Bone Healing
The Role of Shockwaves in the Enhancement of Bone Repair - From Basic Principles to Clinical Application
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 demon- strated, which in their entirety trigger an endogenous regeneration process via cell proliferation, migra- tion 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. More...
Treatment of scaphoid waist nonunion by one, two headless compression screws or plate with or without additional extracorporeal shockwave therapy. - Scaphoid nonunion remains challenging for hand surgeons. Several treatment options are available such as: non-vascularized or vascularized bone grafting, with or without additional stabilization. In the last few decades, extracorporeal shockwave therapy (ESWT) has become an established procedure for treating delayed and nonunions. Purpose of this retrospective follow-up study was (a) to investigate union rate and clinical outcome of the different implants [either one/two headless compression screws (HCS) or a plate] and (b) union rate and clinical outcome using only surgery, or a combination of surgery and ESWT. More..
Is it possible to change of the duration of consolidation period in the distraction osteogenesis with the repetition of extracorporeal shock waves - It was found a statistically significant difference between the study groups and control group in the bone mineral density measurements and the highest value was in the E1000*2 group. In the stereological analysis, new bone formation was highest in the E1000*2 group and there was a significant difference compared to the other groups (E0*2 and E500*2) (p=0.000). The lowest connective tissue volume was found in the E500*2 and there was a significant difference compared to the other groups (E0*2 and E1000*2) (p=0.000). The volume of the new vessel was highest in the E500*2 and lowest in the E0*2 group. It was found statistically significant difference between the values of the study and control groups. More..
Extracorporeal shockwave therapy shows site-specific effects in osteoarthritis of the knee in rats - Methods: Sixty SD rats were divided into five groups. Group I was the control and received sham surgery without anterior cruciate ligament transection (ACLT) and medial meniscectomy (MM) and no ESWT. Group II received ACLT þ MM, but no ESWT. Group III received ACLT þ MM and ESWT at distal femur. Group IV received ACLT þ MM and ESWT at proximal tibia. Group V received ACLT þ MM and ESWT at distal femur and proximal tibia. Each ESWT session consisted of 800 impulses at 14 kV (1⁄4 0.219 mJ/mm2 energy flux density). The evaluations included radiograph, bone mineral density (BMD), histomorphologic examination, and immunohistochemical analysis. More..
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 demon- strated, which in their entirety trigger an endogenous regeneration process via cell proliferation, migra- tion 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. More...
Treatment of scaphoid waist nonunion by one, two headless compression screws or plate with or without additional extracorporeal shockwave therapy. - Scaphoid nonunion remains challenging for hand surgeons. Several treatment options are available such as: non-vascularized or vascularized bone grafting, with or without additional stabilization. In the last few decades, extracorporeal shockwave therapy (ESWT) has become an established procedure for treating delayed and nonunions. Purpose of this retrospective follow-up study was (a) to investigate union rate and clinical outcome of the different implants [either one/two headless compression screws (HCS) or a plate] and (b) union rate and clinical outcome using only surgery, or a combination of surgery and ESWT. More..
Is it possible to change of the duration of consolidation period in the distraction osteogenesis with the repetition of extracorporeal shock waves - It was found a statistically significant difference between the study groups and control group in the bone mineral density measurements and the highest value was in the E1000*2 group. In the stereological analysis, new bone formation was highest in the E1000*2 group and there was a significant difference compared to the other groups (E0*2 and E500*2) (p=0.000). The lowest connective tissue volume was found in the E500*2 and there was a significant difference compared to the other groups (E0*2 and E1000*2) (p=0.000). The volume of the new vessel was highest in the E500*2 and lowest in the E0*2 group. It was found statistically significant difference between the values of the study and control groups. More..
