Extracorporeal shockwave for hip necrosis in systemic lupus erythematosus

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.

Dose dependent effects of extracorporeal shockwave therapy on pain and function in osteonecrosis of femoral head: A systematic review

Purpose

To investigate the effectiveness of different dosages of extracorporeal shockwave therapy (ESWT) on pain, function and radiographic outcomes in patients with osteonecrosis of femoral head (ONFH).

Procedure

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta Analysis) guidelines were followed to conduct this review. The systematic literature search was done by using six different electronic databases include MEDLINE (assessed by Pubmed) CENTRAL (Cochrane Library Central Register of Controlled Trials), Web of Science, PEDro (Physiotherapy Evidence Database), Scopus and Science Direct. Retrospective and prospective cohort studies; case control study, randomized clinical trials were included. Screening conducted by two independent authors along with inclusion and exclusion criteria of included studies. The methodological quality assessment for cohort studies and randomized clinical trials was done by using Structured Effectiveness Quality Evaluation Scale (SEQES) and Newcastle-Ottawa Scale for case control study.

Result

Total 1410 articles were found from various databases. After duplicates removed 450 articles remained. Followed by title and abstract screening 53 articles eligible for full text reading, out of them 13 articles met the inclusion criteria and included in this review.

Conclusion

High energy flux densities of ESWT found to be more effective followed by low and moderate energy flux densities in earlier course of the disease compared to later stages in terms of pain relief, functional improvement and disease progression. Due to high variability among study design, ESWT dosages, patient characteristics and considering the paucity of well conducted studies, the present study cannot be conclusive.

The effects of shockwave therapy on musculoskeletal conditions based on changes in imaging: a systematic review and meta-analysis with meta-regression

BACKGROUND

Shockwave therapy (SWT) is a commonly used intervention for a number of musculoskeletal conditions with varying clinical outcomes. However, the capacity of SWT to influence pathophysiological processes and the morphology of affected tissues remains unclear. The objective of the current review is to evaluate changes in imaging outcomes of musculoskeletal conditions following SWT.

METHODS

A comprehensive search of Medline, Embase, Cochrane Controlled Trials Register, CINAHL and SportDiscus was conducted from inception to October 2018. Prospective clinical trials evaluating the effectiveness of SWT based on changes in imaging outcomes were eligible for inclusion. Articles were evaluated independently for risk of bias using the Cochrane Risk of Bias list and the Methodological Index for Non-Randomized Studies. Random-effects meta-analysis and meta-regression with a priori determined covariates was conducted for each condition to determine potential predictors of SWT effects.

RESULTS

Sixty-three studies were included, with data from 27 studies available for effect size pooling. Meta-analyses and meta-regression on imaging outcomes were performed for rotator cuff calcific tendinitis (n = 11), plantar fasciitis (n = 7) and osteonecrosis of the femoral head (n = 9). There was an overall reduction in the size of measured lesion following SWT (MD 8.44 mm (95%CI -4.30, 12.57), p < 0.001) for calcium deposit diameter, (MD 0.92 mm (95%CI -0.03, 1.81), p = 0.04) for plantar fascia thickness and (MD 4.84% (95%CI -0.06, 9.75), p = 0.05) for lesion size in femoral head osteonecrosis. Meta-regression showed no influence of SWT dosage parameters, however, baseline lesion size was an independent predictor for changes in imaging outcomes.

CONCLUSIONS

SWT altered the morphology of musculoskeletal conditions, potentially reflecting changes in underlying pathophysiological processes. The parameters of SWT dosage are not significant predictors of changes in imaging outcomes. Lack of adequate reporting of imaging outcomes limited the conclusions that could be drawn from the current review. Registration number: PROSPERO CRD42018091140.

High-energy extracorporeal shock wave therapy for nontraumatic osteonecrosis of the femoral head

Background

Nontraumatic osteonecrosis of the femoral head (ONFH) is treated with a series of methods. High-energy extracorporeal shock wave therapy (ESWT) is an option with promising mid-term outcomes. The objective of this study was to determine the long-term outcomes of ESWT for ONFH.

