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Table 1 Summary of results

From: The role of electrical stimulation in the management of avascular necrosis of the femoral head in adults: a systematic review

Reference Study type Number of patients Stage Pre-treatment hip outcome score Aetiology Clinical technique Additional management Results Post-treatment hip outcome score Other
J.L. Cebrián et al. [3]. Retrospective 51 (70 hips) ARCO staging used.
I: 20
II: 50
Symptomatic, AVN + no collapse on MRI and X-ray Idiopathic: 40
Steroids: 26
Alcohol: 4
1 pair of coils attached anteriorly & posteriorly, held in place over greater trochanter on molded splint. Single pulse of
Frequency: 75 Hz Intensity: 400 mA
Time: 1 at 3 ms
Duration of tx: Coils worn for 8 h/day for 6 months
- Follow up at 3, 6, 12, 24, 48 months with AP + Axial X-ray and MRI.
Mean follow-up = 26 months.
Collapse
ARCO I + IIA: 0 collapse
ARCO IIB: 3 collapse
ARCO IIC: 5 collapse
D’Aubigne pain scale
Improve: 55
Stable: 11
Decline: 4
80% had radiological success.
88.57% had no progression.
11.43% collapsed.
Progression = ↑ARCO stage or collapse >2 mm compared to pre-treatment
L. Massari et al. [4] Prospective 68 Steinberg staging used - Primary: 34
Steroids: 17
Trauma: 5
SPT BIOSTIM pulse generator used. Single voltage pulses
Frequency: 75 Hz
Time: each pulse at 1.3 ms
Duration of tx: 8 h/day for 6 months
Core decompression and autologous bone graft (from proximal metaphysis and femoral neck) X-ray and MRI at 1, 3, 6, 12, 24 months from surgery.
After, X-ray yearly and MRI every 2 or 3 yr.
Mean follow-up = 5.8 yrs.
Steinberg II: 81% no pain and limping, good radiographic results.
Steinberg III: 70% success
Steinberg IV: 53% good clinical results.
27% good radiographic results.
  2 patients needed total hip arthroplasty:
- Bilateral in 1 patient (Steinberg III)
- Unilateral in 1 patient (Steinberg IV)
L. Massari et al. [2] Retrospective 66 (76 hips) Ficat staging used.
I: 31
II: 22
III: 23
1/3 were Ficat stage III
Intense pain and significant functional restriction
Primary: 51
Secondary (alcohol, trauma, steroids): 15
SPT BIOSTIM pulse generator used:
Duration of tx: 8 h/day for 6 months (mean duration = 5+/−2 months)
NSAIDS for pain.
Non-weight bearing advised but only 50% complied.
Mean follow-up = 28 months
X-ray at follow-up with CT and MRI confirmation if available.
Ficat I + II: 50/53 hips preserved;
3 Ficat II had progression
Ficat III: 12 hips had progression
Ficat I: 45% improved to stage 0; 45% unchanged; 10% worsened to stage II
Ficat II: 35% improved to stage I; 50% unchanged; 25% worsened to stage III
Ficat III: 0% improved; 50% unchanged; 50% worsened to stage IV
15 of 76 hips progressed.
Pain
- 35 were pain free after 60 days of treatment.
- 17 had pain of moderate intensity.
- 14 still had intense pain.
Hip joint function
- Normal in 46%
- Sufficient in 39%
- Insufficient in 15%
The hips that progressed led to severe degenerative OA that required surgery.
C. Windisch et al. [5] Prospective 35 ARCO staging used.
Group 1
IIA: 3
IIB: 8
IIC: 7
IIIC: 4
Group 2 (non-PEMF)
IIA: 4
IIB: 9
IIIB: 2
IIIC: 3
Group 1: 3/19 pts. had bilateral involvement
Group 2: 2/16 had bilateral involvement
- Magnetodyn – external magnetic field coil and an invasive bipolar induction screw.
Frequency: Sinus shaped external magnetic field of ~20 Hz
Magnetic flux density: ~5mT
Voltage: ~700 mV induced
Electric field strength: 50-700 mV/cm
Curettage, autologous bone grafting (from greater trochanter and proximal femur). Follow-up checks at 6 and 12 months: clinical exam, clinical evaluation – modified Harris Hip score, Merle D’Aubigne hip score, VAS; imaging – X-ray with pelvic view and axial projection of hip, bilateral MRI.
Group 1:
- 2 stage 2C patients had THA
- 2 stage 3C patients had THA
Group 2:
- 1 stage 2B patient had THA
- 1 stage 3B patient had THA
- 2 stage 3C patients had THA
Comparing clinical outcomes of group 1 and 2:
- No significant difference between groups for D’Aubigne score.
- No significant difference in Harris Hip score.
- No significant difference in VAS.
- No significant improvement/deterioration as a result of the procedure in group 1.
- Both procedures promising up to stage 2A.
  18% of patients in Group 1 had to have THA.
22% of patients in Group 2 had to have THA.
M.E. Steinberg et al. [11] Prospective 285 (406 hips) Steinberg staging used.
I: 62 hips
II: 133
III: 13
IV: 85
V: 4
- Primary: 10%
Steroids: 38%
Alcohol: 37%
Alcohol + Steroids: 15%
Trauma: 12%
Group 1: Constant DC via cathode wire coiled about the graft and attached to an Osteostem/ Orthofuse
Group 2: Capacitative coupling via surface electrodes applied anteriorly and posteriorly to the skin over the femoral head and connected to a portable power unit.