Extracorporeal shockwave therapy shows site-specific effects in osteoarthritis of the knee in rats - Methods: Sixty SD rats were divided into five groups. Group I was the control and received sham surgery without anterior cruciate ligament transection (ACLT) and medial meniscectomy (MM) and no ESWT. Group II received ACLT þ MM, but no ESWT. Group III received ACLT þ MM and ESWT at distal femur. Group IV received ACLT þ MM and ESWT at proximal tibia. Group V received ACLT þ MM and ESWT at distal femur and proximal tibia. Each ESWT session consisted of 800 impulses at 14 kV (1⁄4 0.219 mJ/mm2 energy flux density). The evaluations included radiograph, bone mineral density (BMD), histomorphologic examination, and immunohistochemical analysis. More..
The Role of Extracorporeal Shockwave Treatment in Musculoskeletal Disorders - Shockwave therapy was originally developed to disintegrate urinary stones 4 decades ago1 . Since then, there has been remarkable progress regarding the knowledge of its biological and therapeutic effects. Its mechanism of action is based on acoustic mechanical waves that act at the molecular, cellular, and tissue levels to generate a biological response. More..
Extracorporeal shockwave therapy (ESWT) e First choice treatment of fracture non-unions? - Fracture non-unions are still a challenging problem in orthopedics. The treatment of non-unions remains highly individualized, complex, and demanding. In most countries the surgical approach with debridement of the non-union gap, anatomical reduction and appropriate osteosynthesis along with autologous bone grafting is considered as the standard of care. One of the very first non-urologic applications of extracorporeal shockwave treatment (ESWT) concerned non-healing fractures. Since the early 1990 ties the knowledge of the working mechanism has increased enormously. The purpose of this review article is to demonstrate by peer-reviewed literature in conjunction with our own experiences that ESWT can be an efficient, non-invasive, almost complication-free and cost effective alternative to surgical treatment of non-healing fractures. More..
Extracorporeal Shock-Wave Therapy Compared with Surgery for Hypertrophic Long-Bone Nonunions - : 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. More..
Extracorporeal shockwave therapy (ESWT) e First choice treatment of fracture non-unions? - Fracture non-unions are still a challenging problem in orthopedics. The treatment of non-unions remains highly individualized, complex, and demanding. In most countries the surgical approach with debridement of the non-union gap, anatomical reduction and appropriate osteosynthesis along with autologous bone grafting is considered as the standard of care. One of the very first non-urologic applications of extracorporeal shockwave treatment (ESWT) concerned non-healing fractures. Since the early 1990 ties the knowledge of the working mechanism has increased enormously. The purpose of this review article is to demonstrate by peer-reviewed literature in conjunction with our own experiences that ESWT can be an efficient, non-invasive, almost complication-free and cost effective alternative to surgical treatment of non-healing fractures. More..
Extracorporeal Shock-Wave Therapy Compared with Surgery for Hypertrophic Long-Bone Nonunions - : 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. More..
Biological mechanism of shockwave in bone - Shockwave is a rapid, short duration acoustic wave that carries energy and can propagate through tissue medium. This kind of physical force can be a mechanical stimulus that induces biological effects in living tissue. Extracorporeal shockwave therapy (ESWT) acts as a mechanical stimulus which promotes biological healing processes through a mechanotransduction. The biological effects of ESWT are reported such as tissue regeneration, wound healing, angiogenesis, bone remodeling, and anti-inflammation. Until now, however, little is known about the basic mechanism of action of this type of therapy. This article describes the molecular mechanism on the current status of ESWT with pre-clinical and clinical applications for treating disorders in bone. More..
Shock Wave Therapy Compared with Intramedullary Screw Fixation for Nonunion of Proximal Fifth Metatarsal Metaphyseal-Diaphyseal Fractures - The current ‘‘gold standard’’ for treatment of chronic fracture nonunion in the metaphyseal-diaphyseal region of the fifth metatarsal is intramedullary screw fixation. Complications with this procedure, however, are not uncommon. Shock wave therapy can be an effective treatment for fracture nonunions. The purpose of this study was to evaluate the safety and efficacy of shock wave therapy as a treatment of these nonunions. More..
