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Osteonecrosis of the humeral head after extracorporeal shock-wave lithotripsy

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A 59-year-old woman with calcific tendinitis in her right shoulder underwent extracorporeal shock-wave lithotripsy. Three years and four months later she presented with osteonecrosis of the head of the right humerus. It is known that shock waves in patients with urological disorders can damage blood vessels. A possible reason for the development of osteonecrosis in this patient may have been damage to the blood supply of the head of the humerus.
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744 THE JOURNAL OF BONE AND JOINT SURGERY
H. B. Durst, MD, Registrar
G. Blatter, MD, Consultant Orthopaedic Surgeon
M. S. Kuster, MD, PD, PhD, Consultant Orthopaedic Surgeon
Department of Orthopaedic Surgery, Kantonsspital St Gallen, 9007 St
Gallen, Switzerland.
Correspondence should be sent to Dr M. S. Kuster.
©2002 British Editorial Society of Bone and Joint Surgery
0301-620X/02/512282 $2.00
Case report
OSTEONECROSIS OF THE HUMERAL HEAD AFTER
EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY
H. B. Durst, G. Blatter, M. S. Kuster
From Kantonsspital, St Gallen, Switzerland
A
59-year-old woman with calcific tendinitis in her right
shoulder underwent extracorporeal shock-wave
lithotripsy. Three years and four months later she presented
with osteonecrosis of the head of the right humerus. It is
known that shock waves in patients with urological
disorders can damage blood vessels. A possible reason for
the development of osteonecrosis in this patient may have
been damage to the blood supply of the head of the
humerus.
J Bone Joint Surg [Br] 2002;84-B:744-6.
Received 21 March 2001; Accepted after revision 24 July 2001
Extracorporeal shock-wave lithotripsy has become a common
treatment for calcific tendinitis of the shoulder. No severe compli-
cations have been reported,
1-8
and it is considered to be a safe
procedure. We present a case of osteonecrosis of the head of the
humerus after extracorporeal shock-wave lithotripsy. Possible
pathomechanisms are discussed.
Case report
In June 1996, a 59-year-old woman presented with chronic pain in
her right shoulder. Radiographs showed a deposit of calcium of 28
10 mm in the tendon of supraspinatus (Fig. 1). Since three
subacromial injections of cortisone had not given symptomatic
relief she underwent three sessions of extracorporeal shock-wave
lithotripsy with 1600 to 1700 impulses at each session at a level of
12 to 13 kV over a period of one month. After treatment there was
less pain and a full range of movement. Radiographs revealed a
reduction in the size of the deposit of calcium by 79% to 12
5 mm, without any evidence of osteonecrosis of the humeral head
(Fig. 2). Three years and four months later she presented again
with chronic pain in the shoulder. Radiographs showed partial
necrosis of the humeral head which was stage IV according to the
classification of Neer
9
(Fig. 3). MRI confirmed the radiological
diagnosis of partial necrosis. There were no signs of osteonecrosis
in the contralateral shoulder. Investigations for known predispos-
ing factors for osteonecrosis were negative.
Discussion
To our knowledge no severe complications of extracorporeal
shock-wave lithotripsy have been published in the orthopaedic
literature. Minor problems such as pain in the shoulder, local soft-
tissue swelling, cutaneous erosions, erythema, petechial haemor-
rhage and local subcutaneous haematomas have been described.
1-8
Apart from a single report of changes in the MRI signal in the
subcortical area of the greater tuberosity 12 weeks after treat-
ment,
2
no bony or cartilaginous changes have been demonstrated
by radiography, MRI, sonography or arthroscopy.
1-8
The longest
radiological follow-up after shock-wave treatment to the shoulder
is, however, only two years.
8
Gerber, Schneeberger and Vinh
10
identified the ascending
branch of the anterior humeral circumflex artery and its continua-
tion, the arcuate artery, as being the main supply to the proximal
humeral epiphysis. It was further shown that the closer this artery
is injured to its point of entry into the bone the greater is the risk
to the vascularity of the humeral head, because of a lack of distal
anastomoses. The vessel enters the bone in the area of the lateral
and superior aspects of the intertubercular groove. In our patient
this point was only 10 mm from the deposit of calcium.
It is known that shock waves in patients with urological
disorders have caused damage to blood vessels ranging from
benign lesions of the endothelium to arterial occlusion with
capillary extravasation, and even ruptures of the vessel wall.
11,12
Destruction of the ascending branch of the anterior humeral
circumflex artery could thus be responsible for the osteonecrosis
in our patient. Also, the time interval between injury and the
radiological appearance of osteonecrosis is comparable to that
which may occur with fractures of the proximal humerus. Darder
et al
13
showed that it may take up to four years for radiological
signs of osteonecrosis to develop in patients with four-part frac-
tures of the proximal humerus. In our patient MRI showed that the
osteonecrosis occurred in the area of perfusion of the anterior
circumflex artery. The bone in the area of perfusion of the
posterior circumflex artery was not affected (Fig. 4).
