Article

Extracorporeal shockwave therapy (ESWT) in the Treatment of Atrophic Non-unions of Femoral Shaft Fractures.

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Abstract

As of now, the role of extracorporeal shockwave therapy (ESWT) in the treatment of atrophic non-unions is inconclusive. The purpose of the study was to investigate the effectiveness of ESWT and the role of this technology in the treatment of atrophic non-union of femurs. We retrospectively analyzed 22 patients treated in between July 1999 and September 2007 in our hospital with ESWT for atrophic non-unions of isthmic femoral shaft fractures that were initially treated surgically using closed reamed nailing procedure. Patients with open fractures, skeletal immaturity, on anti-osteoporotic medications, with infections, pathological fractures, smokers, with systemic disease compromising bone healing, and excessive deformity were excluded from this study. Due to incomplete follow-up one (1) patient who moved abroad after ESTW treatment was not included in this study and as part of the 22-patients cohort. Radiographs were obtained before treatment and once a month after treatment for 12 months. Using ESWT we showed that 14 fractures out of 22 (63.6 %) achieved bony union with an average union time of 9.2 months (range 6 ∼13 months). The union rate was 100% (8 of 8 cases) when ESWT was performed within 12 months from closed reamed nailing surgery versus 42.9% (6 of 14 cases) when ESWT was performed after 12 months from initial surgery. The eight (8) patients out of the total 22 patients cohort, who did not achieve bony union after ESWT, received subsequent treatment with bone grafting with augmentative plating surgery and all achieved bony union within 5 months after intervention. For patients with atrophic non-unions of femoral shaft fractures, ESWT can be used as an alternative and effective non-invasive method of treatment. ESWT treatment does not negatively influence/compromise previous surgeries and if needed it can be followed by additional surgeries without any complications. Copyright © 2015. Published by Elsevier Ltd.

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... Our review included two randomized controlled trials (RCTs) [28,34], one non-randomized controlled trial [35], and 20 observational studies (14 retrospective [5,9,25,26,[36][37][38][39][40][41][42][43][44][45] and six prospective [11,[46][47][48][49][50]). Together, the included papers reported a total of 1838 cases of delayed union or nonunion (Table 1). However, only the data for 1200 of the 1838 cases could be included in the meta-analysis, as several papers did not separate the results for long bones from those for other bones. ...
... In total, 22 humeri were treated, 14 of which (63.6%) healed by the last follow-up. Seven studies [25,29,39,43,47,49,50] reported separate outcomes for femurs, and of 139 femurs, 93 (66.9%) healed. Eight studies [5,25,26,29,38,43,47,50] reported results for tibiae; a total of 377 tibiae were treated, of which 281 (75.54%) healed. ...
... Nevertheless, we note that in one study of femurs treated with an EFD of 0.40 mj/mm 2 , 93% of the femurs healed [24], whereas the four other papers with evaluable data used higher EFDs, ranging from 0.55-0.62 mj/mm 2 , which corresponded to lower healing rates of 52-75% ( Figure 3) [29,39,43,50]. Similarly, in tibiae, lower EFDs (0.39-0.40 mj/mm 2 ) tended to correspond to higher healing rates (80-89%) ( Figure 3) [39,43,50]. ...
Article
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Background: Nonunion is one of the most challenging problems in the field of orthopedics. The aim of this study was to perform a systematic review of the literature to evaluate the effectiveness of extracorporeal shockwave therapy (ESWT) in the treatment of nonunion in long bones. Methods: We conducted a search of three databases (PubMed, Scopus, and Web of Science) and found 646 total publications, of which 23 met our inclusion criteria. Results: Out of 1200 total long bone nonunions, 876 (73%) healed after being treated with ESWT. Hypertrophic cases achieved 3-fold higher healing rates when compared to oligotrophic or atrophic cases (p = 0.003). Metatarsal bones were the most receptive to ESWT, achieving a healing rate of 90%, followed by tibiae (75.54%), femurs (66.9%) and humeri (63.9%). Short periods between injury and treatment lead to higher healing rates (p < 0.02). Conversely, 6 months of follow-up after the treatment appears to be too brief to evaluate the full healing potential of the treatment; several studies showed that healing rates continued to increase at follow-ups beyond 6 months after the last ESWT treatment (p < 0.01). Conclusions: ESWT is a promising approach for treating nonunions. At present, a wide range of treatment protocols are used, and more research is needed to determine which protocols are the most effective.
... Kuo, et al. [20] examined the efficacy of ESWT and its application to the management of atrophic femoral nonunion. Studies using ESWT demonstrated that, with a 9.2-month average union time, 14.6% of the 22 fractures achieved bone union (range 6-13 months). ...
... According to one meta-analysis, the success rate of ESWT application for long bone fractures depends on the kind of non-union, with a 29% success rate for atrophic non-unions and a 76% success rate for hypertrophic nonunions [32]. In contrast, [20] found that the treatment of atrophic non-unions had an overall union rate of 63.6%. Additionally, when ESWT was used within 12 months of the first fracture therapy, the union rate was 100% and fell to 42.6% when ESWT was applied more than a year after the initial operation. ...
Article
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Background: Among other non-invasive procedures, Extracorporeal Shockwave Treatment (ESWT) has been used to resolve many musculoskeletal ailments. The authors completed a systematic review to study articles that reported the effectiveness of focused shockwave therapy in patients with orthopedic conditions. Methods: A comprehensive search was conducted across reputable databases including Pub Med, The Cochrane Library, Science Direct, PEDro, Clinicaltrials.gov, and Google Scholar, ensuring a thorough review of the literature until October 10, 2022. Original articles of any design reporting on the use of ESWT in orthopedic patients were meticulously selected. Information related to study design, sample size, participants, intervention, and key findings of the study were extracted. The PEDro classification scale, a recognized tool, was used to evaluate the quality of the studies, further enhancing the credibility of findings. Results: Nineteen research articles (including 1157 participants) were retrieved and included for qualitative analysis. The sample size ranged from twenty-one to one hundred fifteen subjects, and the articles were published between 2001 and 2022. Out of 19 studies published, five were conducted in China, three in Germany, two in Iran and Turkey, and one in the United States, Canada, Italy, Denmark, Spain, Taiwan, and Saudi Arabia. The risk of bias was either moderate or low among the included studies. In patients with various orthopedic conditions, considerable moderate evidence of ESWT’s effectiveness and success in lowering pain levels, increasing treatment success rates, promoting patient-reported functional recovery, and raising performance-based functional outcomes was seen in the results. Conclusion: The systematic literature review provided compelling evidence of the successful application of ESWT in treating a wide range of musculoskeletal problems. These positive outcomes were achieved without severe complications and morbidities, offering a promising outlook for the future of orthopedic treatment.
... The best results are reached using electro-hydraulic and electro-magnetic generators. Focused shock wave treatment has importante support in the literature, it is safe and effective, with several articles proving good results being the best treatment method when using mechanical waves to treat non-unions [24][25][26]. When using radial waves, anesthesia is not necessary and at least three sessions are performed with at an intervals of one week, applying 3000 waves in each session directly to the focus of the non-union with a level of energy between 0.18 to and 0.20 mJ/mm2. ...
... The best results are reported with the use of focused shock waves devices with hydraulic and magnetic generators, using fluoroscopy to locating the exact point of treatment. A success rate between with 65 to and 78% has been reported [24][25][26][27][28]. Good results are observed in both hypertrophic and atrophic non-unions. ...
Article
The treatment of bone non-unions continues to be complex and prolonged in many cases. The advent of the use of mechanical waves has made it possible, through the phenomenon of mechanotransduction, to have a non-invasive tool with a low rate of complications. This study analyzes the experience of the last 20 years with the use of shock waves. Keywords: Non-union, shock waves, Delayed union, Mechanotransduction
... In term of biomechanics, ESW has been proven to be effective in inducing angiogenesis and bone remodeling, which might be the key link in the regeneration of the diseased femoral head. [13][14][15] From shock wave generation to the final effect phase, this procedure includes four phases, namely physical phase, physicochemical phase, chemical phase, and biological phase. [2] This procedure begins with a physical phase. ...
... [3] (The difference between the two waves is shown in Figure 1B.) The Chinese Medical Journal 2019;132 (15) www.cmj.org biological effects of RPW on living tissue are different from ESWT and are related to the pressure waveform. ...
