Table 1.

Description of studies

Trial	Fracture location	Fracture treatment	Intervention and control therapy duration	No. patients		Age, mean ± SD yr		Type of device (I: intervention; C: control)
				LIPUS/ESTIM	Control	LIPUS/ESTIM	Control
LIPUS trials
Heckman et al.35	Tibia	Closed reduction and above-knee casting. An alignment window was placed in the cast at the level of the fracture over the anteromedial aspect of the leg. Reduction of the casting to a below-knee cast; any subsequent splinting and weight bearing status was at the discretion of the clinician.	20 min/d for 20 wk or until investigator believed fracture was healed sufficiently	48	49	36 ± 2.3	31 ± 1.8	I: Unidentified ultrasonography device C: Sham device
Kristiansen et al.36	Radius	Closed reduction and immobilization of the limb in a cast with volar flexion and ulnar deviation. A window was created on the dorsal aspect of the cast overlying the fracture and a retaining alignment fixture was placed in the window.	20 min/d for 10 wk	40	45	Not reported	Not reported	I: SAFHS 2A, Exogen Inc. C: Sham device
Emami et al.32*	Tibia	Reamed intramedullary nailing.	Started within 3 d after surgery, consisted of 20 min/d for 75 d; for max 25 h	15	17	39.9 ± 16.2	34.3 ± 14	I: SAFHS 2A, Exogen Inc. C: Sham device
Strauss et al.41*	5th metatarsal	Short leg cast and weight bearing as tolerated for a mean of 10 d; all were converted to a hinged ankle foot orthosis and continued with weight bearing until fracture union.	20 min/use, twice daily	10	10	Not reported	Not reported	I: Adjunctive active treatment with ultrasonography C: Standard care
Mayr et al.39*	Scaphoid	Forearm plaster splint was applied. After the swelling subsided a circular [arthrodesis] bandage replaced the splint and stayed on until the fracture was bridged.	20 min/d	15	15	37 ± 14†	37 ± 14†	I: SAFHS R, Exogen Inc. C: Standard care
Leung et al.37*	Tibia	Closed fractures or Gustillo grade 1 or 2 open fractures in the diaphysis underwent fixation with reamed, locked intramedullary nail. Fractures in the metaphysis or Gustillo grade 3 open fractures were treated with an external fixator. All open fractures were treated with emergency débridement and delayed closure.	20 min/d for 90 d	16	14	35.3†	35.3†	I: Exogen 2000_ device (Exogen, Smith & Nephew Inc.) C: Sham device
Rue et al.40	Tibia	Protected weight bearing, alternative aerobic exercise, calcium and multivitamin supplements.	20 min/d	14	12	18.6 ± 0.8	18.4 ± 0.8	I: Exogen Inc. C: Sham device
Handolin et al.33*	Malleolar	Fixed with a 4.5 mm self-reinforced poly-L-lactic acid screw placed anteriorly. The ankle was immobilized for 6 wk with a removable brace.	20 min/d for 6 wk	15	15	41.4	39.4	I: SAFHS 2A, Exogen Inc. C: Sham device
Handolin et al.34*	Malleolar	Fixed with 1 anteriorly placed 4.5 mm self-reinforced poly-L-lactic acid, immobilized for 6 wk with a removable brace.	20 min/d for 6 wk, beginning third postoperative week	11	11	37.5	45.5	I: SAFHS 2A; Exogen Inc. C: Sham device
Ricardo22	Scaphoid	Initially immobilized with a long-arm thumb spica cast, followed by a short-arm cast until healing was demonstrated by radiograph.	20 min/d	10	11	26.7†	26.7	I: TheraMed 101-B bone-growth stimulator C: Ultrasonography device adjusted to give no signal output across the transducer
Lubbert et al.38*	Clavicle	Passive support with a collar and cuff for patients’ convenience as long as needed.	20 min/d for 28 d	61	59	Not reported	Not reported	I: Exogen 2000 battery powered main operating unit and a treatment head module transducer (Smith and Nephew Inc.) C: Sham device
Yadav et al.42	Tibia	Managed nonoperatively and prescribed paracetamol and ice packs.	10 min/d	39	28	Not reported	Not reported	I: Conventional ultrasonography C: Sham device
ESTIM trials
Barker et al.44*	Tibia	Full leg plaster immobilization, non–weight bearing.	10 h/d for 24 wk	9	7	38.0 ± 18.3	29.9 ± 8.0	I: EM-S; circumferential coils fitted around the cast over fracture site. Pulse frequency: 15Hz. C: Inactive coil
Wahlström55	Extra-articular distal radius	Immobilization alone.	4 wk (use/d unknown)	15	15	61.0 ± 4.3	60.8 ± 4.6	I: Active EM-S; single copper wire placed outside of plaster over fracture. Pulse frequency: 1–1000Hz, Magnetic flux density: 4 gauss. C: As above, without EM-S unit
