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

[Non-unions of the upper extremities]

The diagnosis and treatment of non-unions still represents an interdisciplinary challenge. Therefore, prevention, early detection and specific treatment are of great importance. Non-unions of the upper extremities, although less common than that of the lower extremities, requires special attention for successful treatment due to the central role of the shoulder girdle and arm in day to day activities. Successful treatment of non-unions requires a comprehensive evaluation of the patient's medical history, a thorough clinical examination and in particular radiological imaging. In order to effectively treat the pseudarthrosis it is crucial to distinguish between pseudarthroses that are suspected to be due to infections and those that are not. This article presents a treatment algorithm for managing both pseudarthrosis due to infection and pseudarthrosis without infection in the upper extremities.

Combined Electromagnetic and Electrohydraulic Focused ESWT and EMTT for Delayed Calcaneal Union in an Adolescent Parkour Athlete - A Case Report

This case report describes a novel and unique combination of both electromagnetic and electrohydraulic focused extracorporeal shockwave therapy (ESWT) and extracorporeal magnetotransduction therapy (EMTT) for accelerated healing in a calcaneus epiphyseal fracture with delayed healing in an adolescent Parkour athlete. After a 2.5m jump, the 14-year-old experienced significant heel pain, however avoided telling his parents. After eight weeks, the initial imaging using ultra low dose weight-bearing cone beam CT (WBCT) revealed a calcaneus non-union situation adjacent to the open calcaneal physis. To improve and accelerate bony healing substantially, we chose to apply both combined focused electromagnetic (Storz Ultra, Storz Medical AG, Tägerwillen, CH) and focused electrohydraulic (MTS, Konstanz, Germany) ESWT in a fractioned fashion plus EMTT (Storz Magnetolith, Tägerwillen, CH) in five consecutive weekly sessions while allowing the patient to fully weight bear. The follow-up WBCT after six weeks revealed a near to total healing of the delayed union and being pain-free. Notably, combination therapy with focused ESWT and EMTT did not result in early closure of the calcaneal epiphysis. We conclude that combined focused electromagnetic and electrohydraulic ESWT and EMTT facilitate bony healing in adolescent calcaneal apophyseal fractures without any adverse effects on the open physis. Evidence level IV (case report).

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.

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.

[Extracorporeal shockwave therapy as an alternative treatment in cases of posttraumatic delayed bone union]

BACKGROUND

Impaired posttraumatic bone healing is a relevant complication of fractures. Usually, the standard treatment is surgical revision. For about 30 years extracorporeal shockwave therapy (ESWT) has emerged as an alternative treatment option with similar consolidation rates but less complications.

OBJECTIVE

This article aims to present our data in context to the current literature MATERIAL AND METHODS: From 2007 to 2016 a total of 97 patients diagnosed with impaired posttraumatic bone healing were treated with ESWT. Clinical and demographic data of this population were retrieved and analyzed retrospectively.

RESULTS

The general consolidation rate was 60.8%. Multiple variables were analyzed. A preinterventional bone gap ≥ 5 mm, initial dislocation > ½ of the bone shaft, nicotine consumption and a long time span from fracture to ESWT (> 6 months) were found as factors which significantly impair bone healing after ESWT.

CONCLUSION

ESWT is a safe and promising alternative treatment option for delayed unions. Regarding risk factors of a poor outcome may be identified before and increase the rate of success.

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.

Which non-infection related risk factors are associated with impaired proximal femur fracture healing in patients under the age of 70 years?

BACKGROUND/PURPOSE

Impaired healing is a feared complication with devastating outcomes for each patient. Most studies focus on geriatric fracture fixation and assess well known risk factors such as infections. However, risk factors, others than infections, and impaired healing of proximal femur fractures in non-geriatric adults are marginally assessed. Therefore, this study aimed to identify non-infection related risk factors for impaired fracture healing of proximal femur fractures in non-geriatric trauma patients.

METHODS

This study included non-geriatric patients (aged 69 years and younger) who were treated between 2013 and 2020 at one academic Level 1 trauma center due to a proximal femur fracture (PFF). Patients were stratified according to AO/OTA classification. Delayed union was defined as failed callus formation on 3 out of 4 cortices after 3 to 6 months. Nonunion was defined as lack of callus-formation after 6 months, material breakage, or requirement of revision surgery. Patient follow up was 12 months.