... This phenomenon of biological conversion from a mechanical stimulus into electrochemical activity is called "mechanotransduction." 141 The use of ESWT for nonhealing fractures was first reported, to our knowledge, in 1991 by Valchanou and Michailov 142 . Since then, several observations and trials have supported the efficacy of ESWT for nonunion and delayed fracture-healing [143][144][145][146][147][148][149][150][151][152][153][154][155][156][157] (Table IV). ...
... Kuo et al. 156 reported that the success rate of ESWT was 63.6% in the treatment of atrophic nonunions of the femoral shaft and could be as high as 100% if applied within 12 months after the initial treatment. Poor results were associated with instability, a gap at the nonunion site of >5 mm, and atrophic nonunion. ...
Article
Full-text available
Increasing evidence suggests that extracorporeal shockwave treatment (ESWT) is safe and effective for treating several musculoskeletal disorders. Two types of technical principles are usually included in ESWT: focused ESWT (F-ESWT) and radial pressure waves (RPW). These 2 technologies differ with respect to their generation devices, physical characteristics, and mechanism of action but share several indications. Strong evidence supports the use of ESWT in calcifying tendinopathy of the shoulder and plantar fasciitis. The best evidence for the use of ESWT was obtained with low to medium energy levels for tendon disorders as well as with a high energy level for tendon calcification and bone pathologies in a comprehensive rehabilitation framework.
... Adequate periosteal responses was observed from two sessions in different patients beside this study, situation that it is in accordance with experimental data obtained by Kearney [22,23]. Our results are similar to those reported in literature [7,8,13,24] ( Figs. 1 and 2), but with higher femur failure numbers (12/25, 48%). Kuo [7] reported 36,2% of failure in 22 femur atrophic fractures non-healed series. ...
... Our results are similar to those reported in literature [7,8,13,24] ( Figs. 1 and 2), but with higher femur failure numbers (12/25, 48%). Kuo [7] reported 36,2% of failure in 22 femur atrophic fractures non-healed series. ...
Article
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Background High energy diaphyseal fractures constitute a complicated matter for trauma units and urgent medical and surgical decisions to prompt stabilization of these patients, might leave some skeletal distortions that affect bone union. The objective is to evaluate the safety and efficacy of extracorporeal shockwave therapy (ESWT), as a treatment for patients with atrophic or pseudoatrophic nonunion. Patients and Methods Case series which included 50 patients with nonseptic and stable nonunion diaphyseal fracture of femur and tibia. They received a defined protocol of up to three high-energy ESWT (10.000 shocks per session). Each patient was evaluated with x-rays or CT between 4 and 6 weeks, to determine the necessity to continue the protocol and obtain data about initial periosteal-endosteal responses and its evolution. We analyzed, semi-quantitatively, the volume of the fracture zone from initial CT using a mathematical method to calculate the volume in cylinders, and confronting this data with Winquist Classification. Results 17/25 (68%) tibia and 13/25 (52%) femur nonunion were treated successfully. There were no complications during or after treatment. Conclusions ESWT induced bone healing in an average 60% of cases, which is consistent with current reported literature. CT studies gave some clues to patients' real condition of fracture anatomy before treatment, allowing a better decision in the orientation of ESWT application for each case. Volumetric Fracture Analysis for Winquist Classification shown that ESWT was able to induce significant bone regeneration in fractures with high volume. This kind of therapy was well accepted in reluctant patients to invasive methods.
... This necessitates the exploration of noninvasive alternatives. One such promising modality is extracorporeal shock wave therapy (ESWT), which has demonstrated clinical efficacy comparable to surgery for bone nonunions without the associated complications [3][4][5][6]. ...
Article
BACKGROUND Extracorporeal shock wave therapy (ESWT) is increasingly being recognized as an advantageous alternative for treating non-union due to its efficacy and minimal associated complications. Non-union following Bernese periacetabular osteotomy (PAO) is particularly challenging, with a reported 55% delayed union and 8% non-union. Herein, we highlight a unique case of ischial non-union post-PAO treated successfully with a structured ESWT regimen. CASE SUMMARY A 50-year-old patient, diagnosed with left ischial non-union following the PAO, underwent six cycles of ESWT treatment across ten months. Each cycle, spaced four weeks apart, consisted of five consecutive ESWT sessions without anesthesia. Regular X-ray follow-ups showed progressive disappearance of the fracture line and fracture union. The patient ultimately achieved a satisfactory asymptomatic recovery and bone union. CONCLUSION The results from this case suggest that this ESWT regimen can be a promising non-invasive treatment strategy for non-union following PAO.
... Initially, it creates tensile forces that are converted into cavitation forces. This, in turn, creates hematoma formation, cell death, and bone formation ( The review of the literature shows that ultrasounds could have a beneficial effect on the healing of fractures [75][76][77][78][79][80][81][82][83][84][85][86]. A study compares patients with delayed unions after long bone fixation, and the authors, by the application of nails, achieved a union rate of 60%. ...
Article
Full-text available
Bone healing constitutes a complex process involving cellular and pathophysiological mechanisms. Despite progress in osteosynthesis techniques, fracture union continues to be challenging. In some cases, it is not ultimately achieved or is delayed relative to the expected time resulting in economic and social outcomes for the patient and the health system. In addition to surgical treatment, biophysical methods have been developed to assist in fracture healing used in combination or individually. Biophysical stimulation is a non-invasive therapy used in orthopedic practice to increase and enhance tissue's reparative and anabolic activities. This study reviewed the existing literature, including electromagnetic fields, ultrasound, laser, extracorporeal shockwave therapy, and electrical stimulation, and revealed the efficacy of biophysical stimulation for bone healing. This study aims to define if these methods are helpful, especially in cases of non-union. Biophysical stimulation requires care and precision in use to ensure the success expected of it by physicians and patients.
... The use of shock waves for non-healing fractures in humans was first reported in 1991 by Valchanou and Michailov [2]. Since then, several studies have supported the efficacy of shock waves for the treatment of nonunions and delayed healing of long bone fractures in adults [2][3][4][5][6][7][8][9][10][11][12][13][14], however, to date, no cases have been reported in the literature on the use of this therapy in pediatric patients. The aim of this article is to report on the satisfactory results with the application of shock waves in a patient with femoral septic non-union, initially treated surgically. ...
Article
Full-text available
Non-unions of the femur in children are not frequent, but when they do occur they can be very difficult to manage. Shock wave therapy has emerged as an effective option for well-chosen pseudoarthrosis cases, however there are no reports of pediatric cases. We report a 12-year-old male patient with a history of pathological fracture due to mid-diaphyseal osteomyelitis of the right femur at 8 years of age. After several surgical procedures the integrity of the femur was restored but an area of non-union persisted at mid-diaphyseal level. He was treated with 3 sessions of focused shock waves with an electrohydraulic generator. He presented a rapid healing avoiding a new endomedullary nailing surgery with bone graft. Focused shock waves may be a useful therapeutic option in children with non-unions in well-selected cases.
... Lower energy protocols were used for short bones while higher protocols were reserved to long or multiple bones, or more severe fractures. Kuo et al, 2015 Secondary ? crutches 4-6 weeks 1 treatment session. ...
Article
https://www.tandfonline.com/eprint/QZBQUAAM9JM8ZCBY2YZS/full?target=10.1080/09593985.2022.2112117 Introduction The treatment of tibial nonunion is challenging and treatment may be conservative or surgical. Conservative strategies include functional braces and weight bearing, or focused extracorporeal shockwave therapy (fESWT). Case Description A 45-year-old male patient sustained spiral tibial shaft fractures and was treated surgically within 24 hours after the initial accident with intramedullary nails. The tibial fracture was later classified as nonunion after 11 months. Radiologic evaluation 17 months after the initial trauma demonstrated clinical nonunion, and subsequently the patient was offered a conservative approach with fESWT to facilitate an increase in callus formation. The handpiece was fitted with a stand-off II (long), penetration depth of 15 mm. Three cycles were administered in month 17, 19 and 20 after baseline. Each cycle consisted of three treatments sessions spaced with 6–8 days apart, and consisted of 3000 to 4000 impulses each given at 0.25–0.84 mJ/mm2. The number of impulses and the power at the focus point varied according to the pain response. Outcomes The patient achieved union 23 months after fracture. A clinical important improvement was observed with both Lower Extremity Functional Scale (LEFS) (18-point difference) and Patient Specific Functional Scale (PSFS) (average: 4.7 points,) The “worst pain last 24 hours” was reduced by 5 points. These values express minimal clinically important difference (MCID) values in these functional patient-reported outcome measures. Conclusion This treatment strategy may be viable in a broader setting, including private practice physiotherapy thereby treating the patient in close proximity to the patient’s everyday life.
