Ultrasound for Fracture Healing: Current Evidence

Low-intensity pulsed ultrasound (LIPUS) is a relatively new technique for the acceleration of fracture healing in fresh fractures and nonunions. It has a frequency of 1.5 MHz, a signal burst width of 200 μs, a signal repetition frequency of 1 kHz, and an intensity of 30 mW/cm2. In 1994 and 1997, two milestone double-blind randomized controlled trials revealed the benefits of LIPUS for the acceleration of fracture healing in the tibia and radius. They showed that LIPUS accelerated the fracture healing rate from 24% to 42% for fresh fractures. Some literature, however, has shown no positive effects. The beneficial effect of acceleration of fracture healing by LIPUS is considered to be larger in the group of patients or fractures with potentially negative factors for fracture healing. The incidence of delayed union and nonunion is 5% to 10% of all fractures. For delayed union and nonunion, the overall success rate of LIPUS therapy is approximately 67% (humerus), 90% (radius/radius-ulna), 82% (femur), and 87% (tibia/tibia-fibula). LIPUS likely has the ability to enhance maturation of the callus in distraction osteogenesis and reduce the healing index. The critical role of LIPUS for fracture healing is still unknown because of the heterogeneity of results in clinical trials for fresh fractures and the lack of controlled trials for delayed unions and nonunions.

[1]  L. Handolin,et al.  The effect of low intensity ultrasound and bioabsorbable self-reinforced poly-L-lactide screw fixation on bone in lateral malleolar fractures , 2005, Archives of Orthopaedic and Trauma Surgery.

[2]  C. van der Werken,et al.  Low-intensity pulsed ultrasound (LIPUS) in fresh clavicle fractures: a multi-centre double blind randomised controlled trial. , 2008, Injury.

[3]  Hideki Yoshikawa,et al.  Low-intensity pulsed ultrasound accelerates maturation of callus in patients treated with opening-wedge high tibial osteotomy by hemicallotasis. , 2004, The Journal of bone and joint surgery. American volume.

[4]  J. Nyland,et al.  Does pulsed low intensity ultrasound allow early return to normal activities when treating stress fractures? A review of one tarsal navicular and eight tibial stress fractures. , 1999, The Iowa Orthopaedic Journal.

[5]  J. Ryaby,et al.  Treatment of Jones' fractures of the foot with adjunctive use of low-pulsed ultrasound stimulation , 1999 .

[6]  Emil H Schemitsch,et al.  A Lack of Consensus in the Assessment of Fracture Healing Among Orthopaedic Surgeons , 2002, Journal of orthopaedic trauma.

[7]  M. Itoman,et al.  Low-intensity pulsed ultrasound treatment for postoperative delayed union or nonunion of long bone fractures , 2007, Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association.

[8]  J A Kanis,et al.  Effect of pulsed electromagnetic fields on bone formation and bone loss during limb lengthening. , 1996, Bone.

[9]  L. Qin,et al.  Dose‐dependent effect of low‐intensity pulsed ultrasound on callus formation during rapid distraction osteogenesis , 2006, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[10]  A. Emami,et al.  No effect of low-intensity ultrasound on healing time of intramedullary fixed tibial fractures. , 1999, Journal of orthopaedic trauma.

[11]  G. L. Guit,et al.  Use of low-intensity pulsed ultrasound for posttraumatic nonunions of the tibia: a review of patients treated in the Netherlands. , 2007, The Journal of trauma.

[12]  L. R. Duarte.  The stimulation of bone growth by ultrasound , 2004, Archives of orthopaedic and traumatic surgery.

[13]  W. Sato,et al.  Acceleration of increase in bone mineral content by low‐intensity ultrasound energy in leg lengthening. , 1999, Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine.

[14]  J. Heckman,et al.  The economics of treating tibia fractures. The cost of delayed unions. , 1997, Bulletin (Hospital for Joint Diseases (New York, N.Y.)).

[15]  L Claes,et al.  Radiographic Results of Callus Distraction Aided by Pulsed Low-intensity Ultrasound , 2001, Journal of orthopaedic trauma.

[16]  C. Romanò,et al.  Low-intensity pulsed ultrasound for the treatment of bone delayed union or nonunion: a review. , 2009, Ultrasound in medicine & biology.

[17]  L. Qin,et al.  Low intensity pulsed ultrasound accelerated bone remodeling during consolidation stage of distraction osteogenesis , 2006, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[18]  N S El-Said,et al.  Selective release of the flexor origin with transfer of flexor carpi ulnaris in cerebral palsy. , 2001, The Journal of bone and joint surgery. British volume.

[19]  J. M. Janes,et al.  Ultrasonic energy and surgically produced defects in bone. , 1957, The Journal of bone and joint surgery. American volume.

[20]  Y Yamano,et al.  Low-intensity pulsed ultrasound accelerates bone maturation in distraction osteogenesis in rabbits. , 2000, The Journal of bone and joint surgery. British volume.

[21]  W. Sharrard,et al.  A double-blind trial of pulsed electromagnetic fields for delayed union of tibial fractures. , 1990, The Journal of bone and joint surgery. British volume.