RESULTS

This study included 150 patients. Delayed union was observed in 32 (21.3%) patients and nonunion with subsequent revision surgery occurred in 14 (9.3%). With an increasing fracture classification (31 A1 up to 31 A3 type fractures), there was a significantly higher rate of delayed union. Additionally, open reduction and internal fixation (ORIF) (OR 6.17, (95% CI 1.54 to 24.70, p ≤ 0.01)) and diabetes mellitus type II (DM) (OR 5.74, (95% CI 1.39 to 23.72, p = 0.016)), were independent risk factors for delayed union. The rate of nonunion was independent of fracture morphology, patient's characteristics or comorbidities.

CONCLUSION

Increasing fracture complexity, ORIF and diabetes were found to be associated with delayed union of intertrochanteric femur fractures in non-geriatric patients. However, these factors were not associated with the development of nonunion.

Individualized herbal prescriptions for delayed union: A case series

Background Bone fractures are important clinical events for both patients and professionals. Active treatment options are limited for delayed unions and for nonunions; surgery is common but not entirely risk-free. This report describes three cases of delayed union successfully treated with herbal decoction. Participants Three patients had trapezoid and 3rd metacarpal bone fractures, 2nd, and 5th metatarsal bone fractures, respectively. All three patients were diagnosed with delayed union by an independent orthopedic surgeon based on computed tomography (CT) scan/radiographic imaging and fracture duration without a healing process. Patients took herbal decoction, Jeopgol-tang, with individually added herbs based on symptom manifestations, twice daily for 56, 85 and 91 days with no additional interventions except for a splint that they had been wearing since fracture diagnosis. Outcomes Improvement of delayed union was evaluated using radiographic imaging or CT during treatment with Jeopgol-tang. Results After taking herbal medicine, callus and bony bridging were confirmed on follow-up imagings and the patients described their experience with pain reduction at an interview after recovery. Conclusions This case series suggests that the herbal decoction Jeopgol-tang warrants further investigation to establish its role as a complementary and integrative medicine treatment option for delayed unions.

Combination of radiographic apparent bone gap and nonunion risk determination score improves accuracy of prediction of tibial shaft delayed union

BACKGROUND

There is a need for a novel therapeutic strategy for an earlier prediction of long bone union failure as compared to previous methodologies. This study aimed to determine whether a combination of two diagnostic tools would result in a more accurate diagnosis of delayed union.

METHODS

The inclusion criteria were as follows: patients with tibial shaft fracture who underwent treatment with intramedullary nailing (IMN) as definitive internal fixation (IF). The study included a total of 114 patients with 116 tibial shaft fractures treated with IMN as definitive IF. Radiographic apparent bone gap (RABG) and nonunion risk determination score (NURDS) can be used to predict nonunion. However, this study aimed to determine whether combination of RABG and NURDS could help deduce a more accurate prediction of delayed union.

RESULTS

The union rate was found to be 85% (99 fractures), the delayed union rate was found to be 15% (17 fractures), and the rate of nonunion requiring additional surgical intervention was estimated to be 4% (5 out of the 17 delayed union cases). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of RABG were found to be 82.3%, 76.0%, 36.8%, and 96.2%, respectively, when an RABG cutoff value of 5.0 mm was applied to our patient cohort. The sensitivity, specificity, PPV, and NPV of NURDS were found to be 47.1%, 82.0%, 30.8%, and 90.1%, respectively, when a NURDS cutoff value of 8.0% was applied to our patient cohort. When RABG and NURDS were above their respective cutoff values, the sensitivity and PPV were estimated to be 90.0% and 56.3%, respectively. When RABG and NURDS were below their respective cutoff values, the specificity and NPV were estimated to be 90.1% and 98.5%, respectively.

CONCLUSIONS

The combination of RABG and NURDS evaluation immediately after surgery helps surgeons identify patients who are at a high risk of delayed union, facilitating careful monitoring of these patients and consideration of additional treatments.

Trochanteric fracture pattern is associated with increased risk for nonunion independent of open or closed reduction technique

PURPOSE

Soft tissue injury and soft tissue injury as risk factors for nonunion following trochanteric femur fractures (TFF) are marginally investigated. The aim of this study was to identify risk factors for impaired fracture healing in geriatric trauma patients with TFF following surgical treatment with a femoral nail.

METHODS

This retrospective cohort study included geriatric trauma patients (aged > 70 years) with TFF who were treated with femoral nailing. Fractures were classified according to AO/OTA. Nonunion was defined as lack of callus-formation after 6 months, material breakage, and requirement of revision surgery. Risk factors for nonunion included variables of clinical interest (injury pattern, demographics, comorbidities), as well as type of approach (open versus closed) and were assessed with uni- and multivariate regression analyses.