A possible alternative aetiology, although unlikely, may be the
repeated subacromial infiltrations of cortisone. We were unable to
find any evidence in the literature of osteonecrosis after sub-
acromial infiltration of steroid, although there are some case
reports of osteonecrosis after intra-articular injection.
14,15
We found no other predisposing factors for osteonecrosis in our
patient. The development of idiopathic osteonecrosis may have
b
a
been simply coincidence and the reason for the development of
osteonecrosis of the humeral head in this patient remains uncer-
tain. With the increasing popularity of this form of treatment,
experimental and long-term clinical follow-up studies are neces-
sary to establish whether avascular osteonecrosis of the humeral
head is in fact a rare, but severe, complication of extracorporeal
shock-wave treatment. If shock waves are found to be harmful to
the blood supply of the humeral epiphysis, care must be taken to
avoid the intertubercular groove when targeting the shock wave
on deposits of calcium.
No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this
article.
References
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745CASE REPORT
VOL. 84-B, N
O
. 5, JULY 2002
Fig. 1
AP radiograph of the right shoulder before
extracorporeal shock-wave lithotripsy showing
the deposit of calcium.
Fig. 2
AP radiograph of the right shoulder after extra-
corporeal shock-wave lithotripsy showing the
reduction in size of the deposit of calcium.
Fig. 3
AP radiograph of the right shoulder showing
osteonecrosis of the right humeral head three
years and four months after treatment.
Fig. 4a Fig. 4b
Figure 4a – Axial MRI of the right shoulder showing osteonecrosis of the right humeral head in the area of
perfusion of the anterior humeral circumflex artery. Figure 4b – According to Gerber et al
10
the non-hatched
area is supplied by the anterior humeral circumflex artery (a, greater tuberosity; b, lesser tuberosity); reproduced
with permission of Journal of Bone and Joint Surgery [Am] ).
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tol 1990;17:549-51.
746 CASE REPORT
THE JOURNAL OF BONE AND JOINT SURGERY
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Fragestellung: Die extrakorporale Stoßwellentherapie (ESWT) ist ein neues Verfahren zur Behandlung der chronisch schmerzhaften Tendinosis calcarea der Rotatorenmanschette. Das Therapiekonzept kann hinsichtlich der Energieflußdichte der Einzelimpulse sowie der Gesamtzahl der applizierten Impulse und damit der Gesamtenergie variieren. Ziel dieser Studie war es, die Hypothese zu überprüfen, daß bei gleicher Gesamtenergie eine niederenergetische Behandlung (3 × 5000 Impulse; 0,04 - 0,12 mj/mm²) einer hochenergetischen Behandlung (1 × 5000 Impulse; >0,12 mJ/mm²) äquivalent ist. Methode: Es handelte sich um eine prospektiv randomisierte Studie. Die niederenergetische Behandlung wurde in 3 Sitzungen im Wochenabstand ohne Anästhesie durchgeführt (Gruppe 1, n = 25). Hochenergetisch wurde einmal in Analgosedierung behandelt (Gruppe 2, n = 25). Kontrolluntersuchungen erfolgten klinisch und radiologisch nach 6 Wochen, 3 und 6 Monaten. Ergebnisse: Der Constant-Score verbesserte sich von 64,5 auf 77,5 in Gruppe 1 und von 67,2 auf 79,4 in Gruppe 2 jeweils vor und 6 Monate nach der Behandlung (p < 0,001). Die rein subjektiven Punktwerte der visuellen Analogskala, welche von 0 (kein Schmerz) bis 100 (Maximalschmerz) reicht, verbesserten sich ebenfalls von 76,8 auf 48,8 (Gruppe 1) und von 75,4 auf 45,6 (Gruppe 2) vor und 6 Monate nach der Behandlung (p< 0,05). Das Behandlungsergebnis veränderte sich nach 3 Monaten nur noch unwesentlich. Röntgenologisch wurde eine komplette oder subtotale Resorption des Kalkdepots bei 8 (Grup-pe 1,32%) und 12 Patienten (Gruppe 2,48%) erreicht. Schlußfolgerungen: Die klinischen Ergebnisse waren in beiden Gruppen signifikant gebessert, so daß eine niederenergetische einer hochenergetischen Behandlung äquivalent erscheint. Die Kalkresorptionsrate von 40% läßt einen Therapieeffekt wahrscheinlich erscheinen.
