Extracorporeal shockwave therapy (ESWT)--First choice treatment of fracture non-unions?

Mechanosensitive Ca2+ channel TRPV1 activated by low-intensity pulsed ultrasound ameliorates acute kidney injury through Notch1-Akt-eNOS signaling

Acute Kidney Injury (AKI) is a significant medical condition characterized by the abrupt decline in kidney function.Low-intensity pulsed ultrasound (LIPUS), a non-invasive therapeutic technique employing low-intensity acoustic wave pulses, has shown promise in promoting tissue repair and regeneration. A novel LIPUS system was developed and evaluated in rat AKI models, focusing on its effects on glomerular filtration rate (GFR), blood urea nitrogen (BUN), serum creatinine (SCr), and the Notch1-Akt-eNOS signaling pathway. The results demonstrated that LIPUS treatment improved GFR, BUN, SCr levels, and renal pathology in AKI rats. In vitro experiments using HUVEC cells revealed that LIPUS stimulation promoted angiogenesis, cell migration mechanically-dependent calcium ion influx, which was partially attenuated by TRPV1 knockdown. RNA sequencing analysis indicated LIPUS-induced activation of the Notch pathway, phosphorylation of Akt and eNOS. Furthermore, inhibition or genetic silencing of Notch1 abolished the beneficial effects of LIPUS on angiogenesis, renal function, and Akt-eNOS phosphorylation in both cells and AKI rats. These findings suggest that LIPUS-induced calcium influx promotes Akt-eNOS phosphorylation, nitric oxide (NO) production, angiogenesis, and improved renal function in AKI via Notch1-Akt-eNOS signaling, positioning LIPUS as a promising therapeutic strategy for AKI by targeting vascular regeneration.

A novel shockwave-driven nanomotor composite microneedle transdermal delivery system for the localized treatment of osteoporosis: a basic science study

BACKGROUND

Clinical protocols in osteoporosis treatment could not meet the requirement of increasing local bone mineral density. A local delivery system was brought in to fix this dilemma. The high-energy extracorporeal shock wave (ESW) can travel into the deep tissues with little heat loss. Hence, ESW-driven nanoparticles could be used for local treatment of osteoporosis.

MATERIALS AND METHODS

An ESW-actuated nanomotor (NM) sealed into microneedles (MNs) (ESW-NM-MN) was constructed for localized osteoporosis protection. The NM was made of calcium phosphate nanoparticles with a high Young's modulus, which allows it to absorb ESW energy efficiently and convert it into kinetic energy for solid tissue penetration. Zoledronic (ZOL), as an alternative phosphorus source, forms the backbone of the NM (ZOL-NM), leading to bone targeting and ESW-mediated drug release.

RESULTS

After the ZOL-NM is sealed into hyaluronic acid (HA)-made microneedles, the soluble MN tips could break through the stratum corneum, injecting the ZOL-NM into the skin. As soon as the ESW was applied, the ZOL-NM would absorb the ESW energy to move from the outer layer of skin into the deep tissue and be fragmented to release ZOL and Ca 2+ for anti-osteoclastogenesis and pro-osteogenesis. In vivo , the ZOL-NM increases localized bone parameters and reduces fracture risk, indicating its potential value in osteoporotic healing and other biomedical fields.

CONCLUSION

The ESW-mediated transdermal delivery platform (ESW-NM-MN) could be used as a new strategy to improve local bone mineral density and protect local prone-fracture areas.

Cardiac shockwave therapy in addition to coronary bypass surgery improves myocardial function in ischaemic heart failure: the CAST-HF trial

BACKGROUND AND AIMS

In chronic ischaemic heart failure, revascularisation strategies control symptoms but are less effective in improving left ventricular ejection fraction (LVEF). The aim of this trial is to investigate the safety of cardiac shockwave therapy (SWT) as a novel treatment option and its efficacy in increasing cardiac function by inducing angiogenesis and regeneration in hibernating myocardium.

METHODS

In this single-blind, parallel-group, sham-controlled trial (cardiac shockwave therapy for ischemic heart failure, CAST-HF; NCT03859466) patients with LVEF ≤40% requiring surgical revascularisation were enrolled. Patients were randomly assigned to undergo direct cardiac SWT or sham treatment in addition to coronary bypass surgery. The primary efficacy endpoint was the improvement in LVEF measured by cardiac magnetic resonance imaging from baseline to 360 days.

