Does radial shock wave therapy works in pseudarthrosis? Prospective analysis of forty four patients

Callus formation and bone remodeling in a tibial nonunion after minimal invasive percutaneous screw fixation followed by extracorporeal shockwave therapy 17-months after initial trauma - A case report

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.

A modern approach to the rehabilitation of patients with fractures of the bones of the lower extremities

BACKGROUND: General injury rates tend to increase in most federal districts of Russia. The patients with fractures of the bones of the lower extremities reaches for 8.525% of the total number of patients with fractures. Fractures of the bones of the lower extremities are characterized by long period of reparation, persistent contractures, a violation of the congruence of the articular surfaces, and changes in the biomechanics of walking. Only full course of rehabilitation can eliminate the these complications and restore the previous motor activity. АIMS: The study aimed to analyze the structure of injuries in patients of the traumatology department and to present and the results of the recovery of patients with fractures of the bones of the lower extremities using and algorithm of organization of medical rehabilitation in the case study. MATERIALS AND METHODS: A retrospective analysis of statistical data on 995 patients of the traumatology department № 1 of the Kazan City Clinical Hospital, who underwent 981 operations, was carried out. Randomly selected two groups of patients ― I main (n=45) and II control (n=45). Patients of group II after the treatment at the trauma center underwent outpatient medical rehabilitation, group I received inpatient medical rehabilitation in the rehabilitation department of the Kazan City Clinical Hospital № 7. In a hospital setting, a comprehensive rehabilitation program included physiotherapy exercises, CPM-veloergometry, exercises on rehabilitation simulators, the PNF kinesiotherapy technique, etc. RESULTS: A more pronounced statistically significant positive dynamics at the end of the course of medical rehabilitation was noted in patients of group I (reduction of pain syndrome, increased joint mobility, degree of dependence on others, increased mobility index, the ability to dress independently, maintain body position in space, reduced dysfunction in lifting and carrying objects, walking disorders, and caring for body parts). The dynamics of motor function and psycho-emotional sphere also improved to a greater extent in patients of group I. CONCLUSIONS: The effectiveness of the presented algorithm of organization of medical rehabilitation of patients with fractures of the bones of the lower extremities is confirmed by the results of present study. It is revealed that patients in the I (main) group showed more significant improvement in functions, activity and participation, a decrease of disability, reduce of pain, anxiety and depression, as well as an increase of the level of quality of life compared to patients of group II (control), who did not receive comprehensive medical rehabilitation in the hospital (p 0.1).

Exposure of zebra mussels to radial extracorporeal shock waves: implications for treatment of fracture nonunions

Background

Radial extracorporeal shock wave therapy (rESWT) is an attractive, non-invasive therapy option to manage fracture nonunions of superficial bones, with a reported success rate of approximately 75%. Using zebra mussels (Dreissena polymorpha), we recently demonstrated that induction of biomineralization after exposure to focused extracorporeal shock waves (fESWs) is not restricted to the region of direct energy transfer into calcified tissue. This study tested the hypothesis that radial extracorporeal shock waves (rESWs) also induce biomineralization in regions not directly exposed to the shock wave energy in zebra mussels.

Methods

Zebra mussels were exposed on the left valve to 1000 rESWs at different air pressure (between 0 and 4 bar), followed by incubation in calcein solution for 24 h. Biomineralization was evaluated by investigating the fluorescence signal intensity found on sections of the left and right valves prepared two weeks after exposure.

Results

General linear model analysis demonstrated statistically significant (p < 0.05) effects of the applied shock wave energy as well as of the side (left/exposed vs. right/unexposed) and the investigated region of the valve (at the position of exposure vs. positions at a distance to the exposure) on the mean fluorescence signal intensity values, as well as statistically significant combined energy × region and energy × side × region effects. The highest mean fluorescence signal intensity value was found next to the umbo, i.e., not at the position of direct exposure to rESWs.

Conclusions

As in the application of fESWs, induction of biomineralization by exposure to rESWs may not be restricted to the region of direct energy transfer into calcified tissue. Furthermore, the results of this study may contribute to better understand why the application of higher energy flux densities beyond a certain threshold does not necessarily lead to higher success rates when treating fracture nonunions with extracorporeal shock wave therapy.