Methods

Fifty-three hips in 39 consecutive patients were treated with ESWT in our hospital between January 2005 and July 2006. Forty-four hips in 31 patients with stage I–III nontraumatic ONFH, according to the Association Research Circulation Osseous (ARCO) system, were reviewed in the current retrospective study. The visual analog pain scale (VAS), Harris hip score, radiography, and magnetic resonance imaging were used to estimate treatment results. The progression of ONFH was evaluated by imaging examination and clinical outcomes. The results were classified as clinical success (no progression of hip symptoms) and imaging success (no progression of stage or substage on radiography and MRI).

Results

The mean follow-up duration was 130.6 months (range, 121 to 138 months). The mean VAS decreased from 3.8 before ESWT to 2.2 points at the 10-year follow-up (p < 0.001). The mean Harris hip score improved from 77.4 before ESWT to 86.9 points at the 10-year follow-up. The clinical success rates were 87.5% in ARCO stage I patients, 71.4% in ARCO stage II patients, and 75.0% in ARCO stage III patients. Imaging success was observed in all stage I hips, 64.3% of stage II hips, and 12.5% of stage III hips. Seventeen hips showed progression of the ARCO stage/substage on imaging examination. Eight hips showed femoral head collapse at the 10-year follow-up. Four hips in ARCO stage III and one hip in ARCO stage II were treated with total hip arthroplasty during the follow-up. Three were performed 1 year after ESWT, one at 2 years, and one at 5 years.

Conclusions

The results of the current study indicated that ESWT is an effective treatment method for nontraumatic ONFH, resulting in pain relief and function restoration, especially for patients with ARCO stage I–II ONFH.

Insights into the mechanism of a novel shockwave-assisted needle-free drug delivery device driven by in situ-generated oxyhydrogen mixture which provides efficient protection against mycobacterial infections

Background

Needle-free, painless and localized drug delivery has been a coveted technology in the area of biomedical research. We present an innovative way of trans-dermal vaccine delivery using a miniature detonation-driven shock tube device. This device utilizes~2.5 bar of in situ generated oxyhydrogen mixture to produce a strong shockwave that accelerates liquid jets to velocities of about 94 m/s.

Method

Oxyhydrogen driven shock tube was optimized for efficiently delivering vaccines in the intradermal region in vivo. Efficiency of vaccination was evaluated by pathogen challenge and host immune response. Expression levels of molecular markers were checked by qRT-PCR.

Results

High efficiency vaccination was achieved using the device. Post pathogen challenge with Mycobacterium tuberculosis, 100% survival was observed in vaccinated animals. Immune response to vaccination was significantly higher in the animals vaccinated using the device as compared to conventional route of vaccination.

Conclusion

A novel device was developed and optimized for intra dermal vaccine delivery in murine model. Conventional as well in-house developed vaccine strains were used to test the system. It was found that the vaccine delivery and immune response was at par with the conventional routes of vaccination. Thus, the device reported can be used for delivering live attenuated vaccines in the future.

An evidence-based guide to the treatment of osteonecrosis of the femoral head

Non-traumatic osteonecrosis of the femoral head is a potentially devastating condition, the prevalence of which is increasing. Many joint-preserving forms of treatment, both medical and surgical, have been developed in an attempt to slow or reverse its progression, as it usually affects young patients. However, it is important to evaluate the best evidence that is available for the many forms of treatment considering the variation in the demographics of the patients, the methodology and the outcomes in the studies that have been published, so that it can be used effectively. The purpose of this review, therefore, was to provide an up-to-date, evidence-based guide to the management, both non-operative and operative, of non-traumatic osteonecrosis of the femoral head. Cite this article: Bone Joint J 2017;99-B:1267-79.

Radial Extracorporeal Shock Wave Therapy in a Person With Advanced Osteonecrosis of the Femoral Head

Supplemental digital content is available in the text.