Extracorporeal shockwave therapy (ESWT) ameliorates healing of tibial fracture non-union unresponsive to conventional therapy - Tibial non-unions are common cause of demanding revision surgeries and are associated with a significant impact on patients’ quality of life and health care costs. Extracorporeal shockwave therapy (ESWT) has been shown to improve osseous healing in vitro and in vivo. The main objective of present study was to evaluate the efficacy of ESWT in healing of tibial non-unions unresponsive to previous surgical and non-surgical measures. A retrospective multivariant analysis of a prospective open, singlecentre, clinical trial of tibia non-union was conducted. 56 patients with 58 eligible fractures who met the FDA criteria were included. All patients received 3000–4000 impulses of electrohydraulic shockwaves at an energy flux density of 0.4 mJ/mm2 (6 dB). On average patients underwent 1.9 times (1.3 SD) surgical interventions prior to ESWT displaying the rather negatively selected cohort and its limited therapy responsiveness. In 88.5% of patients receiving ESWT complete bone healing was observed after six months irrespective of underlying pathology. The multivariant analysis showed that time of application is important for therapy success. Patients achieving healing received ESWT earlier: mean number of days between last surgical intervention and ESWT (healed – 355.1 days 167.4 SD vs. not healed – 836.7 days 383.0 SD; p < 0.0001). ESWT proved to be a safe, effective and non-invasive treatment modality in tibial non-unions recalcitrant to standard therapies. The procedure is well tolerated, time-saving, lacking side effects, with potential to significantly decrease health care costs. Thus, in our view, ESWT should be considered the treatment of first choice in established tibial non-unions. More..
Extracorporeal shockwave therapy (ESWT) in the treatment of atrophic non-unions of femoral shaft fractures - Introduction: 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. Methods: We retrospectively analyzed 22 patients treated 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. More..
Current concepts of shockwave therapy in stress fractures - Stress fractures are common painful conditions in athletes, usually associated to biomechanical overloads. Low risk stress fractures usually respond well to conservative treatments, but up to one third of the athletes may not respond, and evolve into high-risk stress fractures. Surgical stabilization may be the final treatment, but it is a highly invasive procedure with known complications. Shockwave treatments (ESWT), based upon the stimulation of bone turnover, osteoblast stimulation and neovascularization by mechanotransduction, have been successfully used to treat delayed unions and avascular necrosis. Since 1999 it has also been proposed in the treatment of stress fractures with excellent results and no complications. We have used focused shockwave treatments in professional athletes and military personnel with a high rate of recovery, return to competition and pain control. We present the current concepts of shockwave treatments for stress fractures, and recommend it as the primary standard of care in low risk patients with poor response to conventional treatments. More..
Extracorporeal shockwave therapy for atrophic and oligotrophic nonunion of tibia and femur in high energy trauma patients. Case series - 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 More..
Extracorporeal shockwave therapy (ESWT) e First choice treatment of fracture non-unions? - Fracture non-unions are still a challenging problem in orthopedics. The treatment of non-unions remains highly individualized, complex, and demanding. In most countries the surgical approach with debridement of the non-union gap, anatomical reduction and appropriate osteosynthesis along with autologous bone grafting is considered as the standard of care. One of the very first non-urologic applications of extracorporeal shockwave treatment (ESWT) concerned non-healing fractures. Since the early 1990 ties the knowledge of the working mechanism has increased enormously. The purpose of this review article is to demonstrate by peer-reviewed literature in conjunction with our own experiences that ESWT can be an efficient, non-invasive, almost complication-free and cost effective alternative to surgical treatment of non-healing fractures. More..
Development of a Prognostic Naïve Bayesian Classifier for Successful Treatment of Nonunions - Predictive models permitting individualized prognostication for patients with fracture nonunion are lacking. The objective of this study was to train, test, and cross-validate a Bayesian classifier for predicting fracture-nonunion healing in a population treated with extracorporeal shock wave therapy. More..