RESULTS

Overall, 63 patients were randomized, out of which 30 patients of the SWT group and 28 patients of the Sham group attained 1-year follow-up of the primary endpoint. Greater improvement in LVEF was observed in the SWT group (Δ from baseline to 360 days: SWT 11.3%, SD 8.8; Sham 6.3%, SD 7.4, P = .0146). Secondary endpoints included the 6-minute walking test, where patients randomized in the SWT group showed a greater Δ from baseline to 360 days (127.5 m, SD 110.6) than patients in the Sham group (43.6 m, SD 172.1) (P = .028) and Minnesota Living with Heart Failure Questionnaire score on day 360, which was 11.0 points (SD 19.1) for the SWT group and 17.3 points (SD 15.1) for the Sham group (P = .15). Two patients in the treatment group died for non-device-related reasons.

CONCLUSIONS

In conclusion, the CAST-HF trial indicates that direct cardiac SWT, in addition to coronary bypass surgery improves LVEF and physical capacity in patients with ischaemic heart failure.

Treatment of delayed union of the forearm with extracorporeal shockwave therapy: a case report and literature review

Compared to other long bones, forearm fractures are particularly challenging due to the high rate of complications. These include malunion, delayed/nonunion, wrist and elbow movement reduction, and pain. Surgical procedure is considered the gold standard for managing delayed union and nonunion of the long bones. However, in the last decades, extracorporeal shockwave therapy (ESWT) has emerged as an effective and less invasive approach to enhance bone regeneration and fracture healing, avoiding major complications of surgical procedures. In contrast to the broad literature reporting good clinical results of ESWT in the treatment of nonunions, there is currently limited evidence regarding the clinical application of shock waves on long bone delayed fractures, particularly those of the forearm. In the present paper, we report a case of delayed bone healing of the diaphyseal region of the ulna treated with focused ESWT. The successful case experienced bone healing at the fracture site in less than 3 months after initial ESWT treatment. Acknowledging the limitation of reporting a case report, however, the remarkable clinical results and the absence of side effects contribute valuable information in support of the use of ESWT as an effective alternative to standard surgery for forearm fractures.

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

BACKGROUND

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

OBJECTIVE

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

RESULTS

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

CONCLUSION

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

Biophysical Enhancement in Fracture Healing: A Review of the Literature

Bone healing constitutes a complex process involving cellular and pathophysiological mechanisms. Despite progress in osteosynthesis techniques, fracture union continues to be challenging. In some cases, it is not ultimately achieved or is delayed relative to the expected time resulting in economic and social outcomes for the patient and the health system. In addition to surgical treatment, biophysical methods have been developed to assist in fracture healing used in combination or individually. Biophysical stimulation is a non-invasive therapy used in orthopedic practice to increase and enhance tissue's reparative and anabolic activities. This study reviewed the existing literature, including electromagnetic fields, ultrasound, laser, extracorporeal shockwave therapy, and electrical stimulation, and revealed the efficacy of biophysical stimulation for bone healing. This study aims to define if these methods are helpful, especially in cases of non-union. Biophysical stimulation requires care and precision in use to ensure the success expected of it by physicians and patients.

Safe and Effective Treatment of Compromised Clavicle Fracture of the Medial and Lateral Third Using Focused Shockwaves

A delay or failure to heal is the most common possible complication in clavicle fractures, especially in cases primarily treated conservatively. As the current standard therapy, surgical revision achieves good healing results, but is associated with potential surgery-related complications. Shockwave therapy as a non-invasive therapy shows similar reasonable consolidation rates in the non-union of different localizations, but avoids complications. Compromised clavicle fractures in the middle and lateral third treated with focused high-energy shockwave therapy were compared with those treated with surgical revision (ORIF). In addition, a three-dimensional computer simulation for evaluating the pressure distribution during shockwave application accompanied the clinical study. A comparable healing rate in bony consolidation was achieved in both groups. Significantly fewer complications, however, occurred in the shockwave group. The simulations showed safe application in this instance, particularly in avoiding lung tissue affection. When applied correctly, shockwaves represent a safe and promising therapy option for compromised clavicle fractures in the middle and lateral third.

