Extracorporeal shockwave therapy for avascular necrosis of femoral head

Tranexamic Acid Use in Total Hip Arthroplasty for Avascular Necrosis: A Single-Center Experience

Background: Avascular necrosis (AVN) of the femoral head is a major indication for total hip arthroplasty (THA), often associated with significant blood loss and high transfusion rates. Tranexamic acid (TXA) has been shown to reduce perioperative bleeding, but evidence in AVN-specific populations remains limited. Methods: This retrospective, single-center study analyzed 115 patients undergoing primary THA due to AVN between 2016 and 2023. Patients who received TXA were compared with those who did not. Baseline and perioperative data including hemoglobin (HGB), erythrocyte count (RBC), transfusion rates, and PRBC unit use were collected. Results: Baseline characteristics were comparable between groups. TXA significantly reduced transfusion incidence (7.9% vs. 36.5%, p < 0.0001) and total PRBC unit use (0.1 ± 0.3 vs. 0.8 ± 1.1, p < 0.0001). The mean HGB drop was smaller in the TXA group (2.1 ± 1.2 vs. 3.2 ± 2.0 g/dL, p = 0.001), as well as the RBC drop (0.8 ± 0.4 vs. 1.3 ± 1.4 million/μL, p = 0.02). Conclusions: TXA effectively reduces blood loss and transfusion needs in AVN-related THA, supporting its routine perioperative use in this patient population.

The Relationship Between Femoral Head Avascular Necrosis and Erectile Dysfunction: A Retrospective Case-Control Study Conducted in Türkiye

Background/Objectives: Femoral head avascular necrosis (FAN) is a serious orthopedic disorder that causes the death of bone tissue as the outcome of the occlusion or insufficiency of the vessels supplying blood to the femoral head. It is especially common in middle-aged men. Factors such as alcohol consumption, corticosteroid use, trauma, and systemic diseases have influential roles in the development of FAN, and the ensuing vascular disruptions can also negatively affect the patient's broader systemic vascular health. Erectile dysfunction (ED) is a condition caused by an impairment in penile blood flow, which reduces quality of life in men and has psychosocial effects. This study examined the potential relationship between FAN and ED in consideration of the similar pathophysiological mechanisms of these conditions. Methods: The research was planned as a retrospective case-control study and conducted between January 2020 and December 2023. FAN was diagnosed based on the Ficat-Arlet classification using plain radiography and magnetic resonance imaging, and staging was performed with expert clinical evaluations. The International Index of Erectile Function (IIEF) scale was administered to evaluate ED. Data from 50 patients with FAN and 50 healthy men were evaluated using appropriate statistical methods, including univariate comparisons and correlation analysis. Results: The analysis demonstrated a significant association between increasing FAN stages and greater severity of erectile dysfunction (ED). ED was identified in 35 out of 50 patients in the FAN group (70%), compared to 15 out of 50 individuals in the control group (30%). This difference was statistically significant (p < 0.05), indicating a substantially higher prevalence of ED in patients with FAN. A significant negative correlation was also observed between the FAN stage and International Index of Erectile Function (IIEF) scores (Spearman's rho = -0.631; p = 0.001). The mean IIEF score was 23.4 in patients with FAN stage 1, which declined to 9.6 in those with stage 4, reflecting a marked deterioration in erectile function with advancing FAN stages. No statistically significant difference was found in the age distribution between the FAN and control groups (p > 0.05). Conclusions: This study demonstrates that, with the progression of FAN, systemic vascular deterioration affects penile blood flow, increasing the severity of ED. This finding highlights the common pathophysiological mechanisms of FAN and ED and reveals the importance of early diagnosis and multidisciplinary treatment approaches. This relationship should be examined in detail with larger samples and prospective designs in future studies.

Measurement and spectral analysis of medical shock wave parameters based on flexible PVDF sensors

Extracorporeal shock wave therapy (ESWT) achieves its therapeutic purpose mainly through the biological effects produced by the interaction of shock waves with tissues, and the accurate measurement and calculation of the mechanical parameters of shock waves in tissues are of great significance in formulating the therapeutic strategy and evaluating the therapeutic effect. This study utilizes the approach of implanting flexible polyvinylidene fluoride (PVDF) vibration sensors inside the tissue-mimicking phantom of various thicknesses to capture waveforms at different depths during the impact process in real time. Parameters including positive and negative pressure changes (P+, P-), pulse wave rise time ([Formula: see text]), and energy flux density (EFD) are calculated, and frequency spectrum analysis of the waveforms is conducted. The dynamic response, propagation process, and attenuation law of the shock wave in the phantom under different impact intensities were analyzed. Results showed that flexible PVDF sensors could precisely acquire the characteristics of pulse waveform propagating within the phantom. At the same depth, as the driving pressure increases, P+ and P- increase linearly, and [Formula: see text] remains constant. At the same driving pressure, P+, P-, and EFD decay exponentially with increasing propagation depth. At the same depth, the spectra of pulse waveforms are similar, and the increasing driving pressure does not cause significant changes in carrier frequency and modulation frequency. The research findings could provide a reference for developing ESWT devices, improving treatment strategies, and enhancing the safety of clinical applications.

Extracorporeal shock wave therapy with imaging examination for early osteonecrosis of the femoral head: a systematic review

BACKGROUND

Extracorporeal shockwave therapy (ESWT) is a traditional noninvasive therapy to treat osteonecrosis of the femur head (ONFH). This systematic review aims to investigate whether ESWT can improve the clinical function of ONFH and whether differences in improvement can be observed in radiographic outcomes.

MATERIALS AND METHODS

Two authors independently searched PubMed, Embase, Cochrane Library, and Web of Science for English articles until 21 October 2023. After screening and reading the literature, the two authors independently used corresponding scales to evaluate the quality of the included articles and extracted data. The key data extracted included the Harris Hip Score (HHS), Visual Analog Scale (VAS), changes in lesion size, the change in the Association Research Circulation Osseous (ARCO) stage, and bone marrow edema (BME) stage.

RESULTS

Nine articles included 468 males and 248 females. The average age was 43.29 years and the mean follow-up time was 15.19 months. After receiving ESWT, five studies involving 146 hips showed a higher HHS (MD=-33.38; 95% CI: -46.31, -20.45), and the difference was statistically significant ( P <0.00001). The average VAS before treatment was above 5, but it dropped to 1.2 after ESWT (MD=4.64; 95% CI: 3.63-5.64), and the difference was statistically significant ( P <0.00001). Three studies found no significant differences in the areas of femoral head necrosis before and after treatment with ESWT(MD=9.66; 95% CI: -0.36, 19.67; P =0.06; I2 =84%). Two articles showed that the use of ESWT had no significant effect on the change in the ARCO stage (MD=1.11; 95% CI: 0.76-1.62; P =0.60; I2 =0%). Three studies indicated that using ESWT could improve the BME symptom in the early stage of ONFH (MD=4.35; 95% CI: 1.32-14.37; P =0.02; I2 =62%).