Extracorporeal Shock Wave Treatment for Delayed Union and Nonunion Fractures: A Systematic Review - Delayed unions and nonunions are failures of bony healing after fractures, osteotomies, or arthrodesis. In practice, a wide variety exists in the exact definition of delayed unions and nonunions depending on fracture site and criteria used for the assessment of bony union.1 In this review, we define delayed unions as fractures that do not show radiological union 3 months after a fracture and nonunions as fractures that do not show radiological union 6 months after a fracture. More..
Influence of extracorporeal shock wave therapy (ESWT) on bone turnover markers in organisms with normal and low bone mineral density during fracture healing: a randomized clinical trial - : Low bone mineral density (BMD) leads to metaphyseal fractures, which are considered of delayed, qualitatively reduced healing Christoph Wölfl 1 Laura Schuster2 resulting in prolonged care phases and increased socioeconomic costs. Bernd Höner3 Extracorporeal shockwave therapy (ESWT) is already approved to support Sarah Englert 1 bone healing of pseudarthrosis and delayed unions. With this study, we examined its influence on bone turnover markers (BTM) during fracture healing in patients with low and normal BMD More..
Extracorporeal Shock Wave Therapy: Current Evidence - 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 More..
Extracorporeal shock-wave therapy reduces progression of knee osteoarthritis in rabbits by reducing nitric oxide level
and chondrocyte apoptosis - The goal for treating osteoarthritis (OA) is finding ways to decrease joint pain and dysfunction and prevent and slow the cartilage degeneration. Extracorporeal shock-wave therapy (ESWT) has been found to improve
motor dysfunction and ameliorate pain with OA in animals. However, few studies have found that it can prevent and
slow joint degeneration in vivo. The aim of study was to investigate the effect of ESWT on OA in rabbit. More..
Shock Wave Therapy Compared with Intramedullary Screw Fixation for Nonunion of Proximal Fifth Metatarsal Metaphyseal-Diaphyseal Fractures - The current ‘‘gold standard’’ for treatment of chronic fracture nonunion in the metaphyseal-diaphyseal region of the fifth metatarsal is intramedullary screw fixation. Complications with this procedure, however, are not uncommon. Shock wave therapy can be an effective treatment for fracture nonunions. The purpose of this study was to evaluate the safety and efficacy of shock wave therapy as a treatment of these nonunions. More..
Extracorporeal shockwave therapy (ESWT) ameliorates healing of tibial fracture non-union unresponsive to conventional therapy - Tibial non-unions are common cause of demanding revision surgeries and are associated with a significant impact on patients’ quality of life and health care costs. Extracorporeal shockwave therapy (ESWT) has been shown to improve osseous healing in vitro and in vivo. The main objective of present study was to evaluate the efficacy of ESWT in healing of tibial non-unions unresponsive to previous surgical and non-surgical measures. A retrospective multivariant analysis of a prospective open, singlecentre, clinical trial of tibia non-union was conducted. 56 patients with 58 eligible fractures who met the FDA criteria were included. All patients received 3000–4000 impulses of electrohydraulic shockwaves at an energy flux density of 0.4 mJ/mm2 (6 dB). On average patients underwent 1.9 times (1.3 SD) surgical interventions prior to ESWT displaying the rather negatively selected cohort and its limited therapy responsiveness. In 88.5% of patients receiving ESWT complete bone healing was observed after six months irrespective of underlying pathology. The multivariant analysis showed that time of application is important for therapy success. Patients achieving healing received ESWT earlier: mean number of days between last surgical intervention and ESWT (healed – 355.1 days 167.4 SD vs. not healed – 836.7 days 383.0 SD; p < 0.0001). ESWT proved to be a safe, effective and non-invasive treatment modality in tibial non-unions recalcitrant to standard therapies. The procedure is well tolerated, time-saving, lacking side effects, with potential to significantly decrease health care costs. Thus, in our view, ESWT should be considered the treatment of first choice in established tibial non-unions. More..
Extracorporeal shockwave therapy (ESWT) in the treatment of atrophic non-unions of femoral shaft fractures - Introduction: 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. Methods: We retrospectively analyzed 22 patients treated 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. More..
