Influence of shock waves on fracture healing

doi:10.1016/0090-4295(92)90009-L

Urology

Volume 39, Issue 6, June 1992, Pages 529-532

https://doi.org/10.1016/0090-4295(92)90009-L Get rights and content

Abstract

During the last decades the influence of physical factors on fracture healing has been widely described. With the use of shock waves for the treatment of urolithiasis, a new mechanical medium has been introduced into medicine. For the first time the influence of shock waves on fracture healing was studied in rats. With fractioned shock-wave treatment (5 times 100 shock waves at 14 or 18 kV) an enhancement in healing could be achieved.

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The use of shock waves for medical therapy has been driven by the success of shock wave lithotripsy (SWL) which revolutionized the treatment of kidney stones and remains one of the first-line treatments to this day. The use of shock waves for other medical conditions has been explored in the subsequent four decades with indications including: gall stones, joint pain (including calcifications), tendon pain, nonhealing bone fractures, chronic wound repair, loss of blood supply to the heart tissue, and even brain disorders. Over the same period new devices have been developed and approved with the general trend being to make smaller, more portable, and cheaper systems. This chapter reviews the technology that is used to create shock waves, or in the case of some newer devices pulsed acoustic waves, that are used in clinical applications. It also reviews the clinical literature for some of the indications to show where successes have been achieved and where challenges remain.
Low-energy Shockwave Therapy in the Management of Wound Healing Following Fournier's Gangrene
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We report on postoperative management of wound healing in four cases of Fournier’s gangrene successfully treated with low-intensity shockwave therapy (LI-ESWT). In three cases, LI-ESWT (3 sessions per week with 2000 shockwaves at 3 Hz applied at 0.25 mJ/mm²) was able to close wound dehiscence secondary to plastic surgery with skin flaps. In one patient, LI-ESWT resulted in complete closure of an extensive wound with restoration of the local scrotal and penile skin. This is the first report of successful application of LI-ESWT for this indication. Restoration of local skin rather than wound closure by fibrous tissue could be related to promotion of stem cells, which has been discussed previously for other indications, such as treatment of chronic ulcers and restoration of the pelvic floor.
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Citation Excerpt :
Among non-surgical options, extracorporeal shockwave treatment (ESWT) has emerged as a reliable and effective non-invasive modality for patients suffering from delayed or non-healing fractures. Following lithotritpic procedures, Haupt et al., a German urologist, observed cortical reactions at areas where the shockwaves propagated through the iliac bone [1]. Sticking to the theory of causing microfractures at this time thus inducing repair processes, Valchanou presented already in 1991 their first results on non-unions [2].
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.
Protective effects of extracorporeal shockwave on rat chondrocytes and temporomandibular joint osteoarthritis; preclinical evaluation with in vivo <sup>99m</sup>Tc-HDP SPECT and ex vivo micro-CT
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Citation Excerpt :
Based on our 99mTc-HDP SPECT/CT and micro-CT results, future in vitro and in vivo studies on the protective effects of ESWT on osteoblasts and TMJ subchondral bone are recommended. Although the exact mechanism of ESWT remains unclear, the alleviation of subchondral bone remodeling might be due to both the mitigation of inflammatory processes in the joints and direct ESW-associated effects on bone architecture41,42. Further study on ESWT effects on subchondral bone are necessary, as thus far, only one clinical study has been published on the effects of ESWT on TMDs in humans13.
Extracorporeal shockwave therapy (ESWT) has been shown to have chondroprotective effects on arthritic diseases. We investigated the effects of ESWT on temporomandibular joint osteoarthritis (TMJOA) using rat chondrocytes and TMJOA rat models.
Cell viability and expression of pro-inflammatory cytokines, cartilage degradation, and apoptosis markers were measured in control, monosodium iodoacetate (MIA)-treated and ESWT plus MIA-treated chondrocytes in vitro, and intra-articular MIA injection (TMJOA) and ESWT on TMJOA rats in vivo. In vivo ^99mTc-hydroxymethylene diphosphonate (HDP) single-photon emission computerized tomography/computerized tomography (SPECT/CT) and ex-vivo micro-CT and histologic examinations were performed in rat models.
ESWT plus MIA-treated chondrocytes showed increased cell viability significantly (P = 0.007), while decreased genetic expression of pro-inflammatory cytokines [tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and interleukin-6 (IL-6); P < 0.001 for each] and cartilage degradation markers [matrix metalloproteinase-3 (MMP3), matrix metalloproteinase-13 (MMP13), and bone morphogenetic protein 7 (BMP7); P < 0.001 for each], and number of apoptotic cells (P < 0.001) compared to MIA-treated chondrocytes. Changes in cytochrome c and cleaved caspase-3 levels relative to procaspase-3 were decreased over MIA-treated chondrocytes. ESWT on TMJOA rat models was associated with a significant decrease in pro-inflammatory and cartilage degradation markers, as demonstrated by real-time PCR and immunohistochemistry stains (P < 0.001 for each). On ^99mTc-HDP SPECT/CT, the ESWT group showed a significantly lower uptake ratio compared to the TMJOA group (P = 0.008). Micro-CT analysis revealed that the ESWT group showed improved structure and bone quality compared to the TMJOA control group.
ESWT was associated with a protective effect on cartilage and subchondral bone structures of TMJOA by reducing inflammation, cartilage degradation, and chondrocyte apoptosis.
Effect of Shockwave Treatment for Management of Upper and Lower Extremity Musculoskeletal Conditions: A Narrative Review
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Extracorporeal shockwave therapy (ESWT) is a technology that was first introduced into clinical practice in 1982 for urologic conditions. Subsequent clinical applications in musculoskeletal conditions have been described in treatment of plantar fasciopathy, both upper and lower extremity tendinopathies, greater trochanteric pain syndrome, medial tibial stress syndrome, management of nonunion fractures, and joint disease including avascular necrosis. The aim of this review is to summarize the current understanding of treatment of musculoskeletal conditions with ESWT, accounting for differences in treatment protocol and energy levels. Complications from ESWT are rare but include 2 reported cases of injury to bone and Achilles tendon rupture in older adults using focused shockwave. Collectively, studies suggest ESWT is generally well-tolerated treatment strategy for multiple musculoskeletal conditions commonly seen in clinical practice.
III

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: Study supported by Dormer Medizintechnik GmbH, Germany.

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Influence of shock waves on fracture healing

Abstract

Lancet

Orthop Clin North Am

J Surg Res

Lancet

J Urol

J Surg Res

Effects of electric currents on bone “in vivo”

Nature

On the piezoelectric effects of bone

J Phys Soc Jpn

Stimulation of bone growth by implanted FEP electrets and PVDF pielzoelectric films