This case report describes the first patient with avascular necrosis of the femoral head of Association Research Circulation Osseous stage IV, treated with radial extracorporeal shock wave therapy. By contrast, previous studies demonstrated the efficacy of a single treatment of focused extracorporeal shock wave therapy in improving pain and Harris Hip Scale in patients with avascular necrosis of the femoral head of Association Research Circulation Osseous stage I to III. The affected hip was treated with 6000 impulses of radial extracorporeal shock wave therapy at 10 Hz and an intensity ranging from 2.5 to 4.0 bar at 7-day intervals for 24 mos. The Harris Hip Scale values were 33, 43, 56, 77, 81, 88, and 92 at baseline and 1, 3, 6, 12, 18, and 24 mos, respectively. The radiographs showed that the subluxation of the right hip was slightly aggravated. Joint effusion was reduced, bone marrow edema disappeared, the density became more uniform, and the gluteal muscles were more developed based on magnetic resonance imaging. Increased tracer uptake was evident along the joint margin and superolateral aspect of the head both before and after radial extracorporeal shock wave therapy. This case report demonstrates the feasibility of long-term radial extracorporeal shock wave therapy in Association Research Circulation Osseous stage IV patients.

Extracorporeal shockwave therapy in osteonecrosis of femoral head: A systematic review of now available clinical evidences

BACKGROUND

Osteonecrosis is an incapacitating disorder with high morbidity. Though extracorporeal shockwave therapy (ESWT) provides a noninvasive treatment option, controversial subjects still exist about its effectiveness, indications, and mechanism of action.

METHODS

An electronic databases search was performed using PubMed, Embase, and the Cochrane library to collect clinical trials, case reports, and cases series on this topic and then useful data were extracted and appraised by experienced clinicians. We evaluated the quality of included evidences by using the Oxford Centre for evidence-based medicine (EBM) Levels of Evidence.

RESULTS

A total of 17 articles including 2 case reports, 9 open label trials, 2 cohorts, and 6 randomized controlled trials were considered to be eligible for this systematic review. Visual analog scale (VAS), Harris hip scores, and the imaging results were the frequently-used outcome estimates of included studies.

CONCLUSION

By systematically analyzing these evidences, we could conclude that ESWT could act as a safe and effective method to improve the motor function and relieve the pain of patients with osteonecrosis of femoral hip, especially those at early stage. Imaging revealed that bone marrow edema was significantly relieved, but the necrotic bone could not be reversed after ESWT. This technique could slow or even block the progression of ONFH and therefore reduce the demand for surgery. Collaboration with other conservative modalities would not improve the curative benefits of ESWT. Meanwhile, ONFH with various risk factors showed similar reaction to this noninvasive treatment method. However, these conclusions should be interpreted carefully for the low-quality of included publications and further studies are requisite to validate the effect of ESWT in ONFH.

High-Energy Extracorporeal Shock Wave for Early Stage Osteonecrosis of the Femoral Head: A Single-Center Case Series

Our retrospective study assessed the effects of treatment of early stage ONFH with extracorporeal shock wave therapy. 335 patients (528 hips) were treated with shockwave therapy in our institution. Each patient underwent two sessions. The hips were divided into two groups according to whether the lateral pillar of the femoral head (LPFH) was preserved: LPFH and non-LPFH groups. Patients were followed up at 3, 6, and 12 months after the treatment. Most of the patients (83.9% hips) demonstrated pain reduction and improved mobility of the treated joint (visual analogue scale score, P = 0.00006; Harris hip score, P = 0.00091). During the follow-up period, 16 hips failed following femoral head collapse and required hip arthroplasty (2 hips in LPFH group and 14 hips in non-LPFH group). The lesion size decreased after ESWT. However, the differences were statistically not significant (LPFH group, P = 0.091; non-LPFH group, P = 0.087). A significant reduction in bone marrow edema was observed after treatment (LPFH group, P = 0.007; non-LPFH group, P = 0.016). High-energy extracorporeal shock wave therapy resulted in considerable improvement in early stage ONFH, which can effectively relieve pain and improve the function of the hip.

Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today? A Ten-Year Update

➤ Although multiple theories have been proposed, no one pathophysiologic mechanism has been identified as the etiology for the development of osteonecrosis of the femoral head. However, the basic mechanism involves impaired circulation to a specific area that ultimately becomes necrotic.➤ A variety of nonoperative treatment regimens have been evaluated for the treatment of precollapse disease, with varying success. Prospective, multicenter, randomized trials are needed to evaluate the efficacy of these regimens in altering the natural history of the disease.➤ Joint-preserving procedures are indicated in the treatment of precollapse disease, with several studies showing successful outcomes at mid-term and long-term follow-up.➤ Studies of total joint arthroplasty, once femoral head collapse is present, have described excellent outcomes at greater than ten years of follow-up, which is a major advance and has led to a paradigm shift in treating these patients.➤ The results of hemiresurfacing and total resurfacing arthroplasty have been suboptimal, and these procedures have restricted indications in patients with osteonecrosis of the femoral head.

Extracorporeal shockwave therapy for avascular necrosis of femoral head

The etiology of osteonecrosis of the femoral head (ONFH) is multifactorial. Treatment of ONFH is disease stage dependent. For early stages, femoral head preservation procedures are preferred including core decompression, muscle pedicle grafting and de-rotational osteotomy. Core decompression with bone grafting is considered the gold standard. However, the results are inconsistence and unpredictable. An effective non-invasive method of treatment is imperative. Recently, extracorporeal shockwave therapy (ESWT) has shown beneficial effects in ONFH. ESWT improves pain and function of the hip and regression of the ONFH lesion. ESWT is more effective than core decompression with or without bone grafting, cocktail therapy that combined HBO, ESWT and oral alendronate is shown effective for patients with early osteonecrosis. The purpose of the article is to review, update and summarize the clinical treatment of ONFH using shockwave therapy.

Management of femoral head osteonecrosis: Current concepts

Osteonecrosis of femoral head (ONFH) is a disabling condition of young individuals with ill-defined etiology and pathogenesis. Remains untreated, about 70-80% of the patients progress to secondary hip arthritis. Both operative and nonoperative treatments have been described with variable success rate. Early diagnosis and treatment is the key for success in preserving the hip joint. Once femoral head collapses (>2 mm) or if there is secondary degeneration, hip conservation procedures become ineffective and arthroplasty remains the only better option. We reviewed 157 studies that evaluate different treatment modalities of ONFH and then a final consensus on treatment was made.

Outcomes of primary total hip arthroplasty in systemic lupus erythematosus with a proximally-coated cementless stem

The purpose of this study was to compare the outcomes of total hip arthroplasty (THA) in systemic lupus erythematosus (SLE) compared to a cohort of osteonecrosis patients who did not have this disease. Between 2001 and 2008, 60 THAs in 44 SLE patients who had a mean age of 42 years (range, 18 to 87 years) and a mean follow-up of 7 years (range, 4 to 11 years) were evaluated. These SLE patients were compared to a cohort of 82 THAs in 70 osteonecrosis patients who did not have this disease. Outcomes evaluated included implant survivorship, Harris hip scores, complications, as well as radiographic results. There was no significant difference in implant survivorship (98% vs. 97.5%), Harris hip score (87 vs. 88 points) and complications (1.7% versus 2.4%) between the SLE and the comparison cohort. The authors believe that SLE does not negatively affect the outcomes of primary total hip arthroplasty at mid-term follow-up.

Osteonecrosis of the hip: treatment options and outcomes

This article reviews the literature regarding the outcomes of various nonoperative and operative treatment options for osteonecrosis of the hip. This article provides the orthopedic community with the latest evidence regarding the suitability of currently available treatment modalities in various stages of the disease.

Clinical application of extracorporeal shock wave therapy in orthopedics: focused versus unfocused shock waves

For the past decade extracorporeal shock wave therapy has been applied to a wide range of musculoskeletal disorders. The many promising results and the introduction of shock wave generators that are less expensive and easier to handle has added to the growing interest. Based on their nature of propagation, shock waves can be divided into two types: focused and unfocused. Although several physical differences between these different types of shock waves have been described, very little is known about the clinical outcome using these different modalities. The aim of the present review is to investigate differences in outcome in select orthopaedic applications using focused and unfocused shock waves.

