Treatment of fractures with shock wave therapy

The expected bone union time (EBUT) is the time required for bone healing. Bone healing time varies depending on the fracture location, the nature of the injury, the patient's age, and any associated medical conditions.

Most bone fractures are healed (consolidated, fused) in 4-6 months, or at least radiological signs of progressive fusion are determined on a series of radiographs. If the fracture has not healed by this time, then we are talking about delayed consolidation or poor fusion of the bone fracture.

Pseudoarthrosis ("ununited fracture") - interruption of the fracture healing process. Fibrous or cartilaginous tissue forms between the main fragments of the fracture and therefore, even after 6-8 months, the fracture does not heal.

The causes of delayed consolidation and, accordingly, non-union of bone fracture and pseudarthrosis are:

Impaired bone blood supply. Without adequate blood supply, bone union is impossible. High-energy fractures with soft tissue damage and open fractures can also significantly limit blood flow.
Biological causes of poor blood flow and poor bone union include diabetes, peripheral vascular disease, vitamin D deficiency, kidney failure, and medications (steroids, NSAIDs, opiates).
Excessive bone fragment mobility due to inadequate immobilization.
Fracture types that contribute to bone nonunion include bone loss with a gap between fragments greater than 3 mm.
Disruption of cortical continuity, high comminuted fractures, and the presence of butterfly-shaped fragments.
Infection.
Other factors leading to delayed fracture union include advanced age, poor nutrition, anticoagulant use, radiation, and burns.

It's worth noting that the use of medications such as bisphosphonates can impact bone healing time. For example, a study by Aydogen et al.[2] found that delayed union (failure to achieve union within six months) was more common in atypical femur fractures, which are thought to be caused by long-term bisphosphonate use., burns. These factors predispose to the onset of pseudarthrosis, but do not cause it by themselves.

Types of nonunion:

Hypertrophic nonunion. Radiographically, abundant callus formation is detected. Importantly, there is a lack of connective bone tissue, and the bone ends are not fused. This indicates adequate blood supply and biological activity (with callus formation), but insufficient stability.
Atrophic nonunion. Radiographically, the absence of callus is confirmed, indicating impaired biological activity (due to one or more of the traditional causes mentioned above) and insufficient blood supply (see above). Inadequate fixation.
Oligotrophic nonunion. This is a balance and combination of atrophic and hypertrophic processes, in which callus formation is incomplete. Inadequate repositioning.
Septic nonunion. Infection reduces blood flow due to the development of extensive changes and also promotes the supply of nutrients to healthy bone. This slows the formation of new bone tissue.

The division into delayed consolidation of bone fracture, bone nonunion and pseudoarthrosis is used as a basis for planning the treatment process. It must be emphasized that prevention is always better than cure!

Treatment of delayed fracture consolidation (pseudoarthrosis).

Therapeutic measures for bone fractures (fusion of bone fractures) consist of reposition, firm fixation of the fragments for the entire period of fusion and auxiliary treatment methods (physiotherapy, physiotherapy, massage, etc.) aimed at restoring the functional usefulness of the injured limb. The word "auxiliary" here does not diminish their importance and in some cases are just as important in restoring the integrity of the bone as surgical treatment.

Fixation of bone fragments is achieved by using conservative immobilization, as well as by surgical techniques.

Surgical treatment of delayed fracture union and pseudoarthrosis.

Treatment is individualized based on the degree of nonunion. It's important to understand that there are many surgical techniques, and it's crucial to tailor them to the patient's specific needs. For example, in the hypertrophic nonunion, the goal of treatment is to improve mechanical stability with internal fixation. This can include compression plates, replacement osteosynthesis, plate osteosynthesis using ORIF, and rod dynamization.

The use of extracorporeal shock wave therapy in the treatment of delayed fracture union: research papers.

