Shock wave therapy of fracture nonunion

Extracorporeal Shock Wave Therapy Combined With Platelet-Rich Plasma Injection to Treat the Nonunion of a Stress Fracture of the Proximal Phalanx of the Great Toe: A Case Report

A 15-year-old female short-distance track and field athlete started to experience pain in her left great toe while competing. One month after the onset of symptoms, she was diagnosed with a stress fracture of the proximal phalanx of the great toe. Despite three months of conservative treatment, no bone healing was observed, resulting in a nonunion. To promote healing of the fractured area, a treatment method involving the combination of extracorporeal shock wave therapy (ESWT) with platelet-rich plasma (PRP) injection was pursued. Complete bone healing was achieved six weeks after the start of the treatment, enabling the patient to fully return to her sport. Based on our findings, the combined use of ESWT and PRP injections, both beneficial for bone healing, is a potentially effective treatment for nonunion of the stress fracture of the proximal phalanx of the great toe.

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.

Synergistic effects of autologous platelet-rich plasma combined with an extracorporeal shock wave in treatment of long diaphysis aseptic nonunion

INTRODUCTION

Union of long bone fractures is a complicated biological mechanism affected by numerous systemic and local variables. Disruption of any of these components may result in fracture nonunion. There are various types of clinically available treatment strategies for aseptic nonunion. Both activated platelet plasma and extracorporeal shock waves play important roles in fracture healing. This study aimed to investigate the interaction of platelet-rich plasma (PRP) and extracorporeal shock wave (ESW) in bone healing of nonunion.

HYPOTHESIS

PRP and ESW have synergistic effects in treating long bone nonunion.

METHODS

Between January 2016 and December 2021, a total of 60 patients with established nonunion of a long bone (18 tibias, 15 femurs, 9 humerus, 6 radii, and 12 ulnae) were included in this study, comprising 31 males and 29 females, ranging from 18 to 60 years old. Patients with bone nonunion were separated into two groups: PRP alone (Monotherapy group) and those treated with PRP combined with ESW (Combined treatment group). The two groups were compared to assess the therapeutic benefits, callus development, local problems, bone healing time, and Johner Wruhs functional classification of operated limbs.

RESULTS

Fifty-five patients were followed up, 5 patients were lost to follow-up, two in the PRP group and three in the PRP+ESW group, the follow-up time varied from 6 to 18 months, with an average of 12.7±5.2 months. At 8, 12, 16, 20, and 24 weeks following intervention, the callus score in the monotherapy group was significantly lower than in the combined treatment group (p<0.05). Both groups had no swelling and infection in the soft tissue of the nonunion operation site. In the PRP+ESW group, the fracture union rate was 92.59% and the healing time was 16.3±5.2 weeks. In the PRP group, the fracture union rate was 71.43% and the healing time was 21.5±3.7 weeks. The clinical healing time of the monotherapy group was significantly longer than the combined treatment group (p<0.05). All the nonunion patients with no signs of healing were treated with revision surgery. The excellent and good rate of Johner-Wruhs functional classification of affected limbs in the monotherapy group was significantly lower than in the combined treatment group (p<0.05).

CONCLUSION

PRP combined with ESW has a certain synergistic effect in treating aseptic nonunion after fracture surgery. It can significantly improve the formation of new bone, it is a minimally invasive and effective strategy to treat aseptic nonunion in a clinical setting.

LEVEL OF EVIDENCE

III, retrospective, single-centre, case-control study.

Effect of extracorporeal shock wave combined with Kinesio taping on upper limb function during individuals with biceps brachii tendinopathy：protocol for a double-blind, randomised controlled trial

INTRODUCTION

Long head of biceps brachii tendinopathy (LHBT) is characterised by persistent pain and disability of shoulder joint, impairing patients' quality of life. Extracorporeal shock wave therapy (ESWT) is a non-invasive treatment, which promotes tissue regeneration and repair. However, ESWT has a side effect that often causes short-term pain and swelling in the treatment area. It is known that the effects of Kinesio taping (KT) on relieving swelling and pain. Due to insufficient clinical evidence from current limited studies, this randomised controlled study aims to explore the effects of ESWT combined with KT on upper limb function during individuals with LHBT.

METHODS AND ANALYSIS

A 2×2 factorial design, double-blind, randomised controlled trial will be conducted. A total of 144 participants will be randomly allocated into one of four groups (KT+ESWT, KT+sham ESWT, sham KT+ESWT or sham KT+sham ESWT) to participate in a 4-week treatment programme. Measurements will be taken at pretreatment (baseline), immediately after treatment and 6 weeks after treatment. The primary endpoint will be the Constant-Murley score (CMS), the secondary endpoints will include the pain Numerical Rating Scale, range of motion, pressure pain threshold and soft tissue hardness of biceps, speed test and global rating of change. Repeated measures analysis of variance will be used to compare differences among the effects of different interventions.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of the Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. In addition to international conference reports, findings will be disseminated through international publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2100051324.

The use of extracorporeal shock wave therapy (ESWT) in treating osteonecrosis of the femoral head (AVNFH): a retrospective study

PURPOSE

As most of the cases of avascular necrosis (AVN) in Saudi Arabia is seen in young population and as literature showed good effect of extracorporeal shock wave therapy (ESWT) in reducing pain and oedema in avascular necrosis and delaying the need of surgical intervention. Our purpose of this study is to assess the effectiveness of ESWT in reducing pain, improving range of motion (ROM) and delaying the surgical intervention in patient with AVN of femoral head and compare our results to published literature.

MATERIAL AND METHODS

We have treated 24 patients, 13 males and 11 females with a mean age of 29 years (range 14-48) with 34 hips affected. There were 14 unilateral and ten bilateral lesions. In our series 11 out of 24 patients (45.8%) were due to sickle cell disease. Other causes included idiopathic in five patients (20.8%), corticosteroids use and systemic lupus erythematous in three patients each (12.5% each) and post-traumatic AVN in two patients (8.3%). Extracorporeal shock wave therapy was implanted in FICAT stage I, II and III. All patients had two sessions of extracorporeal shock wave therapy, four to six weeks apart, each with 4000 impulses divided into four points. Radiological and MRI assessment were performed at regular time intervals with a minimum follow-up of two years. Clinical assessment was based on Visual Analog Scale and Harris Hip Score (HHS). The end point outcome measurement was the need for any operative intervention.

RESULTS

Operative intervention was necessary in eight out of 34 hips (23.5%), within an average of 2.5 years (range 1 to 5 years). A hip salvage was achieved in 76.5%. Function was improved with the Harris Hip Score from a mean of 54.6 to 80.4 (P value using paired t test ≤ 0.05). Pain assessed with Visual Analog Scale improved from 5.73 to 2.75 (P value using paired t test ≤ 0.05).

CONCLUSION

We do recommend the use of ESWT in treating AVN of bone whether of femoral head or other sites prior to the collapse of the articular surface. Further studies are needed to compare using two or more sessions as well as using four or six points for ESWT.

