X-ray
micro-analysis. In the stimulation group, strong proliferation of osteoblasts
and new trabecular formation in the bone marrow were observed at the 3rd day,
and transition from fibrous to bony callus were noted at the 9th day; after the
3rd week bone remodeling was sparsely seen and bone healing period was
shortened. In electromicroscopic observation, calcification of bone matrix and
bone remodeling also seemed to be facilitated in this group. However, no marked
differences in histological process of bone healing were observed between the
stimulation group and the control group
Collier M.A., Kallfelz F.A.,
Rendano V.T., Krook L.P., and Schryver H.F. (1985) Capacitively coupled
electrical stimulation of bone healing in the horse: in vivo study with a Salter
type IV osteotomy model with stainless steel surface electrodes. Am. J. Vet.
Res. 46, 622-631.
Abstract: The use of capacitively coupled low-voltage signals for stimulation of
osteogenesis has been reported in a variety of animal models. Electrically
induced osteogenesis was investigated with a capacitively coupled electric field
on a radius (distal-lateral orientation) osteotomy model, in conjunction with
internal fixation and postoperative loading. Twelve adult horses of either sex
were allotted to 2 groups of 6; 1 group was given electrical stimulation and the
other served as controls. A low-voltage high-frequency capacitively coupled
electrical signal was locally and continuously applied to the electrically
stimulated group for 60 days through external, bare stainless steel surface
electrodes which were placed on the skin in circuit with a small, portable power
source. Harness compatibility and stimulator and battery durability were
excellent. However, stainless steel electrodes required a rigid maintenance
schedule to maintain consistent current levels. Synovial fluid evaluation
demonstrated intra- articular inflammation (decreased viscosity, hyaluronic
acid, and increased protein concentration) 1 week postoperatively that generally
improved during subsequent weeks and no distinction between groups was observed
at 60 days. Radiographically, there was no difference in the appearance of the
healing process of control and that of stimulated horses during the 60 days.
Angiography showed bridging blood vessels in both groups. Uptake of a bone
seeking radiopharmaceutical peaked at 3 weeks in both groups and was 1.92 +/-
0.6 cps/pixel/mCi and 1.26 +/- 0.40 csp/pixel/mCi for control and stimulated
horses, respectively. At any given observation period, uptake in the lesion area
was greater in the control group. Ultimate strengths of trabecular bone in
60-day control radii and stimulated radii were 12.64 +/- 3.013 and 9.60 +/- 3.95
MN/m2, and the flexural moduli of elasticity were 698.0 +/- 423 and 402.0 +/-
523 MN/m2, respectively. Porosity index was similar for all specimens. Gross,
histologic, and microradiographic evaluations indicated that controls healed
more efficiently than stimulated horses. A capacitively coupled applied voltage
of 2.2 V RMS (mean) producing a current of 17.32 mA (mean) did not stimulate
sufficient bone production in a metaphyseal osteotomy model to affect the
mechanical properties of the bone or accelerate the healing process
Cochran G.V., Johnson M.W.,
Kadaba M.P., Vosburgh F., Ferguson-Pell M.W., and Palmieri V.R. (1985)
Piezoelectric internal fixation devices: a new approach to electrical
augmentation of osteogenesis. J. Orthop. Res. 3, 508-513.
Abstract: Prototype testing has been accomplished on a piezoelectric, internal
fixation plate. This device combines a piezoelectric material with an internal
fixation device as an integrated structure that provides mechanical stability,
together with self-generated electrical stimulation, for treating fractures and
nonunion. In bench and animal tests we have demonstrated that cyclical loading
can cause a device of this type to generate electrical charge while attached to
bone. After rectification, direct currents within the range known to stimulate
osteogenesis can be produced by weight-bearing loads. Furthermore, electrical
output of the implants can be increased by externally applied ultrasonic energy.
These twin developments add significantly to the potential armamentarium of
devices to enhance bone healing
Ahl T., Andersson G., Herberts
P., and Kalen R. (1984) Electrical treatment of non-united fractures. Acta
Orthop. Scand. 55, 585-588.
Abstract: The semi-invasive technique for electrical stimulation of bone healing
developed by Brighton et al. (1977) was used in 23 patients with nonunited
fractures of the tibia (14 cases), humerus (4 cases), scaphoid, femur and fibula
as well as one failed arthrodesis of the ankle. The fractures were clinically
not healed and not operated on within a minimum of 6 months. The mean period
from fracture to treatment was 18 months. Electrical stimulation led to solid
bone healing in 10 cases. Two deep infections occurred during the treatment. Of
13 cases that did not unite, a great range of motion in the nonunion area was an
obvious cause of failure in seven cases. The results in this series cannot
compete with those of bone graft surgery for nonunions
Paterson D. (1984) Treatment of
nonunion with a constant direct current: a totally implantable system. Orthop.
Clin. North Am. 15, 47-59.