... ("extracorporeal shockwave*" OR eswt OR shockwave* OR "shock wave*" OR "shock-wave*" OR "high intensity focused ultrasound" OR "highintensity focused ultrasound" OR hifu OR "electrohydraulic" OR "piezoelectric" OR "electromagnetic") AND ("pseudarthros*" OR "nonunion*" OR "non-union*" OR "fracture*") [41] x [47] ...
Technical Report
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Informe de respuesta rápida que evalúa la efectividad de las ondas de choque focales extracorpóreas de cualquier tipo, en el tratamiento de la pseudoartrosis de cualquier localización. Para ello se realizó una revisión rápida de revisiones (rapid overview), con el objetivo de sintetizar la evidencia proveniente de las revisiones sistemáticas publicadas en revistas revisadas por pares, incluyeran o no meta-análisis.
... The mechanical stimuli can induce physiological responses at the cellular level (14)(15). Several studies have reported the effectiveness of shockwave therapy on bone structure (13,(16)(17)(18) and tendon structure (19) alone. However, collective scientific evidences regarding the exact dosage of application and effectiveness of shockwave therapy on enthesopathy is still lacking. ...
Article
Full-text available
Extracorporeal shockwave therapy (ESWT) for the treatment of musculoskeletal diseases is a field that is developing rapidly and attracting increasing attention. Studies exploring the effects of shockwave therapy on enthesopathy have resulted in equivocal findings. Therefore, the purpose of this review article is to collectively review and analyze published literature on the effects of shockwave therapy on enthesopathy in human studies. This is a literature review study however, systematic search was performed on Scopus, EBSCOhost (Medline, CINAHL, and Sport Discus), and Google Scholar databases. The search resulted in 112 articles, nine relevant articles that met the inclusion criteria were selected for analysis in this review. Shockwave therapy can be safe and effective to reduce pain, improve functions and activities as it accelerates the entheses healing. The exact mechanisms of shockwave therapy on en-thesopathy are still debatable. Further investigation is needed to confirm and validate the findings of previous related studies.
... As to the type of pseudarthrosis best results are to the hypertrophic, but in also reported good results are atrophic. Immobilization after treatment for 6 to 8 weeks may be necessary in cases of greater instability in the focus of pseudarthrosis [29,30]. ...
... Серед ефектів ЕУХТ відзначають: сприяння неоваскуляризації внаслідок активації судинноендотеліального фактору росту з наступною пролі-ферацією ендотеліальних клітин [13,20]; індукцію остеогенетичних факторів росту, таких як трансформуючий фактор росту бета-1 та кісткових морфогенетичних білків, що ініціює активність остеобластів [13,19,21]; зниження больового синдрому [14,22]; зменшення набряку [23]. Відповідно до цього, низкою дослідників були сформульовані наступні показання до застосування ЕУХТ у щелепно-лицевій ділянці: лінійні переломи кісток, зокрема неконсолідовані [24,25]; пародонтит [20,26]; імплантація, зокрема лікування периімплантитів [27]; захворювання скронево-нижньощелепного суглоба [28]. ...
... Extracorporeal shockwave therapy (ESWT) is a non-invasive treatment for a variety of injuries seen in athletes. While initially used for lithotripsy, over the past two decades, ESWT has been documented to improve pain and functional outcomes for musculoskeletal conditions including Achilles [1][2][3][4][5][6][7], patellar [8, 9•, 10-12], proximal hamstring [13], and gluteal tendinopathies [14][15][16], as well as plantar fasciitis [17][18][19][20][21][22][23][24], medial tibial stress syndrome (MTSS) [25][26][27], and bony non-unions or stress fractures [28][29][30][31][32]. Prior reviews and systematic methods to quantify efficacy often include study populations with a mix of both athletes and non-athletes [33][34][35] and report the best evidence for use in the treatment of plantar fasciitis [36]. ...
Article
Full-text available
Purpose of Review To outline current evidence on the use of ESWT for the treatment of lower limb sports injuries. Recent Findings There is growing evidence to support the use of extracorporeal shockwave therapy (ESWT) for a variety of musculoskeletal conditions in the general population. However, research focused on the use of ESWT specifically for lower extremity injuries in the athletic population is more limited. Athletes represent a subgroup of patients that may benefit from ESWT. Compared with injections or surgical interventions, athletes undergoing ESWT often are able to continue sports participation with fewer limitations in activity during treatment. Summary The review identifies considerable variability in study design and treatment protocols that affect the overall quality of evidence. Sports participation was allowed in most studies. One case of plantar fascia tear was identified during ESWT treatment; this injury was self-limited. Most studies report pain-relieving and/or functional benefit with the use of ESWT for common lower extremity tendinopathies, plantar fasciitis, and medial tibial stress syndrome. This review highlights the need for further investigations on optimal methods of ESWT use in athletes given the high prevalence of lower extremity injuries and favorable safety profile for treatment.
... Birnbaum et al [57] examined 10 studies and concluded that though ESWT yielded high healing rates, 75%-91%, this treatment was to remain considered "experimental" as there were no prospective RCTs. Efficacy appears to depend on the type of bone-related pathology, differentiating between nonunion, atrophy, or hypertrophy [58,59,60]. Cacchio et al [61] published a prospective RCT that compared ESWT in treatment of long-bone nonunions to surgical treatment. ...
Article
Full-text available
Extracorporeal shockwave therapy (ESWT) is a technology that was first introduced into clinical practice in 1982 for urologic conditions. Subsequent clinical applications in musculoskeletal conditions have been described in treatment of plantar fasciopathy, both upper and lower extremity tendinopathies, greater trochanteric pain syndrome, medial tibial stress syndrome, management of nonunion fractures, and joint disease including avascular necrosis. The aim of this review is to summarize the current understanding of treatment of musculoskeletal conditions with ESWT, accounting for differences in treatment protocol and energy levels. Complications from ESWT are rare but include 2 reported cases of injury to bone and Achilles tendon rupture in older adults using focused shockwave. Collectively, studies suggest ESWT is generally well‐tolerated treatment strategy for multiple musculoskeletal conditions commonly seen in clinical practice. Level of Evidence III
... While tibial nonunions performed best, the scaphoid showed only a union rate of approximately 60% (unpublished data) [65] . Dr. Kuo et al. [70] in their retrospective study demonstrated a healing rate of 64% in atrophic diaphyseal nonunions of the femur ( n = 22) treated with shockwaves. Besides potential differences in the generation of shockwaves and in energy flux densities, our database as open prospective source yields a healing rate of approximately 75% in that very same location (unpublished data). ...
Chapter
Numerous studies have proven that extracorporeal shockwave therapy (ESWT) is effective in the noninvasive treatment of delayed healing fractures and nonunions. Imposing shockwave therapy as first-line treatment for the above-mentioned indications could significantly reduce costs and surgery associated complications. Further applications comprising acute or fragility fractures prone to develop healing disorders as well as stress fractures also show promising results after ESWT. In contrast to the past, where the mechanistic (destructive) model as method of action of ESWT was favored, recent studies have brought light into the fundamental working mechanisms of ESWT. Shockwaves are converted in the target tissue into biochemical signals via activating different signaling pathways (mechanism called mechanotransduction), which reflect the stimulation of the endogenous regeneration potential. This chapter tries to summarize the recent literature of ESWT in the treatment of bone healing disturbances.
... La pseudoartrosis atrófica secundaria a necrosis avascular es una complicación de las fracturas de huesos cortos de difícil manejo, pero que en los últimos años está dentro de las indicaciones de manejo con ondas de choque extracorpóreas 14,15 . Para este caso se demostró que después de la intervención con ondas de choque radiales extracorpóreas hubo recuperación y remodelación de la fractura de astrágalo, además de la disminución del dolor, la recuperación de arcos de movilidad y la mejoría de la funcionalidad del paciente. ...
Article
Con este estudio de caso se quiere dar a conocer la efectividad de las ondas de choque radiales extracorpóreas en las fallas de consolidación; para este caso en particular la pseudoartrosis de astrágalo es una falla en la consolidación de la fractura de este hueso, es decir, la no unión de los trazos de fractura por alteración en alguna de las fases de cicatrización ósea. Este es un estudio de caso de un paciente con pseudoartrosis de astrágalo y la respuesta al manejo con ondas de choque radiales.