Treatment of delayed union of the forearm with extracorporeal shockwave therapy: a case report and literature review

Compared to other long bones, forearm fractures are particularly challenging due to the high rate of complications. These include malunion, delayed/nonunion, wrist and elbow movement reduction, and pain. Surgical procedure is considered the gold standard for managing delayed union and nonunion of the long bones. However, in the last decades, extracorporeal shockwave therapy (ESWT) has emerged as an effective and less invasive approach to enhance bone regeneration and fracture healing, avoiding major complications of surgical procedures. In contrast to the broad literature reporting good clinical results of ESWT in the treatment of nonunions, there is currently limited evidence regarding the clinical application of shock waves on long bone delayed fractures, particularly those of the forearm. In the present paper, we report a case of delayed bone healing of the diaphyseal region of the ulna treated with focused ESWT. The successful case experienced bone healing at the fracture site in less than 3 months after initial ESWT treatment. Acknowledging the limitation of reporting a case report, however, the remarkable clinical results and the absence of side effects contribute valuable information in support of the use of ESWT as an effective alternative to standard surgery for forearm fractures.

Nonunion of the so-called acromion: a systematic review with consideration of the terminology

INTRODUCTION

There is no widely accepted standard for the classification and treatment of traumatic acromion/scapular spine fracture nonunion due to the scarcity of this condition and the confusion of terminology.

MATERIALS AND METHODS

PubMed and Scopus were searched using "scapular fracture" and "acromion fracture" or "scapular spine fracture" as search terms. The inclusion criteria were English full-text articles concerning acromion/scapular spine fracture nonunion that described patient characteristics and presented appropriate images. The exclusion criteria were cases without appropriate images. Citation tracking was conducted to find additional articles and notable full-text articles written in other languages. Fractures were classified using our newly proposed classification system.

RESULTS

Twenty-nine patients (19 men, 10 women) with 29 nonunions were identified. There were four type I, 15 type II, and 10 type III fracture nonunions. Only 11 fractures were isolated. The mean period from initial injury to final diagnosis was 35.2 ± 73.2 months (range 3-360 months) (n = 25). The most frequent cause of delayed diagnosis was conservative treatment for fracture in 11 patients, followed by oversight by the physician in 8. The most common reason for seeking medical advice was shoulder pain. Six patients received conservative therapy, and 23 received operative treatment. Fixation materials included various plates in 15 patients, and tension band wiring in 5. Bone grafting was performed in 16 patients (73%, 16/22). Of the 19 surgically treated patients with adequate follow-up, the outcome was rated excellent in 79%.

CONCLUSIONS

Isolated acromion/scapular spine fracture nonunion is rare. Fracture type II and III, arising in the anatomical scapular spine, accounted for 86% of the fractures. Computed tomography is required to prevent fracture oversight. Surgical therapy produces good stable results. However, it is important to select the appropriate surgical fixation method and material after considering the anatomical characteristics of the fracture and stress on the fractured portion.

LEVEL OF EVIDENCE

V.

Extracorporeal shock wave treatment for post‑surgical fracture nonunion: Insight into its mechanism, efficacy, safety and prognostic factors (Review)

Post-surgical fracture nonunion (PSFN) represents the failure to achieve cortical continuity at radiological examination after an orthopedic operation, which causes a considerable disease burden in patients with fractures. As one of the traditional treatment modalities, surgical therapy is associated with a high fracture union rate; however, post-surgical complications are not negligible. Therefore, less invasive therapies are needed to improve the prognosis of patients with PSFN. Extracorporeal shock wave treatment (ESWT) is a noninvasive method that presents a similar efficacy profile and favorable safety profile compared with surgical treatment. However, the application and detailed mechanism of ESWT in patients with PSFN remain unclear. The present review focuses on the mechanism, efficacy, safety and prognostic factors of ESWT in patients with PSFN, aiming to provide a theoretical basis for its application and improve the prognosis of these patients.

The effects and underlying mechanism of extracorporeal shockwave therapy on fracture healing

The clinical efficacy of ESWT in treating bone non union has been widely recognized, but the biological mechanism of ESWT promoting bone non union healing is still unclear. ESWT can make old callus micro fracture through mechanical conduction, form subperiosteal hematoma, promote the release of bioactive factors, reactivate the fracture healing mechanism, rebalance the activities of osteoblasts and osteoclast, promote the angiogenesis of fracture site, and accelerate the healing of bone nonunion.Over recent years, great efforts have been made by both scientists and clinicians to explore the underlying mechanism behind the healing effect of ESWT on bone fractures. In this review, we introduced the growth factors during osteogenesis induced by ESWT hoping to provide new insights in the clinical use of ESWT.

Biophysical Enhancement in Fracture Healing: A Review of the Literature

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.

Quantitative proteomics reveals potential anti-inflammatory protein targets of radial extracorporeal shock wave therapy in TNF-α-induced model of acute inflammation in primary human tenocytes

Tendinopathy refers to a type of tendon disease with a multifactorial spectrum. Recent research has begun to reveal the effects of inflammation on the tendinopathic process, especially in the first stage of tendinopathy. Radial extracorporeal shock wave therapy (rESWT) has been successfully used to treat orthopedic diseases. However, the molecular mechanisms underlying the anti-inflammatory effects of rESWT on tumor necrosis factor-α treated tenocytes have not been fully elucidated. In this study, we applied total protein tandem mass tag-labeled quantitative proteomics with liquid chromatography-mass spectrometer/mass spectrometer technology to identify differentially expressed proteins (DEPs) among inflammatory tenocytes, rESWT inflammatory tenocytes, and controls using three biological replicates. Human tenocytes were used and they were cultured in vitro. In total, 1028 and 40 DEPs were detected for control versus inflammatory tenocytes and for inflammatory tenocytes versus rESWT inflammatory tenocytes, respectively. Further, we identified integrin α2, selenoprotein S, and NLR family CARD domain-containing protein 4 as pivotal molecular targets of the anti-inflammatory effects of rESWT. This is the first study to provide a reference proteomic map for inflammatory tenocytes and rESWT inflammatory tenocytes. Our findings provide crucial insight into the molecular mechanisms underscoring the anti-inflammatory effects of rESWT in tendinopathy.

IC-Type Electric stimulation for delayed bone healing: monocentric evaluation over eight years of experience

Electrostimulation is suggested to positively influence bone healing for delayed unions of both fractures and osteotomies. This monocentric series aims to retrospectively assess the outcome of electrostimulation treatment for delayed union after traumatic fractures or knee osteotomy. Patients treated with electrostimulation for delayed union (no bony union on radiographic imaging at 90 days after osteotomy or fracture treatment) over an 8-year period were screened. The delay of treatment, success rate, revision rate and demographic data (age, sex, location of fracture, presence of osteosynthesis materials) were investigated. A questionnaire assessed objective (nicotine abuse, NRS pain assessment, activity levels) and subjective (comfort, usability, cost-effectiveness) aspects. Electrostimulation delivered radiographic healing in 75% of the fracture group and 66% of the osteotomy group. No statistical significant difference (N=136) in success rate was found for age, sex, presence of osteosynthesis material, delay or fracture location. Success rate did differ significantly with pain, activity level and smoking (p<0.05). Reflective questions to patients were answered mostly positively. The use of electrostimulation for the delayed union of fractures and knee osteotomies delivers high healing rates avoiding the burden of surgical reintervention. It is generally well received by the patient. No difference in success rate was found between sex, age or fracture location, nor did the delay of therapy onset or presence of osteosynthesis material seem to affect the success rate. Smoking had a negative influence on the efficacy of bone electrostimulation.