CONCLUSION

Based on the current evidence, ESWT shows promise as a therapy to enhance hip function and alleviate pain in the early stage of ONFH. With the advancement of more precise imaging techniques, ESWT can potentially reduce the area affected by ONFH. However, such reduction was not found to be statistically significant at the imaging level. Additionally, ESWT could improve symptoms of BME in the early stage. However, no significant change in ARCO grade was observed with ESWT treatment.

Advances in meniscus tissue engineering: Towards bridging the gaps from bench to bedside

Meniscus is vital for maintaining the anatomical and functional integrity of knee. Injuries to meniscus, commonly caused by trauma or degenerative processes, can result in knee joint dysfunction and secondary osteoarthritis, while current conservative and surgical interventions for meniscus injuries bear suboptimal outcomes. In the past decade, there has been a significant focus on advancing meniscus tissue engineering, encompassing isolated scaffold strategies, biological augmentation, physical stimulus, and meniscus organoids, to improve the prognosis of meniscus injuries. Despite noteworthy promising preclinical results, translational gaps and inconsistencies in the therapeutic efficiency between preclinical and clinical studies exist. This review comprehensively outlines the developments in meniscus tissue engineering over the past decade (Scheme 1). Reasons for the discordant results between preclinical and clinical trials, as well as potential strategies to expedite the translation of bench-to-bedside approaches are analyzed and discussed.

Is core decompression and bone marrow concentrate with demineralized bone matrix and platelet-rich fibrin suitable for treating femoral head osteonecrosis?

The aim of this article is to determine the safety and efficacy of core decompression (CD) combined with injection of autologous bone marrow concentrate (BMC), demineralized bone matrix (DBM), and platelet-rich fibrin (PRF) for treating femoral head osteonecrosis. Seventy-seven patients (53 males and 24 females) for a total of 87 hips were treated for hip osteonecrosis with CD combined with injection of autologous BMC, DBM, and PRF at Rizzoli Orthopedic Institute from September 2008 to December 2019. Patients were assessed at baseline, at 45 days, and at 3, 6, 12, 24, and 36 months postoperatively. The primary outcome was the survival rate of hips not converted to total hip arthroplasty (THA). The secondary outcomes were (I) radiographic positive evolution assessed by X-ray films and magnetic resonance imaging and (II) the clinical symptoms evaluated with the Harris Hip Score (HHS). Eighty-seven hips from 77 patients with femoral head osteonecrosis (FHON), 60 males and 27 females, with a median age of 34 years (range 15-55) were included. The cause of necrosis was steroid treatment in 30 patients (17 of these for hematological malignancies, 2 for lupus, 1 for Churg-Strauss syndrome, and the remaining for other causes), 1 was alcohol-related, 4 followed hip injury, while 15 patients had idiopathic causes. THA was carried out in 20 hips (40%). These patients had lesions classified as IIa on the Ficat stage in four cases, six were IIb, nine were III, and one was 4. No CD-related complications were found during THA surgery or at the last follow-up in these cohorts of patients. Radiographic progression of the FHON was found in 14 hips (28%), with a higher percentage on Ficat's stage IIb. There were procedure-related complications in two hips, including one femoral neck fracture and one deep infection. Nineteen hips with successful treatment had good to excellent functional results at a 3-year follow-up or more (HHS ≥ 80). The long-term outcomes of treatment with CD and injection with BMC combined with DBM and PRF are promising to prevent femoral head collapse in patients with FHON. Moreover, CD does not influence the outcome in cases of THA.

Radial extracorporeal shock wave therapy as an additional treatment modality for spastic equinus deformity in chronic hemiplegic patients. A randomized controlled study

PURPOSE

To evaluate the effectiveness of radial extracorporeal shock wave therapy (r ESWT) as an additional treatment modality for spastic equinus deformity in chronic hemiplegic patients.

METHODS

100 eligible stroke patients with calf muscles spasticity were randomized into 2 groups. Group I: 50 patients exposed to rESWT 1.500 pulses, 0.10 mJ to 0.3mJ/mm2, with a frequency 4 Hz once weekly for one month. Group II: 50 patients exposed to Sham rESWT once weekly for one month. Clinical, electrophysiological & musculoskeletal ultrasound assessments were done for all patients.

RESULTS

After controlling baseline as covariate, the trend for modified Ashworth scale (MAS), Passive ankle dorsiflexion motion (PADFM), 10 meters walk test (10-MWT), and Ratio of maximum H reflex to maximum M response (H/M ratio) after one & two months was significantly different between the two groups, with improvement of all clinical and electrophysiological parameters in group I.

CONCLUSION

ESWT represents a useful non-invasive, additional modality for the reduction of foot spasticity and equinus deformity in stroke patients.

Conservative Treatment in Avascular Necrosis of the Femoral Head: A Systematic Review

INTRODUCTION

Avascular necrosis (AVN) of the femoral head is a pressing orthopedic issue, leading to bone tissue death due to disrupted blood supply and affecting the quality of life of individuals significantly. This review focuses on conservative treatments, evaluating their efficacy as mainstay therapies. Enhanced understanding of AVN's pathophysiology and advancements in diagnostic tools have rekindled interest in non-surgical interventions, emphasizing personalized, multidisciplinary approaches for improved outcomes.

MATERIAL AND METHOD

A systematic search was conducted on PubMed, SCOPUS, and Google Scholar databases from January 2020 to August 2023, with the objective of focusing on conservative treatments for AVN of the femoral head. Eligible studies, including original research, case reports, and observational studies, were examined for relevant, well-documented patient outcomes post-conservative treatments, excluding non-English and surgically focused articles without comparative conservative data.

RESULTS

A systematic search yielded 376 records on AVN of the femoral head across multiple databases. After de-duplication and rigorous screening for relevance and quality, 11 full-text articles were ultimately included for a comprehensive qualitative synthesis, focusing on conservatively managing the condition.

CONCLUSIONS

This review evaluates the effectiveness of conservative treatments such as pharmacological interventions and physical modalities in managing AVN of the femoral head. Despite promising results in symptom alleviation and disease progression delay, variability in outcomes and methodological limitations in studies necessitate further rigorous, randomized controlled trials for a robust, patient-centric approach to optimize therapeutic outcomes in AVN management.