Core decompression and bone grafting Post-operative evaluation by Harris Hip score, AP + lateral X-rays, taken at 3, 6,12, 18, 24 months and then yearly/two yearly thereafter.
Mean follow-up = 46 months
DC group
- Radiographic progression in 70%.
- Mean progression: 2/3 stage
- Mean 5 point improvement in HHS (64% improved or remained unchanged)
- 41% needed THA
Control
- 79% radiographic progression
- Mean progress: 1 1/3 a stage
- Mean 3 point drop in HHS
- 43% improved or unchanged
- 37% needed THA
Capacitive coupling
- Clinically and radiographically, 42% improved or remained unchanged
- 25% needed THA
Control
- Radiographically and clinically, 50% improved or remained unchanged
- 20% needed THA
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M.E. Steinberg et. Al [15] Prospective + historical control 116 hips
55 hips for historical controls
40 hips for disease progression (separate studies)
Steinberg staging used.
Mean stages:
Non-stimulated: IIIA
Stimulated: IIIB
Non-stimulated: IIIA
Stimulated: IIIB
Mean Harris scores
Non-stimulated: 65
Stimulated: 65
- Constant DC electrical stimulator coiled longitudinally, delivering
Intensity: 20microA
Duration: 24 h a day for 6 months.
Core decompression and grafting Mean follow up time =
Non-stimulated: 33 months
Stimulated: 44 months
Electrical stimulation gave better Harris scores, less roentgenographic progression, but similar need for arthroplasty. No fractures or complications
No electricity: IVB
Electricity: IVA
Mean Harris scores
No electricity: 62
Electricity: 70
Nil
Bassett et al. [10] Prospective 95 (118 hips) Steinberg staging used.
I: 0
II: 12
III: 3
IV: 79
V: 21
VI: 3
Charnley modification of Merle D’Aubigne-Postel system
Mean scores =
Pain:3.9
Function: 3.7
Mobility: 5.2
Total: 12.8
Primary: 44
Trauma: 17
Alcohol: 9
Steroid: 46
Sickle cell: 2
Helmholtz-aiding coils, mounted anteriorly & posteriorly on splint.
7″ diameter coils, 6–8″ apart on brace.
Single 12″ diameter contoured coil on femoral head with Velcro around pelvis.
Duration: 8–10 h/day, discontinued ″1 year. No changes with weight-bearing
Nil Mean follow up = 5.3 years; every 2/3 months in 1st year, then 3–6 months after
PEMF treatment. Average 4.1 years prior.
9 hips (60%) in Stage II-III improved (3 returned to normal), 90 (76%) hips in stages IIA to VI stayed same, 19 (16%) in IVA to VC worsened (<2 mm collapse). Joint space width increased on average 1 mm in 17 of these 19, but most of these showed clinical improvement
One year: 15
Most recent: 15.8
20 required surgical procedures
R.K. Aaron et al. [6] Prospective 77 (106 hips) Ficat staging used.
PEMF
II: 23
III: 33
Core decompression
II: 26
III: 24
Modified D’Aubigne scale: actual scores not given - Coil positioned over greater trochanter.
Single pulse
Frequency: 72 Hz, quasirectangular, 380microsec.
Duration: 8 h/day, 12–18 months.
Core decompression in non-PEMF group Mean follow-up = 3 years
Percentage demonstrating both clinical & roentgenographic success
PEMF: 52%
Core: 20%
Clinical success (based on Modified D’Aubigne scale):
PEMF: 38 hips (68%)
Core decompression: 22 hips (44%)
Nil
Steinberg et al. [14] Prospective + historical control 40 (40 hips)
55 control hips
Steinberg staging used.
Stimulated
I: 3
II: 16
III: 1
Non-stimulated
I: 4
II: 16
Harris score
Stimulated: 94
Unstimulated: 75
Mean stage:
Stimulated: IIB
Unstimulated: IIA
Steroids: 19
Alcohol: 13
Other: 4
Idiopathic: 4
2 capacitive-coupling units (self-adhering electrodes) over femoral head
Frequency: 60 kHz
Duration: 24 h
Intensity: 5 V peak-peak amplitude.
All 40 patients had core decompression + grafting Harris score
Stimulated: 82
Unstimulated: 76
Clinically unchanged
Stimulated: 42%
Unstimulated: 50%
Mean stage
Stimulated: IIIA
Unstimulated: IIIA
No significant difference
Comparison with conservative
Core: 54% progress, 23% required total hip arthroplasty
Conservative: 81%progress, 69% required total hip arthroplasty
- 25% of stimulated & 20% of unstimulated hips required total hip arthroplasty.
R.K. Aaron et al. [2, 6]. Prospective 264 (373 hips) Steinberg staging Radiographic progression - PEMF - Mean follow-up = 35 months
Stage I: all hips conserved. 75% radiographic progression
Stage II: 77% preserved. 54% radiographic progression
Stage III: 53% preserved. 68% radiographic progression
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  1. AVN Avascular Necrosis, ARCO Association Research Circulation Osseous, CD Core Decompression, PEMF Pulsed Electromagnetic Field, DC Direct Current, NSAIDs Non-steroidal Anti-Inflammatory Drugs