Extracorporeal shock wave treatment in foot and ankle fracture non-unions - A review

BACKGROUND

The authors reviewed the current evidence and conducted a comprehensive review on the use of extracorporeal shock wave therapy (ESWT) in the treatment of foot and ankle fracture non-unions.

METHODS

Four databases were searched to identify relevant studies in the available literature.

RESULTS

Eight studies were reviewed, demonstrating union rates of 65%-100% and 90-100% at 3- and 6-months following ESWT treatment respectively. No major complications were seen in any of the studies. Minor complications included local soft tissue swelling, petechiae, bruising and pain.

CONCLUSIONS

The literature that is currently available is limited to case series of relatively small sample sizes, highlighting the need for a prospective randomised controlled trial to further investigate the efficacy of ESWT in the treatment of foot and ankle fracture non-unions.

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

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.

Extracorporeal shockwave therapy for the treatment of scaphoid delayed union in a tennis player: A case report

Operative procedures are considered the gold standard when treating delayed union or non-union of the scaphoid despite their considerable complexity and the risk of intraoperative complications. Although extracorporeal shockwave therapy has been reported as a non-invasive treatment option for non-union cases, only a few papers on delayed union or non-union of the scaphoid have been published. A 57-year-old man with delayed union of a scaphoid fracture was treated with extracorporeal shockwave therapy and showed complete bone healing with promising results two months after the start of treatment without undergoing surgery. This result indicated that extracorporeal shockwave therapy could be an option for treating delayed union of scaphoid fractures.

Low-intensity extracorporeal shock wave therapy for midshaft clavicular delayed union: A case report and review of literature

BACKGROUND

One of the most common complications following surgery for midshaft clavicle fracture is nonunion/delayed union. Extracorporeal shock wave therapy (ESWT) is an alternative to promote new bone formation without surgical complications. To date, no literature has reported low-intensity ESWT (LI-ESWT) in delayed union of midshaft clavicle fracture.

CASE SUMMARY

We reported a 66-year-old Chinese amateur cyclist with clavicle delayed union treated with 10 sessions of LI-ESWT (radial, 0.057 mJ/mm², 3 Hz, 3000 shocks). No anesthetics were applied, and no side effects occurred. At the 4 mo and 7 mo follow-ups, the patient achieved clinical and radiographical recovery, respectively.

CONCLUSION

In conclusion, our findings indicated that LI-ESWT could be a good option for treating midshaft clavicular delayed union.

High-energy extracorporeal shockwave therapy in humeral delayed and non-unions

INTRODUCTION

Within the last few decades, focused high-energy extracorporeal shockwave therapy (ESWT) has proven to be an effective alternative to standard of care revision surgery in delayed healing fractures or manifest non-unions in various anatomical regions.

MATERIALS AND METHODS

A retrospective multi-variant analysis of an open prospective, single-armed clinical study was conducted. Patients receiving focused high-energy ESWT for a delayed healing or an apparent non-union of a humeral fracture between January 1999 and December 2015 at a single trauma center were included in the study. Bony healing was defined as cortical continuity in three of four cortices and pain-free force loading and evaluated using CT scans and clinical examination at three- and six-month follow-ups after ESWT.

RESULTS

A total of 236 patients were included. N = 93 (43.8%) showed bony consolidation three months after ESWT and n = 105 (52.5%) after six months. Sub-group analysis showed significantly better healing for the proximal metaphyseal humerus (66.7% after six months, n = 42) compared to the diaphyseal region (48.1%, n = 133) and distal metaphyseal humerus (48.1%, n = 25). Regression analysis indicated significantly increased healing rates for patients of younger ages (p = 0.001) and a fracture diastasis of less than 5 mm (p = 0.002).

CONCLUSION

The findings of this study indicate that ESWT can be considered as a treatment option for a well-selected patient population despite the lower healing rates compared to other anatomical regions.

Non-union bone fractures

The human skeleton has remarkable regenerative properties, being one of the few structures in the body that can heal by recreating its normal cellular composition, orientation and mechanical strength. When the healing process of a fractured bone fails owing to inadequate immobilization, failed surgical intervention, insufficient biological response or infection, the outcome after a prolonged period of no healing is defined as non-union. Non-union represents a chronic medical condition not only affecting function but also potentially impacting the individual's psychosocial and economic well-being. This Primer provides the reader with an in-depth understanding of our contemporary knowledge regarding the important features to be considered when faced with non-union. The normal mechanisms involved in bone healing and the factors that disrupt the normal signalling mechanisms are addressed. Epidemiological considerations and advances in the diagnosis and surgical therapy of non-union are highlighted and the need for greater efforts in basic, translational and clinical research are identified.

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 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.

Extracorporeal Shockwave Therapy in the Treatment of Trigger Finger: A Randomized Controlled Study

OBJECTIVES

To determine the efficacy of extracorporeal shockwave therapy (ESWT) and to determine the ideal energy flux density of wide-focused ESWT in the treatment of trigger finger (TF).

DESIGN

Double-blind randomized controlled trial.

SETTING

A university hospital.

PARTICIPANTS

A total of 60 patients (N=60) with grade II TF according to the Quinnell classification were randomly and evenly allocated to 3 treatment groups.

INTERVENTIONS

Three treatment groups included a high-energy ESWT (HS) group (energy flux density of 0.01 mJ/mm², 5.8 bar, 1500 impulses, once per week for 4wk), a low-energy ESWT (LS) group (energy flux density of 0.006 mJ/mm², 3 bar, 1500 impulses, once per week for 4wk), and a sham intervention group (sham group). All participants received 6 months of follow-up after intervention when only painkillers were allowed as concomitant treatment.

MAIN OUTCOME MEASURES

Clinical outcomes were followed at baseline and 1, 3, and 6 months after intervention, including pain score, frequency of triggering, severity of triggering, functional impact of triggering, and quick Disabilities of the Arm, Shoulder, and Hand questionnaire (qDASH).

RESULTS

All groups showed significant improvements from baseline in all clinical parameters, except for functional impact of triggering, 6 months after the interventions. However, the HS group demonstrated a higher magnitude of improvement than the LS and sham groups. In addition, the HS group reported significantly lower pain (P=.01) and lower qDASH (P=.008) than the sham group 6 months after the interventions. No adverse effects were reported in the HS and LS groups within 6 months of follow-up.

CONCLUSIONS

Wide-focused ESWT is a safe and effective but dose-dependent alternative facilitating pain relief and functional improvement in the treatment of grade II TF according to the Quinnell classification.