Complex causal association between genetically predicted 731 immunocyte phenotype and osteonecrosis: a bidirectional two-sample Mendelian randomization analysis

PURPOSE

Previous studies have explored the role of immune cells on osteonecrosis. This Mendelian randomization (MR) study further assessed 731 immunocyte phenotypes on osteonecrosis, whether a causal relationship exists, and provides some evidence of causality.

METHODS

The 731 immunocyte phenotypes and osteonecrosis data used in this study were obtained from their respective genome-wide association studies (GWAS). The authors used inverse variable weighting (IVW) as the primary analysis method. In addition, the authors simultaneously employed multiple analytical methods, including MR-Egger, weighted mode, simple mode, and weighted median, to strengthen the final results. Finally, sensitivity analyses were conducted to verify the stability and feasibility of the data.

RESULTS

The results of the IVW method of MR analysis showed that 8 immunocyte phenotypes were positively associated with osteonecrosis [ P <0.05, odds ratio (OR) > 1]; 18 immunocyte phenotypes were negatively associated with osteonecrosis ( P <0.05, OR<1), none of which were heterogeneous or horizontally pleiotropic ( P > 0.05) or reverse causality. In addition to this, in reverse MR, osteonecrosis was positively associated with 10 additional immunocyte phenotypes ( P <0.05, OR > 1) and negatively associated with 14 immunocyte phenotypes ( P <0.05, OR<1). And none of them had heterogeneity and horizontal pleiotropy ( P > 0.05) or reverse causality.

CONCLUSIONS

The authors demonstrated a complex causal relationship between multiple immune phenotypes and osteonecrosis through a comprehensive two-way, two-sample MR analysis, highlighting the complex pattern of interactions between the immune system and osteonecrosis.

rESWT promoted angiogenesis via Bach1/Wnt/β-catenin signaling pathway

Previous reports have established that rESWT fosters angiogenesis, yet the mechanism by which rESWT promotes cerebral angiogenesis remains elusive. rESWT stimulated HUVECs proliferation as evidenced by the CCK-8 test, with an optimal dosage of 2.0 Bar, 200 impulses, and 2 Hz. The tube formation assay of HUVECs revealed that tube formation peaked at 36 h post-rESWT treatment, concurrent with the lowest expression level of Bach1, as detected by both Western blot and immunofluorescence. The expression level of Wnt3a, β-catenin, and VEGF also peaked at 36 h. A Bach1 overexpression plasmid was transfected into HUVECs, resulting in a decreased expression level of Wnt3a, β-catenin, and VEGF. Upon treatment with rESWT, the down-regulation of Wnt3a, β-catenin, and VEGF expression in the transfected cells was reversed. The Wnt/β-catenin inhibitor DKK-1 was utilized to suppress Wnt3a and β-catenin expression, which led to a concurrent decrease in VEGF expression. However, rESWT treatment could restore the expression of these three proteins, even in the presence of DKK-1. Moreover, in the established OGD model, it was observed that rESWT could inhibit the overexpression of Bach1 and enhance VEGF and VEGFR-2 expression under the OGD environment.

Automatic planning and geometric analysis of the drilling path in core decompression surgery for osteonecrosis of the femoral head

BACKGROUND AND OBJECTIVE

Core decompression surgery is an effective treatment method for patients with pre-collapse osteonecrosis of the femoral head (ONFH). The treatment relies on accurately predrilling the wire into the necrotic lesion. However, the surgical planning of this drilling path remains unclear. This paper aims to develop a framework to automatically plan the drilling path and analyze its geometric parameters.

METHODOLOGY

The proposed system consists of two stages. The first stage is to detect the key points. Besides the entry point and target point for the drilling path, the center of the femoral head (FH) and the boundary points of the necrotic lesion are also detected for the subsequent geometric analysis. In the second stage, the geometric parameters of the drilling path are analyzed, including the size of the necrotic lesion, the length from the entry point to the target point, the relative location between the FH center and the necrosis center, and the angular range of the drilling path in the anterior-posterior (AP) direction and superior-inferior (SI) direction.

RESULTS

All of the drilling paths designed by the proposed system were considered successful, starting from the proximal subtrochanteric region, terminating at the center of the necrotic lesion, and remaining within the femoral neck. The relative coordinates of the centers of the femoral head and necrotic lesion were (-0.89,5.14,2.63) mm for the left femurs and (1.55,5.92,2.63) mm for the right femurs, on average. The angular range of the drilling path was 39.99±29.58 degrees in the SI direction and 46.18±40.73 degrees in the AP direction.

CONCLUSION

This study develops a framework that allows for automatic planning and geometric analysis of the drilling path in core decompression surgery. The target point of the drilling path primarily resides in the lateral-anterior-superior region relative to the femoral head center. Surgeons and researchers can benefit from our unified framework while still maintaining the flexibility to adapt to variations in surgical cases.

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.

Effect of three clinical therapies on cytokines modulation in the hip articular cartilage and bone improvement in rat early osteonecrosis of the femoral head

BACKGROUND

Extracorporeal shockwave therapy (ESWT) and adipose-derived mesenchymal stem cells (ADSCs) have been used clinically for the treatment of osteonecrosis of the femoral head (ONFH). The study elucidated that ESWT, ADSCs, and combination therapy modulated pro-inflammatory cytokines in the articular cartilage and subchondral bone of early rat ONFH.

METHODS

ESWT and ADSCs were prepared and isolated for treatment. Micro-CT, pathological analysis, and immunohistochemistry were performed and analysed.

RESULTS

After treatments, subchondral bone of ONFH was improved in trabecular bone volume (BV/TV) (p < 0.001), thickness (Tb.Th) (p < 0.01 and 0.001), and separation (Tb.Sp) (p < 0.001) and bone mineral density (BMD) (p < 0.001) using micro-CT analysis. The articular cartilage was protected and decreased apoptosis markers after all the treatments. The expression of IL33 (p < 0.001), IL5 (p < 0.001), IL6 (p < 0.001), and IL17A (p < 0.01) was significantly decreased in the ESWT, ADSCs, and Combination groups as compared with ONFH group. The IL33 receptor ST2 was significantly increased after treatment (p < 0.001) as compared with ONFH group. The Combination group (p < 0.01) decreased the expression of IL6 better than the ESWT and ADSCs groups.

CONCLUSION

ESWT, ADSCs and combination therapy significantly protected articular cartilage and subchondral bone of early rat ONFH by modulating the expression of pro-inflammatory cytokines including, IL33 and its receptor ST2, IL5, IL6, and IL17A.