... La terapia con oCEC es un procedimiento emergente a nivel mundial; es abundante la bibliografía que respalda su indicación en diversas entidades nosológicas del sistema musculoesquelético, tanto a nivel de tejido óseo como de partes blandas. 9,15 Se han descrito modelos experimentales in vivo (en especies animales) que demuestran: a) efectos favorables sobre la consolidación ósea (neovascularización, formación de nuevo hueso cortical y promoción de factores de crecimiento del tipo de las BMP) 16 y b) efectos desfavorables sobre la estabilidad mecánica del hueso involucrado y la necrosis de médula ósea. 17 Algunos de los modelos experimentales de seudoartrosis atrófica más relevantes, son: ...
Article
Full-text available
Introduction The effects of extracorporeal shock wave therapy (ESWT) have been investigated in: human osteoblasts, fracture foci, non union and periosteum cells. The best results of non union treatment with ESWT have been documented for hypertrophic type. The objective of this study is to investigate the effects of ESWT in an atrophic non union focus generated in a rabbit tibia model. Methods Three groups were included: a) Group A: fractures receiving extracorporeal shock wave therapy (ESWT); b) Group B: (“control”): fractures not receiving ESWT; c) Group C: no fractures (right leg). Staining with hematoxylin-eosin was performed. ESWT included one session of 2000 extracorporeal shock wave impacts at 10 kV. A biomechanical analysis with a 3-point loading system was performed. Eighteen samples were included in the biomechanical study, 7 in Group A, 3 in Group B and 8 in group C. The samples were placed between two 19 mm cylindrical supports which were 75 mm apart, oriented concentrically to the compression punch. Results The histological test evidenced signs of union - periosteal and endosteal fracture callus - which were considerably larger in the tibias in Group A (treated with extracorporeal shock wave therapy) as compared to the control group (Group B). The maximum load for the healthy tibia Group (Group C) was higher as compared to Groups A (p
... The present study represents a retrospective case series in 22 In line with several reports on fESWT for facture nonunions in the literature [11,37,39,43], a nonunion was defined as a fracture that has failed to show continuity of three of four cortices after surgical or nonsurgical treatment for six or more months from the time of the fracture-related injury, or has failed to demonstrate any radiographic change (improvement) for three consecutive months, and is associated with clinical findings consistent with a fracture nonunion (an inability to bear weight on the affected extremity, pain on palpation, or motion at the fracture site for 3 to 6 months or more following the incident traumatic event or the last surgical procedure. Patients included 9 females and 13 males, with a mean age of 35.3 ± 3.5 years (mean ± standard error of the mean) (range 14 to 69) ( Table 2). ...
Article
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BackgroundA substantial body of evidence supports the use of focused extracorporeal shock wave therapy (fESWT) in the non-invasive treatment of fracture nonunions. On the other hand, virtually no studies exist on the use of radial extracorporeal shock wave therapy (rESWT) for this indication. Methods We retrospectively analyzed 22 patients treated with rESWT for fracture nonunions of superficial bones that failed to heal despite initial surgical fixation in most cases. Radial extracorporeal shock wave therapy was applied without anesthesia in three rESWT sessions on average, with one rESWT session per week and 3000 radial extracorporeal shock waves at an energy flux density of 0.18 mJ/mm2 per session. Treatment success was monitored with radiographs and clinical examinations. ResultsSix months after rESWT radiographic union was confirmed in 16 out of 22 patients (73%), which is similar to the success rate achieved in comparable studies using fESWT. There were no side effects. The tibia was the most common treatment site (10/22) and 70% of tibia nonunions healed within 6 months after rESWT. Overall, successfully treated patients showed a mean time interval of 8.8 ± 0.8 (mean ± standard error of the mean) months between initial fracture and commencement of rESWT whereas in unsuccessfully treated patients the mean interval was 26.0 ± 10.1 months (p < 0.05). In unsuccessful tibia cases, the mean interval was 43.3 ± 13.9 months. Conclusions Radial extracorporeal shock wave therapy appears to be an effective and safe alternative in the management of fracture nonunions of superficial bones if diagnosed early and no fESWT device is available. The promising preliminary results of the present case series should encourage the implementation of randomized controlled trials for the early use of rESWT in fracture nonunions.
... Some studies also investigated serum level of BMP-2, NO, TGF-β1 and VEGF, which were higher in treated individuals. Again, atrophic nonunions, smoking and treatment performed at late stages (after 12 months) provided decreased healing rates [115][116][117][118][119][120][121][122][123][124]. ...
Chapter
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Acoustic therapy is a branch of mechanotherapy. This modality of treatment can be used for osteogenesis-related orthopaedic disorders. Because bone cells are responsive to acoustic forces, specially designed devices were developed to generate acoustic forces in the form of low-intensity pulsed ultrasound, extracorporeal shock waves or radial pressure waves. With the developed devices, it became possible to provide patients an alternative, or adjunctive, treatment for pathologies involving bone homeostasis, that is, the balance of bone formation and bone resorption. The so-called acoustic therapy (low-intensity pulsed ultrasound stimulation, LIPUS; extracorporeal shock wave therapy, ESWT; and radial pressure wave therapy, RPWT) acts through physical phenomena produced when acoustic waves are transmitted into living tissue and converted to biological reactions, thereby activating signalling pathways that drive a cellular response in favour of osteogenesis. In this chapter, an extensive review of the literature was performed to provide the reader the “state of the art” about the physical phenomena, molecular events and clinical uses of acoustic forces for osteogenesis-related orthopaedics disorders.
... In this article from Taiwan, Kuo et al. [4] showed that the union rate was 100 percent after the application of ESWT twelve months from initial surgery (8 out of 8 patients), and 42.9 percent when applied after twelve months (6 out of 14 patients). This study albeit small is very encouraging for this difficult condition of atrophic nonunion. ...
Article
Background Nonunion of long bone fractures is a significant complication following surgical fixation, with an incidence ranging from 5% to 10%. Surgical intervention is the standard treatment for nonunions, but it may come with potential complications. Nonoperative approaches, such as Extracorporeal Shockwave Therapy (ESWT), have been advocated as alternatives. Methods The retrospective study, conducted between January 2004 and January 2018, 91 patients who underwent ESWT for tibia or femur nonunions were included. Nonunion was defined based on radiographic criteria and clinical symptoms. The nonunion morphology was categorized as hypertrophic, oligotrophic, or atrophic. ESWT was administered using the OssaTron device in a single treatment session. Bony union was defined as the presence of bridging callus over fracture site with more than three-fourths of the circumference in both planes within the 12-month postoperative period Results The study included 91 patients, with an overall union rate of 62.6%. Higher healing rate was observed in trophic nonunion(69.9%) than atrophic nonunion(33.3%). Multivariate analysis identified the number of surgeries, maximum fracture gap, and atrophic nonunion as independent factors influencing the risk of fracture nonunion after ESWT. ROC curves were generated for these factors, providing more than one surgical interventions, and fracture gap greater than 3.94 mm as negative predictors of ESWT for long bone nonunions. Conclusion The study’s primary findings suggest that ESWT is effective in achieving bony union for nonunions in long bones(62.6%). Despite the overall positive results, the study highlights that atrophic nonunions, larger fracture gaps more than 3.94 mm, and multiple surgeries are associated with poorer outcomes.
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The optimal balance between mechanical environment and biological factors is crucial for successful bone healing, as they synergistically affect bone development. Any imbalance between these factors can lead to impaired bone healing, resulting in delayed union or non-union. To address this bone healing disorder, clinicians have adopted a technique known as "dynamization" which involves modifying the stiffness properties of the fixator. This technique facilitates the establishment of a favorable mechanical and biological environment by changing a rigid fixator to a more flexible one that promotes bone healing. However, the dynamization of fixators is selective for certain types of non-union and can result in complications or failure to heal if applied to inappropriate non-unions. This review aims to summarize the indications for dynamization, as well as introduce a novel dynamic locking plate and various techniques for dynamization of fixators (intramedullary nails, steel plates, external fixators) in femur and tibial fractures. Additionally, Factors associated with the effectiveness of dynamization are explored in response to the variation in dynamization success rates seen in clinical studies.
