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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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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
H. B. Durst, G. Blatter, M. S. Kuster
From Kantonsspital, St Gallen, Switzerland
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
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,
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
(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.
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.
Apart from a single report of changes in the MRI signal in the
subcortical area of the greater tuberosity 12 weeks after treat-
no bony or cartilaginous changes have been demonstrated
by radiography, MRI, sonography or arthroscopy.
The longest
radiological follow-up after shock-wave treatment to the shoulder
is, however, only two years.
Gerber, Schneeberger and Vinh
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.
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
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.
We found no other predisposing factors for osteonecrosis in our
patient. The development of idiopathic osteonecrosis may have
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
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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
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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... 11,42,59,60,79 Existe en la literatura médica mundial el informe de un solo caso de una necrosis cefálica de húmero en una mujer de 59 años que había sido tratada más de tres años antes con onda de choque por presentar una calcificación del supraespinoso. 28 Aún se discute cuál fue el mecanismo real de producción de la necrosis, ya que la paciente también había recibido tres infiltraciones previas con corticoides. Se especuló que la aplicación de la onda de choque podría haber causado una lesión de la arteria circunfleja anterior, sin embargo durante muchos años ésta era ligada al seccionar el subescapular en los abordajes anteriores de hombro sin que se informara acerca de necrosis cefálicas posoperatorias. ...
La terapia por onda de choque extracorpórea ha tenido gran impacto en la terapéutica de la litiasis renal desde su introducción en la práctica médica hace más de veinte años. Actualmente, es la elección para el tratamiento de los cálculos renales y ureterales. Este procedimiento ha sido considerado eficaz para tratar hasta el 98% de los cálculos del riñón. 68 En estas situaciones el efecto busca-do es la desintegración de depósitos calcáreos. Su utilización en el campo de la Ortopedia y Trauma-tología está aún en sus comienzos pero en los últimos años ha tenido, en especial en Europa, un desarrollo ace-lerado y exitoso. Su aplicación a la patología musculoesquelética no só-lo se basa en el efecto desintegrador de la onda para tra-tar, por ejemplo, las calcificaciones del manguito rotador, sino también en sus efectos analgésicos y de estimulación del proceso de reparación en tendones, partes blandas y huesos. 11,23,42,54,69,76,91,98 El mecanismo de acción biológico todavía no ha sido completamente descubierto por lo que aún es necesario trabajar en investigación básica, pero su aplicación ha de-mostrado ser segura y eficaz. Permite evitar procedimien-tos quirúrgicos con una adecuada relación costo-benefi-cio. 27,53 Sólo en Alemania en 1997 y 1998 fueron tratados con este nuevo procedimiento, 60.000 pacientes anuales que padecían patología ortopédica. 11 Antecedentes históricos Las ondas de choque son ondas acústicas presentes en situaciones diarias, como en el caso del sonido de un trueno o generadas a partir del aplauso de un auditorio o por un avión que rompa la barrera del sonido. Sin embargo , comenzaron a ser reconocidas a partir de la segunda guerra mundial cuando las necropsias de náufragos que habían sufrido el efecto de ataques con cargas de profun-didad evidenciaron severas lesiones a nivel pulmonar a pesar de no existir signos externos de violencia. 88 Esta fue la primera oportunidad en la que pudo comprobarse el efecto de las ondas de choque sobre el cuerpo humano. En la década de los cincuenta, se desarrollaron diferen-tes líneas de investigación con relación a este fenómeno. Así, por ejemplo se descubrió que ondas de choque gene-radas por un dispositivo electrohidráulico podían romper platos de cerámica en un medio líquido. Poco después se describió la posibilidad de generar las ondas con una fuente electromagnética. En 1966, durante la experimentación con proyectiles de alta velocidad en la empresa aerospacial Dornier, un em-pleado tocó el plato que se utilizaba como blanco exacta-mente en el momento en que impactaba el proyectil. Sin-tió que una especie de descarga eléctrica corría por su cuerpo. Los estudios posteriores demostraron que no existía ningún tipo de electricidad en el medio y que en realidad el impacto había viajado desde el plato hacia el cuerpo del operario. 88 Posteriormente se profundizó el conocimiento de este fenómeno al evaluar las alteraciones que se producían en los materiales, a nivel del sitio de impacto de gotas de llu-via sobre la superficie de aviones supersónicos 11 y de mi-crometeoritos sobre los satélites. Se evidenció que con el tiempo se producían daños por la generación de lo que dio en llamarse ondas de choque. A principios de los años setenta, el Ministerio de De-fensa Alemán financió investigaciones acerca del efecto de las ondas sobre tejidos animales. Se hizo hincapié en su recorrido a través de los tejidos. Se evidenció entonces que se producían efectos colaterales leves en los múscu-los y en los tejidos adiposo y conectivo. Se comprobó que el tejido óseo sano no se afectaba bajo la carga de la on-da de choque. También se investigó el daño del tejido ce-rebral, el pulmonar y el de los órganos abdominales. A partir de estas investigaciones surgió el interés en su aplicación terapéutica. En 1971 Haeusler y Kiefer 43 co-municaron la primera desintegración in vitro de un cálcu-lo renal por medio de ondas de choque. En 1980 fue tratado en Munich el primer caso de litia-sis renal. En 1983, se lanzó en Stuttgart el primer genera-Terapia por onda de choque extracorpórea para el tratamiento de las lesiones musculoesqueléticas
... In the orthopedic field, the most frequently reported adverse reactions are skin redness, swelling, and subcutaneous ecchymosis that can recover spontaneously (7). Osteonecrosis of the humeral head and ulnar neuropathy after ESWT have also been reported (8). ...