Metabolomic analysis of bone-derived exosomes in osteonecrosis of the femoral head based on UPLC-MS/MS

INTRODUCTION

Osteonecrosis of the femoral head (ONFH) is a disorder that causes a collapse of the femoral head, requiring subsequent total hip replacement. However, the pathogenesis of ONFH remains largely unclear. Herein, exosome metabolomics analyses were conducted to explore the pathophysiology of ONFH.

OBJECTIVES

This study aimed to conduct metabolic profiling of bone-derived exosomes of ONFH.

METHODS

30 ONFH patients and 30 femoral neck fracture (FNF) patients were included in this study. Exosomes were harvested from the femoral head by using ultracentrifugation. Ultraperformance liquid chromatography/tandem mass spectrometry (UPLC-MS/MS) was performed in combination with multivariate statistical analysis to reveal and provided new insight into identify the global metabolic profile of ONFH.

RESULTS

The results of transmission electron microscope (TEM), nanoparticle tracking analysis (NTA), and Western blots indicated that the microvesicles isolated from the femoral head were exosomes. Several compounds were identified, including lipids and lipid-like molecules, amino acids, peptides, organooxygen compounds. 44 differential metabolites were screened between ONFH and FNF patients. The up-and down-regulation of Riboflavin metabolism, Pantothenate and CoA biosynthesis, Glycerophospholipid metabolism, and Sphingolipid metabolism were associated with ONFH pathophysiology.

CONCLUSION

Our results suggest that metabolomics has huge prospects for elucidating pathophysiology of ONFH.

Concepts and clinical aspects of active implants for the treatment of bone fractures

Nonunion is a complication of long bone fractures that leads to disability, morbidity and high costs. Early detection is difficult and treatment through external stimulation and revision surgery is often a lengthy process. Therefore, alternative diagnostic and therapeutic options are currently being explored, including the use of external and internal sensors. Apart from monitoring fracture stiffness and displacement directly at the fracture site, it would be desirable if an implant could also vary its stiffness and apply an intervention to promote healing, if needed. This could be achieved either by a predetermined protocol, by remote control, or even by processing data and triggering the intervention itself (self-regulated 'intelligent' or 'smart' implant). So-called active or smart materials like shape memory alloys (SMA) have opened up opportunities to build active implants. For example, implants could stimulate fracture healing by active shortening and lengthening via SMA actuator wires; by emitting pulses, waves, or electromagnetic fields. However, it remains undefined which modes of application, forces, frequencies, force directions, time durations and periods, or other stimuli such implants should ideally deliver for the best result. The present paper reviews the literature on active implants and interventions for nonunion, discusses possible mechanisms of active implants and points out where further research and development are needed to build an active implant that applies the most ideal intervention. STATEMENT OF SIGNIFICANCE: Early detection of delays during fracture healing and timely intervention are difficult due to limitations of the current diagnostic strategies. New diagnostic options are under evaluation, including the use of external and internal sensors. In addition, it would be desirable if an implant could actively facilitate healing ('Intelligent' or 'smart' implant). Implants could stimulate fracture healing via active shortening and lengthening; by emitting pulses, waves, or electromagnetic fields. No such implants exist to date, but new composite materials and alloys have opened up opportunities to build such active implants, and several groups across the globe are currently working on their development. The present paper is the first review on this topic to date.

Avascular Necrosis of Femoral Head-Overview and Current State of the Art

Avascular necrosis (AVN) of the femoral head is caused by disruption of the blood supply to the proximal femur. The alterations in the blood supply may occur following a traumatic event or result from a non-traumatic cause. Femoral neck fracture and hip dislocation and associated surgical procedures, corticosteroid therapy, and alcohol abuse frequently lead to AVN development. Type of fracture (displaced or undisplaced) and time between injury and surgery are the most critical factors in assessing the risk of developing AVN. Diagnosis of AVN can be established based on patients’ complaints, medical history, and radiographic findings. There is no consensus on the treatment of patients with AVN to date. Non-surgical methods are dedicated to patients in the early pre-collapse stages of the disease and consist of pharmacotherapy and physiotherapy. Surgery is recommended for patients with advanced disease.

Nonoperative and Operative Bone and Cartilage Regeneration and Orthopaedic Biologics of the Hip: An Orthoregeneration Network (ON) Foundation Hip Review

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and, optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electromagnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the hip, including osteonecrosis (aseptic necrosis) involving bone marrow, bone, and cartilage, and chondral injuries involving articular cartilage, synovium, and bone marrow. Promising and established treatment modalities for osteonecrosis include nonweightbearing; pharmacological treatments including low molecular-weight heparin, prostacyclin, statins, bisphosphonates, and denosumab, a receptor activator of nuclear factor-kB ligand inhibitor; extracorporeal shock wave therapy; pulsed electromagnetic fields; core decompression surgery; cellular therapies including bone marrow aspirate comprising mesenchymal stromal cells (MSCs aka mesenchymal stem cells) and bone marrow autologous concentrate, with or without expanded or cultured cells, and possible addition of bone morphogenetic protein-2, vascular endothelial growth factor, and basic fibroblast growth factor; and arterial perfusion of MSCs that may be combined with addition of carriers or scaffolds including autologous MSCs cultured with beta-tricalcium phosphate ceramics associated with a free vascularized fibula. Promising and established treatment modalities for chondral lesions include autologous platelet-rich plasma; hyaluronic acid; MSCs (in expanded or nonexpanded form) derived from bone marrow or other sources such as fat, placenta, umbilical cord blood, synovial membrane, and cartilage; microfracture or microfracture augmented with membrane containing MSCs, collagen, HA, or synthetic polymer; mosaicplasty; 1-stage autologous cartilage translation (ACT) or 2-stage ACT using 3-dimensional spheroids; and autologous cartilage grafting; chondral flap repair, or flap fixation with fibrin glue. Hip pain is catastrophic in young patients, and promising therapies offer an alternative to premature arthroplasty. This may address both physical and psychological components of pain; the goal is to avoid or postpone an artificial joint. LEVEL OF EVIDENCE: Level V, expert opinion.

Comparisons of Ultrasound-Guided Platelet-Rich Plasma Intra-Articular Injection and Extracorporeal Shock Wave Therapy in Treating ARCO I–III Symptomatic Non-Traumatic Femoral Head Necrosis: A Randomized Controlled Clinical Trial

Background and Objective

Osteonecrosis of the femoral head (ONFH) is a devastating disease, and there is some evidence that extracorporeal shock wave therapy (ESWT) and intra-articular platelet-rich plasma (PRP) injection might alleviate pain and improve joint function in individuals with ONFH. The objective of this study was to compare the effectiveness and safety of PRP and ESWT in symptomatic ONFH patients.