Current concepts of shockwave therapy in stress fractures - Stress fractures are common painful conditions in athletes, usually associated to biomechanical overloads. Low risk stress fractures usually respond well to conservative treatments, but up to one third of the athletes may not respond, and evolve into high-risk stress fractures. Surgical stabilization may be the final treatment, but it is a highly invasive procedure with known complications. Shockwave treatments (ESWT), based upon the stimulation of bone turnover, osteoblast stimulation and neovascularization by mechanotransduction, have been successfully used to treat delayed unions and avascular necrosis. Since 1999 it has also been proposed in the treatment of stress fractures with excellent results and no complications. We have used focused shockwave treatments in professional athletes and military personnel with a high rate of recovery, return to competition and pain control. We present the current concepts of shockwave treatments for stress fractures, and recommend it as the primary standard of care in low risk patients with poor response to conventional treatments. More..
Extracorporeal shockwave therapy for atrophic and oligotrophic nonunion of tibia and femur in high energy trauma patients. Case series - 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 More..
Extracorporeal shockwave therapy (ESWT) e First choice treatment of fracture non-unions? - Fracture non-unions are still a challenging problem in orthopedics. The treatment of non-unions remains highly individualized, complex, and demanding. In most countries the surgical approach with debridement of the non-union gap, anatomical reduction and appropriate osteosynthesis along with autologous bone grafting is considered as the standard of care. One of the very first non-urologic applications of extracorporeal shockwave treatment (ESWT) concerned non-healing fractures. Since the early 1990 ties the knowledge of the working mechanism has increased enormously. The purpose of this review article is to demonstrate by peer-reviewed literature in conjunction with our own experiences that ESWT can be an efficient, non-invasive, almost complication-free and cost effective alternative to surgical treatment of non-healing fractures. More..
Development of a Prognostic Naïve Bayesian Classifier for Successful Treatment of Nonunions - Predictive models permitting individualized prognostication for patients with fracture nonunion are lacking. The objective of this study was to train, test, and cross-validate a Bayesian classifier for predicting fracture-nonunion healing in a population treated with extracorporeal shock wave therapy. More..
Extracorporeal Shock Wave Treatment for Delayed Union and Nonunion Fractures: A Systematic Review - Delayed unions and nonunions are failures of bony healing after fractures, osteotomies, or arthrodesis. In practice, a wide variety exists in the exact definition of delayed unions and nonunions depending on fracture site and criteria used for the assessment of bony union.1 In this review, we define delayed unions as fractures that do not show radiological union 3 months after a fracture and nonunions as fractures that do not show radiological union 6 months after a fracture. More..
Influence of extracorporeal shock wave therapy (ESWT) on bone turnover markers in organisms with normal and low bone mineral density during fracture healing: a randomized clinical trial - : Low bone mineral density (BMD) leads to metaphyseal fractures, which are considered of delayed, qualitatively reduced healing Christoph Wölfl 1 Laura Schuster2 resulting in prolonged care phases and increased socioeconomic costs. Bernd Höner3 Extracorporeal shockwave therapy (ESWT) is already approved to support Sarah Englert 1 bone healing of pseudarthrosis and delayed unions. With this study, we examined its influence on bone turnover markers (BTM) during fracture healing in patients with low and normal BMD More..
Extracorporeal Shock Wave Therapy: Current Evidence - 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 More..
Extracorporeal shock-wave therapy reduces progression of knee osteoarthritis in rabbits by reducing nitric oxide level
and chondrocyte apoptosis - The goal for treating osteoarthritis (OA) is finding ways to decrease joint pain and dysfunction and prevent and slow the cartilage degeneration. Extracorporeal shock-wave therapy (ESWT) has been found to improve
motor dysfunction and ameliorate pain with OA in animals. However, few studies have found that it can prevent and
slow joint degeneration in vivo. The aim of study was to investigate the effect of ESWT on OA in rabbit. More..