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INTRODUCTION: One session of high energy extracorporeal shockwave therapy (ESWT) was found to improve the healing of anterior cruciate ligament (ACL) after reconstruction in animal and human studies. This study investigated the effects of three and six sessions of low energy ESWT on graft incorporation and knee functions post ACL reconstruction in humans. MATERIALS AND METHODS: Thirty participants with ACL injuries were recruited and assigned equally into three groups with 10 participants per group (n=10). Participants in the control group received physiotherapy alone without low energy ESWT. Participants in the 3ESWT group underwent three sessions of low energy ESWT (one session per week) combined with physiotherapy, and participants in the 6ESWT group received six sessions of low energy ESWT (one session per week) combined with physiotherapy. However, five participants were lost to follow-up. Evaluations of graft incorporation of the tibial tunnel using magnetic resonance (MRI) and Lysholm score were carried out before ACL reconstruction and after six months post ACL reconstruction. RESULTS: The number of grafts with partial incorporation in the tibia tunnel in 6ESWT was significantly higher compared with the number of grafts with non-incorporation at six months post-operatively, X2 (1, N=9) =5.44, p =0.02. However, there was no significant difference between frequencies of graft incorporation in tibia tunnel in the control and 3ESWT groups, X2 (1, N=7) =3.57, p =0.06 and X2 (1, N=9) =2.78, p =0.10, respectively at 6 months post- operatively. Lysholm scores were significantly higher at 6 months post ACL reconstruction compared to the baseline value for each group (p
Article
Extracorporeal shockwave therapy is a treatment modality, originally introduced into the clinic as lithotripsie, which has also been successfully used in the last two decades in the non-invasive treatment of delayed or non-healing fractures. Initially, the mechanism of action was attributed to microfracture-induced repair, but intensive basic research has now shown that the shockwave generates its effect in tissue via mechanotransduction. Numerous signal transduction pathways have already been demonstrated, which in their entirety trigger an endogenous regeneration process via cell proliferation, migration and differentiation. Clinically, these shockwave-conveyed biological signals support healing of acute, delayed and non-union fractures. The attainable outcome is comparable to surgery but avoiding an open approach with associated potential complications. These advantageous properties with a clearly positive cost-benefit ratio make shockwave therapy a first line treatment in delayed and non-union fractures.
Article
Navicular stress fractures are multifactorial injuries due to chronic overload on the navicular, particularly in young athletes. The navicular is subject to unique stresses and has a complex blood supply, making it susceptible to stress fractures and potentially delayed union or nonunion. Expeditious diagnosis is critical to prevent a delay in treatment and a poor outcome. Advanced imaging is essential in making the diagnosis and monitoring healing. Both nonsurgical and surgical treatments have demonstrated good results. Nonsurgical management consists of a period of immobilization and nonweight bearing, and surgical management typically involves open reduction and internal fixation. Patients need to be appropriately counseled regarding expectations for these challenging injuries.
Article
Introduction: In this study, we analyze a new treatment option for pseudarthrosis using radial shock waves. The traditional treatment to pseudarthrosis is surgical. As an option to specific cases, focal shock waves seem to present good results with bone union without a subsequent surgical procedure. As radial shock waves reach less energy and less depth penetration than focal shock waves, they usually are not indicated for the treatment of pseudarthrosis of any bone segment. There are publications that show evidences of the action of radial shock waves stimulating bone consolidation in vitro, in animals and in humans. We will present a new option for failure of consolidation in superficial bones submitted to radial shock wave therapy. Objective: To analyze the effectiveness of radial shock waves in the treatment of superficial bone pseudarthrosis. Patients and methods: Between 2016 and 2019, we conducted a prospective study with 44 consecutive patients with pseudarthrosis. All patients had prior indication for treatment with surgery and were treated with radial shock waves as a nonsurgical treatment option. Patients were evaluated clinically and radiographically pre-treatment and 6 months after. Clinically, patients complained of pain and dysfunction, according to the segment affected, and radiographically, evidences of pseudarthrosis in at least two X-ray views. As the outcomes: satisfactory when there was bone union, no pain, and return function; unsatisfactory when there was no bone union and maintain pain and dysfunction. All patients were treated with the same equipment and by the same physician. The treatment consisted in 3 sessions with weekly interval; in each session, 3000 radial shock waves were applied with 4 bar of energy. Results: After 6 months, clinical analysis and X-ray evidence on 77.2% of the patients presented bone union and clinical improvement classified as satisfactory result. There were no complications. Conclusion: Treatment of pseudarthrosis in superficial bones with radial shock waves is effective and safe.
Article
Background Non-unions occur in 5–10% of all fractures, whereby there is a large variability in the rate with respect to the anatomical location. All non-unions have in common that without any further medical treatment no healing can be expected, independent of the time. There is a wide range of surgical approaches for treatment of these extremely complex pathological situations, which are successful in 75–85% of the cases. Besides surgical approaches there are various conservative treatment options, which should be considered in every treatment planning. Vital non-unions sometimes shows a very good response to noninvasive procedures, particularly in the early stages.Methods and resultsHealing can be achieved even by using basic medical measures, such as optimization of comorbidities, reduction of risk factors and conditioning of an extremity. More elaborate procedures, such as low-intensity pulsed ultrasound (LIPUS) or extracorporeal shockwave therapy (EWST) can make surgical treatment superfluous in 63–94% of cases and show no or only very few side effects at a much lower cost; however, a high patient compliance level is necessary when performing these procedures. As optimal preconditions for a successful conservative treatment, non-unions should be stable due to an adequate osteosynthesis and free of infections, should not show any malalignment and the defect area should be less than 5 mm.Conclusion In every individual case an experience physician should determine whether a conservative treatment option is possible for this complex condition.
Chapter
Extracorporeal shockwave treatment (ESWT) has been in use for more than 20 years in the treatment of musculoskeletal disorders. It is used more commonly for tendinopathies such as plantar fasciitis, lateral epicondylitis of the elbow, and shoulder calcific tendinitis. It has also been used for delayed and nonunion of fractures and early avascular necrosis and bone ischemia. Although ESWT started initially in Europe, its use has spread over the whole world. There is a vast number of reputable publications on the use of ESWT. FDA has approved the use of ESWT for plantar fasciitis (2000) and lateral epicondylitis of the elbow (2002). The ease of application and the low complication rate, with a success rate ranging from 65% to 90%, has led to an exponential increase in its clinical use and applications. This chapter reviews the current status of ESWT in orthopedics.
Article
Objectives: Nonunions after bone fractures are usually treated surgically with risk of infections and failure of osteosynthesis. A noninvasive alternative is extracorporeal shock wave treatment (ESWT), which potentially stimulates bone regeneration. Therefore this review investigates whether ESWT is an effective and safe treatment for delayed unions and nonunions. Data sources: Embase.com, MEDLINE ovid, Cochrane, Web of Science, PubMed publisher, and Google Scholar were systematically searched. Study selection: Inclusion criteria included studies with patients with delayed union or nonunion treated with ESWT; inclusion of ≥10 patients; and follow-up period ≥6 weeks. Data extraction: Assessment for risk of bias was conducted by 2 authors using the Cochrane tool. Union rates and adverse events were extracted from the studies. Data synthesis: Two RCTs and 28 nonrandomized studies were included. One RCT was assessed at medium risk of bias and reported similar union rates between ESWT-treated patients (71%) and surgery-treated patients (74%). The remaining 29 studies were at high risk of bias due to poor description of randomization (n = 1), nonrandomized allocation to control groups (n = 2), or absence of control groups (n = 26). The average union rate after ESWT in delayed unions was 86%, in nonunions 73%, and in nonunions after surgery 81%. Only minor adverse events were reported after ESWT. Conclusions: ESWT seems to be effective for the treatment of delayed unions and nonunions. However, the quality of most studies is poor. Therefore, we strongly encourage conducting well-designed RCTs to prove the effectiveness of ESWT and potentially improve the treatment of nonunions because ESWT might be as effective as surgery but safer. Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Article
Extracorporeal shockwave therapy (ESWT) has been implemented as a treatment for musculoskeletal injuries in horses. ESWT uses acoustic waves applied to a region of injury, and has been shown to improve lameness, decrease time of healing and improve ultrasonographic appearance of tendon and ligament injuries. However, much of the current literature surrounding the use of ESWT in veterinary medicine is positively biased and most studies have lower levels of evidence-based experimental design. Randomised clinical trials are needed to determine specific energy settings, dose, frequency and case selection for different anatomical regions, and to investigate long-term effects of ESWT as well as interactions between ESWT and regenerative biological therapies.