Methods

A total of 60 patients aged 40–79 with unilateral ONFH at Association Research Circulation Osseous (ARCO) stages I, II, and III were randomly assigned to the PRP (N=30) or the ESWT group (N=30). Four treatment sessions were provided in both groups. Assessments were performed at baseline, and 1-, 3-, 6-, and 12-month. Primary outcomes were measured by the visual analogue scale (VAS), and pressure pain thresholds (PPTs). Secondary outcomes were assessed by Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Harris Hip Score (HHS), and magnetic resonance imaging (MRI). The linear mixed-model analysis was used to evaluate the differences between groups and within groups and the “group by time” interaction effects.

Results

There were significant differences between groups in terms of changes over time for VAS, PPTs, WOMAC, and HHS since 3-month and maintained up to 12-month (P<0.05, except for PPTs at 12-month). The simple main effects showed that the patients in PRP group had greater improvements in VAS (mean difference = −0.82, 95% CI [−1.39, −0.25], P=0.005), WOMAC (mean difference = −4.19, 95% CI [−7.00, −1.37], P=0.004), and HHS (mean difference = 5.28, 95% CI [1.94, 8.62], P=0.002). No related adverse events were reported.

Conclusion

This study supported the effectiveness and safety of both the PRP injection and ESWT in treating ONFH patients. For symptomatic patients with ONFH, intra-articular PRP injection appeared superior to ESWT in pain relief and functional improvement.

Bone Marrow Edema: Overview of Etiology and Treatment Strategies

➤

Bone marrow edema (BME) is a nonspecific but relevant finding, usually indicating the presence of an underlying pathology.

➤

The gold standard technique for detecting BME is magnetic resonance imaging (MRI), as it allows for a correct diagnosis to be made, which is extremely important given the heterogeneity of BME-related diseases.

➤

Depending on the severity of painful symptomatology and the MRI evidence, different treatment strategies can be followed: physical modalities, pharmacological options, and surgical therapy.

Quantitative Magnetic Resonance Imaging of Femoral Head Articular Cartilage Change in Patients with Hip Osteonecrosis Treated with Extracorporeal Shock Wave Therapy

BACKGROUND

Multiple reports have demonstrated the therapeutic potential of extracorporeal shock wave (ESWT) in osteonecrosis of the femoral head (ONFH). However, few studies reported the changes in hip articular cartilage after the intervention. This study aimed to investigate the effect of ESWT on femoral head cartilage using a novel technique, quantitative T2-mapping magnetic resonance imaging.

METHODS

A total of 143 eligible patients with unilateral early-stage ONFH were randomized into the ESWT group and control group. Seventy-three patients in the ESWT group received two sessions of ESWT with oral drug treatment, while seventy patients in the control group received oral drug treatment only. The visual analog pain scale (VAS) and Harris hip score (HHS) at 3-month, 6-month, and 12-month follow-up were used as the clinical evaluation index. The radiological evaluation index used the T2 mapping values, necrotic size, and China-Japan Friendship Hospital (CJFH) classification.

RESULTS

A total of 143 patients (62 females and 81 males) were finally included, and the characteristics before treatment were comparable between the two groups. At the last follow-up (12 months), the T2 values and ΔT2 changes in the ESWT group were all smaller than those in the control group (p=0.042; p=0.039), while the CJFH classification of ONFH and necrotic lesion size were not statistically significant. At 3 months and 6 months, the VAS in the ESWT group was lower than that in the control group (p=0.021; p=0.046) and the HHS in the ESWT group was higher (p=0.028; p=0.039). However, there were no significant differences in the VAS and HHS at 12 months between the ESWT and control groups.

CONCLUSIONS

The results of the current study indicated that, based on drug treatment, ESWT is an effective treatment method for nontraumatic ONFH, which could result in significant pain relief and function restoration. Furthermore, it could delay the injury of femoral head cartilage during the progression of ONFH.

Extracorporeal Shockwave Therapy Modulates the Expressions of Proinflammatory Cytokines IL33 and IL17A, and Their Receptors ST2 and IL17RA, within the Articular Cartilage in Early Avascular Necrosis of the Femoral Head in a Rat Model

Avascular necrosis (AVN) of the femoral head (AVNFH) is a disease caused by injury to the blood supply of the femoral head, resulting in a collapse with osteonecrosis and damage to the articular cartilage. Extracorporeal shockwave therapy (ESWT) has been demonstrated to improve AVNFH owing to its anti-inflammation activity, angiogenesis effect, and tissue regeneration in clinical treatment. However, there are still so many pieces of the jigsaw that need to be fit into place in order to ascertain the mechanism of ESWT for the treatment of AVNFH. The study demonstrated that ESWT significantly protected the trabecular bone volume fraction BV/TV (P < 0.01) and the trabecular thickness (P < 0.001), while in contrast, the trabecular number and trabecular separation were not significantly different after treatment as compared with AVNFH. ESWT protected the articular cartilage in animal model of AVNFH. The levels of IL1-β and IL33 were significantly induced in the AVNFH group (P < 0.001) as compared with Sham and ESWT groups and reduced in ESWT group (P < 0.001) as compared with AVNFH group. In addition, the expression of the receptor of IL33, ST2, was reduced in AVNFH and induced after ESWT (P < 0.001). The expression of IL17A was induced in the AVNFH group (P < 0.001) and reduced in the ESWT group (P < 0.001). Further, the expression of the receptor of IL17A, IL17RA, was reduced in the AVNFH group (P < 0.001) and improved to a normal level in the ESWT group as compared with Sham group (P < 0.001). Taken together, the results of the study indicated that ESWT modulated the expression of IL1-β, pro-inflammatory cytokines IL33 and IL17A, and their receptors ST2 and IL17RA, to protect against loss of the extracellular matrix in the articular cartilage of early AVNFH.

Retrospective Study of Rehabilitation Exercise Combined with Extracorporeal Shock Wave Therapy for Knee Osteoarthritis

Background

The aim of this study was to investigate the effect of rehabilitation exercise combined with extracorporeal shock wave therapy (ESWT) on knee osteoarthritis (KOA).

Material/Methods

The clinical data of 217 patients with KOA who underwent ESWT in our hospital from December 2017 to January 2020 were retrospectively analyzed. The patients were divided into a rehabilitation exercise (RE) group and a non-rehabilitation exercise (NRE) group according to whether they were given RE. The treatment course of the 2 groups was 5 weeks. Pain Visual Analog Scale (VSA), Western Ontario and McMaster Universities knee osteoarthritis index visualized scale (WOMAC), Lequesne index scores, Range of motion (ROM) score, and Japanese Orthopaedic Association (JOA) scores were used to evaluate the treatment effect of the 2 groups of patients.

