Clinical comment

Approximately, 5% of fractures go on to nonunion.⁶ Due to limited soft tissue coverage, the risk of developing nonunion is higher in tibia compared to other bones. In addition, the risk of nonunion is increased with increasing Gustilo–Anderson grades.⁷

Available literature and quality of the evidence

There are three randomized controlled trials (RCTs) of acute tibial fractures and two meta‐analyses including other bones that are available to answer this question (all level I).^2–4,8–10 Earlier RCTs showed an effectiveness of LIPUS on radiographic union, but limitations of those studies are small sample size, risk of bias, inconsistent results, and lack of evaluation of patient‐based outcome measures. Previous meta‐analysis by Griffin et al. was based on those RCTs.⁴ An RCT in 2016 which evaluated the functional outcome of patients who had sustained acute tibial fracture and subsequent meta‐analysis has cast doubt on the effectiveness of LIPUS in acute fractures.^9,10

Heckman et al. (level I) conducted an RCT in simple closed or Gustilo I open tibial fracture treated by cast.² Patients in the LIPUS group healed significantly faster both on radiographs and overall healing compared to the control group (86 ± 5.8 days vs 114 ± 10.4 days, p = 0.01, 96 ± 4.9 days vs 154 ± 13.7 days, p = 0.0001, respectively). The weakness of this study is that there is a 31% loss to follow‐up. Leung et al. (level I) investigated the effect of LIPUS on fracture healing for open and/or severely comminuted tibial shaft fractures fixed by intramedullary nail or external fixator.³ They concluded that the LIPUS‐treated group showed statistically significantly better healing as demonstrated by all assessments. The downside of this study was high risk of bias such as selection bias and detection bias. However, in the study of fresh tibial fractures treated with reamed and statically locked intramedullary nail by Emami et al. (level I), the average healing time was 155 ± 22 days (median 113 days) for the active treatment group and 125 ± 11 days (median 112 days) for the placebo group (p = 0.76).⁸ It was concluded that LIPUS treatment did not shorten healing time. None of these studies measured the functional outcome and pain score of the patients. Based on the inconsistency and lack of patient‐based outcomes in the result and high risk of bias, Busse et al. (level I) reevaluated the effectiveness of LIPUS compared with sham treatment in acute tibial fractures by randomized trial with a parallel group design of 501 patients.⁹

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