The Journal of Bone and Joint Surgery (American). 2008;90:85-91.
doi:10.2106/JBJS.G.01521
© 2008 The Journal of Bone and Joint Surgery, Inc.
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Critical Analysis of the Evidence for Current Technologies in Bone-Healing and Repair

Wendy M. Novicoff, PhD, Abhijit Manaswi, MD, MS, DNB, FRCS, MaCalus V. Hogan, MD, Shawn M. Brubaker, DO, William M. Mihalko, MD, PhD and Khaled J. Saleh, MD, FRCSC, MSc(Epid)

Corresponding author:
Khaled J. Saleh, MD, FRCSC, MSc(Epid)
P.O. Box 800159, Charlottesville, VA 22908-0159.
E-mail address: kjs3x{at}virginia.edu

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from Stryker Inc., and Smith and Nephew, Inc. In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Stryker Inc. and Ethicon, Inc.). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Substances that enhance fracture-healing and bone regeneration have valuable clinical application and merit future research. Advances in these technologies will enhance our ability to heal fractures in a more effective and expedient manner. This review provides a brief description of the different techniques and technologies and their respective clinical utility. This paper also reviews the available literature on gene therapy, tissue engineering, growth factors, osteoconductive agents, and physical forces and assesses the evidence regarding the current status of these techniques of healing and regenerating bone.

Only twenty-seven articles met our guidelines for studies containing Level-I evidence. We were able to determine that atrophic nonunions and pseudarthrosis led to poorer outcomes, and the results were uniformly poor irrespective of the technique used.

Although the literature contains a large number of studies on the effects of different agents and modalities on bone repair and healing, it still is not clear how these agents work or in what circumstances they should be used. Many of the treatment modalities of interest are still at an experimental stage, so good evidence to support clinical practice is lacking. Additional multicenter, prospective randomized studies are needed to define the indications, specifications, dosage, limitations, and contraindications in the treatment of nonunions. Studies are also needed to address the full clinical feasibility of the role of each modality in fracture-healing and repair.


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