The effect of extracorporeal shock wave therapy in acute traumatic spinal cord injury on motor and sensory function within 6 months post-injury: a study protocol for a two-arm three-stage adaptive, prospective, multi-center, randomized, blinded, placebo-controlled clinical trial

BACKGROUND

The pathological mechanism in acute spinal cord injury (SCI) is dual sequential: the primary mechanical lesion and the secondary injury due to a cascade of biochemical and pathological changes initiated by the primary lesion. Therapeutic approaches have focused on modulating the mechanisms of secondary injury. Despite extensive efforts in the treatment of SCI, there is yet no causal, curative treatment approach available. Extracorporeal shock wave therapy (ESWT) has been successfully implemented in clinical use. Biological responses to therapeutic shock waves include altered metabolic activity of various cell types due to direct and indirect mechanotransduction leading to improved migration, proliferation, chemotaxis, modulation of the inflammatory response, angiogenesis, and neovascularization, thus inducing rather a regeneration than repair. The aim of this clinical study is to investigate the effect of ESWT in humans within the first 48 h after an acute traumatic SCI, with the objective to intervene in the secondary injury phase in order to reduce the extent of neuronal loss.

METHODS

This two-arm three-stage adaptive, prospective, multi-center, randomized, blinded, placebo-controlled study has been initiated in July 2020, and a total of 82 patients with acute traumatic SCI will be recruited for the first stage in 15 participating hospitals as part of a two-armed three-stage adaptive trial design. The focused ESWT (energy flux density: 0.1-0.19 mJ/mm2, frequency: 2-5 Hz) is applied once at the level of the lesion, five segments above/below, and on the plantar surface of both feet within the first 48 h after trauma. The degree of improvement in motor and sensory function after 6 months post-injury is the primary endpoint of the study. Secondary endpoints include routine blood chemistry parameters, the degree of spasticity, the ability to walk, urological function, quality of life, and the independence in everyday life.

DISCUSSION

The application of ESWT activates the nervous tissue regeneration involving a multitude of various biochemical and cellular events and leads to a decreased neuronal loss. ESWT might contribute to an improvement in the treatment of acute traumatic SCI in future clinical use.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04474106.

Extracorporeal shockwave therapy for the treatment of scaphoid delayed union in a tennis player: A case report

Operative procedures are considered the gold standard when treating delayed union or non-union of the scaphoid despite their considerable complexity and the risk of intraoperative complications. Although extracorporeal shockwave therapy has been reported as a non-invasive treatment option for non-union cases, only a few papers on delayed union or non-union of the scaphoid have been published. A 57-year-old man with delayed union of a scaphoid fracture was treated with extracorporeal shockwave therapy and showed complete bone healing with promising results two months after the start of treatment without undergoing surgery. This result indicated that extracorporeal shockwave therapy could be an option for treating delayed union of scaphoid fractures.

The Effects of Three and Six Sessions of Low Energy Extracorporeal Shockwave Therapy on Graft Incorporation and Knee Functions Post Anterior Cruciate Ligament Reconstruction

Introduction

One session of high energy extracorporeal shockwave therapy (ESWT) was found to improve the healing of anterior cruciate ligament (ACL) after reconstruction in animal and human studies. This study investigated the effects of three and six sessions of low energy ESWT on graft incorporation and knee functions post ACL reconstruction in humans.

Materials and methods

Thirty participants with ACL injuries were recruited and assigned equally into three groups with 10 participants per group (n=10). Participants in the control group received physiotherapy alone without low energy ESWT. Participants in the 3ESWT group underwent three sessions of low energy ESWT (one session per week) combined with physiotherapy, and participants in the 6ESWT group received six sessions of low energy ESWT (one session per week) combined with physiotherapy. However, five participants were lost to follow-up. Evaluations of graft incorporation of the tibial tunnel using magnetic resonance (MRI) and Lysholm score were carried out before ACL reconstruction and after six months post ACL reconstruction.

Results

The number of grafts with partial incorporation in the tibia tunnel in 6ESWT was significantly higher compared with the number of grafts with non-incorporation at six months post-operatively, X2 (1, N=9) =5.44, p =0.02. However, there was no significant difference between frequencies of graft incorporation in tibia tunnel in the control and 3ESWT groups, X2 (1, N=7) =3.57, p =0.06 and X2 (1, N=9) =2.78, p =0.10, respectively at 6 months postoperatively. Lysholm scores were significantly higher at 6 months post ACL reconstruction compared to the baseline value for each group (p<0.002, respectively). However, there was no significant difference in the Lysholm score between each group (F = 2.798, p = 0.083).