Chapter
The use of shock waves and radial pressure waves generated outside the patient’s body and delivered to the affected region to trigger the body’s mechanisms to initiate natural healing, called extracorporeal shock wave therapy (ESWT) is gaining worldwide recognition and the list of indications is increasing. ESWT is often considered when easier treatment modalities have failed. Many companies offer shock wave sources that use ballistic, electrohydraulic, electromagnetic, or piezoelectric transducers to generate either shock waves or radial pressure waves. Nevertheless, more research is still needed because the cellular and molecular working mechanisms for most ESWT modalities are not fully understood. In many applications evidence is still inconclusive, mainly due to short follow-up times, small sample sizes, different parameters and equipment used, subjective scores, and lack of treatment blinding. This chapter describes some representative ESWT devices and briefly covers results of clinical applications, such as pain relief therapy, and ESWT for patients suffering from plantar fasciitis, calcaneal spur, Achilles tendinopathy, tendinopathy of the shoulder, tennis elbow, patellar tendinopathy, spasticity, chronic pelvic pain syndrome, Peyronie’s disease, and erectile dysfunction. Comments on articles reporting bone and wound healing, treatments in dermatology, acupuncture, as well as ESWT to treat heart diseases are also included. A brief section of ESWT in veterinary medicine describes that devices designed to treat indications such as stress fractures, osteoarthritis, and injuries in tendons and ligaments of horses have been on the market for many years.
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Background: Treatment options for nonunion of the femoral shaft fracture after intramedullary nail fixation are controversial. The methods of exchanging an existing nail with a larger-sized nail, dynamization, removal of the nail followed by plating, and bone grafting have all been reported. From those options, exchange nailing seems to be the most popular choice. In our study, we used plate augmentation and bone grafting with retention of the nail. The purpose of our study was to evaluate the effectiveness of this method in treating femoral shaft nonunion after open reduction and internal fixation with intramedullary nail fixation. Methods: Between January 2003 and December 2009, 22 patients who had nonunion after open reduction and internal fixation with intramedullary nail for femoral shaft fracture were included in our study. There were 13 men and nine women participants, with a mean age of 34.3 years (range, 17-77 years). The mean period of nonunion after surgery was 20.0 months (range, 7-63 months). The patients were classified into three groups, atrophic, oligotrophic, and hypertrophic. We retained the nail and performed plate augmentation for all patients, with simultaneous autologous bone grafting as indicated. We followed up on all patients with plain film examination, and to assess functional recovery status to determine osseous union condition. Results: All 22 of the patients achieved postoperative bony union uneventfully at a mean time of 22.1 weeks (range, 12-40 weeks). The mean operative time was 105 minutes (range, 60-150 minutes), and the mean blood loss was 340 ml (range, 150-700 ml). All of the patients could walk bearing full weight without pain within 3 months. There were no significant complications such as broken hardware, implant back-out, axial or rotational malalignment, or deep infections. Conclusion: Plate augmentation with retention of the nail with autologous bone grafting may be an effective and reliable alternative in treating nonunion of the femoral shaft fracture after open reduction and internal fixation with intramedullary nail.
Article
Background: The care of the patient with the fractured femur entails a multiple surgical team approach. Healing of the fracture and expediency in the operating room are both important. We sought to determine the results of the treatment of fractures of the femoral shaft with interlocking femoral nails inserted with closed techniques, and to compare the outcomes of fractures nailed by using a fracture table with those stabilized with the leg draped free on a radiolucent table. Methods: Eight hundred eighty-two consecutive patients with fractures of the femoral shaft treated with a first-generation intramedullary nail at the authors' institution during the Sears 1986 to 1996 were identified. Five hundred fifty-one fractures in 515 patients met the inclusion criteria. Results: Treatment with an intramedullary nail led to a union rate of 98.9%, There were six infections, all occurring in closed fractures. Thirty-eight percent of the fractures had hardware removed, mast commonly because of pain. One nail and 13 locking bolts broke. Pour hundred eighteen fractures had adequate radiographs available to assess fracture alignment. No fracture healed with more than 10 degrees of angulation in either plane, Forty-four fractures healed with more than 5 degrees of angulation. A distal third fracture was found to be associated with an increased incidence of malalignment. There were no differences in outcomes between fractures stabilized with or without a fracture table, Conclusion: Reamed intramedullary nailing of femoral shaft fractures results in a low rate of nonunion, malunion, infection, and hardware failure. There is no difference in the outcomes of fractures treated with and without the use of a fracture table. This is particularly useful in the patient with multiple injuries for whom transfer to a fracture table may not be time effective.
Article
Tibial nonunion remains a significant clinical challenge despite advances in surgical management. New techniques to help manage tibial nonunion include extracorporeal shock wave therapy and percutaneous application of bone marrow aspirate. Management strategies vary based on the type of nonunion: aseptic or infected, and atrophic or hypertrophic. Extracorporeal shock wave therapy has been shown to be as effective as surgical management in patients with stable hypertrophic nonunion. New fixation options include locked plates and intramedullary compression nails. Novel methods of external fixation have been developed for bone graft harvest from the intramedullary canal. Several biologic adjuncts also are available, including bone marrow aspirates, stem cells, and bone morphogenetic protein.
Article
The aim of this article is to provide a concise review of the basic science of extracorporeal shock wave therapy (ESWT) and to perform a systematic review of the literature for the use of ESWT in the treatment of fractures and delayed unions/nonunions. Articles in the English or German language were identified for the systematic review by searching PubMed-MEDLINE from 1966 until 2008, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and relevant meeting abstracts from 2007 to 2008. Moreover, the bibliographies of the identified articles were reviewed. We included clinical outcome studies of ESWT in the treatment of fractures and delayed unions/nonunions. Reports with less than 10 patients were excluded. Nonunions after corrective osteotomies or arthrodeses were excluded. Sample size, level of evidence, definition of delayed union, definition of nonunion, time from injury to shock wave treatment, location of fracture, union rate, and complications were extracted from the identified articles. Data of 924 patients undergoing ESWT for delayed union/nonunion were extracted from 10 studies. All articles were graded as level 4 studies. The overall union rate was 76% (95% confidence interval 73%-79%). The union rate was significantly higher in hypertrophic nonunions than in atrophic nonunions. Data from level 4 studies suggest that shock wave therapy seems to stimulate the healing process in delayed unions/nonunions. However, further investigations are required.
Article
Low-intensity pulsed ultrasound (LIPUS) is a relatively new technique for the acceleration of fracture healing in fresh fractures and nonunions. It has a frequency of 1.5 MHz, a signal burst width of 200 micros, a signal repetition frequency of 1 kHz, and an intensity of 30 mW/cm2. In 1994 and 1997, two milestone double-blind randomized controlled trials revealed the benefits of LIPUS for the acceleration of fracture healing in the tibia and radius. They showed that LIPUS accelerated the fracture healing rate from 24% to 42% for fresh fractures. Some literature, however, has shown no positive effects. The beneficial effect of acceleration of fracture healing by LIPUS is considered to be larger in the group of patients or fractures with potentially negative factors for fracture healing. The incidence of delayed union and nonunion is 5% to 10% of all fractures. For delayed union and nonunion, the overall success rate of LIPUS therapy is approximately 67% (humerus), 90% (radius/radius-ulna), 82% (femur), and 87% (tibia/tibia-fibula). LIPUS likely has the ability to enhance maturation of the callus in distraction osteogenesis and reduce the healing index. The critical role of LIPUS for fracture healing is still unknown because of the heterogeneity of results in clinical trials for fresh fractures and the lack of controlled trials for delayed unions and nonunions.
Article
Delayed and nonunion of the tibia are not uncommon in orthopaedic practice. Multiple methods of treatment have been developed with variable results. The objective of this study was to define disease-specific and treatment-related factors of prognostic significance in patients undergoing shock wave therapy for tibia nonunion. Retrospective analysis. One hundred ninety-two patients treated with extracorporeal shock wave therapy (ESWT) at a single referral trauma center, AUVA-Trauma Center Meidling, a large single-referral trauma center located in Vienna, Austria, in an attempt to determine the feasibility and factors associated with the use of ESWT in the treatment for tibia nonunion. ESWT coupled with posttreatment immobilization, external fixation, or ESWT alone. Fracture healing, overall healing percent, and factors associated with ESWT success or failure. At the time of last follow up, 138 of 172 (80.2%) patients have demonstrated complete fracture healing. Mean time from first shock wave therapy to complete healing of the tibia nonunion was 4.8+/-4.0 months. Number of orthopaedic operations (P=0.003), shock wave treatments (P=0.002), and pulses delivered (P=0.04) were significantly associated with complete bone healing. Patients requiring multiple (more than one) shock wave treatments versus a single treatment had a significantly lower likelihood of fracture healing (P=0.003). This may be attributable to the finding that a significantly greater proportion of patients with multiple rather than single ESWT treatments had three or more prior orthopaedic procedures (more than one ESWT, 63.9% versus one ESWT, 23.5%; P<0.001). ESWT is a feasible treatment modality for tibia nonunion.
