Low intensity pulsed ultrasound for bone healing: systematic review of randomized controlled trials

Abstract

Objective To determine the efficacy of low intensity pulsed ultrasound (LIPUS) for healing of fracture or osteotomy.Design Systematic review and meta-analysis.Data sources Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and trial registries up to November 2016.Study selection Randomized controlled trials of LIPUS compared with sham device or no device in patients with any kind of fracture or osteotomy.Review methods Two independent reviewers identified studies, extracted data, and assessed risk of bias. A parallel guideline committee (BMJ Rapid Recommendation) provided input on the design and interpretation of the systematic review, including selection of outcomes important to patients. The GRADE system was used to assess the quality of evidence.Results 26 randomized controlled trials with a median sample size of 30 (range 8-501) were included. The most trustworthy evidence came from four trials at low risk of bias that included patients with tibia or clavicle fractures. Compared with control, LIPUS did not reduce time to return to work (percentage difference: 2.7% later with LIPUS, 95% confidence interval 7.7% earlier to 14.3% later; moderate certainty) or the number of subsequent operations (risk ratio 0.80, 95% confidence interval 0.55 to 1.16; moderate certainty). For pain, days to weight bearing, and radiographic healing, effects varied substantially among studies. For all three outcomes, trials at low risk of bias failed to show a benefit with LIPUS, while trials at high risk of bias suggested a benefit (interaction P<0.001). When only trials at low risk of bias trials were considered, LIPUS did not reduce days to weight bearing (4.8% later, 4.0% earlier to 14.4% later; high certainty), pain at four to six weeks (mean difference on 0-100 visual analogue scale: 0.93 lower, 2.51 lower to 0.64 higher; high certainty), and days to radiographic healing (1.7% earlier, 11.2% earlier to 8.8% later; moderate certainty).Conclusions Based on moderate to high quality evidence from studies in patients with fresh fracture, LIPUS does not improve outcomes important to patients and probably has no effect on radiographic bone healing. The applicability to other types of fracture or osteotomy is open to debate.Systematic review registration PROSPERO CRD42016050965

Low-intensity pulsed ultrasound does not promote bone healing and functional recovery after open wedge high tibial osteotomy

“…Given the conflicting data, recent systematic reviews concluded that there was insufficient evidence to support the routine use of LIPUS for acute fractures. [33][34][35] Although the same cellular processes are present in bone healing after osteotomies and fracture healing, a few studies demonstrated that LIPUS enhanced bone healing at the osteotomy site after osteotomy surgeries. [18][19][20][21] Regarding HTO, Tsumaki et al 19 suggested that LIPUS accelerated callus maturation during the consolidation phase after open-wedge HTO by hemicallotasis.…”

“…Given the conflicting data, recent systematic reviews concluded that there was insufficient evidence to support the routine use of LIPUS for acute fractures. 33 - 35 …”

GRADE Guidance 34: update on rating imprecision using a minimally contextualized approach

“…Consider a systematic review of low intensity pulsed ultrasound (LIPUS) vs. no ultrasound in patients with any type of fracture [11]. A meta-analysis of RCTs reports that LI-PUS results in five additional days before patients could return to work, with a CI from 15 fewer to 20 more days (Fig.…”

Systematic Review of Complementary and Alternative Veterinary Medicine in Sport and Companion Animals: Therapeutic Ultrasound

“…In human clinical practice, TU was generally introduced in the 1950s. However, systematic reviews have failed to find evidence from high-quality or intermediate-quality studies that the treatment is superior to a placebo in promoting fracture healing [ 7 ] or, in early reviews, in treating various other conditions affecting muscles, tendons, ligaments, and joints [ 8 , 9 ].…”