Conclusions

Six sessions of low energy ESWT improved graft incorporation in the tibial tunnel. Both three and six sessions of low energy of ESWT does not affect the knee function score at six months post ACL reconstruction.

Addition of shock wave therapy to nail dynamization increases the chance of long-bone non-union healing

Background

Long-bone non-unions after intramedullary nailing can be treated by nail dynamization or focused high-energy extracorporal shock wave therapy (fESWT). The objective of this study was to assess the effect of the combination therapy of nail dynamization and fESWT on long-bone non-unions.

Materials and methods

49 patients with long-bone non-unions (femur and tibia) after nailing were treated with nail dynamization (group D, n = 15), fESWT (group S, n = 17) or nail dynamization in addition to fESWT (group DS, n = 17). Patients were followed up for 6 months retrospectively. Furthermore, age, sex, Non-Union Scoring System (NUSS) score, time intervals from primary and last surgery until intervention and smoking status were analysed for their correlations to bone union.

Results

Union rates were 60% for group D, 64.7% for group S and 88.2% for group DS, with a significant difference between group D and DS (p = 0.024). Successful treatment was correlated with high age (OR 1.131; 95% CI 1.009–1.268; p = 0.034), female gender (OR 0.009; 95% CI 0.000–0.89; p = 0.039), low NUSS score (OR 0.839; 95% CI 0.717–0.081; p = 0.028) and negative smoking status (OR 86.018; 95% CI 3.051–2425.038; p = 0.009).

Conclusions

Data from the present study indicate that the combination therapy of nail dynamization and fESWT leads to a higher union rate than dynamization or fESWT alone.

Level of evidence

Level 3.

Treatment for subtrochanteric fracture and subsequent nonunion in an adult patient with osteopetrosis: A case report and review of the literature

BACKGROUND

As a congenital metabolic bone disease caused by defective osteoclastic resorption of immature bone, osteopetrosis is characterized by diffused sclerosis of bones, brittle bones, easy fracturing, narrow medullary canals, and a weak fracture healing ability. At present, clear standards and principles for the treatment of fractures in patients with osteopetrosis are lacking. Non-operative treatment can prevent fracture hematoma and preserve the blood supply to the bone fragments, while being associated with frequent failures and higher mortality rates. Meanwhile, closed reduction and internal fixation with intramedullary nail (CRIF + IMN) approaches can also protect blood supply to the fracture site. However, IMN cannot be used for the vast majority of patients with osteopetrosis due to the narrowing of medullary canals. Thus, open reduction and internal fixation with plate remains the most appropriate surgical method for treating fractures in patients with osteopetrosis, but this approach is complicated by the lack of intramedullary hematopoiesis in such patients. Fracture healing primarily depends on the blood supply to the external periosteum. Open reduction can also easily destroy the periosteum and cause delayed fracture healing or even nonunion; however, CRIF may be the most practical approach. As a result, it would be prudent to solve the difficulty of drilling during the operation and the problem of postoperative nonunion.

CASE SUMMARY

In 2018, we treated an adult patient with osteopetrosis presenting with a subtrochanteric fracture. The fracture was fixed using a femoral locking compression plate. Because of delayed consolidation, at 12 mo postoperatively the patient was further treated with platelet-rich plasma (PRP) combined with radial extracorporeal shock wave therapy (rESWT). Antero-posterior and lateral radiographs obtained at the latest follow-up (10 mo) showed that the callus had grown at the original fracture site, and the medial fracture line almost disappeared.

CONCLUSION

Osteosynthesis remains the first choice of treatment approach for fractures in patients with osteopetrosis, especially peritrochanteric fractures. Preoperative preparation is necessary to avoid risks such as drill bit breakage and iatrogenic fracture during the operation. Moreover, fractures in a patient with osteopetrosis present with a high risk of delayed union and nonunion, which can be potentially cured with PRP + rESWT.

Low-intensity extracorporeal shock wave therapy for midshaft clavicular delayed union: A case report and review of literature

BACKGROUND

One of the most common complications following surgery for midshaft clavicle fracture is nonunion/delayed union. Extracorporeal shock wave therapy (ESWT) is an alternative to promote new bone formation without surgical complications. To date, no literature has reported low-intensity ESWT (LI-ESWT) in delayed union of midshaft clavicle fracture.