Article
Fragestellung: Die Anwendung der extrakorporalen Stoßwellentherapie (ESWT) außerhalb der ableitenden Harnwege ist umstritten und bedarf einer aktuellen Betrachtung. Methode: Im Sinne einer Metaanalyse wurden 105 zu dem Themenkomplex der Stoßwellentherapie an den Bewegungsorganen vorliegende Publikationen ausgewertet und nach einem international gebräuchlichen Schlüssel validiert. Rückschlüsse i.S. einer Therapieempfehlung müssen sowohl wissenschaftliche als auch wirtschaftliche Faktoren berücksichtigen. Ergebnisse: Aus 55 Publikationen und Abstracts konnten 4825 mittels ESWT therapierte Fälle gesammelt werden. Nur 24 Publikationen mit 1585 Fällen (33%) erfüllen die Ansprüche einer auswertbaren wissenschaftlichen Untersuchung. Demnach ist die ESWT bei Tendinosis calcarea, bei der Epicondylopathia humeri und beim Fersensporn gleich wirksam wie andere herkömmliche Methoden. Aus derzeitiger wirtschaftlicher Sicht ist die ESWT wegen der höheren Komplikationsrate operativer Verfahren beim therapierefraktären Fersensporn zu rechtfertigen. Die Untersuchungen zur Therapie der Pseudarthrosen und der Enthesiopathien genügen den Ansprüchen wissenschaftlicher Studien nicht. Schlußfolgerungen: Die derzeit weitgesteckte Indikation zur ESWT ist wissenschaftlich nicht begründet. Ziel mußes sein, mit Hilfe qualitativ hochwertiger Studien, einheitliche, d.h. adaequate Energiedichten und Impulsraten für die jeweiligen Indikationsgruppen anzugeben. Untersuchungen im Sinne einer evidence-based-medicine stehen aus, um die Indikation zu präzisieren. Summary Aim: Up to now ESWT is not a standard therapeutic technique in orthopaedics. The mechanisms of the induced analgesic effect or the mechanism of shock-waves in bony defects are still unknown. By metaanalysis successrates and indications for ESWT are worked out as well as adequate impulse- and energyrates according to actual state of knowledge. Aim of this study is to rate the published cases. Method: 105 papers refering to ESWT of the locomotor system are rated. Validation was performed for each paper according to the international accepted system of the American Association of Spine Surgery in Type A-E. Advise for therapy is taken only from high quality publications of Type A and B. This advise should regard scientific as well as economic aspects. Results: 4825 cases from 55 publications and abstracts that underwent ESWT were evaluated. 24 papers with 1585 cases (33%) live up to the standards of a scientific investigation. Numerous studies exist about therapy of calcifying tendinitis, epicondylitis humeri radialis, painfull heel, pseudarthrosis and other enthesiopathies. Especially the studies concerning pseudarthosis and other enthesiopathies do hardly live up to scientific standards. In calcifying tendinitis and painfull heel ESWT achieves nearly the same results than the established methods. No serious complications were observed. Because of the high complication rate in operative treatment of heel spur ESWT seems to be justifiable. The techniques of ESWT, energy density levels, impulse rates and complications will be described. Conclusion: The advantages of ESWT are non-invasiveness and low rate of complications. Primary aim should be to evaluate adequate energy density levels and impulse rates for specific groups of indications using high quality studies according to evidence-based-medicine. Long term results need to be awaited to be able to compare ESWT with established methods. Recent inflationary use of ESWT especially in outpatient departments has no scientific indication in numerous cases as conservative methods are not used consequently.
Article
In einer prospektiven klinischen Pilotstudie wurde der Einsatz der extrakorporalen Stoswellen-Lithotripsie (ESWL) mit sonographischer Ortung bei 5 Patienten mit seit Jahren therapieresistenten Beschwerden bei Tendinosis calcarea der Schulter uberpruft. Bei einer Patientin trat unmittelbar nach der Behandlung Beschwerdefreiheit ein, das Kalkdepot war am folgenden Tag nicht mehr rontgenologisch darstellbar. 3 weitere Patienten waren innerhalb von 6 Wochen weitgehend beschwerdefrei bei rontgenologicher Auflosung des Kalkdepots. Bei einem Patienten konnte trotz partieller rontgenologischer Desintegration des Konkrementes keine Beschwerdebesserung erreicht werden. In a prospective investigation the use of high energetic shock waves for treatment of chronical painful calcareous tendinitis of the shoulder was examined in a pilot group of 5 patients. The deposits were localiced by sonography. Immediatly after treatment 1 patient felt complete release of pain, the calcium deposit had disappeared on the x-ray control one day after treatment. In 3 cases pain release and elimination of the calcification appeared during 6 weeks after treatment. One patient showed only radiological desintegration of the calcification with no release of pain.