Results

After 5 weeks of treatment, the VSA scores (p<0.001), WOMAC scores (P<0.001) and Lequesne index scores (P<0.001) of the RE group and NRE group were significantly lower than those before treatment, while ROM score (P<0.001) and JOA score (p=0.006) were significantly increased. Compared with the NRE group, the VAS score (3.14±0.64 vs. 4.78±0.85, P=0.002), WOMAC score (20.37±4.06 vs. 27.82±4.57, P<0.001) and Lequesne index score (6.13±1.83 vs. 7.35±2.21, P=0.019) in the RE group were significantly lower than those in the NHE group; however, the ROM score (89.13±9.83 vs. 79.15±6.25, P=0.021) and JOA score (79.53±7.59 vs. 67.85±8.27, P=0.016) were significantly higher than those in the NRE group.

Conclusions

RE combined with ESWT has a positive effect on KOA, which may more significantly relieve the patient’s clinical symptoms and improve joint function and quality of life.

Extracorporeal shockwave therapy combined with multiple drilling and intramedullary drug injection for treating early-stage Femur Head Necrosis: Protocol for a randomized controlled trial

BACKGROUND

Early diagnosis and treatment of the osteonecrosis of the femoral head (ONFH), a refractory disease, is imperative to prevent femoral head collapse; however, the existing solutions remain controversial. This study assessed the safety and efficacy of extracorporeal shock wave therapy (ESWT) combined with multiple drilling and intramedullary drug injection, a novel cocktail therapy, as a randomized controlled trial (RCT) model to postulate an alternative therapy for patients with early-stage ONFH.

METHODS

Femoral head necrosis patients aged 20 to 60 years with stage ARCO I-II were recruited. One hundred twenty eligible participants were randomized into four groups in a 1:1:1:1 ratio: extracorporeal shock wave therapy combined with multiple drilling and intramedullary drug injection (group EMI), extracorporeal shock wave therapy (group E), multiple drilling combined with intramedullary drug injection (group MI), and multiple drilling ("positive" control group; group M). The primary outcomes included effective rate, subchondral collapse rate of the femoral head, lesion size, and grade of bone marrow edema. Secondary outcomes included the Harris Hip Score and the visual analog scale. All outcomes were measured at the screening visit (baseline) and at the planned time intervals during treatment and follow-up, and the efficacy was statistically analyzed according to the intention-to-treat sub-populations and per-protocol sub-populations.

OBJECTIVES

To examine the clinical efficacy of ESWT combined with multiple drilling and intramedullary drug injection to provide a safe and more effective method for treating early-stage ONFH.

TRIAL REGISTRATION NUMBER

ChiCTR1900020888; Pre-results.

Pain and Muscles Properties Modifications After Botulinum Toxin Type A (BTX-A) and Radial Extracorporeal Shock Wave (rESWT) Combined Treatment

BACKGROUND AND OBJECTIVE

Spasticity (most common disability in upper motor neuron syndrome or UMNS) caused an inability of patients' to perform daily activities and a decrease inquality of life. One of the promising methods nowadays, but still not widely used in everyday practice, for spasticity reduction is extracorporeal shock wave. The aim of this study was to evaluate the objective clinical effects of combined treatment botulinum toxin type A and radial Extracorporeal Shock Wave Therapy in spasticity post stroke.

METHODS

We considered 30 subjects (14 female and 16 male) with post stroke spasticity of Biceps Brachii, Superficial Flexor Digitorum, Gastrocnemius Medialis and Lateralis and we divided patients into two groups (group A received botulinum toxin injection and physiotherapy while group B received botulinum toxin injection, rESWT and physiotherapy). Assessments were performed before treatment (t0), after 1 (t1), 2 (t2) e 3 (t3) months using Modified Ahworth Scale, Visual Analogical Scale for pain and MyotonPro® device (to assessed myometric evaluation of muscles tone and stiffness).

RESULTS

Visual Analogical Scale, Modified Ahworth Scale, muscles tone and stiffness statistically decreased until t3 in the group A and in the group B, but the differences between the two groups were significant at the t1 only.

CONCLUSION

Radial Extracorporeal Shock Wave Therapy could be an effective physical treatment aimed at the reduction of upper and lower limbs spasticity and could lead to the improvement of trophic conditions of the spastic muscles in post-stroke.

Osteonecrosis in pediatric cancer survivors: Epidemiology, risk factors, and treatment

Several treatment regimens for childhood malignancies have been associated with the development of osteonecrosis, including radiation therapy, glucocorticoid medications, immunotherapy (including anti-angiogenic agents), and several chemotherapeutic agents. Adolescents older than 10 years are at greatest risk of developing osteonecrosis within 1 year of initiating therapy. Screening with magnetic resonance imaging in this high-risk population may be a useful method for detecting osteonecrosis. Surgery may be required for lesions that have progressed substantially despite nonoperative interventions.

Clinical and Radiological Outcomes of Extracorporeal Shock Wave Therapy in Early-Stage Femoral Head Osteonecrosis

Objective

Femoral head osteonecrosis is a progressive clinical condition with significant morbidity and long-term disability. Several treatment modalities including both surgical and nonsurgical options have been used with variable levels of success. High-energy extracorporeal shock wave therapy is a nonoperative treatment option that has been described for early-stage disease. We aimed to assess the functional and radiological outcomes of extracorporeal shockwave therapy (ESWT) in the treatment of osteonecrosis of the femoral head (ONFH).

Methods

Thirty-three hips of 21 patients were included in this study. Adult patients with ONFH of any etiology and in the precollapse stage were included. Clinical (visual analogue scale [VAS] and Harris hip score [HHS]) and radiological (plain radiographs and magnetic resonance imaging [MRI]) evaluations were performed before and after intervention. We used 3000–4500 pulses in a single session performed under general anesthesia.

Results

At an average of 8 months after ESWT, pain scores and HHS were significantly improved compared with the preintervention scores (p<0.001). The overall clinical outcomes were improved in 21 hips (63.3%), unchanged in 5 hips (15.15%), and worsened in 7 hips (21.2%). A trend toward a decrease in the size of the ONFH was observed although not of clinical significance (p=0.235). MRI revealed significant resolution of bone marrow edema (p<0.003). Regression was observed in 9 lesions (42.9%) and progression in 1 lesion (4.7%); no change was observed in the remaining 23 lesions (52.4%).

Conclusion

ESWT is a viable noninvasive treatment option for early-stage ONFH. It significantly improves clinical outcomes and may halt or delay the radiographic progression of the disease in the precollapse stage.