CASE SUMMARY

We reported a 66-year-old Chinese amateur cyclist with clavicle delayed union treated with 10 sessions of LI-ESWT (radial, 0.057 mJ/mm2, 3 Hz, 3000 shocks). No anesthetics were applied, and no side effects occurred. At the 4 mo and 7 mo follow-ups, the patient achieved clinical and radiographical recovery, respectively.

CONCLUSION

In conclusion, our findings indicated that LI-ESWT could be a good option for treating midshaft clavicular delayed union.

High-energy extracorporeal shockwave therapy in humeral delayed and non-unions

INTRODUCTION

Within the last few decades, focused high-energy extracorporeal shockwave therapy (ESWT) has proven to be an effective alternative to standard of care revision surgery in delayed healing fractures or manifest non-unions in various anatomical regions.

MATERIALS AND METHODS

A retrospective multi-variant analysis of an open prospective, single-armed clinical study was conducted. Patients receiving focused high-energy ESWT for a delayed healing or an apparent non-union of a humeral fracture between January 1999 and December 2015 at a single trauma center were included in the study. Bony healing was defined as cortical continuity in three of four cortices and pain-free force loading and evaluated using CT scans and clinical examination at three- and six-month follow-ups after ESWT.

RESULTS

A total of 236 patients were included. N = 93 (43.8%) showed bony consolidation three months after ESWT and n = 105 (52.5%) after six months. Sub-group analysis showed significantly better healing for the proximal metaphyseal humerus (66.7% after six months, n = 42) compared to the diaphyseal region (48.1%, n = 133) and distal metaphyseal humerus (48.1%, n = 25). Regression analysis indicated significantly increased healing rates for patients of younger ages (p = 0.001) and a fracture diastasis of less than 5 mm (p = 0.002).

CONCLUSION

The findings of this study indicate that ESWT can be considered as a treatment option for a well-selected patient population despite the lower healing rates compared to other anatomical regions.

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

INTRODUCTION

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Extracorporeal shock wave therapy accelerates endochondral ossification and fracture healing in a rat femur delayed-union model

Extracorporeal shock wave therapy (ESWT) has been demonstrated to accelerate bone healing; however, the mechanism underlying ESWT-induced bone regeneration has not been fully elucidated. This study aimed to examine the effects of ESWT and the process of fracture healing. A rat model of femur delayed-union was established by cauterizing the periosteum. ESWT treatment at the fracture site was performed 2 weeks after the operation and the site was radiographically and histologically evaluated at weeks 4, 6, and 8. The bone union rate and radiographic score of the ESWT group were significantly higher than those of the control group at 8 weeks. Histological evaluation revealed enhanced endochondral ossification at the fracture site. The effects of ESWT on ATDC5 cells were examined in vitro. ESWT promoted chondrogenic differentiation without inhibiting the proliferation of ATDC5 cells. ESWT may induce significant bone healing by promoting endochondral ossification at the fracture site.

Extracorporeal Shock Wave Therapy for the Treatment of Osteoarthritis: A Systematic Review and Meta-Analysis

Background

Osteoarthritis is the most common musculoskeletal disease. Extracorporeal shockwave therapy had shown an effect on osteoarthritis in both some animal experiments and clinical studies, but there was no systematic review to confirm the value of shockwave therapy in the treatment of all types of osteoarthritis and compare it with other traditional therapies (especially traditional Chinese medicine).

Method

PubMed, Medline, the Cochrane Central Register of Controlled Trials, Web of Science, Chinese National Knowledge Infrastructure, WANFANG database, and VIP database were searched up to December 10, 2019, to identify randomized controlled trials comparing shockwave therapy and other treatments for osteoarthritis. Visual analogue scale and the Western Ontario and McMaster Universities Osteoarthritis Index were extracted and analyzed by RevMan and STATA software as outcomes of pain reduction and functional improvement. Adverse reactions were recorded to evaluate the safety of shockwave therapy.