RESULTS

This study included 225 geriatric trauma patients. Nonunion was significantly more frequently following AO/OTA 31A3 fractures (N = 10, 23.3%) compared with AO/OTA type 31A2 (N = 6, 6.9%) or AO/OTA 31A1 (N = 3, 3.2%, p < 0.001). Type 31A3 fractures had an increased risk for nonunion compared with type 31A1 (OR 10.3 95%CI 2.2 to 48.9, p = 0.003). Open reduction was not associated with increased risk for nonunion (OR 0.9, 95%CI 0.1 to 6.1. p = 0.942) as was not the use of cerclage (OR 1.0, 95%CI 0.2 to 6.5, p = 0.995). Factors such as osteoporosis, polytrauma or diabetes were not associated with delayed union or nonunion.

CONCLUSION

The fracture morphology of TFF is an independent risk factor for nonunion in geriatric patients. The reduction technique is not associated with increased risk for nonunion, despite increased soft tissue damage following open reduction.

A scoping review of operative and non-invasive management in the treatment of non-unions

INTRODUCTION

Non-union occurs when a fracture fails to adequately heal, and requires additional intervention to achieve union. The purpose of this scoping review is to provide a high-level overview of the existing non-union management literature. This review aims to highlight the current literature on non-union management, as well as identify key areas that require future research to provide a better understanding of potential non-union management strategies.

METHODS

This study utilized the scoping review framework from Arksey and O'Malley All relevant literature on non-union management was systematically searched for within the OVID Medline, OVID Embase, and Web of Science databases. As a scoping review, this study aimed to identify the high-level trends in non-union literature. This was assessed through a visual and numerical summary of the general themes in non-union literature, as well as the timeline in which these trends have occurred.

RESULTS

The literature search identified 8081 articles, of which 2210 articles were included. There is a large body of evidence for various surgical treatment options for non-union. The literature suggests healing rates between 80 and 100 percent for commonly utilized surgical procedures, such as plating with bone graft for long bones. Despite these beneficial healing rates, the requirement of a surgery creates a large socioeconomic burden. The possibility for bone growth stimulator (BGS) options to achieve non-union healing rates in a similar realm as surgical options suggests that the use of a BGS may be a beneficial option prior to surgical intervention, as this would potentially reduce the number of patients who would otherwise require surgery.

CONCLUSION

A large body of evidence exists on non-union management, which is largely comprised of case series and reports. The most commonly assessed non-unions include the tibia, wrist, and femur. Bone grafting, plating, and nailing are the most investigated treatment options. BGS are a non-operative treatment options for non-union that provide similar healing rates to surgical options in certain indications within initial observational data. BGS are a potential option for non-operative management of non-unions to reduce socioeconomic burdens of surgical intervention, with a need for further high-quality investigation in this therapeutic area.

Bone Union Assessment with Computed Tomography (CT) and Statistical Associations with Mechanical or Histological Testing: A Systematic Review of Animal Studies

Objective and accurate assessment of bone union after a fracture, arthrodesis, or osteotomy is relevant for scientific and clinical purposes. Bone union is most accurately imaged with computed tomography (CT), but no consensus exists about objective assessment of bone union from CT images. It is unclear which CT-generated parameters are most suitable for bone union assessment. The aim of this review of animal studies is to find which CT-generated parameters are associated most strongly with actual bone union. Scientific databases were systematically searched. Eligible studies were studies that (1) were animal studies, (2) created a fracture, (3) assessed bone union with CT, (4) performed mechanical or histological testing as measure of actual bone union, and (5) associated CT-generated outcomes to mechanical or histological testing results. Two authors selected eligible studies and performed risk of bias assessment with QUADAS-2 tool. From 2567 studies that were screened, thirteen studies were included. Most common CT parameters that were investigated were bone mineral density, bone volume, and total callus volume. Studies showed conflicting results concerning the associations of these parameters with actual bone union. CT-assessed torsional rigidity (assessed by three studies) and callus density (assessed by two studies) showed best results. The studies investigating these two parameters reported moderate to strong associations with actual bone union. CT-assessed torsional rigidity and callus density seem the most promising parameters to represent actual bone union after a fracture, arthrodesis, or osteotomy.Prospero trial registration number: CRD42020164733.

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.