Extracorporal shock wave therapy for the treatment of arthrodesis non-unions

INTRODUCTION

Non-union is a regular complication of arthrodeses. Standard treatment includes revision surgery with frequent need for re-revision due to persistent non-union. Particularly patients with concomitant diseases are at risk of secondary complications. There is a need for evaluation of alternative treatment options. The aim of this study is to provide first evidence on union-rate and pain course after focussed extracorporeal shock-wave therapy of arthrodesis non-unions.

PATIENTS AND METHODS

In a retrospective single-centre study, 25 patients with non-union following arthrodesis received one session of focussed extracorporeal shock-wave therapy (energy flux density 0.36 mJ/mm², 3000 impulses, 23 kV, 4 Hz). Radiographic and clinical results were recorded 6, 12 and 24 weeks after treatment.

RESULTS

24 patients were followed-up. After 24 weeks arthrodeses of the hand healed in 80%, of the upper ankle in 50%, of subtalar joint in 27.2% and of the midfoot in 0% of the cases. Pain decreased from 4.8 (± 2.8) points on the visual analogue scale to 3.4 (± 2.3), 2.9 (± 2.5) and 2.4 (± 2.8) points after 6, 12 and 24 weeks, respectively (p < 0.0001).

CONCLUSION

Our data indicate that the effect of focussed, high-energy shock wave therapy depends on body region and is effective for the treatment of non-unions of the hand as well as for pain relief.

LEVEL OF EVIDENCE

Level IV.

High-energy focused extracorporeal shock wave therapy for bone marrow edema syndrome of the hip: A retrospective study

The objective of this retrospective study was to evaluate the efficacy of high-energy focused extracorporeal shock wave therapy (HF-ESWT) on painful bone marrow edema syndrome (BMES) of the hip and shorten the natural course of disease.Thirty-four consecutive patients with BMES of the hip were treated with HF-ESWT in our department between August 2017and July 2018. The progression and treatment results of BMES were evaluated by imaging examination and clinical outcomes. The clinical outcomes include hip pain and function which were measured using the visual analog scale (VAS) and Harris hip score (HHS), respectively, and the VAS and HHS of all patients were calculated and evaluated before treatment (s0), at 1 month (s1), 3 months (s2), 6 months (s3)post-treatment. Imaging examination including Pelvic radiographs and frog views and double hip magnetic resonance imaging (MRI) were also obtained and scheduled before treatment, at 1, 3, 6, and the final follow-up post-treatment to exclude avascular necrosis and other pathology.All patients successfully completed the treatment and follow-up. Compared with pretherapy, the pain was alleviated to varying degrees and the HHS was significantly improved, and the VAS was significantly reduced at S1-2 (1- and 3-months post-treatment) after therapeutic intervention (P < .05). The mean improvements were strongly statistically significant between S0 and S1 and between S1 andS2 (P < .0001) and less significant between S2 and S3 (P < .01). The mean improvement between 6 months (S3) and final follow-up (more than 12 months) was not statistically significant. The MRI findings demonstrated that the diffuse BMES in the femoral head and neck disappeared completely.HF-ESWT is a safe, effective, reliable, and noninvasive treatment in patients with painful BMES of the hip, and it can accelerate the recovery of BMES of the hip, shorten the treatment time and course of disease, improve hip joint function and the quality of life of patients.

Can Extracorporeal Shockwave Promote Osteogenesis of Equine Bone Marrow-Derived Mesenchymal Stem Cells In Vitro?

Both bone marrow-derived mesenchymal stem cells (BMDMSCs) and extracorporeal shockwave (ESW) have shown promise for enhancing fracture repair. If exposure of BMDMSCs to ESW enhances osteogenic differentiation, these therapies may be combined in vivo or used as a method for preconditioning BMDMSCs. The objective of this study was to determine the effect of ESW on the osteogenic ability of equine BMDMSCs. We hypothesized that ESW would promote osteogenesis evidenced by increased gene expression, alkaline phosphatase (ALPL) expression, slide morphologic score, and protein expression. BMDMSCs were evaluated from six horses. BMDMSCs were culture expanded to passage 3, dissociated, then placed in conical tubes. Treatment cells ("shocked") were exposed to 500 pulses at 0.16 mJ/mm² energy. Cells were then reseeded and grown in either growth medium or osteogenic medium. Cellular proliferation and trilineage potential were determined. Cellular morphology was scored and cells were harvested at 1, 3, 7, 14, and 21 days for rtPCR gene expression of osteogenic markers [osteonectin (ONT), osteocalcin (OCN), ALPL, collagen type 3 (COL3), and runt-related transcription factor 2 (RUNX2)]. Media supernatants were evaluated for secretion of BMP-2, VEGF, TGFβ, and PGE₂ and cellular lysates were evaluated for ALPL production. There was no difference between the proliferative ability of shocked cells versus unshocked cells in either growth medium or osteogenic medium. ALPL production was greater in shocked cells maintained in osteogenic medium versus unshocked cells in osteogenic medium at day 3 (P < 0.005). Independent of media type, ESW caused a decrease in VEGF and TGFβ production at day 3. No significant increases in gene expression were identified by rtPCR. Exposure of BMDMSCs to ESW does not result in negative effects. An initial significant increase in ALPL was detected but no persistent osteogenic effect was observed with cell expansion.

Definitive Treatment of Femoral Shaft Fractures: Comparison between Anterograde Intramedullary Nailing and Monoaxial External Fixation

Background: Femoral shaft fractures result from high-energy trauma. Despite intramedullary nailing (IMN) representing the gold standard option of treatment, external fixation (EF) can be used temporarily for damage control or definitively. The purpose of this study is to compare two different options, anterograde IMN and monoaxial EF, for the treatment of femoral shaft fractures. Methods: Between January 2005 and December 2014, patients with femoral shaft fractures operated on in two centers were retrospectively evaluated and divided into two groups: the IMN group (n = 74), and the EF group (n = 73). For each group, sex; laterality; age; and AO classification type mean follow-up, mean union time, and complications were reported. Results: Both groups were found to have no statistical differences (p > 0.05) in sex, laterality, age, and AO classification types. In the IMN group the average surgery duration was 79.7 minutes (range 45–130). The average time for bone union was 26.9 weeks. Major complications occurred in 4 (5.4%) patients. In the EF group the average follow-up duration was 59.8 months (range 28–160). The average time for bone union was 24.0 weeks. Major complications occurred in 16 (21.9%) patients. Conclusions: IMN is the gold standard for definitive treatment of femoral shaft fractures. In patients with severe associated injuries, EF should be a good alternative.

Definitive Treatment of Femoral Shaft Fractures: Comparison between Anterograde Intramedullary Nailing and Monoaxial External Fixation

BACKGROUND

Femoral shaft fractures result from high-energy trauma. Despite intramedullary nailing (IMN) representing the gold standard option of treatment, external fixation (EF) can be used temporarily for damage control or definitively. The purpose of this study is to compare two different options, anterograde IMN and monoaxial EF, for the treatment of femoral shaft fractures.