Osteonecrosis in systemic lupus erythematosus: an early, frequent, and not always symptomatic complication

Osteonecrosis may complicate the course of systemic lupus erythematosus and may contemporaneously affect multiple joints. The major risk factor associated with the development of osteonecrosis is the use of glucocorticoid at high doses. Recent studies using serial MRI, which represents the “gold standard” for the early detection of osteonecrosis, yielded some interesting findings about the natural history of this clinical entity. Osteonecrosis in the majority of the cases is asymptomatic and occurs early in the course of the disease. Its later occurrence is associated with lupus flare that requires the increase of corticosteroid dose. The optimal treatment of osteonecrosis is controversial. In case of silent osteonecrosis involving a small area conservative strategy is usually adequate. When lesions are symptomatic surgical treatment as core decompression or free vascularized fibular grafting is required; extracorporeal shockwave treatment may represent an alternative therapeutic approach. When the lesion has a medium-large dimension or involves a weight-bearing area bone collapse is a common complication requiring total joint replacement. Coadministration of bisphosphonate or warfarin with high doses of corticosteroid might be a promising preventive strategy of osteonecrosis.

Radial extracorporeal pressure pulse therapy for the primary long bicipital tenosynovitis a prospective randomized controlled study

Long bicipital tenosynovitis is regarded as one of the common causes of shoulder pain and dysfunction. The traditional therapeutic approach includes a variety of conservative treatments, but these treatments are not substantiated, owing to the lack of proven clinical efficacy. Radial extracorporeal shock wave therapy (rESWT) uses a pneumatically generated and radially propagating low-energy pressure pulse and has been clinically shown to be a new alternative form of treating refractory soft tissue inflammation. While treating patients suffering from long bicipital tenosynovitis, a randomized, controlled trial was conducted to analyze the effects of radial shock wave therapy on pain and function. Seventy-nine adults with long bicipital tenosynovitis were randomized to receive either active (1500 pulses, 8 Hz, 3 bars) or sham treatment through four sessions that were held once a week. All of these adults were assessed before treatment and at time intervals of 1, 3 and 12 months since the completion of the treatment. The outcomes were measured through the visual analogue scale (VAS) and L'Insalata shoulder questionnaire. Mean VAS in the rESWT group showed significant and sustained reduction from 5.67 ± 1.32 at baseline to 2.58 ± 1.49 at one month, 1.83 ± 1.25 at three months and 1.43 ± 0.94 at 12 months from baseline, whereas the sham group's mean VAS was 6.04 ± 0.97 before treatment and stabilized at 5.57 ± 0.84 at 12 months. Similar trends were found for the function scores. Mean scores were increased after rESWT from 60.57 ± 6.91 at baseline to 79.85 ± 6.59 at 1 month and 83.44 ± 5.21 at 12 months from baseline. Both pain and function scores showed significant differences between the two groups (p < 0.001). The rESWT group consisted of "invalid conservative treatment subgroup" and "none conservative treatment subgroup." Both groups showed good recovery and prognosis. Therefore, we recommend rESWT in treating primary long bicipital tenosynovitis.

Extracorporeal shockwave therapy in musculoskeletal disorders

The sources of shockwave generation include electrohydraulic, electromagnetic and piezoelectric principles. Electrohydraulic shockwaves are high-energy acoustic waves generated under water explosion with high voltage electrode. Shockwave in urology (lithotripsy) is primarily used to disintegrate urolithiasis, whereas shockwave in orthopedics (orthotripsy) is not used to disintegrate tissues, rather to induce tissue repair and regeneration. The application of extracorporeal shockwave therapy (ESWT) in musculoskeletal disorders has been around for more than a decade and is primarily used in the treatment of sports related over-use tendinopathies such as proximal plantar fasciitis of the heel, lateral epicondylitis of the elbow, calcific or non-calcific tendonitis of the shoulder and patellar tendinopathy etc. The success rate ranged from 65% to 91%, and the complications were low and negligible. ESWT is also utilized in the treatment of non-union of long bone fracture, avascular necrosis of femoral head, chronic diabetic and non-diabetic ulcers and ischemic heart disease. The vast majority of the published papers showed positive and beneficial effects. FDA (USA) first approved ESWT for the treatment of proximal plantar fasciitis in 2000 and lateral epicondylitis in 2002. ESWT is a novel non-invasive therapeutic modality without surgery or surgical risks, and the clinical application of ESWT steadily increases over the years. This article reviews the current status of ESWT in musculoskeletal disorders.