Results

Shockwave therapy had significant improvement in both pain reduction and functional improvement compared with placebo, corticosteroid, hyaluronic acid, medication, and ultrasound (P < 0.05). In functional improvement, shockwave therapy showed statistical improvement compared with kinesiotherapy and moxibustion (P < 0.05) but not with acupotomy surgery (P = 0.24). A significant difference between shockwave therapy and platelet-rich plasma was observed in pain reduction (P < 0.05) but not in functional improvement (P = 0.89). Meanwhile, a statistical difference was found between shockwave therapy and fumigation in functional improvement (P < 0.05) but not in pain reduction (P = 0.26). Additionally, there was no statistically significant difference between shockwave therapy and manipulation in both pain reduction (P = 0.21) and functional improvement (P = 0.45). No serious adverse reaction occurred in all of studies.

Conclusions

Extracorporeal shockwave therapy could be recommended in the treatment of osteoarthritis as a noninvasive therapy with safety and effectiveness, but the grade of recommendations needs to be discussed in a further study.

Radial Extracorporeal Shock Wave Treatment Promotes Bone Growth and Chondrogenesis in Cultured Fetal Rat Metatarsal Bones

BACKGROUND

Substantial evidence exists to show the positive effects of radialextracorporeal shock wave therapy (ESWT) on bone formation. However, it is unknown whether rESWT can act locally at the growth plate level to stimulate linear bone growth. One way to achieve this is to stimulate chondrogenesis in the growth plate without depending on circulating systemic growth factors. We wished to see whether rESWT would stimulate metatarsal rat growth plates in the absence of vascularity and associated systemic growth factors.

QUESTIONS/PURPOSES

To study the direct effects of rESWT on growth plate chondrogenesis, we asked: (1) Does rESWT stimulate longitudinal bone growth of ex vivo cultured bones? (2) Does rESWT cause any morphological changes in the growth plate? (3) Does rESWT locally activate proteins specific to growth plate chondrogenesis?

METHODS

Metatarsal bones from rat fetuses were untreated (controls: n = 15) or exposed to a single application of rESWT at a low dose (500 impulses, 5 Hz, 90 mJ; n = 15), mid-dose (500 impulses, 5 Hz, 120 mJ; n = 14) or high dose (500 impulses, 10 Hz, 180 mJ; n = 34) and cultured for 14 days. Bone lengths were measured on Days 0, 4, 7, and 14. After 14 days of culturing, growth plate morphology was assessed with a histomorphometric analysis in which hypertrophic cell size (> 7 µm) and hypertrophic zone height were measured (n = 6 bones each). Immunostaining for specific regulatory proteins involved in chondrogenesis and corresponding staining were quantitated digitally by a single observer using the automated threshold method in ImageJ software (n = 6 bones per group). A p value < 0.05 indicated a significant difference.

RESULTS

The bone length in the high-dose rESWT group was increased compared with that in untreated controls (4.46 mm ± 0.75 mm; 95% confidence interval, 3.28-3.71 and control: 3.50 mm ± 0.38 mm; 95% CI, 4.19-4.72; p = 0.01). Mechanistic studies of the growth plate's cartilage revealed that high-dose rESWT increased the number of proliferative chondrocytes compared with untreated control bones (1363 ± 393 immunopositive cells per bone and 500 ± 413 immunopositive cells per bone, respectively; p = 0.04) and increased the diameter of hypertrophic chondrocytes (18 ± 3 µm and 13 ± 3 µm, respectively; p < 0.001). This was accompanied by activation of insulin-like growth factor-1 (1015 ± 322 immunopositive cells per bone and 270 ± 121 immunopositive cells per bone, respectively; p = 0.043) and nuclear factor-kappa beta signaling (1029 ± 262 immunopositive cells per bone and 350 ± 60 immunopositive cells per bone, respectively; p = 0.01) and increased levels of the anti-apoptotic proteins B-cell lymphoma 2 (718 ± 86 immunopositive cells per bone and 35 ± 11 immunopositive cells per bone, respectively; p < 0.001) and B-cell lymphoma-extra-large (107 ± 7 immunopositive cells per bone and 34 ± 6 immunopositive cells per bone, respectively; p < 0.001).

CONCLUSION

In a model of cultured fetal rat metatarsals, rESWT increased longitudinal bone growth by locally inducing chondrogenesis. To verify whether rESWT can also stimulate bone growth in the presence of systemic circulatory factors, further studies are needed.

CLINICAL RELEVANCE

This preclinical proof-of-concept study shows that high-dose rESWT can stimulate longitudinal bone growth and growth plate chondrogenesis in cultured fetal rat metatarsal bones. A confirmatory in vivo study in skeletally immature animals must be performed before any clinical studies.