What is the role of core decompression in the early stages of osteonecrosis of the femoral head? Evaluation of the surgical result by functional score and radiological follow-up

Objectives

This study is aimed at evaluating whether core decompression of the femoral head in the early stages of femoral head osteonecrosis improves patients’ subjective perception of pain and avoids the progression of the disease to a femoral head collapse and a final indication of total hip arthroplasty.

Methods

Eighteen patients (30 hips) in the early stages of the disease (Ficat and Arlet 1 and 2A) were evaluated through clinical, radiological, risk factor maintenance, and by the functional Merle D’Aubigné, and Postel score before and after core decompression of the femoral head.

Results

There was an improvement of symptoms up to the sixth month in 83.3% of the hips evaluated through the Merle D’Aubigné and Postel score. However, 73.3% of the cases evolved with femoral head collapse, and in 50%, total hip arthroplasty was indicated regardless of whether or not the risk factors were maintained.

Conclusions

Core decompression of the femoral head improves patients’ pain early in the initial stages of the pathology. However, it does not alter the prognosis and the ultimate indication of total hip arthroplasty in the final stages of the disease.

Clinical reports of surgical dislocation of the hip with sequestrum clearance and impacting bone graft for grade IIIA-IIIB aseptic necrosis of femoral head (ANFH) patients

Objective

To analyze the treatment effect of surgical dislocation of the hip with sequestrum clearance and impacting bone graft in grade IIIA-IIIB aseptic necrosis of femoral head (ANFH) patients.

Methods

From June 2012 to December 2014, 6 patients (total 8 hips) with grade IIIA-IIIB ANFH were retrospectively followed. All the patients were operated with surgical dislocation of the hip with sequestrum clearance and impacting bone graft. Collapse of the femoral head, healing of the osteotomy, along with Harris hip scores were observed after surgeries.

Results

All the patients were followed up, the osteotomies were all healed. Only 1 of the 8 hips (12.5%) was collapsed by the last follow-up. Harris hip scores were improved from 54.52 ± 8.16 to 80.53 ± 7.62 (P <0.001). The excellent rate was 87.5%.

Conclusion

For grade IIIA-IIIB ANFH patients, surgical dislocation with sequestrum clearance and impacting bone graft could possibly achieve satisfactory clinical benefit, particularly for the young patients.

Nationwide study on the risk of unprovoked venous thromboembolism in non-traumatic osteonecrosis of femoral head

PURPOSE

Endothelial dysfunction is a risk factor for osteonecrosis of femoral head (ONFH) and venous thromboembolism (VTE) [defined as deep venous thrombosis (DVT) or pulmonary embolism (PE)]. However, the risk of unprovoked VTE in non-traumatic ONFH patients remains unclear.

METHODS

We investigated the relationship between ONFH and VTE using Taiwan National Health Insurance Research Database (NHIRD). Between 1997 and 2010, a total of 1514 non-traumatic ONFH patients were identified from 1,000,000 general populations after excluding initially concomitant diagnoses of DVT and PE, and subjects undergoing lower limb surgery within one year since enrollment. The comparison group (n = 15,140) without ONFH was set up by matching study cohort with age, gender, income and urbanization in a 1:10 ratio. Subjects diagnosed with VTE within one year after surgery were also excluded.

RESULTS

The patients with non-traumatic ONFH had significantly higher frequency of unprovoked VTE, including DVT, than general population (1.19 vs. 0.5%, p < 0.0007), whereas the frequency of PE was similar between these two groups (p = 0.4922). The cumulative incidence of VTE and DVT was also remarkably higher in the ONFH than non-ONFH group (all p < 0.001). After adjusting for age, gender, medications and comorbidities with multivariate analysis, the ONFH patients had a 2.3-fold increase in risk of DVT compared with non-ONFH counterparts (95% CI 1.28 to 4.13, p = 0.0053). Apart from ONFH, age > 65 years and hypertension were also identified as risk factors for DVT occurrence.

CONCLUSIONS

The incidence and risk of unprovoked VTE were significantly increased in the non-traumatic ONFH population.

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.

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.

Clinical analysis of 23 cases of steroid-associated osteonecrosis of the femoral head with normal initial magnetic resonance imaging presentation

To explore the clinical characteristics of steroid-associated osteonecrosis of the femoral head (ONFH) presenting initially normal magnetic resonance imaging (MRI) results.This retrospective study examined data from 23 cases that suffered from ONFH but presented a normal image at the first MRI examination after corticosteroid therapy from June 2005 to December 2013. Data on protopathy, age, sex, time of pain onset, MRI examination, and initial diagnosis were collected and analyzed.Average time from steroid therapy to first MRI examination was 45.7 ± 25.5 days (range, 10-94 days). Average time to final diagnosis was 199.9 ± 165.8 days (range, 32-762 days). Of the 23 cases, 21 cases complained of discomfort and were misdiagnosed because of a normal initial MRI scan. Twelve hips progressed to collapse and 1 hip received lumbar discectomy when got the final diagnosis. Cases with continuous pain (9/21) presented with pain at a later time than those with intermittent pain (12/21), although the continuous pain cases were diagnosed earlier.MRI performed 2 to 3 months after steroid therapy may present normal images. Another MRI examination is necessary to make a definite diagnosis.

Osteonecrosis following treatment for childhood acute lymphoblastic leukaemia: The Southampton Children's Hospital experience

PURPOSE

To determine the prevalence of osteonecrosis (ON) in children following treatment of acute lymphoblastic leukaemia (ALL), characterise these cases and review treatment methods.

METHODS

All children diagnosed and treated for ALL between 01 January 2003 and 31 December 2013 at our centre were retrospectively reviewed. Logistic regression was used to investigate risk factors for ON occurrence.

RESULTS

Of 235 children treated for ALL, 48/235 (20.4%) children suffered musculoskeletal symptoms necessitating radiological investigation. A total of 13 (5.5%) had MRI-diagnosed ON, with a median diagnosis time of 12 months (interquartile range 10 to 14) following initiation of chemotherapy.ON affected 40 joints in 13 children. The most commonly involved joints were hips (14 joints in eight patients) and knees (12 joints in seven patients).Older age at ALL diagnosis was associated with significantly increased risk of development of ON per year (odds ratio 1.35, 95% confidence interval 1.17 to 1.57, p < 0.001).Eight children underwent at least one surgical intervention. Joint arthroplasty was undertaken in nine joints of four children at a mean age of 18.3 years. All patients who underwent hip arthroplasty had previously received core decompression, with a mean time of 27.8 months (18 to 33) between treatments.