Extracorporeal shockwave therapy (ESWT) has been widely used in the treatment of various musculoskeletal disorders with remarkable efficacy, with no relevant severe complications being reported. In this study, we report a rare case of acute irritant contact dermatitis following ESWT with serious skin damage, which has never been previously reported. A 42-year-old male patient with osteonecrosis of the femoral head (ONFH) was subjected to two sessions of ESWT. In the first session of low-energy ESWT (0.15 mJ/mm2 , 3 Hz, and a total of 2,000 impulses), no local or systematic adverse reactions occurred. Three months later, he was subjected to a second session of high-energy ESWT (0.28 mJ/mm2 , 4 Hz, and a total of 2,000 impulses). However, on the second day, the patient presented with itching and painful erythema and blisters on the local skin of the hip. Based on these manifestations and the results of patch testing, the patient was diagnosed with irritant contact dermatitis and treated by an oral antihistamine combined with external calamine lotions. The skin lesions began to develop exudate from erosion and scabs had gradually formed with treatment, and finally dry scabs fell off with no scar left. This is the first reported irritant contact dermatitis after ESWT. Although bone pathologies should be treated with high energy, patients should be informed of this potential rare complication.
... [11,12] However, despite its highly successful and minimally invasive nature, the application of high-energy shock waves rarely may cause some minor and major complications reported as follows: fascia ruptures, osteonecrosis of the humeral head, acute myocardial infarction and damage to nerves or other structures. [12][13][14][15] On the other hand, another potential risk could originate from the noise produced by the high-energy acoustic shock waves with possible negative effects on the hearing function of treated cases. Auditory functions may be deteriorated by repeated exposure to loud sound over an extended period of time, exposure to very loud impulse sound(s), or a combination of both. ...
Background: Radial extracorporeal shock wave therapy (r-ESWT) is commonly used for the treatment of chronic plantar fasciitis. Previously in the urology literature, some studies reported hearing impairment after extracorporeal shock wave lithotripsy. However, there is no study that evaluates the possible side effects of r-ESWT on the hearing function of patients. The aim of this study was to investigate the effects of r-ESWT on the pure tone audiometry of the patients on whom r-ESWT was applied for chronic plantar fasciitis. Material and methods: Patients with the diagnosis of plantar fasciitis who were treated with r-ESWT were included in this prospective case-control study. Before and after the r-ESWT application, all patients were consulted to our otolaryngology department for pure tone audiometric examination to detect any hearing impairment before and after the treatment. A control group was also constructed that consisted of patients who were admitted to our department for any complaint. Results: A total of 67 patients participated in the study. Radial ESWT group consisted of 47 patients (39 female, 8 male) with the mean age of 44.1 years. The control group consisted of 20 patients (12 female, 8 male) with the mean age of 36.9 years. We observed a 20-dB threshold shift at 8000Hz in 1 patient who had no clinical symptom. This patient had no threshold shift at the 1-month control audiometric measurement. Conclusion: According to the results acquired from this study, we can consider that r-ESWT treatment in patients with chronic plantar fasciitis has no markedly detrimental effect on the hearing function.
... However, high-energy extracorporeal shockwave also causes iatrogenic injury. Durst [18] reported that a woman with calcific tendinitis received high-energy extracorporeal shockwave lithotripsy, and about 3 and a half years later she was diagnosed with osteonecrosis of humeral head. Liu [19] presented another similar case report in which the onset of osteonecrosis of humeral head occurred only 3 months after ESWT. ...
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Purpose To present the accuracy and safety of treat nonunion of children femoral neck fracture using the technique with extracorporeal shockwave therapy (ESWT) under navigation guidance. Methods We retrospectively reviewed 3 consecutive children patients. A total of 3 nonunion of femoral neck fracture in 3 patients had been used the technique with extracorporeal shockwave therapy under navigation guidance. We also assessed the clinical and radiological outcomes and analyzed the union degree of femoral neck fracture on the postoperative X ray. Results Radiological and clinical outcomes of three patients are satisfactory and achieve the recovery standard. There was no neurovascular (femoral nerve, femoral vein, femoral artery) complication related with ESWT under navigation guidance. Conclusion This technique (extracorporeal shockwave therapy under navigation guidance) could be considered relatively safe and easy method to treat nonunion of femoral neck fracture of children.