Low-energy extracorporeal shock wave therapy promotes BDNF expression and improves functional recovery after spinal cord injury in rats

Low-energy extracorporeal shock wave therapy (ESWT) has been used to treat various human diseases. Previous studies have shown that low-energy ESWT promotes the release of various cell growth factors and trophic factors from the cells surrounding the target lesion. The aim of the current study was to determine whether the application of low-energy ESWT upregulates the expression of brain-derived neurotrophic factor (BDNF) and reduces neural tissue damage and functional impairment using a rat model of thoracic spinal cord contusion injury. We found that low-energy ESWT promoted BDNF expression in the damaged neural tissue. The expression of BDNF was increased in various neural cells at the lesion. Additionally, low-energy ESWT increased the area of spared white matter and the number of oligodendrocytes in the injured spinal cord compared with untreated control animals. There were more axonal fibers around the injured site after the application of low-energy ESWT than control. Importantly, low-energy ESWT improved the locomotor functions evaluated by both the BBB scale and ladder rung walking test in addition to the sensory function measured using a von Frey test. Moreover, the electrophysiological assessment confirmed that the conductivity of the central motor pathway in the injured spinal cord was restored by low-energy ESWT. These findings indicate that low-energy ESWT promotes BDNF expression at the lesion site and reduces the neural tissue damage and functional impairment following spinal cord injury. Our results support the potential application of low-energy ESWT as a novel therapeutic strategy for treating spinal cord injury.

The effects of shock wave and dry needling on active trigger points of upper trapezius muscle in patients with non-specific neck pain: A randomized clinical trial

BACKGROUND

Chronic neck pain is associated with various myofascial trigger points (MTrPs).

OBJECTIVE

A single-blind randomized clinical trial was designed to compare the effects of extracorporeal shock wave therapy (ESWT) with dry needling (DN) techniques on the upper trapezius muscle trigger point in patients with non-specific neck pain (NSNP).

METHODS

Seventy patients with NSNP and active MTrPs of the upper trapezius muscle were randomly divided into two groups: an ESWT group (n= 35) and a DN group (n= 35). Treatment sessions were performed for three weeks and all participants received related intervention once a week. The outcome measures were pain intensity, measured by a numeric pain rating scale (NPRS), pain pressure threshold (PPT), measured with a digital algometer, and functional disability, evaluated by using the neck disability index (NDI).

RESULTS

NPRS and NDI were significantly decreased in the DN group and ESWT group (P< 0.05). Also, the PPT was significantly increased in the DN group and ESWT. However, there was no significant difference in pain intensity, NDI, and the PPT between the two groups (P⩾ 0.05).

CONCLUSION

Both ESWT and DN can be employed to treat MTrPs of the upper trapezius muscle in patients with NSNP.

Histological examination of skin tissue in the porcine animal model after simultaneous and consecutive application of monopolar radiofrequency and targeted pressure energy

BACKGROUND

The cosmetic appearance of skin is substantially influenced by the organization of connective fibers and underlying subcutaneous tissue. It has been previously documented that radiofrequency and pressure energies alone are able to improve skin appearance; however, detailed histological evaluation should be done to determine their synergistic effect.

AIMS

This histological study investigates the difference between simultaneous and consecutive application of monopolar radiofrequency with targeted pressure energy on porcine skin.

METHODS

In a total of four weekly abdominal treatments, simultaneous emission of the energies was applied to two pigs (12 minutes per session); additionally, two pigs were treated consecutively (12 + 12 minutes per session). The 5th pig served as a control subject. Biopsies were obtained at baseline, after the 4th treatment, and at 1-month follow-up. Primary outcomes were to document changes of dermal and hypodermal tissues.

RESULTS

In the treated subjects, the amount of collagen and elastin fibers increased significantly (P < .001). At follow-up, simultaneous application showed a significantly higher increase in collagen and elastin fibers (by 59% and 64%, respectively), when compared to consecutive. Thickness of the dermis increased more in the pigs treated simultaneously (+848.8 µm/50.17%; P < .001). Treated tissue also showed the upper part of dermis to be rich in blood vessels and better organized interlobular septa in hypodermis. No significant change was observed in the control subject.

CONCLUSION

Simultaneous application produces significantly more profound changes, when compared to consecutive treatment. Further research is needed but our findings represent a new potential treatment of various skin conditions like cellulite or laxity.