Abstract: There is now sufficient basic research and clinical experience to
establish that electrical stimulation produces osteogenesis. Furthermore,
electrical stimulation significantly helps union where impaired bone healing
exists. The implanted bone growth stimulator is one effective method of
electrical stimulation. It can be used in a wide variety of problems: delayed
union and nonunion of bones with or without chronic infection and in failed
posterior spinal fusion. Successful treatment of congenital pseudarthrosis of
the tibia has been encouraging. The implanted bone growth stimulator technique
requires a simple operation with strict adherence to detail. There is minimal
postoperative discomfort and a short hospital stay. The average time to union is
16 weeks. The Osteostim can be used in the presence of chronic infection and
internal fixation. Above all, the technique does not require any cooperation
from the patient. The implanted bone growth stimulator should be accepted as a
method of treatment for delayed and nonunion of bones, as it is at least as
effective as other more conventional methods of surgical treatment for this
situation. It has been proved that electrical stimulation produces osteogenesis.
Orthopedic surgeons should no longer be skeptical about this
Hanaoka T. (1983) [The effects
of pulsed micro-electrical currents on internal remodeling in long tubular bone
and bone healing]. Nippon Seikeigeka Gakkai Zasshi 57, 151-166.
Abstract: The effects of pulsed micro-electrical currents on internal remodeling
in the cortex of long tubular bone were evaluated by the following three
experiments. 1. Electrodes were inserted in both femora of 14 adult mongrel
dogs, 15 mm apart, and pulsed micro-electrical current was applied in the right
femoral cortex for 4 weeks, but not in the left femur, which was left as a
control. Dogs were divided into 4 groups; in each of these groups current with
1Hz-10 microA, 0.1 Hz-10 microA, 50 Hz-10 microA and 1Hz-20 microA was applied.
The effects were evaluated by histometric parameters, i.e. number of resorption
cavities (Ar), osteons with osteoid seam (osAf), mineralization rate of osteoid
seam (Mo), and perimeter of osteoid seam (Sf). Number of Ar and osAf increased.
Bone formation rate (Vf) which is the product of osAf, Mo and Sf increased,
especially in the group in which current with 1Hz-10 microA was applied. The
main reason for increase of Vf was considered due to that the activation
frequency in internal remodeling increased by electrical stimulation. 2. A metal
plate was placed on the right humerus, not on the left humerus, both femora of 5
dogs, and electrical current of 1Hz-10 microA was applied in the right femur for
either 12 or 16 weeks. Decrease of internal remodeling tended to take place in
the mid-portion of the plated area of femur, whereas Vf increased by pulsed
micro-electrical currents. Decrease of internal remodeling thus caused by
placing a plate and screws increased by pulsed micro- electrical current. 3.
Number of osteons in the newly formed bone in the osteotomized gap and in the
cortex adjacent to the gap of femora of 7 dogs, which were plated for either 4
or 6 weeks, was measured in longitudinal sections labelled by tetracycline. The
number of osteons increased more in the right femur in which current of 1Hz-10
microA was applied than in the left femur. Based on the results above described,
it was concluded that bone healing was enhanced by pulsed micro- electrical
currents
Paterson D.C., Hillier T.M.,
Carter R.F., Ludbrook J., Maxwell G.M., and Savage J.P. (1977) Experiemtnal
delayed union of the dog tibia and its use in assessing the effect of an
electrical bone growth stimulator. Clin. Orthop. 340-350.
Abstract: A technique has been described for the consistent production of
delayed bone healing of the tibia in an animal model. A controlled double blind
trial, where independent observors did not know the coding of the stimulators
and did not collaborate with each other, has evaluated the use of a direct
current bone growth stimulator in such an animal model. The conclusion of the
experiment is that this commercially available direct current stimulator does
produce a significant acceleration of bone healing at 4 weeks in the
experimental model used. There is no evidence of inflammatory or neoplastic
changes. The eventual clinical role of electrical bone stimulation remains
uncertain and many questions remain unanswered, but are promising enough to
encourage a controlled clinical trial in situations of disturbed bone healing.
Electrical stimulation is apparently safe and appears to significantly augment
bone formation. A controlled clinical trial is now being carried out in major
medical centers in Australia
Paterson D.C., Carter R.F.,
Maxwell G.M., Hillier T.M., Ludbrook J., and Savage J.P. (1977) Electrical
bone-growth stimulation in an experimental model of delayed union. Lancet
1, 1278-1281.
Abstract: An experimental model has been devised for the consistent production
of delayed bone healing of the tibia in adult dogs. A double-blind trial, with
bias eliminated, was used to evaluate the use of a commercially available
direct-current bone-growth stimulator with this model. The stimulator produced a
statistically significant acceleration of bone healing at four weeks in the
experimental model. Osteogenesis was normal, and no dysplastic, inflammatory, or
neoplastic changes were found. This research has shown that electrical
stimulation of bone is safe and augments bone formation. The bone-growth
stimulator unit remains on trial, but in future it may alter the management of
many difficult orthopaedic problems
McElhannon F.M., Jr. (1975)
Congenital pseudarthrosis of the tibia. South. Med. J. 68, 824-827.
Abstract: Congenital pseudarthrosis of the tibia is a rare and difficult
problem. The cause is unknown, the treatment is nonstandardized, and the results
are generally poor. One or two good attempts at union should be made, followed
by amputation if union is not obtained or if deformity is worse than that
produced by a prosthesis. Electrical stimulation of bone healing is not yet
technically advanced enough for use in stimulating fractures to heal in humans,
but it has been proven to promote healing in animals and holds considerable
promise for the future
Van Cochran G. (1974)
Acceleration of bone healing by electrical stimulation. Bull. Prosthet. Res.
291-294.
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