Shock Wave for the Treatment of Nonunions

September 19, 2012 | Category: Fracture management


  Paul G. Peters, MD

  Dr. Peters is Resident Advisory Board Member of The American Journal of  
  Orthopedics; and Associate Faculty, Wright State University School of
  Medicine, Dayton, Ohio.


There may be another good alternative for the treatment of nonunions and delayed unions other than surgery. A study just published in The American Journal of Orthopedics by Vulpiani and colleagues, reported that extracorporal shock wave therapy (ESWT) is safe and effective for the treatment of fracture nonunions.

Overall, 143 patients were treated with high-energy shock wave therapy. Complete healing occurred in 80 patients (55.9%). The success rate increased to 89.1% when atrophic nonunions were excluded. An electromagnetic shock wave generator was used to apply 2500 to 3000 impulses given at 0.25-0.84 mL/mm(2) in 3-5 sessions. No significant adverse events were reported.

The results reported by this medical center further add to the body of evidence supporting the use of ESWT as an alternative for treatment of fracture nonunion. Two points that I was able to take away from this paper are a positive treatment effect is typically evident in the first 3 months and the importance of exclusion criteria, which include open and neoplastic fractures, infection, gross instability and bone gap greater than 0.5 cm. The exclusion of atrophic nonunions is likely prudent based on the success rate reported here.

ESWT is a very interesting treatment modality with a wide array of attempted applications from its initial FDA approval for the treatment of plantar fasciitis to many off-label uses such as fracture nonunion, lateral epicondylitis of the elbow, calcific tendinitis of the shoulder, patellar tendinopathy, Achilles tendinopathy and more recently diabetic ulcers. Reported success rates are variable and likely related to patient selection criteria and variable treatment protocols. Complication rates are low with the most common reported being local swelling, petechiae, and hematoma. The low risk profile is even more prominent as our knowledge of the deleterious effects of cortisone expands.

My personal experience relates predominantly to the treatment of plantar fasciitis and Achilles tendonosis. The majority of my patients have appreciated a clinical improvement and often have avoid surgical intervention. I have found that ESWT is a viable treatment in a select patient population, including patients that did not have good outcomes in standard nonoperative treatment, are not good surgical candidates, or that desire an alternative to surgery.

To read the full study, see:
Vulpiani MC, Vetrano M, Conforti F, et al. Effects of Extracorporeal Shock Wave Therapy on Fracture Nonunions. Am J Orthop. 2012;41(9):E122-E127.

 

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Comments (2) -

9/20/2012 3:10:26 PM

I read with great interest the study by Vulpiani and colleagues published in the September issue of The American Journal of Orthopedics. While recent literature has shown promise for this technology in the treatment of long bone nonunions,[Zelle BA, et al. J Orthop Trauma. 2010; Cacchio A, et al. J Bone Joint Surg Am. 2009; Elster EA, et al. J Orthop Trauma. 2010] it appears that extracorpeal shock wave (ESW) therapy is still a relatively uncommon treatment method for nonunions.

Although their study had some methodological differences from previously published data on ESW [Cacchio 2009; Elster 2010], it is important to note that their study began in 2001, when ESW was still quite novel, and they included patients over a 6-year period. One of the more interesting findings of their study was that patients with atrophic nonunions had a significantly worse success rate than patients with hypertrophic/oligotrophic nonunions. This finding adds to the growing body of evidence suggesting that ESW may not be the optimal treatment for atrophic nonunions [Zelle 2010].

It would have been great if this paper included a control group that underwent standard surgical therapy, but their study has strength in the number of patients they were able to treat and follow nonetheless. I applaud Dr. Vulpiani and his group for the study and hope it can further investigations into what fracture patterns are best for ESW and the basic science behind how ESW works.

Chad Krueger, MD, CPT, MC, USA United States | Reply

9/21/2012 4:23:55 PM

The management of fracture nonunions remains a challenging problem for surgeons and patients with significant morbidity including pain, loss of function, increased hospitalization, prolonged rehabilitation, and reoperation. In this month’s issue of The American Journal of Orthopedics, Dr. Vulpiani and colleagues prospectively investigated the use of ESWT in a cohort of 143 patients with fracture nonunions in various body parts and showed that approximately 56% of nonunions were able to heal by 7.6 months. Patients with atrophic nonunions had lower union rates than trophic nonunions, a finding that is in agreement with previous results in the literature (Zelle BA et al. J Orthop Trauma. 2010). The findings of the present study support an important alternative nonsurgical treatment approach to fracture nonunions that may help decrease the morbidity and costs associated with standard revision surgery.

Previous studies of ESWT on delayed unions and nonunions have largely been retrospective case series with low levels of evidence with the exception of a prospective randomized clinical trial by Wang et al. comparing operative treatment of acute femur and tibia fractures versus surgery with ESWT (Zell 2010; Wang CJ et al. Arch Orthop Trauma Surg. 2007). As a result, evidence for its use has been limited with a low recommendation grade despite promising initial results. The present study is an important step forward in the use of ESWT for nonunions, but is limited in its lack of a control group or comparison experimental group such as surgical intervention.  While the results show that roughly 85% of patients had partial or complete healing, it is important to note that the variability in fracture characteristics and treatment doses of ESWT make it difficult to come to any conclusions regarding its overall efficacy. In addition, the lack of clinical data from patient questionnaires such as SF-36 and VAS is another study limitation.

Future studies need to investigate the optimal dose, timing, and frequency of ESWT for nonunions as well as how it compares alone to other treatment options such as surgery. Current uses for ESWT include treatment of nonunions, plantar fasciitis, lateral epicondylitis, and various tendinopathies, but evidence is largely anecdotal in nature and without explanation of the basic science behind the treatment effects observed.  Therefore, while the clinical data is promising for ESWT to treat nonunions, concurrent basic science studies are critical in the future to better define the precise molecular mechanisms by which ESWT stimulates bone formation and healing before its widespread implementation can be achieved.

Andrew R. Hsu, MD United States | Reply

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