Extracorporeal Shock Wave Combined with Teriparatide-Loaded Hydrogel Injection Promotes Segmental Bone Defects Healing in Osteoporosis

BACKGROUND

Osteoporosis is a systemic bone disease characterized by decreased bone density and deterioration of bone microstructure, leading to an increased probability of fragility fractures. Once segmental bone defect occurs, it is easy to cause delayed union and nonunion.

METHODS

The aim of this study is to investigate the efficacy of extracorporeal shock wave (ESW) and teriparatide-loaded hydrogel (T-Gel) combined strategy on the cell activity and differentiation of osteoporosis derived bone marrow mesenchymal stem cells (OP-BMSCs) in vitro and bone regeneration in osteoporotic segmental bone defects in vivo.

RESULTS

In vitro, the strategy of combining ESW and T-Gel significantly enhanced OP-BMSCs proliferation, survival, migration, and osteogenic differentiation by up-regulating the alkaline phosphatase activity, mineralization, and expression of runt-related transcription factor-2, type I collagen, osteocalcin, and osteopontin. In the segmental bone defect models of osteoporotic rabbits, Micro-CT evaluation and histological observation demonstrated this ESW-combined with T-Gel injection significantly induced bone healing by enhancing the osteogenic activity of the local microenvironment in osteoporotic defects.

CONCLUSION

In conclusion, ESW-combined with T-Gel injection could regulate the poor osteogenic microenvironment in osteoporotic defects and show potential for enhancing fragility fractures healing.

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

INTRODUCTION

In this study, we analyze a new treatment option for pseudarthrosis using radial shock waves. The traditional treatment to pseudarthrosis is surgical. As an option to specific cases, focal shock waves seem to present good results with bone union without a subsequent surgical procedure. As radial shock waves reach less energy and less depth penetration than focal shock waves, they usually are not indicated for the treatment of pseudarthrosis of any bone segment. There are publications that show evidences of the action of radial shock waves stimulating bone consolidation in vitro, in animals and in humans. We will present a new option for failure of consolidation in superficial bones submitted to radial shock wave therapy.

OBJECTIVE

To analyze the effectiveness of radial shock waves in the treatment of superficial bone pseudarthrosis.

PATIENTS AND METHODS

Between 2016 and 2019, we conducted a prospective study with 44 consecutive patients with pseudarthrosis. All patients had prior indication for treatment with surgery and were treated with radial shock waves as a nonsurgical treatment option. Patients were evaluated clinically and radiographically pre-treatment and 6 months after. Clinically, patients complained of pain and dysfunction, according to the segment affected, and radiographically, evidences of pseudarthrosis in at least two X-ray views. As the outcomes: satisfactory when there was bone union, no pain, and return function; unsatisfactory when there was no bone union and maintain pain and dysfunction. All patients were treated with the same equipment and by the same physician. The treatment consisted in 3 sessions with weekly interval; in each session, 3000 radial shock waves were applied with 4 bar of energy.

RESULTS

After 6 months, clinical analysis and X-ray evidence on 77.2% of the patients presented bone union and clinical improvement classified as satisfactory result. There were no complications.

CONCLUSION

Treatment of pseudarthrosis in superficial bones with radial shock waves is effective and safe.

[Physical treatment options with impact on bone healing]

The impact of physical stimulation of a fracture remains unsolved because of the complexity of this process. Differences in the localization and the morphology of the fracture, soft tissue injury, pretreatment and risk factors have an influence on study results, leading to problems in evaluation of physical modulation concerning fractures and nonunions. Extracorporeal shock wave therapy (ESWT) is technically demanding and often associated with local complications including bone and soft tissue stress; however, it is still applied in some centers for the treatment of nonunions. The study situation assessing the effectiveness of this treatment consists of a single randomized controlled trial (RCT) with a medium risk of bias. A positive effect for bony healing could be seen in 70-71% of ESWT patients but also in 73% of the surgically treated group. A systematic review and meta-analysis demonstrated an insufficient and inconsistent study quality but acknowledged that ESWT can be an effective treatment for delayed union and nonunion. For low-intensity pulsed ultrasound (LIPUS) studies with a reduced bias are available, representing a better level of evidence. Concerning advantages in the consolidation of acute fractures, only one RCT showed a reduction of healing time in fractures with an expected prolonged bony bridging. For the treatment of delayed unions, a highly rated RCT showed a significantly improved consolidation of midshaft tibial fractures using LIPUS. A systematic review and meta-analysis of nonunions showed positive effects in biologically active lesions, e.g. in hypertrophic pseudarthrosis, leading to a fusion rate of 80%. The consolidation process was better in patients without surgical revision 3-6 months prior to LIPUS.