Extracorporeal shockwave therapy for atrophic and oligotrophic nonunion of tibia and femur in high energy trauma patients. Case series

Abstract

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. Highlights

Extracorporeal Shockwave Therapy in the Treatment of Nonunion in Long Bones: A Systematic Review and Meta-Analysis

“…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 ).…”

“…Five studies reported separate results for hypertrophic and atrophic or oligotrophic cases [ 11 , 26 , 38 , 43 , 46 ]. The probability that bone healing would occur with ESWT was 3.05-fold greater in hypertrophic cases when compared to oligotrophic or atrophic cases (OR = 3.05, 95% CI: 1.68–5.53, p = 0.0003) ( Figure 2 ).…”

“…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.…”

“…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. Lastly, four studies [ 5 , 35 , 48 , 49 ] reported separate outcomes for metatarsals; out of a total of 50 metatarsals, 45 (90%) healed.…”

“…As a result of the small sample size, our results do not allow us to postulate on the ideal EFD to implement in treating nonunion. 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 ].…”