METHODS

Between January 2005 and December 2014, patients with femoral shaft fractures operated on in two centers were retrospectively evaluated and divided into two groups: the IMN group (n = 74), and the EF group (n = 73). For each group, sex; laterality; age; and AO classification type mean follow-up, mean union time, and complications were reported.

RESULTS

Both groups were found to have no statistical differences (p > 0.05) in sex, laterality, age, and AO classification types. In the IMN group the average surgery duration was 79.7 minutes (range 45-130). The average time for bone union was 26.9 weeks. Major complications occurred in 4 (5.4%) patients. In the EF group the average follow-up duration was 59.8 months (range 28-160). The average time for bone union was 24.0 weeks. Major complications occurred in 16 (21.9%) patients.

CONCLUSIONS

IMN is the gold standard for definitive treatment of femoral shaft fractures. In patients with severe associated injuries, EF should be a good alternative.

Augmentative antirotational plating provided a significantly higher union rate than exchanging reamed nailing in treatment for femoral shaft aseptic atrophic nonunion - retrospective cohort study

Background

Atrophic nonunion of femoral shaft fracture after intramedullary (IM) nailing is uncommon. The treatment for femoral shaft aseptic atrophic non-union remained controversial. The aim of this study was to compare the surgical results between exchanging reamed nailing (ERN) and augmentative antirotational plating (AAP) for femoral shaft aseptic atrophic nonunion.

Methods

We retrospectively reviewed the patients with femoral shaft nonunion between the year of 2014 and 2015. The patients with nonunion after plate osteosynthesis, septic nonunion, hypertrophic nonunion, additional surgery during revision surgery were excluded. All the patients were followed up at least 12 months.

Results

Overall, the union rate after revision surgery was 70.8%. The union rate was significantly higher in the AAP group than in the ERN group. Operating time was also significantly shorter in the AAP group. Regarding the location of nonunion, the union rate was comparable between groups for isthmic nonunions. However, for non-isthmic nonunions, the union rate was significantly higher and operating time was significantly shorter in the AAP group.

Conclusion

AAP showed an overall higher union rate for management of femoral shaft aseptic atrophic nonunion compared with ERN. Especially for non-isthmic femoral shaft atrophic nonunions, AAP provided a significantly higher union rate and significantly shorter operating time.

Extracorporeal Shock Wave Treatment for Delayed Union and Nonunion Fractures: A Systematic Review

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.

Effect of unfocused extracorporeal shockwave therapy on bone mineral content of twelve distal forearms of postmenopausal women: a clinical pilot study

Extracorporeal shockwave therapy showed a pronounced effect on bone mass in previous animal studies. We showed in this pilot study that a single treatment with unfocused shockwave therapy in unselected patients does not show side effects. Although our study did not show any effect of shockwave on BMD, the limited sample size does not definitively exclude this and a study with 174 subjects per group would be needed to show an effect size of 0.3 with a power of 80%.

PURPOSE

Unfocused extracorporeal shockwave therapy might stimulate bone formation to reduce the fracture risk. In this study, we assessed the safety of unfocused extracorporeal shockwave therapy and its effects on bone mass.

METHODS

A clinical pilot study with twelve female patients free of bone disease undergoing elective surgery of the lower extremity or elective spinal surgery under general anesthesia received 3.000 electrohydraulic-generated unfocused extracorporeal shockwaves (energy flux density 0.3 mJ/mm²) to one distal forearm. The contralateral forearm served as a control. We examined the effect on bone mass with the use of repeated dual energy X-ray absorptiometry measurements and we measured patient discomfort around the therapy.

RESULTS

No difference in bone mineral content and density was measured 6 and 12 weeks after therapy. shockwave therapy occasionally caused transient erythema or mild hematoma, but no discomfort in daily life or (late) adverse events.

CONCLUSIONS

Unfocused extracorporeal shockwave therapy is a safe treatment, but no increase in bone mass on the forearm was found at 0.3 mJ/mm² energy flux density. In this study, we were not able to demonstrate that a single treatment with unfocused shockwave therapy in unselected patients had any effect in terms of bone mineral density (BMD) or bone mineral content (BMC). A power analysis indicated that 174 patients per group are required to show an effect size of 0.3 with a power of 80%.

The effectiveness and safety of parathyroid hormone in fracture healing: A meta-analysis

The very large economic and social burdens of fracture-related complications make rapid fracture healing a major public health goal. The role of parathyroid hormone (PTH) in treating osteoporosis is generally accepted, but the effect of PTH on fracture healing is controversial. This meta-analysis was designed to investigate the efficacy and safety of PTH in fracture healing. The EMBASE, PubMed, and Cochrane Library databases were systematically searched from the inception dates to April 26, 2018. The primary randomized clinical trials comparing PTH treatment for fracture healing with placebo or no treatment were identified. We did not gain additional information by contacting the authors of the primary studies. Two reviewers independently extracted the data and evaluated study quality. This meta-analysis was executed to determine the odds ratio, mean difference, standardized mean difference, and 95% confidence intervals with random-effects models. In total, 8 randomized trials including 524 patients met the inclusion criteria. There were significant differences in fracture healing time, pain relief and function improvement. There were no significant differences in the fracture healing rate or adverse events, including light-headedness, hypercalcemia, nausea, sweating and headache, except for slight bruising at the injection site. We determined that the effectiveness and safety of PTH in fracture healing is reasonably well established and credible.

Atrophic nonunion stromal cells form bone and recreate the bone marrow environment in vivo

Introduction:

Nonunion is a challenging condition in orthopaedics as its etiology is not fully understood. Clinical interventions currently aim to stimulate both the biological and mechanical aspects of the bone healing process by using bone autografts and surgical fixation. However, recent observations showed that atrophic nonunion tissues contain putative osteoprogenitors, raising the hypothesis that its reactivation could be explored to achieve bone repair.

Methods:

Here we characterized atrophic nonunion stromal cells (NUSC) in vitro, using bone marrow stromal cells (BMSC) and osteoblasts as controls cells of the osteoblastic lineage, and evaluated its ability to form bone in vivo.

Results:

NUSC had proliferative and senescence rates comparable to BMSC and osteoblasts, and homogeneously expressed the osteolineage markers CD90 and CD73. Regarding CD105 and CD146 expression, NUSC were closely related to osteoblasts, both with an inferior percentage of CD105⁺/CD146⁺ cells as compared to BMSC. Despite this, NUSC differentiated along the osteogenic and adipogenic lineages in vitro; and when transplanted subcutaneously into immunocompromised mice, new bone formation and hematopoietic marrow were established.

Conclusions:

This study demonstrates that NUSC are osteogenically competent, supporting the hypothesis that their endogenous reactivation could be a strategy to stimulate the bone formation while reducing the amount of bone autograft requirements.

Comparative outcomes of extracorporeal shockwave therapy for shoulder tendinitis or partial tears of the rotator cuff in athletes and non-athletes: Retrospective study

BACKGROUND

Refractory shoulder tendinitis or partial thickness rotator cuff tears (PTRCTs) are common findings in overhead athletes. Previous studies have examined the effectiveness of extracorporeal shockwave therapy (ESWT) for shoulder tendinitis.