Currently, surgery is the most common treatment for nonunion and is characterized by a high healing rate. However, even after surgery, some patients still experience nonunion. Furthermore, a small number of patients have surgical contraindications and are unable to undergo surgery. Therefore, orthopedic traumatologists require alternative treatment methods to improve fracture outcomes. Over the past decade, a large number of research papers have demonstrated the effectiveness of extracorporeal shock wave therapy in the treatment of delayed fracture union and nonunion with pseudoarthrosis formation.

Specialists from the Orthopedic Department of the IRCCS Orthopedic Institute Galeazzi, Via R. Galeazzi 4, 20100 Milan, Italy, noted that even after successful surgical treatment of bone nonunions, such as atrophic nonunions, the success rate drops sharply and in these cases, additional bone regeneration strategies are required to improve the healing of bone nonunions.

According to Valerio Sansone and colleagues, extracorporeal shock wave therapy (ESWT) is one such treatment method that has been successfully used both in cases of delayed healing and in certain non-unions, along with additional methods such as stem cell therapy, or autologous bone grafting, which is currently the gold standard in such cases, but its supply is limited and its recovery potential is unpredictable, or percutaneous transplantation of bone marrow aspirate concentrate.

Based on the fact that the method of extracorporeal shock wave therapy is a conservative (non-surgical) effective therapy for delayed bone fusion and pseudoarthrosis, they concluded that ESWT is a promising method for treating non-union of long tubular bones, which requires further research and the development of more precise protocols and therapy parameters, due to the presence of a large number of treatment protocols.

Nan Jing and co-authors from several institutions in China also note that the outcome of surgical treatment for nonunion is disappointing, necessitating the search for new solutions, one of which is the noninvasive technique of extracorporeal shock wave therapy. In their review, the authors from the Central Hospital, Langfang, and the Department of Orthopedics, Third Hospital of Hebei Medical University, Shijiazhuang, presented a comprehensive overview of the mechanisms underlying shock wave therapy (ESWT) and demonstrated that shock wave therapy is a successful, non-surgical, and cost-effective strategy for treating nonunion. The authors also argue that ESWT may become a new non-invasive treatment option for nonunion. In conclusion, Nan Jing and co-authors point out that ESWT is a reliable and promising interventional method for stimulating fracture healing, which requires further study.

Studies conducted in both living organisms and in vitro have demonstrated that ESWT can have a beneficial effect on both accelerating fracture healing and resuming failed fracture healing. Some animal studies have also shown that ESWT (shock wave therapy) increased trabecular bone thickness and volume.

Treatment of delayed bone fracture consolidation ("fracture fusion") with shock wave therapy at the Awatage Medical Center.

Nonunion is one of the most challenging problems in orthopedics. Research and the experience of orthopedic trauma surgeons show that in some cases, even surgical treatment of fractures is complicated by a lack of consolidation or failure to achieve the expected bone union, necessitating repeat surgeries.

Currently, a real breakthrough in the fusion of bone fractures is radial shock wave therapy. Modern focused ESWT devices, such as MTS-medical, deliver high therapeutic results even in complex cases. These devices intensively stimulate angiogenesis (the growth of new blood vessels — for the first time in medicine!) and osteogenesis (the process of tissue bone formation) at the fracture area. Specialists at the Awatage Medical Center have also developed a treatment method for certain types of delayed fracture consolidation and pseudoarthrosis using radial shock wave therapy using the Gymna Shockmaster 500 device, which also has a positive effect on bone tissue restoration and bone fusion.

Shockwave therapy (especially electro-hydraulic system) significantly accelerates the healing of long-term healing fractures.

We are very proud of the results of successful treatment of cases of long-term (including 8-year) non-union of fractures after serious injuries. In the Avatazh medical center, shock wave therapy is used as an independent method to accelerate the healing of fractures and to slow the healing of fractures. Sometimes three procedures are enough to produce calluses that are clearly visible on X-rays (see below). It should be noted that the presence of metal pins in a patient is not a contraindication for shock wave therapy in the treatment of a fracture (delayed union of fractures).