... Damage to the ascending branch of the anterior humeral circumflex artery is the possible reason for the development of the osteonecrosis. 16 Overall, the risk of ESWT is low and the safety profile is fair. ...
Tendon injuries or tendinopathy are common painful and disabling conditions resulting from overuse and aging. Tendinopathy remains a challenging clinical problem since response to different treatment modalities is usually unsatisfactory and recovery is slow. We performed an extensive literature review focusing on non-surgical treatment options for tendinopathies, including nonsteroidal anti-inflammatory drugs, corticosteroid, eccentric exercise, extracorporeal shock wave therapy, therapeutic ultrasound, hyaluronic acid, platelet-rich plasma, prolotherapy, polydeoxyribonucleotide and stem cells, aimed at providing the most updated evidence as a guideline for caregivers.
... In some case reports Durst et al. express the development of humeral head osteonecrosis, 3 years after the administration of high energy ESWT for calcifi c tendinitis, while Liu et al report a case of humeral head osteonecrosis in 3 month after receiving ESWT. Although these are isolated cases, it has been suggested that a diminished diameter of the anterior humeral circumfl ex artery in these two cases could explain for the development of complications 58,59 . ...
... Shock-wave therapy has been used in the treatment of calcified tendonitis of the rotator cuff, nonunion of bone, chronic tennis elbow, and painful heel syndrome [24][25][26][27]. The efficacy of SW was controversial in previous studies. ...
Full-text available
Background Corticosteroid (CS) injections have been proven to be effective in ameliorating symptoms of plantar fasciitis. Shock-wave (SW) therapy is another common treatment of plantar fasciitis, and several meta-analyses have documented its advantages when compared to placebo treatment. Despite this, few studies have focused on comparing the use of CS and SW in the treatment of plantar fasciitis. The purpose of this meta-analysis is to assess whether SW is superior to CS in managing plantar fasciitis, both in terms of ameliorating pain as well as improving functionality. Methods A systematic search of the literature was conducted to identify relevant articles that were published in Pubmed, Medline, Embase, the Cochrane Library, SpringerLink, Clinical and OVID from the databases’ inception to July 2018. All studies comparing the efficacy of SW and CS in terms of pain levels and functionality improvement were included. Data on the two primary outcomes were collected and analyzed using the Review Manager 5.3. Results Six studies were included in the current meta-analysis. A significant difference in VAS score (MD = − 0.96, Cl − 1.28 to − 0.63, P < 0.00001, I² = 96%) was noted between the SW group and the CS group. No significant difference was seen in the Mayo CSS or FFI or HFI or 100 Scoring System score at the 3 months follow-up (Chi² = 0.62, I² = 0%, P > 0.05). Conclusions The clinical relevance of the present study is that both SW and CS were effective and successful in relieving pain and improving self-reported function in the treatment of plantar fasciitis at 3 months. Although inter-group differences were not significant, the VAS score was better improved in the SW group, highlighting that shock-wave therapy may be a better alternative for the management of chronic plantar fasciitis.
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Extracorporeal shock wave therapy (ESWT) has been studied and applied extensively in medical practice for various applications including musculoskeletal, dermal, vascular, and cardiac indications. These indications have emerged from primary ESWT use in treating urolithiasis and cholelithiasis. Likewise, dental medicine has had its share of utilizing ESWT in various investigations. This review aimed to provide an up-to-date summary of ESWT use in preclinical and clinical dental medicine. There is growing interest in ESWT use stemming from its non-invasiveness, low cost, and safe qualities in addition to its proven regenerative biostimulating aspects. Targeted tissue and parameters of ESWT delivery continue to be an integral part of successful ESWT treatment to attain the clinical value of the anticipated dose’s effect.
Extracorporeal shock wave therapy (ESWT) is a safe therapy and there are only a few side effects known (such as pain during ESWT and minor haematomata), but no severe complications are to be expected if it is performed as recommended. Contraindications are severe coagulopathy for high-energy ESWT, and ESWT with focus on the foetus or embryo and focus on severe infection. The effect mechanism of ESWT is still a component of diverse studies, but as far as we can summarize today, it is a similar process to a cascade triggered by mechano-transduction: mechanical energy causes changes in the cellular skeleton, which provokes a reaction of the cell core (for example release of mRNA) to influence diverse cell structures such as mitochondria, endoplasmic reticulum, intracellular vesicles, etc., so the enzymatic response leads to the improvement of the healing process. The usage of ESWT should be taught, to improve the outcome. Courses should be organized by national societies, since the legal framework conditions are different from one country to another. In this update the musculoskeletal indications are addressed (mainly bone and tendons): pseudoarthrosis, delayed fracture healing, bone marrow oedema and osteonecrosis in its early stages, insertional tendinopathies such as plantar fasciitis and Achilles tendon fasciitis, calcifying tendonitis of the rotator cuff, tennis elbow, and wound healing problems. Cite this article: EFORT Open Rev 2020;5:584-592. DOI: 10.1302/2058-5241.5.190067
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.