CONCLUSIONS

ON is a significant complication of ALL treatment. Our results suggest risk stratification for development of ON by age, and targeted monitoring of high-risk joints is possible. ON treatment is varied with little evidence base.

Osteonecrosis in children and adolescents with acute lymphoblastic leukemia: a therapeutic challenge

Osteonecrosis (ON) represents one of the most common and debilitating sequelae of antileukemic treatment in children and adolescents with acute lymphoblastic leukemia (ALL). Systematic screening strategies can focus on early detection and intervention to prevent ON from progressing to stages associated with pain and functional impairment. These strategies hold promise for reducing ON-associated morbidity without the risk of impairing leukemia control. Herein, we critically reviewed clinical data on pharmacological, nonpharmacological/nonsurgical, and surgical (including cellular) treatment options for ON, which are covered in the literature and/or are conceivable based on the supposed underlying ON pathophysiology. Prevention of ON progression is of paramount importance, and attempts seem to be more effective in early (precollapse) disease status than in late-stage (collapse) ON. Based on the results of ongoing prospective magnetic resonance imaging screening studies, which will hopefully identify those patients with a high risk of ON progression and debilitating sequelae, prospective interventional studies are urgently needed. Although there is still a lack of high-quality studies, based on currently available data, core decompression surgery combined with cellular therapies (eg, employing mesenchymal stem cells) appears most promising for preventing joint infraction in children at high risk of developing late-stage ON.

Sesamoid osteonecrosis treated with radial extracorporeal shock wave therapy

Sesamoid osteonecrosis is a disabling condition resulting in severe forefoot pain, for which there are limited treatment options. We present a 52-year-old man with 1-year history of pain, aggravated by walking and playing tennis. On examination, pain was localised to plantar aspect of the first metatarsophalangeal joint. Imaging revealed evolving end-stage avascular necrosis of lateral sesamoid with early secondary degenerative changes. Previous exhaustive conservative treatment had been unsuccessful in alleviating his pain. As an alternative to surgery, radial extracorporeal shock wave therapy (rESWT) was proposed. Treatment protocol was 2000 pulses at frequency of 5 Hz, and pressure was varied from 1.2 to 1.8 bar according to patient tolerance. A total of eight sessions were delivered. At completion of treatment, the patient reported minimal discomfort to no pain and was able to return to playing tennis with no recurrence. We propose rESWT to be an effective novel conservative treatment for sesamoid osteonecrosis.

Effectiveness of Lower Energy Density Extracorporeal Shock Wave Therapy in the Early Stage of Avascular Necrosis of the Femoral Head

Objective

To evaluate the effectiveness of lower energy flux density (EFD) extracorporeal shock wave therapy (ESWT) in the early stage of avascular necrosis (AVN) of the femoral head.

Methods

Nineteen patients and 30 hips were enrolled. All subjects received 4 weekly sessions of ESWT, at different energy levels; group A (n=15; 1,000 shocks/session, EFD per shock 0.12 mJ/mm²) and group B (n=15; 1,000 shocks/session, EFD per shock 0.32 mJ/mm²). We measured pain by using the visual analog scale (VAS), and disability by using the Harris hip score, Hip dysfunction and Osteoarthritis Outcome Score (HOOS), and the Western Ontario and McMaster University Osteoarthritis Index (WOMAC). To determine the effect of the lower EFD ESWT, we assessed the VAS, Harris hip score, HOOS, WOMAC of the subjects before and at 1, 3, and 6 months.

Results

In both groups, the VAS, Harris hip score, HOOS, and WOMAC scores improved over time (p<0.05).

Conclusion

Lower EFD ESWT may be an effective method to improve the function and to relieve pain in the early stage of AVN.

Extracorporeal Shock Wave Stimulation as Alternative Treatment Modality for Wrist and Fingers Spasticity in Poststroke Patients: A Prospective, Open-Label, Preliminary Clinical Trial

Objective. To evaluate the effectiveness of radial shock waves (rESW) for wrist and fingers flexors spasticity in stroke patients. Methods. Twenty patients with upper limb muscle spasticity were enrolled in the study and treated with a single session of rESW. The spasticity level of the radio carpal (RC) and finger (FF) joints was assessed using Modified Ashworth Scale (MAS). The resting bioelectrical activity of the flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU) was examined using surface electromyography (sEMG). Trophic conditions were measured using infrared thermal (IRT) imaging. All measurements were conducted at baseline (t₀), immediately after rESW (t₁), and 1 (t₂) and 24 (t₃) hours following rESW. Results. Significant reduction in MAS was observed for the RC joint in t₁, as well as for the FF joints in t₁, t₂, and t₃. A significant decrease in sEMG was shown for the FCR muscle in t₁ and t₂, as well as for the FCU muscle in t₁ and t₃. Also, a significant increase in IRT value was observed in t₃ only. Conclusions. A single session of rESW could be an effective alternative treatment for reduction of limb spasticity and could lead to improvement of trophic conditions of the spastic muscles.

Effects of extracorporeal shock wave on upper and lower limb spasticity in post-stroke patients: A narrative review

BACKGROUND

Effective treatment strategies for post-stroke muscle spasticity are still a significant interdisciplinary issue and challenge for neurologists, neurosurgeons, physiatrists nurses and physiotherapists. Extracorporeal shock wave (ESW) treatment is a well-supported physical modality used in a wide range of musculoskeletal disorders. The list of justified indications for ESW treatment and scientific areas of investigations is continuously evolving and adapting to different pathologies, including spasticity after stroke.

OBJECTIVES

To analyze the relevant available research and clinical studies demonstrated that the treatment potentials and effectiveness of ESW procedure including mechanisms of the anti-spastic action within hypertonic muscles after stroke.

LITERATURE SEARCH

A computer research was performed using MEDLINE, PubMed, PEDro, CINAHL, and EMBASE databases. Assessment of eligibility of papers was determined by two independent reviewers. The inclusion criteria comprised: publication in peer-reviewed journals, studies published in the last 10 years, involving clinical trials, full-version available and written in English only.

DISCUSSION

A total of 91 articles were collected, 83 of which were non relevant. Ultimately, 8 clinical studies within a total of 195 patients met inclusion criteria for this review. Only one randomized controlled trial was found and then scored using the Cochrane-based assessment. The other studies involving were analyzed separately according to their methodological quality in a descriptive manner.

CONCLUSIONS

ESW was found to be safe and effective. The mechanism of ESW action is still under investigation.

Enhancing the efficiency of desensitizing agents with shockwave treatment – a new paradigm in dentinal hypersensitivity management

Micro-shockwave assisted dentin hypersensitivity management.