Article
The authors of several studies have recommended extracorporeal shock-wave therapy as an alternative to surgical treatment for long-bone nonunions. This study was performed to compare the results of extracorporeal shock-wave therapy produced by two different devices with those of surgical treatment in the management of long-bone nonunions. One hundred and twenty-six patients with a long-bone nonunion were randomly assigned to receive either extracorporeal shock-wave therapy (Groups 1 and 2) or surgical treatment (Group 3). The patients in the shock-wave groups received four treatments with 4000 impulses of shock waves with an energy flux density of 0.40 mJ/mm(2) (Group 1) or 0.70 mJ/mm(2) (Group 2). The patients in the three groups had similar demographic characteristics, durations of nonunion, and durations of follow-up. Radiographic results (the primary outcome) and clinical results (the secondary outcomes) were determined before and three, six, twelve, and twenty-four months after treatment. The radiographic findings did not differ among the three groups of patients. At six months, 70% of the nonunions in Group 1, 71% of the nonunions in Group 2, and 73% of the nonunions in Group 3 had healed. Three and six months after treatment, the clinical outcomes in the two shock-wave groups were significantly better than those in the surgical group (p < 0.001). However, at both twelve and twenty-four months after treatment, there were no differences among the three groups, with the exception of the DASH score, which differed significantly between Groups 1 and 3 (p = 0.038) and between Groups 2 and 3 (p = 0.021) at twelve months. Extracorporeal shock-wave therapy is as effective as surgery in stimulating union of long-bone hypertrophic nonunions and yields better short-term clinical outcomes.
Article
Following severe burn injury, persistent inflammation perpetuated by surface eschar, bacterial colonisation and neutrophil proteolytic activity can impede normal healing and result in further tissue damage. Extracorporeal shock wave treatment (ESWT) has been shown in the clinical setting to promote the healing of burn and difficult-to-heal wounds; however, the mechanism is unclear. We investigated the role of ESWT on the early proinflammatory response using a severe, full-thickness and highly inflammatory cutaneous burn wound in a murine model. Various wound-healing parameters were measured and leukocyte infiltration quantitated. A panel of 188 candidate genes known to be involved in acute inflammation and wound healing was screened. We show that ESWT of burn wounds 1 hour postwounding significantly blunts polymorphonuclear neutrophil and macrophage infiltration into the wound. ESWT treatment potently attenuates both CC- and CXC-chemokine expression, acute proinflammatory cytokine expression and extracellular matrix proteolytic activity at the wound margin. Given these findings and the clinical success of ESWT, we speculate that ESWT may be a potential therapeutic modality to treat severe wounds wherein excessive inflammatory responses involving increased levels of inflammatory cells, proinflammatory cytokines and proteases may become self-resolving allowing wound healing to progresses by way of normal physiological repair processes.
Article
The treatment of delayed and nonunion of fractures by a single extracorporeal dose of high energy shock waves generated in a water medium and focused on the fracture site is reported. The shock waves break up sclerotic bone by producing microfissures and numerous bony fragments because of the difference in impedance between bone (and calculi) and soft tissues. Osteogenesis is stimulated and contributed to union in 70 out of 82 fractures within a reasonable time. Treatment was given as an outpatient with regional anaesthesia; there were no side effects or complications.
Article
A prospective clinical study investigated the effectiveness of shock waves in the treatment of 72 patients with 72 nonunions of long bone fractures (41 femurs, 19 tibias, seven humeri, one radius, three ulnas and one metatarsal). The doses of shock waves were 6,000 impulses at 28 kV for the femur and tibia, 3,000 impulses at 28 kV for the humerus, 2,000 impulses at 24 kV for the radius and ulna, and 1,000 impulses at 20 kV for the metatarsal. The results of treatment were assessed clinically, and fracture healing was assessed with plain radiographs and tomography. The rate of bony union was 40% at 3 months, 60.9% at 6 months, and 80% at 12 months followup. Shock wave treatment was most successful in hypertrophic nonunions and nonunions with a defect and was least effective in atrophic nonunions. There were no systemic complications or device-related problems. Local complications included petechiae and hematoma formation that resolved spontaneously. In the authors' experience, the results of shock wave treatment were similar to the results of surgical treatment for chronic nonunions with no surgical risks. Shock wave treatment is a safe and effective alternative method in the treatment of chronic nonunions of long bones.
Article
Shock wave therapy is a new modality that has shown efficacy in the treatment of various orthopaedic disorders. To determine the effectiveness, at 2- to 3-year follow-up, of shock wave therapy for calcific tendinitis of the shoulder. Prospective clinical study. Thirty-seven patients (39 shoulders) with calcific shoulder tendinitis were treated with shock wave therapy (1000 impulses at 14 kV) and observed for 24 to 30 months. The control group, which underwent sham treatment with a dummy electrode, consisted of 6 patients (6 shoulders) with an average follow-up of 6 months. Evaluation included use of the 100-point Constant score system and shoulder radiographs. The overall results in the study group were 60.6% excellent (20 of 33 shoulders), 30.3% good (10), 3.0% fair (1), and 6.1% poor (2), and those of the control group were 16.7% fair (1 of 6 shoulders) and 83.3% poor (5). The symptom recurrence rate in the study group was 6.5%. Dissolution of calcium deposits was complete in 57.6% of the study group, partial in 15.1%, and unchanged in 27.3%. Fragmentation was seen in 16.7% of the control group patients; in 83.3% deposits were unchanged. No recurrence of calcium deposits was observed during the 2 years that the study group was followed. Shock wave therapy is a safe and effective noninvasive treatment for patients with calcific tendinitis of the shoulder.
Article
Despite the success in clinical application, the exact mechanism of shock wave therapy remains unknown. We hypothesized that shock wave therapy induces the ingrowth of neovascularization and improves blood supply to the tissues. The purpose of this study was to investigate the effect of shock wave therapy on neovascularization at the tendon-bone junction. Fifty New Zealand white rabbits with body weight ranging from 2.5 to 3.5 kg were used in this study. The right limb (the study side) received shock wave therapy to the Achilles tendon near the insertion to bone. The left limb (the control side) received no shock wave therapy. Biopsies of the tendon-bone junction were performed in 0, 1, 4, 8 and 12 weeks. The number of neo-vessels was examined microscopically with hematoxylin-eosin stain. Neovascularization was confirmed by the angiogenic markers including vessel endothelial growth factor (VEGF) and endothelial nitric oxide synthase (eNOS) expressions and endothelial cell proliferation determined by proliferating cell nuclear antigen (PCNA) expression examined microscopically with immunohistochemical stains. The results showed that shock wave therapy produced a significantly higher number of neo-vessels and angiogenesis-related markers including eNOS, VEGF and PCNA than the control without shock wave treatment. The eNOS and VEGF began to rise in as early as one week and remained high for 8 weeks, then declined at 12 weeks; whereas the increases of PCNA and neo-vessels began at 4 weeks and persisted for 12 weeks. In conclusion, shock wave therapy induces the ingrowth of neovascularization associated with early release of angiogenesis-related markers at the Achilles tendon-bone junction in rabbits. The neovascularization may play a role to improve blood supply and tissue regeneration at the tendon-bone junction.
Article
Background: Shock wave therapy is a new modality that has shown efficacy in the treatment of various orthopaedic disorders.Purpose: To determine the effectiveness, at 2- to 3-year follow-up, of shock wave therapy for calcific tendinitis of the shoulder.Study Design: Prospective clinical study.Methods: Thirty-seven patients (39 shoulders) with calcific shoulder tendinitis were treated with shock wave therapy (1000 impulses at 14 kV) and observed for 24 to 30 months. The control group, which underwent sham treatment with a dummy electrode, consisted of 6 patients (6 shoulders) with an average follow-up of 6 months. Evaluation included use of the 100-point Constant score system and shoulder radiographs.Results: The overall results in the study group were 60.6% excellent (20 of 33 shoulders), 30.3% good (10), 3.0% fair (1), and 6.1% poor (2), and those of the control group were 16.7% fair (1 of 6 shoulders) and 83.3% poor (5). The symptom recurrence rate in the study group was 6.5%. Dissolution of calcium deposits was complete in 57.6% of the study group, partial in 15.1%, and unchanged in 27.3%. Fragmentation was seen in 16.7% of the control group patients; in 83.3% deposits were unchanged. No recurrence of calcium deposits was observed during the 2 years that the study group was followed.Conclusions: Shock wave therapy is a safe and effective noninvasive treatment for patients with calcific tendinitis of the shoulder.