Poli et al.51	Congenital pseudarthrosis	Surgically treated pseudarthrosis followed by cast immobilization for 3 mo then bracing with progression to weight bearing as tolerated.	10 h/d for 52 wk	6	6	Not reported	Not reported	I: Active EM-S; 2 high-impedance coils. Pulse frequency: 75Hz, EMF force: 3.5mV. C: As above, without EM-S unit
Borsalino et al.47	Femoral intertrochant eric wedge osteotomy to treat osteoarthritis	Surgery plus progression to weight bearing as tolerated over 90 d.	8 h/d for 30 d	15	16	56.5 ± 8.8	55.1 ± 8.2	I: Active EM-S; Single coil generating EMF positioned on lateral side of femur. Pulse frequency: 75 Hz; EMF force: 2.5mV or 18 gauss C: Inactive device
Sharrard53*	Tibia	Full leg plaster cast with knee at 20–30º.	12 h/d for 12 wk	20	25	34.7 (range 18–84)	45.4 (range 18–76)	I: EM-S; 2 enclosed external copper wires held over fracture site in Helmboltz configuration. Pulse frequency: 15Hz. C: Sham device
Mammi et al.50	Tibial reduction osteotomy	Postoperation: above-knee cast immobilization and non–weight bearing for 30 d.	8 h/d for 60 d	18	19	62.9 ± 7.9	61.1 ± 9.5	I: Active EM-S unit; EM-S held over cast by Velcro straps. Pulse frequency: 75Hz, EMF force: 3mV C: Sham device
Scott et al.52*	Any long bone	Immobilization and weight bearing as tolerated.	25.4 wk (use/d unknown)	10	11	40.6 ± 10.7	45.8 ± 20.5	I: EM-S; 2 stainless steel disks placed over fracture site delivering sine-shaped EMF at frequency of 60000Hz. EMF force: 5–10V C: Sham device
Eyres et al.48	Limb lengthening osteotomies	Surgery plus circular frame with 1mm of distraction/d.	4 h/d over an average of 24.5 wk	7	6	14.4 ± 3.9	13.7 ± 2.9	I: Active EM-S Saddle-shaped coil placed in between proximal and distal fixator pins. Pulse frequency: 15Hz C: Sham device
Betti et al.46	Femoral neck	Three cannulated screws followed by non-descriptive rehabilitation program.	8 h/d for 90 d	30	35	67.1 ± 6.0 Compliant patients only	68.7 ± 6.0	I: Active EM-S unit; commercially available pulsed EM-S unit. Pulse frequency: 75Hz, EMF force 3.5mV C: Sham device
Simonis et al.54*	Tibia	Fibular osteotomy and external fixator application with compression; non–weight bearing.	14 h/d for 26 wk	18	16	31.7 ± 14.6	32.3 ± 16.3	I: EM-S; pulsed EM-s via 2 external coils in contact with skin held by crepe bandage. Pulse frequency: 23.3Hz, EMF force: 150V, Field intensity: 6A. C: Sham device
Beck et al.45	Tibial stress fracture	Rest from activity plus calcium supplementation (500 mg/d calcium carbonate).	15 h/d until stress fracture clinically healed	22	21	Not reported	Not reported	I: Active EM-S; commercially available stimulator unit delivering sinusoidal wave via 2 water-based gel electrodes. Pulse frequency 60Hz, EMF Force: 3–6V, Current: 5–10mA. C: Inactive device
Faldini et al.49*	Femoral neck	3 cannulated screws followed by progressive weight bearing routine starting at 30 d.	8 h/d for 90 d	30	35	67.1 ± 6 compliant; 71.6 ± 3.1 non-compliant	67.4 ± 6.9 compliant; 69.8 ± 5.2 non-compliant	I: Active EM-S unit; commercially available pulsed EM-S unit. Pulse frequency 75Hz, Peak Value: 2mT C: Sham device
Adie et al.43*	Tibia	Nonoperative or operative (Intramedullary nail, plate, or ex-fix) treatment with surgeon dictated rehabilitation.	10 h/d for 12 wk	106	112	38.5	39.7	I: Active EM-S unit; commercially available pulsed EM-S unit (EBI Bone Healing System, Biomet Inc. C: Inactive device
Hanneman et al.20*	Acute scaphoid	Immobilization in a forearm cast with the first metacarpal and both phalanges immobilized.	24 h/d	24	29	44.3	37.7	I: PEMF (Ossatec) bone growth stimulator C: Disabled PEMF bone growth stimulator (same device as intervention)
Shi et al.31*	Femur, tibia, humerus and radius/ulna	Surgical reduction and fixation of the fracture.	8 h/d	31	27	41 ± 14.5	38.4 ± 11.6	I: Electromagnetic field delivered through a coil (Orthopulse II, OSSATEC) C: Sham signal generator from the same manufacturer

EMF = electromagnetic force; ESTIM = electrical stimulation; LIPUS = low intensity pulsed ultrasonography; PEMF = pulsed electromagnetic field therapy; SAFHS = Sonic Accelerated Fracture Healing System; SD = standard deviation.

^*Analyzed quantitatively in the indirect comparison analysis.

^†Only the age for the full sample was reported, and was thus assumed to be the same for both intervention and control arm.