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Practice Rapid Recommendations

Low intensity pulsed ultrasound (LIPUS) for bone healing: a clinical practice guideline

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j576 (Published 21 February 2017) Cite this as: BMJ 2017;356:j576

Population

Adults and children with a fracture or osteotomy

Choice of intervention

or LIPUS No ultrasound Standard care without ultrasound Low intensity pulsed ultrasound, used to stimulate bone growth (osteogenesis)

Recommendations

Population Favours LIPUS Favours no ultrasound

All Why? We recommend against the use of LIPUS Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option. Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option.

Comparison of benefits and harms Key practical issues Evidence quality Summary Favours LIPUS Favours no ultrasound See full details LIPUS No ultrasound 150 No important difference The panel unanimously agreed that all or nearly all informed patients would elect not to apply LIPUS. Preferences and values Resourcing Other considerations Days to radiographic healing Days to return to work Subsequent operations Device-related adverse effects LIPUS is a costly device which does not represent a wise use of health resources. Number of days (mean) 205 Events per 1000 people 160 0 0 147 200 No important difference 70 Pain score (0–100, lower better) Mean value 40 39 No important difference No important difference No important difference No important difference Days to full weight bearing 73 No important difference LIPUS may be burdensome to use. This is reflected in the TRUST trial, in which many patients reported limited compliance. Usually used for 15-20 minutes each day for 14 to 140 days No practical issues Device can be cumbersome to travel with Health insurance may not cover cost 128 LIPUS probably has little or no impact on time to radiographic healing Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. LIPUS probably has little or no impact on time to return to work Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. LIPUS has no impact on time to full weight bearing High High quality evidence We are very confident in the evidence supporting the recommendation. Further research is very unlikely to change the estimates of effect. LIPUS has no impact on pain reduction High High quality evidence We are very confident in the evidence supporting the recommendation. Further research is very unlikely to change the estimates of effect. LIPUS probably has little or no impact on subsequent operation Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. LIPUS has no impact on device-related adverse effects High High quality evidence We are very confident in the evidence supporting the recommendation. Further research is very unlikely to change the estimates of effect.

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Find recommendations, evidence summaries and consultation decision aids for use in your practice
  1. Rudolf W Poolman, chair, orthopaedic surgeon1,
  2. Thomas Agoritsas, assistant professor2 3,
  3. Reed A C Siemieniuk, methodologist2 4,
  4. Ian A Harris, professor of orthopaedic surgery5 6,
  5. Inger B Schipper, professor of trauma surgery7,
  6. Brent Mollon, orthopaedic surgeon8,
  7. Maureen Smith, patient representative9,
  8. Alexandra Albin, patient representative10,
  9. Sally Nador, patient representative11,
  10. Will Sasges, patient representative12,
  11. Stefan Schandelmaier, methodologist2 13,
  12. Lyubov Lytvyn, patient liaison expert14,
  13. Ton Kuijpers, methodologist15,
  14. Loes W A H van Beers, physiotherapist1 16,
  15. Michael H J Verhofstad, professor of trauma surgery17,
  16. Per Olav Vandvik, methods editor18 19
  1. 1Department of Orthopaedic Surgery, Joint Research, OLVG, 1090 HM Amsterdam, The Netherlands
  2. 2Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada L8S 4L8
  3. 3Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, CH-1211, Geneva, Switzerland
  4. 4Department of Medicine, University of Toronto, Toronto, Ontario, Canada M5G 2C4
  5. 5South Western Sydney Clinical School, UNSW Australia, Sydney NSW 2052, Australia
  6. 6Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia
  7. 7Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
  8. 8Orillia Soldiers’ Memorial Hospital, Orillia, Ontario, Canada L3V 5W6
  9. 9Ottawa, Ontario, Canada
  10. 10Society for Participatory Medicine Member, USA
  11. 11Kindred Northlake Hospital, Northlake, USA
  12. 12Calgary, Alberta, Canada
  13. 13Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, CH-4031 Basel, Switzerland
  14. 14Oslo University Hospital, Forskningsveien 2b, Blindern 0317 Oslo, Norway
  15. 15Dutch College of General Practitioners, 3502 GE Utrecht, The Netherlands
  16. 16Department of Physiotherapy, OLVG, 1090 HM Amsterdam, The Netherlands
  17. 17Trauma Research Unit Erasmus, Department of Surgery, Erasmus MC University Rotterdam, 3000 CA Rotterdam, The Netherlands
  18. 18Institute of Health and Society, Faculty of Medicine, University of Oslo, 0318 Oslo, Norway
  19. 19Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
  1. Correspondence to: R W Poolman rwp{at}jointresearch.org

What you need to know

  • LIPUS is used for bone healing for people who have had fractures or osteotomy

  • LIPUS is costly to purchase

  • A new trial and linked systematic review provide moderate to high certainty evidence to support a strong recommendation against the use of LIPUS for bone healing

  • Further research is unlikely to alter the evidence

  • Healthcare administrators and funders may consider de-implementation of LIPUS as a performance indicator in quality improvement initiatives

Linked articles in this BMJ Rapid Recommendations cluster

  • Schandelmaier S, Kaushal A, Lytvyn L, et al. Low intensity pulsed ultrasound for bone healing: systematic review of randomized controlled trials. BMJ 2017;356:j656

    • Review of all available randomised trials that assessed LIPUS versus sham device or no device that informed the recommendation made by the panel

  • MAGICapp (www.magicapp.org)

    • Expanded version of the results with multilayered recommendations, evidence summaries, and decision aids for use on all devices

Does low intensity pulsed ultrasound (LIPUS) accelerate recovery in adults and children who have experienced bone fractures or osteotomy (cutting of a bone)? An expert panel rapidly produced these recommendations based on a linked systematic review triggered by a large multicentre randomised trial in adults with tibial fracture.

Fracture is common (see box 1). Bones can also be broken for medical reasons; osteotomy is a procedure whereby a bone is cut to shorten, lengthen, or to change its alignment. Following osteotomy, the bone has similar healing problems as traumatic fractures, and may require more extensive recovery.1

Box 1: Background information

Bone fracture
  • More than one in three people have a fracture at some point in their life

  • Each year around four per 100 people of all ages experience a fracture2

  • Some 5-10% of these experience delayed healing or non-union of the fracture3

LIPUS
  • Guidance

    • 1994 US Food and Drug Administration (FDA) approved LIPUS for fracture healing and, in 2000, for treatment of established non-unions4

    • 2010 UK …

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