[22]  T A Einhorn,et al.  Enhancement of fracture-healing. , 1995, The Journal of bone and joint surgery. American volume.

[23]  S. Gold,et al.  Preliminary Results of Tibial Bone Transports With Pulsed Low Intensity Ultrasound (Exogen™) , 2005, Journal of Orthopaedics and Trauma.

[24]  N. Inoue,et al.  Low-intensity Pulsed Ultrasound Does Not Enhance Distraction Callus in a Rabbit Model , 2007, Clinical orthopaedics and related research.

[25]  J. Ryaby,et al.  Low-intensity pulsed ultrasound in the treatment of nonunions. , 2001, The Journal of trauma.

[26]  E. Chao,et al.  The effect of low intensity pulsed ultrasound applied to rabbit tibiae during the consolidation phase of distraction osteogenesis , 2002, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[27]  F. Pigozzi,et al.  Low-intensity pulsed ultrasound in the conservative treatment of pseudoarthrosis. , 2004, The Journal of sports medicine and physical fitness.

[28]  Gordon H Guyatt,et al.  Low intensity pulsed ultrasonography for fractures: systematic review of randomised controlled trials , 2009, BMJ : British Medical Journal.

[29]  V. Frankel,et al.  Ultrasound – an alternative healing method for nonunions? , 2000, Archives of Orthopaedic and Trauma Surgery.

[30]  A. Pilla,et al.  Non-invasive low-intensity pulsed ultrasound accelerates bone healing in the rabbit. , 1990, Journal of orthopaedic trauma.

[31]  Dieter Gebauer,et al.  Low-intensity pulsed ultrasound: effects on nonunions. , 2005, Ultrasound in medicine & biology.

[32]  Kwok-Sui Leung,et al.  Complex tibial fracture outcomes following treatment with low-intensity pulsed ultrasound. , 2004, Ultrasound in medicine & biology.

[33]  Hani El-Mowafi,et al.  The effect of low-intensity pulsed ultrasound on callus maturation in tibial distraction osteogenesis , 2005, International Orthopaedics.

[34]  S. Cook,et al.  Acceleration of Tibia and Distal Radius Fracture Healing in Patients Who Smoke , 1997, Clinical orthopaedics and related research.

[35]  J. Ryaby,et al.  Clinical effects of electromagnetic and electric fields on fracture healing. , 1998, Clinical orthopaedics and related research.

[36]  C I Moorcroft,et al.  Fracture Healing Assessment Comparing Stiffness Measurements using Radiographs , 2006, Clinical orthopaedics and related research.

[37]  Feng-Sheng Wang,et al.  Shock wave treatment shows dose-dependent enhancement of bone mass and bone strength after fracture of the femur. , 2004, Bone.

[38]  D. Gebauer,et al.  Pulsed Low-Intensity Ultrasound: A New Salvage Procedure for Delayed Unions and Nonunions After Leg Lengthening in Children , 2005, Journal of pediatric orthopedics.

[39]  E Y Chao,et al.  Enhancement of fracture healing by mechanical and surgical intervention. , 1998, Clinical orthopaedics and related research.

[40]  J. Ryaby,et al.  Accelerated Healing of Distal Radial Fractures with the Use of Specific, Low-Intensity Ultrasound. A Multicenter, Prospective, Randomized, Double-Blind, Placebo-Controlled Study* , 1997, The Journal of bone and joint surgery. American volume.

[41]  F. Frassica,et al.  The effect of pulsed ultrasound in the treatment of tibial stress fractures. , 2004, Orthopedics.

[42]  J F Connolly,et al.  A multicenter study of the treatment of non-union with constant direct current. , 1981, The Journal of bone and joint surgery. American volume.

[43]  Y. Azuma,et al.  Effects of timing of low‐intensity pulsed ultrasound on distraction osteogenesis , 2004, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[44]  J. Madsen,et al.  Should Insertion of Intramedullary Nails for Tibial Fractures Be With or Without Reaming?: A Prospective, Randomized Study With 3.8 Years' Follow-up , 2004, Journal of orthopaedic trauma.

[45]  C. Rubin,et al.  The use of low-intensity ultrasound to accelerate the healing of fractures. , 2001, The Journal of bone and joint surgery. American volume.

[46]  E. Mayr,et al.  [Does low intensity, pulsed ultrasound speed healing of scaphoid fractures?]. , 2000, Handchirurgie, Mikrochirurgie, plastische Chirurgie : Organ der Deutschsprachigen Arbeitsgemeinschaft fur Handchirurgie : Organ der Deutschsprachigen Arbeitsgemeinschaft fur Mikrochirurgie der Peripheren Nerven und Gefasse : Organ der V....

[47]  N. Matsui,et al.  Ultrasound treatment of nonunion of the hook of the hamate in sports activities , 2004, Knee Surgery, Sports Traumatology, Arthroscopy.

[48]  J. King,et al.  A prospective, double-blind trial of electrical capacitive coupling in the treatment of non-union of long bones. , 1994, The Journal of bone and joint surgery. American volume.

[49]  R F Kilcoyne,et al.  Acceleration of tibial fracture-healing by non-invasive, low-intensity pulsed ultrasound. , 1994, The Journal of bone and joint surgery. American volume.