MATERIALS AND METHODS

In the current study, we recruited 36 shoulders and performed a comparison between the professional athletes (13 shoulders, athletic group; AG) and the non-athletic population (23 shoulders, non-athletic group, NAG) with PTRCTs or shoulder tendinitis of the shoulder after ESWT. Patients with symptomatic tendinitis of the shoulder with or without a partial tear of the rotator cuff tendon and failed oral medication and physical therapy for more than 3 months were treated with electrohydraulic mode of ESWT. All patients that met the inclusion criteria were categorized into two groups according to their pre-treatment activity level.

RESULTS

We found that NAG exhibited significant aging and degenerative change around the glenohumeral joint and subacromial space. After ESWT treatment, the patients in AG were with 53.8% high satisfaction rating and patients in NAG were 52.1% by one-year followed up.

CONCLUSION

The results showed ESWT was equally effective treatment in both AG and NAG. In light of its efficacy and less-invasive nature, we suggest ESWT can be used to treat athletes with refractory tendinitis or PTRCTs before proceeding to arthroscopic intervention.

Optimization of screw fixation in rat bone with extracorporeal shock waves

Screw fixation in osteoporotic patients is becoming an increasing problem in orthopaedic surgery as deterioration of cortical and cancellous bone hamper biomechanical stability and screw fixation. This might result in delayed weight-bearing or failure of instrumentation. We hypothesized that local peri-operative shock wave treatment can optimize osseointegration and subsequent screw fixation. In eight female Wistar rats, two cancellous and two cortical bone screws were implanted in both femora and tibiae. Immediately after implantation, 3.000 unfocused extracorporeal shock waves (energy flux density 0.3 mJ/mm² ) were applied to one side. The other side served as non-treated internal control. Evaluation of osseointegration was performed after 4 weeks with the use of microCT scanning, histology with fluorochrome labeling, and pull-out tests of the screws. Four weeks after extracorporeal shock wave treatment, treated legs exhibited increased bone formation and screw fixation around cortical screws as compared to the control legs. This was corroborated by an increased pull-out of the shock wave treated cortical screws. The cancellous bone screws appeared not to be sensitive for shock wave treatment. Formation of neocortices after shock wave therapy was observed in three of eight animals. Furthermore, de novo bone formation in the bone marrow was observed in some animals. The current study showed bone formation and improved screw fixation as a result of shock wave therapy. New bone was also formed at locations remote from the screws, hence, not contributing to screw fixation. Further, research is warranted to make shock wave therapy tailor-made for fracture fixation. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:76-84, 2018.

Prognostic factors for the outcome of extracorporeal shockwave therapy for calcific tendinitis of the shoulder

AIMS

We conducted a study to identify factors that are prognostic of the outcome of extracorporeal shockwave therapy (ESWT) for calcific tendinitis of the shoulder.

PATIENTS AND METHODS

Since 1998, patients with symptomatic calcific tendinitis of the rotator cuff have been treated with ESWT using an electrohydraulic mode shockwave device. One year after ESWT, patients were grouped according to the level of resorption of calcification.

RESULTS

Of 241 symptomatic shoulders, complete resorption (CR) of calcification occurred in 134 (CR group). The remaining 107 shoulders had incomplete resorption (ICR) (ICR group). Gartner type I calcification was most common (64.5%) in the ICR group. The mean duration of symptoms before ESWT was significantly longer in the ICR group. Overall, 81% of the CR group and 23.4% of the ICR group were symptom free. There was a strong relationship between subsidence of symptoms and remission of calcification. Poor prognosis was significantly related to Gartner type I calcification, calcification extent > 15 mm and duration of symptoms > 11 months.

CONCLUSION

Patients with calcific tendinitis of the shoulder who have the factors identified for a poor outcome after ESWT should undergo a different procedure. Cite this article: Bone Joint J 2017;99-B:1643-50.

Radial extracorporeal shock wave therapy is efficient and safe in the treatment of fracture nonunions of superficial bones: a retrospective case series

BACKGROUND

A 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.

RESULTS

Six 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.

Extracorporeal Shock Wave Rebuilt Subchondral Bone In Vivo and Activated Wnt5a/Ca2+ Signaling In Vitro

Background

This study aimed to identify the optimal extracorporeal shock wave (ESW) intensity and to investigate its effect on subchondral bone rebuilt in vivo and Wnt5a/Ca²⁺ signaling in vitro using an osteoarthritis (OA) rat model and bone marrow mesenchymal stem cells (BMMSCs), respectively.

Methods

OA rats treated with (OA + ESW group) or without (OA group) ESW (n = 12/group) were compared with healthy controls (control group, n = 12). Gait patterns and subchondral trabecular bone changes were measured. Western blot and quantitative real-time polymerase chain reaction detected protein expression and gene transcription, respectively.

Results

The gait disturbances of OA + ESW group were significantly improved compared with the OA group at 6th and 8th weeks. The micro-CT analysis indicated that the BMD, BSV/BV, BV/TV, Tr.S, and Tr.Th are significantly different between OA group and OA + ESW group. Expression of Wnt5a was increased rapidly after ESW treatment at 0.6 bar and peaked after 30 min.

Conclusions

ESW were positive for bone remodeling in joint tibial condyle subchondral bone of OA rat. ESW prevented histological changes in OA and prevented gait disturbance associated with OA progression. Optimal intensity of ESW induced changes in BMMSCs via activation of the Wnt5a/Ca²⁺ signaling pathway.

Treatment of an atrophic clavicle non-union with the chamber induction technique: a case report

The gold standard technique for treating non-union of the clavicle is based on corticocancellous bone graft harvested from the iliac crest and fixation with a plate. In cases of large clavicular defects, this surgical procedure becomes ineffective and only a complex bone reconstruction can be considered. In the herein study we report on a clavicular non-union which was associated with a 4cm bone defect that was managed successfully with optimum fixation and the Chamber Induction Technique (C.I.T)-formation of the masquelet membrane- and subsequent biological augmentation with a composite bone graft.

Effectiveness of Teriparatide on Fracture Healing: A Systematic Review and Meta-Analysis

Purpose

Nowadays, the efficacy of teriparatide in treating osteoporosis was widely accepted, but the discussion about using teriparatide to enhance fracture healing hasn’t come to an agreement. This meta-analysis was conducted to evaluate the effectiveness of teriparatide for fracture healing.

Methods

We searched PubMed, the Cochrane Library, and Embase in August 2016 for randomized controlled trials (RCTs) which concerned the treatment of teriparatide for fracture healing.

Results

Finally, a total of 380 patients were randomly assigned in the 5 trials included in this meta-analysis. There was a significant effectiveness with regards to function improvement in patients following fracture, however, there was no significant effectiveness with regards to time of radiographic fracture healing, fracture healing rate and reduction in pain.

