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Low-Intensity Pulsed Ultrasound in the Treatment of Nonunions

Nolte, Peter A. MD; van der Krans, Arie MD; Patka, Peter MD; Janssen, Ignace M. C. MD; Ryaby, John P.; Albers, G. H. Robert MD

The Journal of Trauma: Injury, Infection, and Critical Care: October 2001 - Volume 51 - Issue 4 - p 693-703
Original Articles

Background Low-intensity ultrasound has demonstrated an acceleration of bone healing and more profound callus formation in animal and human clinical experiments. In this study, the effect of pulsed, low-intensity ultrasound was determined in established nonunion cases.

Methods The enrolled cases were reviewed for the time from their last surgical procedure and evidence of no healing or progression of healing during the 3 or more months before the start of low-intensity ultrasound therapy to determine whether the cases were established nonunions. Twenty-nine cases, located in the tibia, femur, radius/ulna, scaphoid, humerus, metatarsal, and clavicle, met the criteria for established nonunions. On average, the postfracture period before the start of ultrasound treatment was 61 weeks. Initial fracture treatment was conservative in 8 cases and operative in 21 cases. Additional treatments including bone grafting, reosteosynthesis, and other surgical procedures were performed an average of 52 weeks before the start of ultrasound treatment. Daily, 20-minute applications of low-intensity ultrasound at the site of the nonunion were performed by the patients at home.

Results Twenty-five of the 29 nonunion cases (86%) healed in an average treatment time of 22 weeks (median, 17 weeks). Stratification of the healed and failed outcome for age, gender, concomitant disease, bone location, fracture age, prior last surgery interval, nonunion type, smoking habits, and fixation before and during treatment showed a significant difference only in the smoking habit strata.

Conclusion Noninvasive ultrasound therapy can be useful in the treatment of challenging, established nonunions.

From the Department of Orthopaedics, Academic Medical Center, University of Amsterdam (P.A.N.), Department of Traumatology, Academic Hospital Free University (P.P.), Amsterdam, Department of Orthopaedics, University Medical Center Utrecht (A.V.D.K.), Utrecht, Department of Traumatology, Rijnstate Hospital (I.M.C.J.), Arnhem, and Department of Orthopaedics and Traumatology, Hospital Hilversum (G.H.R.A.), Hilversum, The Netherlands, and Exogen, Inc. (J.P.R.), Piscataway, New Jersey.

Submitted for publication April 15, 2000.

Accepted for publication May 6, 2001.

Supported by Exogen Inc., Piscataway, NJ.

Results were presented, in part, at the 6th Annual Meeting of the International Society for Fracture Repair, September 23–26, 1998, Strasbourg, France; and at the 21st World Congress of the Societe Internationale de Chirurgie Orthopaedique et de Traumatologie (SICOT), April 18–23, 1999, Sydney, Australia.

Address for reprints: P. A. Nolte, MD, Department of Orthopaedics, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; email:

© 2001 Lippincott Williams & Wilkins, Inc.