Article
We reviewed 15 patients with femoral non-union after interlocking intramedullary nailing treated with plate augmentation and bone grafting with the nail in situ. The mean time from primary nailing to plate augmentation and bone grafting was 10 months. At the time of presentation, the patients had undergone an average of 1.6 operations from the time of their original injury. To achieve stability of the fracture, we applied an AO plate on the lateral aspect of the femur. The retained nail maintained alignment of the fracture, and plating did not require an extensive surgical approach. In all patients, there was visible motion at the fracture site; however, the motion disappeared after plate augmentation. All patients achieved radiological solid union at an average of 7.2 months.
Article
To study the efficacy of low-intensity pulsed ultrasound (US), or LIPUS, of 85 treated nonunion cases with a minimum fracture age of 8 months, 67 cases met the study criteria. These were: no surgical intervention during 4 months before US treatment and radiographically ceased healing for 3 months before US. In a self-paired control study, the mean fracture age of the 67 patients was 39 +/- 6.2 months. After a daily 20-min US treatment at home for an average of 168 days, 85% (57 of 67) of the nonunion cases were clinically and radiographically healed. The study did not include any cases that were malaligned, grossly instable, actively infected or that had extensive bone loss. The results demonstrate that the specific US can effect heal rates similar to those achieved by surgical means, without the associated risks and complications, and to those achieved by electrical bone growth stimulation or by extracorporeal shock-wave therapy.
Article
There is continuing controversy regarding the optimal treatment for patients with symptomatic early-stage osteonecrosis of the femoral head. We compared the results of noninvasive treatment with extracorporeal shock waves with those of core decompression and bone-grafting in similar groups of patients. Patients with stage-I, II, or III osteonecrosis were randomly assigned to be treated either with shock waves or with core decompression and nonvascularized fibular grafting. The shock-wave group consisted of twenty-three patients (twenty-nine hips), and the surgical group consisted of twenty-five patients (twenty-eight hips). The patients in the two groups had similar demographic characteristics, duration and stage of disease, and duration of follow-up. The patients in the shock-wave group received a single treatment with 6000 impulses of shock waves at 28 kV to the affected hip. The evaluation parameters included clinical assessment of pain with a visual analog pain scale, Harris hip scores, and an assessment of activities of daily living and work capacity. Radiographic assessment was performed with serial plain radiographs and magnetic resonance imaging. Before treatment, the two groups had similar pain and Harris hip scores. At an average of twenty-five months after treatment, the pain and Harris hip scores in the shock-wave group were significantly improved compared with the pretreatment scores (p < 0.001). In this group, 79% of the hips were improved, 10% were unchanged, and 10% were worse. Of the hips treated with a nonvascularized fibular graft, 29% were improved, 36% were unchanged, and 36% were worse. In the shock-wave group, imaging studies showed regression of five of the thirteen lesions that had been designated as stage I or II before treatment and no regression of a stage-III lesion. Two stage-II and two stage-III lesions progressed. In the surgical group, four lesions regressed and fifteen (of the nineteen graded as stage I or II) progressed. The remaining nine lesions were unchanged. Extracorporeal shock-wave treatment appeared to be more effective than core decompression and nonvascularized fibular grafting in patients with early-stage osteonecrosis of the femoral head. Long-term results are needed to determine whether the effect of this novel method of treatment for osteonecrosis of the femoral head endures.
Article
Postoperative delayed union and nonunion is the most common complication in fracture treatment. Recent studies have shown an accelerating effect of low-intensity pulsed ultrasound (LIPUS) on fracture repair. However, the indications for delayed union and nonunion are not clear. To clarify the factors which influence the effects of LIPUS, the data from a previous prospective multicenter study on LIPUS treatment for postoperative delayed union and nonunion of long bone fractures were reanalyzed. Seventy-two cases of long bone fracture, including those of the femur, tibia, humerus, radius, and ulna, were analyzed. The mean time from the most recent operation to the beginning of LIPUS treatment was 11.5 (3-68) months. The relationship between the background factors and the union rate was analyzed using a logistic regression method. In addition, long bone fractures in an upper extremity or in a lower extremity were analyzed separately. The union rate was 75% in all the cases of long bone fracture. There was a significant relationship between the union rate and the period from the most recent operation to the beginning of LIPUS treatment in all cases and in those that had long bone fracture of an upper extremity. There was also a significant relationship between the union rate and the time when a radiological improvement was first observed after the beginning of the treatment in all cases and in those with fractures in a lower extremity. When LIPUS treatment was started within 6 months of the most recent operation, 89.7% of all fractures healed. When an improvement in the radiological changes at the fracture site was observed after 4 months in those cases, then the sensitivity and specificity for union were more than 90%. LIPUS treatment should be started within 6 months of the most recent operation. Because LIPUS has been shown to be effective without causing either serious invasiveness or any undue risk to the patient, it may be considered the treatment of first choice for cases of postoperative delayed union or nonunion.
Article
Chronic patellar tendinopathy is an overuse syndrome with pathologic changes similar to tendinopathies of the shoulder, elbow, and heel. Extracorporeal shockwave was shown effective in many tendinopathies. Extracorporeal shockwave therapy may be more effective than conservative treatment for chronic patellar tendinopathy. Randomized controlled clinical trial; Level of evidence, 2. This study consisted of 27 patients (30 knees) in the study group and 23 patients (24 knees) in the control group. In the study group, patients were treated with 1500 impulses of extracorporeal shockwave at 14 KV (equivalent to 0.18 mJ/mm(2) energy flux density) to the affected knee at a single session. Patients in the control group were treated with conservative treatments including nonsteroidal anti-inflammatory drugs, physiotherapy, exercise program, and the use of a knee strap. The evaluation parameters included pain score, Victorian Institute of Sports Assessment score, and ultrasonographic examination at 1, 3, 6, and 12 months and then once a year. At the 2- to 3-year follow-up, the overall results for the study group were 43% excellent, 47% good, 10% fair, and none poor. For the control group, the results were none excellent, 50% good, 25% fair, and 25% poor. The mean Victorian Institute of Sports Assessment scores were 42.57 +/- 10.22 and 39.25 +/- 10.85, respectively, before treatment (P = .129) and 92.0 +/- 10.17 and 41.04 +/- 10.96, respectively, after treatment (P < .001). Satisfactory results were observed in 90% of the study group versus 50% of the control group (P < .001). Recurrence of symptoms occurred in 13% of the study group and 50% of the control group (P = .014). Ultrasonographic examination showed a significant increase in the vascularity of the patellar tendon and a trend of reduction in the patellar tendon thickness after shockwave treatment compared with conservative treatments. However, no significant difference in the appearance, arrangement, and homogeneity of tendon fibers was noted between the 2 groups. There were no systemic or local complications or device-related problems. Extracorporeal shockwave therapy appeared to be more effective and safer than traditional conservative treatments in the management of patients with chronic patellar tendinopathy.
Article
Despite advances in surgical technique, fracture fixation alternatives, and adjuncts to healing, femoral nonunion continues to be a significant clinical problem. Femoral fractures may fail to unite because of the severity of the injury, damage to the surrounding soft tissues, inadequate initial fixation, and demographic characteristics of the patient, including nicotine use, advanced age, and medical comorbidities. Femoral nonunion is a functional and economical challenge for the patient, as well as a treatment dilemma for the surgeon. Surgeons should understand the various treatment alternatives and their role in achieving the goals of deformity correction, infection management, and optimization of muscle strength and rehabilitation. Used appropriately, nail dynamization, exchange nailing, and plate osteosynthesis can help minimize pain and disability by promoting osseous union. A review of the potential risk factors and treatment alternatives should provide insight into the etiology and required treatment of femoral nonunion.
Article
We reviewed the clinical results of the past 7 years in order to investigate the effect of extracorporeal shock wave therapy (ESWT) in nonunions of long bone fracture. Sixty-nine patients with 69 nonunions (22 femora, 28 tibiae, 13 humeri, 5 radii, and 1 ulna) were treated with extracorporeal shock waves. The technical parameters were 6,000 to 10,000 impulses at 28 kV (0.62 mJ/mm(2) energy flux density) for the femur and tibia, 4,000 impulses at 24 kV for the humerus (0.56 mJ/mm(2) energy flux density), and 3,000 impulses at 24 kV (0.56 mJ/mm(2) energy flux density) for the radius and ulna. Sixty-six patients were followed up. The total successful rate of bony union was 75.4%. ESWT was successful in hypertrophic nonunions and seemed to have no evident effect in atrophic nonunions. We believe that extracorporeal shock wave therapy may be a good choice for nonunions of long bone fracture especially in hypertrophic nonunions.