Conclusions

This analysis showed that administration of teriparatide following fracture lacked the effectiveness for fracture healing. Moreover, teriparatide administration had no apparent adverse effects. These results should be interpreted with caution because of some clear limitations. If we want to confirm whether teriparatide improves fracture healing, more high-quality randomized controlled trials are needed.

Closing the gap: a novel technique for humeral shaft nonunions using cup and cone reamers

INTRODUCTION

Nonunion following closed treatment of humeral shaft fracture is estimated to be 5.5%. Many surgical techniques have been described to address humeral shaft nonunion including: open reduction, internal fixation (ORIF) with compression plating and bone graft, dual plating, cortical strut allograft and autograft, and adding biologic augmentation (BMP). The current standard of care includes ORIF with compression plating and bone grafting, but even this technique has an approximated 10% failure rate. We describe a novel surgical technique using cup and cone reamers, which were originally designed for metatarsophalangeal or metacarpalphalangeal arthrodesis. Cup and cone reamers are the appropriate size for mid-shaft, transverse humeral nonunions to ensure ideal apposition of healthy, bleeding bone.

METHODS AND PATIENTS

We retrospectively reviewed 3 patients with nonunion of the midshaft humerus which were treated with the cup and cone technique and a large fragment LCDC plate. An anterolateral approach was used in 2 cases and a posterior in the other. After exposure of fracture ends, 24-mm hemispherical convex and concave reamers were then used to ream the proximal and distal ends in order to create a "cup and cone" articulation of the fracture ends. All patients were followed for a minimum of 6 months with a mean follow-up of 12 months.

RESULTS

All patients treated with this technique achieved union, reported zero pain and full functional outcome. Specifically, patients had a mean age of 36.3 and the mean interval between injury and time to surgery was 11.5 months. Two of the patients presented with nonunions after attempted closed treatment and the other patient had 3 prior surgeries for infected nonunion. Union was achieved at a mean of 12 weeks.

CONCLUSION

To our knowledge, the use of cup and cone reamers for nonunion of the humerus has never been described. We describe a simple and effective technique for humeral shaft nonunions which has been successful in both septic and hypertrophic nonunions, as well as from multiple approaches-both anterolateral and posterior.

Upper limb non-unions treated with BMP-7: efficacy and clinical results

The management of upper limb non-unions can be challenging and often with unpredictable outcomes. In this study we present our experience with the use of BMP-7 in the treatment of upper limb non-unions. Between 2004 and 2011 all consecutive patients who were treated with BMP-7 were followed up prospectively until fracture union. Fracture union was assessed with regular radiological and clinical assessment. At the final follow up clinical assessment included the short Disabilities of the Arm, Shoulder and Hand (DASH) score. The minimum follow up was 12 months (12-36). In total 42 patients met the inclusion criteria with a mean age of 47 years. Anatomical distribution of the nonunion sites included 19 cases of mid/proximal forearm, 14 humeri, 6 distal radius and 3 clavicle. 35 patients had atrophic non-union, 11 had previous open fractures, and 10 had bone loss (range 1-3 cm). The mean number of operations performed and the mean time from injury to BMP-7 application was 1.5 and 26 months, respectively. 40 fractures had both clinical and radiological union whereas 2 patients had partial radiological union but a pain free range of motion. BMP-7 was applied in isolation in 1 case and in 41 cases the application was combined with autologous bone grafting. DASH scores were available at final follow up in 23 (55%) patients with a mean of 33 score (range 2-86.4). This study supports the view that the combination of ABG and BMP-7 can be considered as a successful treatment modality for the treatment of recalcitrant upper limb non-unions. Further studies preferably randomised controlled trials are desirable to throw more light into the role of BMP-7 in the treatment of upper limb nonunions.

Monofocal bone transport technique for bone defects greater than 5 cm in tibia: our experience in a case series of 24 patients

BACKGROUND

As the tibial bone defect increases in size, the problems in treatment also increase. The treatment may be problematic but different treatment approaches can be used. Among these approaches, distraction osteogenesis is a method an orthopedic surgeon with limited conditions can use although it has a longer treatment period. In our case series, we evaluated current treatment approaches.

METHOD

Retrospective study based on patient records and radiographs. We evaluated our cases with tibial bone defects Type B and greater than 5 cm. Twenty four cases were operated between 1995 and 2013. Clinical follow-up consisted of physical examination, review of radiographs, and Association for the Study of the Method of Ilizarov (ASAMI) scoring system of bone and functional results.

RESULTS

The defects had an average lenght of 7.01 cm (SD:2.88) (range, 5-18). The mean follow-up time from removal of the apparatus to the time of the last clinic visit averaged 74.08 ±24.17 months (range: 39-122). The Ilizarov frame was placed for transport and until bone was solid, average of 275.5 ± 70.6 days (range: 190-437 days). The mean external fixator time (EFT) was 350.91 ± 89.22 days (range: 261-627 days). The mean external fixator index (EFI) was 52 days/cm (range: 34.8-62.8 days/cm). Bone union was obtained in 23/24 (95.8%) patients. Seven patients suffered from stiffness (2 knee, 5 ankle) from which 3 patients developed equinus deformity and required tenoplasty (Achilles tendon lengthening at the time of frame removal. After reaching docking site, 5 patients needed intramedullary nailing to speed up union. Twelve (50%) cases had excellent radiological results, 8 (33%) cases had good, 2 (8%) cases fair and 2 (8%) cases had poor results. Regarding the functional ASAMI scoring system 14 (58%) cases had excellent, 9 (38%) cases had good and one case (4%) had fair result.

CONCLUSION

According to our experience, the Ilizarov bone transport technique remains a reliable method to repair bone defects. However, the treatment time is lengthy with a considerable risk of complications. We found closed intramedullary nailing as an effective and easy solution for cases without pin tract infections to manage the nonunion problem of the docking site and this option should be considered where the surgeon envisages difficulties of healing or the patient has lost patience with the frame. Careful selection of case and patient profile can optimize the outcomes.

Masquelet technique: myth or reality? A systematic review and meta-analysis

INTRODUCTION

The induced membrane technique (IMT) or Masquelet technique, is a two-step surgical procedure used to treat pseudoarthroses and bony defects. Many authors have introduced variants to the technique. This study aims to compare the surgical variants of IMT and to evaluate its efficacy in achieving infection eradication and bone union.

METHODS

A systematic review was carried out following the PRISMA guidelines. PubMed and other medical databases were explored using keywords "Masquelet technique" and "induced membrane technique". Articles were included if written in English, French or Italian, dealing with IMT employed to long bones in adults, reporting at least 5 cases with a 12 months-mean follow-up. Patients' clinical features, bone defect features, aetiologies, surgical data, complications, reinterventions, union rates and infection eradication rates were searched. Fischer's exact test, chi-square test and unpaired t-test were used for the statistical analysis on the individual patient's data.