In our practice, ABSOLUTELY ALL patients received a positive result - bone fracture fusion! Read reviews of real patients of the Avatazh clinic about the method of shock wave therapy.

Examples of successful treatment non-union of fractures of patients of the medical center "Awatage"

Case 1

A femoral shaft fracture. Following a metal osteosynthesis procedure, an intramedullary nail was inserted. However, the surgery did not promote bone healing. Postoperatively, the fracture healed slowly.

More than a year after the surgery, a course of extracorporeal shock wave therapy was administered at the Awatage Medical Center.

Following the course of treatment, imaging showed callus formation, and the final image showed bone remodeling with almost complete restoration of bone tissue structure at the fracture site.

Case 2

Woman about 55 years old. One of the first patients of the Awatage medical center in Kiev in the treatment of delayed consolidation of fractures. I applied to the direction of the insurance company as the last opportunity to avoid the operation and, accordingly, significant financial costs for the insurance payment. The fracture did not heal for more than 8 months.

After 3 SWT procedures, the patient, to our surprise, brought an X-ray, which showed obvious signs of callus formation - fracture healing. Our orthopedic traumatologist recommended taking a picture a month after the treatment. This was the patient's personal initiative. The insurance company, in turn, managed to avoid the cost of financing the operation, and the patient avoided colossal health stress and a long recovery period with no guaranteed result. Shockwave therapy on the Belgian Gymna equipment completely restored the bone after the fracture.

Case 3

Girl 15 years old (born in 2002), delayed fracture consolidation. Attending orthopedic traumatologists from the city hospital insisted on surgical intervention, but they were still sent to our Awatage medical center in Zaporozhye for shock wave therapy. Already after 4 sessions of shock wave therapy, a positive result was recorded - fusion (the first image "BEFORE" dated December 12, 2017, the second image "AFTER" dated January 4, 2018). After only three weeks, a callus began to form in the area of the fracture, and the process of bone fusion began.

In this regard, the operating orthopedic traumatologists made a decision to cancel the operation and continue the sessions of shock wave therapy at the Awatage medical center. Thus, the young patient managed to avoid surgery, significant financial costs and a long period of rehabilitation. The attending physicians and the girl's parents were extremely pleased with the result and possibilities of shock wave therapy in the treatment of nonunion fractures.

Case 4

The result of treatment of delayed consolidation of the fracture of the humerus. The first image (BEFORE treatment) is dated July 18, 2014, the second (AFTER the SWT course) - September 27, 2014. The picture shows all the signs of complete healing of the fracture. It is important to note that metal structures are not a contraindication for shock wave therapy.

An experienced orthopedic traumatologist of the Awatage medical center, focusing on X-ray images, places the shock wave transmitter in such a way that it acts exclusively on the fracture site, bypassing the metal structure. In addition, these procedures are carried out using radial shock wave therapy devices, which by its form and properties excludes any traumatic consequences.

Лечение замедленной консолидации переломов ударно-волновой терапией

References.

Wildemann, B., Ignatius, A., Leung, F. et al. Non-union bone fractures. Nat Rev Dis Primers 7, 57 (2021)

Cunningham BP, Brazina S, Morshed S, Miclau T. Fracture healing: A review of clinical, imaging and laboratory diagnostic options. Injury. 2017 Jun;48 Suppl 1:S69-S75.

Sansone V, Ravier D, Pascale V, Applefield R, Del Fabbro M, Martinelli N. Extracorporeal Shockwave Therapy in the Treatment of Nonunion in Long Bones: A Systematic Review and Meta-Analysis. J Clin Med. April 2022

Wang H and Shi Y: Extracorporeal shock wave treatment for post‑surgical fracture nonunion: Insight into its mechanism, efficacy, safety and prognostic factors (Review). Exp Ther Med 26: 332, 2023