Article
The locations of extracorporeal shock wave treatment induced renal vascular injury and the sources of significant renal hemorrhage were determined in a rat model by means of two different vascular casting procedures. Silicone-rubber injected vascular preparations for light microscopy or corrosion casts for scanning electron microscopy were made following gross examination of the treated organs and their contralateral controls. After 1000 shock waves at 18 kV, five out of 20 treated kidneys appeared to be normal or minimally affected, while 15 showed gross evidence of marked vascular injury. Gross interstitial hemorrhage (15/20), subcapsular hematomas (7/20), and hemorrhages into the renal pelvis (5/20) were confirmed by extravasations of casting materials. These could be traced back to their vascular sources in several instances. Disruptions of interlobar and arcuate veins gave rise to most significant interstitial, subcapsular, and renal pelvic extravasations. On a microscopic scale cortical venules were among the most frequently injured vessels. The arterial vasculature was not spared. Arterial injury ranged from complete arcuate occlusion to small afferent arteriolar and glomerular capillary extravasations. The significance of shock wave induced vascular injury is discussed with respect to potential clinical side effects of ESWL.
Article
We describe a woman with recurrent synovitis in one or both knees treated with intraarticular corticosteroid injections and two 6-day courses of methylprednisolone tablets. She later developed osteonecrosis of her distal femora and proximal tibiae. Her course was complicated by persistent synovitis associated with a large quantity of necrotic fat in the joint fluid.
Article
In twenty-nine specimens from fresh cadavera, we performed an anatomical study of the arteries of the humeral head to determine their intraosseous distributions. A radiopaque suspension was injected into the anterior circumflex, posterior circumflex, suprascapular, thoracoacromial, or subscapular artery and then the specimens were dissected and were analyzed macroscopically, and radiographs were made in three mutually perpendicular projections. In addition, sixteen of the specimens were cut into four-millimeter slices and were studied microradiographically. The humeral head was shown to have been perfused by the anterolateral ascending branch of the anterior circumflex artery in all specimens. That vessel ran parallel to the lateral aspect of the tendon of the long head of the biceps and entered the humeral head where the proximal end of the intertubercular groove met the greater tuberosity. When the intraosseous (terminal) part of the anterolateral branch, the so-called arcuate artery, had been perfused, almost the entire epiphysis was radiopaque. The posterior circumflex artery vascularized only the posterior portion of the greater tuberosity and a small posteroinferior part of the head. Anastomoses between the different arteries were abundant, but vascularization of all of the humeral head was possible only through the anterolateral branch of the anterior circumflex artery.
Article
Two cases of multifocal osteonecroses are described. Two hips were affected in one case, 2 hips and 2 shoulders in the other. In both cases osteonecroses developed after intraarticular instillations of long-acting corticosteroids.
Article
During the past 2 years, 40 patients referred to the authors' hospital for persistent calcifying tendinitis of the shoulder were seen on prospective followup after undergoing a single extracorporal shock wave therapy. During a single therapy session, all patients received 1500 impulses of the energy density 0.28 mJ/mm2 in plexus anesthesia. Followup examinations were done at 6 and 24 weeks. In 62.5% of the patients partial or complete disintegration of the deposit was observed. Statistical analysis showed significant improvement both of subjective and objective criteria. According to the Constant score, 60% of the patients reached normal values, and 72.5% of the patients had no or only occasional discomfort. Only 6 patients (15%) reported no improvement at the 24-week followup.
Article
This study examined the effects of high-energy shock wave treatment on the course of calcifying tendinitis of the shoulder. Twenty patients were included in the protocol. Shock waves were applied to the calcifications with a lithotripter in two sessions of 2000 pulses each. The energy that produced the shock wave was 18 to 22 kV. Six and 12 weeks after treatment the subjective and functional state was assessed with the Constant score. All patients underwent radiographs and magnetic resonance imaging. At the 12-week follow-up evaluation 15 patients had a marked reduction of symptoms with an average of 30% improvement in the Constant score. Radiographs showed a complete elimination of the calcifications in seven patients, and in five cases a partial disintegration was seen. The overall morbidity was low; 14 patients had a transient subcutaneous hematoma. Magnetic resonance imaging did not show any lasting damage to bone or soft tissue.
Article
After their introduction into medicine for kidney stone lithotripsy, extracorporeal shock waves have gained an established or promising role in the treatment of bileduct, pancreatic and salivary stones during the last years. Treatment of gallbladder stones is possible in a large proportion of patients, yet is cumbersome. Beyond lithotripsy, treatment of pseudarthrosis by shock waves reveals positive results. The role of shock waves in the treatment of soft tissue pain is at present unknown. There is a potential for further therapeutic applications of shock waves since shock waves exert a strong biological effect on tissue which is mediated by cavitation. Experiments using shock waves for tumor therapy have shown some promising results, yet devices which generate other waveforms than lithotripters are probably better suited. Shock waves cause a transient increase in the permeability of the cell membrane, and this might lead to further applications of shock waves.