RESULTS

Seventeen papers met the inclusion criteria (427 patients). Among these, only 10 studies reported individual patient's data (137 cases). The union rate was 89.7% and the infections rectified in 91.1% of cases. The bone defect length ranged from 0.6 to 26 cm. The main complications were superficial (21; 4.9%) and deep surgical site infections (19; 4.4%), failure of one of the IMT steps (persistence of infections or non unions, 77, 18%), with subsequent requirement for further surgery. The surgical variants included the use of antibiotic-coated spacers, internal fixation during the first step, use of Reamer-Irrigator-Aspirator technique, iliac crest grafting, bone substitutes and growth factors. However, univariate analysis only showed a positive correlation of the need for reinterventions with poorer bone union rates (p = 0.005) and complications (p <0.001), while patients undergoing IMT because of bone infections had a higher risk of surgical complications (p <0.001).

DISCUSSION

IMT aims to achieve bone union and infection eradication, but persistence of infection or non-union was noted in 18% of cases necessitating re-interventions. This may be related to the different anatomical sites that the technique has been applied and different local and patient related conditions. We believe the choice of a surgical technique to achieve union should be tailored to the individual patient's needs. This systematic review was limited by the few studies meeting our inclusion criteria, and their high variability in data reporting, making it impossible to undertake a meta-analysis.

CONCLUSION

Further studies are needed to demonstrate the role the patients' clinical features and IMT variants have upon achieving bone union and infection eradication.

Femoral non-union with malalignment: reconstruction and biological stimulation with the chipping technique

INTRODUCTION

The purpose of this study was to investigate the effectiveness of the chipping technique for the treatment of femoral non-unions associated with malalignment.

PATIENTS AND METHODS

A total of 21 femoral non-unions were managed with the chipping procedure and re-fixation. 15 of them had malalignment (angular or rotational deformity or limb length discrepancy). The deformities were simultaneously corrected by a combination of chipping and temporal external fixator. The median age of patients were 41 years (range, 19-73 years). The median time from injury or the final surgery to the initial chipping procedure was 24 months (range: 9-240 months). Femoral non-unions were classified as hypertrophic in 9, oligotrophic in 5 and atrophic in 7. Clinical and radiological assessment was performed.

RESULTS

All femoral non-unions radiographically healed with one (19 cases) or two (2 cases) chipping procedures without bone grafting. Pre-existing angular deformity was corrected from 14° to 2°, external rotation 27° to 0°, and limb length discrepancy 16-7 mm. There were no major complications, although swelling of thigh and anemia was common after surgery.

CONCLUSION

Chipping the non-union site was associated with a favorable outcome. It biologically enhances fracture healing and should be considered as a treatment option for femoral non-unions with malalignment.

Do skeletal muscle MSCs in humans contribute to bone repair? A systematic review

Mesenchymal stem cells (MSC) from bone marrow and periosteum are known to be heavily involved in fracture repair and bone regeneration is thought to be impaired when the surrounding skeletal muscle is damaged. Recent literature from mouse in vivo models suggest that cells originating from skeletal muscle can occupy a fracture callus during open fracture repair when periosteum is compromised. This systematic review set out to ascertain whether there are MSCs residing in human skeletal muscle and whether cells from human skeletal muscle are capable of forming bone in vitro and in vivo. Original journal articles were selected if they included the terms "skeletal muscle" and "mesenchymal" and used human skeletal muscle samples. Between January 2005 and September 2016, 1000 articles were screened of which, 16 studies met the inclusion criteria for this review. Human skeletal muscle derived cells (SMDC) had the MSC phenotype, positive for CD73, CD90 and CD105 and negative for CD34 and CD45 as well as the potential to differentiate into osteoblasts, chondrocytes and adipocytes in vitro. In addition, SMDC could form bone in vivo when seeded onto an osteoinductive scaffold. A subset of SMDC expressing a pericyte marker (PDGFRα) also expressed the MSC phenotype and were more osteogenic in vivo in comparison to SMDC expressing a satellite cell marker (CD56). The studies included were limited through variation of SMDC extraction methods and tissue culture conditions, which causes heterogeneuous cell cultures. Also, in vitro differentiation assays were not always carried out with bone marrow MSC positive controls. Current evidence suggests that cells with the MSC phenotype reside within human skeletal muscle and are capable of in vivo bone formation in combination with osteoinductive bone scaffolds. This has implications of future development of guided bone regeneration strategies to enhance large bone defect repair, whereby more thought into whether the fracture site should be "blocked" from the skeletal muscle should be carried out.

Treatment of recalcitrant atrophic non-union of the humeral shaft with BMP-7, autologous bone graft and hydroxyapatite pellets

Recalcitrant humeral non-union is a disabling condition that is extremely difficult to treat. The use of BMP-7 has been proposed to improve bone healing. This is a report of the results obtained in 12 patients with recalcitrant humeral non-union treated using stable fixation with a long locking compression plate and BMP-7, autologous bone graft and hydroxyapatite pellets applied at the non-union site. Patients had up to three surgical attempts at non-union healing prior to our treatment. The average time from the initial fracture to our surgery was 5.2 years. Average follow-up was 5.3 years. At follow-up, non-union had healed in all patients by an average of 7.3 months. All the patients were very satisfied with their final results, despite a restricted range of motion of the elbow and a moderate muscular atrophy, which was frequently observed. Our study shows that BMP-7 associated with autologous bone grafting and hydroxyapatite pellets after stable fixation is an effective adjuvant to stimulate bone healing in the treatment of recalcitrant humeral non-union.

Long bone non-unions treated with the diamond concept: a case series of 64 patients

The aim of this retrospective study with prospectively documented data was to report the clinical results of treatment of long bone non-unions using the "diamond concept". Over a 4-year period, patients that presented with a long bone non-union and were managed with the diamond conceptual framework of bone repair were evaluated. Exclusion criteria were hypertrophic, pathological, and infected non-unions. Fixation was revised as it was indicated whilst biological enhancement included the implantation of RIA graft, BMP-7 and concentrated bone marrow aspirate. Data recorded included patient demographics, initial fracture pattern and type of stabilisation, number of previous interventions, time to reoperation, time to union and functional outcome. Painless full weight bearing defined clinical union. Radiological union was defined as the presence of mature callous bridging to at least 3 bone cortices. The minimum follow up was 12 months (range 12-32). In total 64 patients (34 males) with a mean age of 45 years (17-83) were evaluated. Anatomical distribution of non-unions included the femur (54.68%), tibia (34.38%), humerus (4.68%), radius (3.13%) and clavicle (3.13%). The median number of previous interventions was 1 (range 1-5). The majority of patients (82.62%) underwent revision of fixation whereas only bone grafting was performed 9.38% of patients. Three patients developed superficial wound infection (one was MRSA), 1 had deep vein thrombosis and 1 developed heterotopic bone formation. Union was successful in 63/64 (98.4%) non-unions at a mean time of 6 months (range 3-12). All patients were mobilising pain free and returned to their daily living activities at the final follow up. The application of the "diamond concept" in this cohort of patients was associated with a high union rate by providing an optimal mechanical and biological environment. Such an approach should be considered in the surgeon's armamentarium particularly in such cases where difficulty of bone repair is foreseen.