Can Extracorporeal Shockwave Promote Osteogenesis of Equine Bone Marrow-Derived Mesenchymal Stem Cells In Vitro?

Both bone marrow-derived mesenchymal stem cells (BMDMSCs) and extracorporeal shockwave (ESW) have shown promise for enhancing fracture repair. If exposure of BMDMSCs to ESW enhances osteogenic differentiation, these therapies may be combined in vivo or used as a method for preconditioning BMDMSCs. The objective of this study was to determine the effect of ESW on the osteogenic ability of equine BMDMSCs. We hypothesized that ESW would promote osteogenesis evidenced by increased gene expression, alkaline phosphatase (ALPL) expression, slide morphologic score, and protein expression. BMDMSCs were evaluated from six horses. BMDMSCs were culture expanded to passage 3, dissociated, then placed in conical tubes. Treatment cells ("shocked") were exposed to 500 pulses at 0.16 mJ/mm² energy. Cells were then reseeded and grown in either growth medium or osteogenic medium. Cellular proliferation and trilineage potential were determined. Cellular morphology was scored and cells were harvested at 1, 3, 7, 14, and 21 days for rtPCR gene expression of osteogenic markers [osteonectin (ONT), osteocalcin (OCN), ALPL, collagen type 3 (COL3), and runt-related transcription factor 2 (RUNX2)]. Media supernatants were evaluated for secretion of BMP-2, VEGF, TGFβ, and PGE₂ and cellular lysates were evaluated for ALPL production. There was no difference between the proliferative ability of shocked cells versus unshocked cells in either growth medium or osteogenic medium. ALPL production was greater in shocked cells maintained in osteogenic medium versus unshocked cells in osteogenic medium at day 3 (P < 0.005). Independent of media type, ESW caused a decrease in VEGF and TGFβ production at day 3. No significant increases in gene expression were identified by rtPCR. Exposure of BMDMSCs to ESW does not result in negative effects. An initial significant increase in ALPL was detected but no persistent osteogenic effect was observed with cell expansion.

Effects of Extracorporeal Shock Wave Therapy on Distraction Osteogenesis in Rat Mandible

BACKGROUND

Distraction osteogenesis has widespread clinical use in the treatment of congenital and acquired craniofacial deformities. Nonetheless, during the prolonged consolidation period, the newly regenerated bone carries the risk of complications. A known method for enhancing bone healing is extracorporeal shock wave therapy, which has been shown to induce neovascularization and promote tissue regeneration. The authors investigated whether extracorporeal shock wave therapy can accelerate bony consolidation and regeneration in distraction osteogenesis of the rat mandible and at which stage of distraction osteogenesis it should be applied.

METHODS

Twenty-four male Sprague-Dawley rats were subjected to distraction osteogenesis of the right mandible (latency period, 3 days; distraction period, 10 days; 0.5 mm/day). Experimental groups consisted of the following: group I (control), no extracorporeal shock wave therapy; group II, extracorporeal shock wave therapy (0.18 mJ/mm(2)) at the latency period; and group III, extracorporeal shock wave therapy (0.18 mJ/mm(2)) at the consolidation period. Explants were removed for evaluation after 4 weeks of consolidation.

RESULTS

Histologic evaluation showed well-developed cortical cortex and a higher degree of bone formation and mature bone in group III; micro-computed tomography showed significantly increased bone mineral density, bone volume fraction, and trabecular thickness; immunohistochemistry demonstrated significantly increased expression of bone morphogenetic protein-2, vascular endothelial growth factor, and proliferating cell nuclear antigen.

CONCLUSION

Extracorporeal shock wave therapy application at the consolidation period during distraction osteogenesis in the rat mandible enhances bone formation and osteogenic and angiogenic growth factors, improves bone mechanical properties, and accelerates bone mineralization.

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

OBJECTIVES

Nonunions after bone fractures are usually treated surgically with risk of infections and failure of osteosynthesis. A noninvasive alternative is extracorporeal shock wave treatment (ESWT), which potentially stimulates bone regeneration. Therefore this review investigates whether ESWT is an effective and safe treatment for delayed unions and nonunions.

DATA SOURCES

Embase.com, MEDLINE ovid, Cochrane, Web of Science, PubMed publisher, and Google Scholar were systematically searched.

STUDY SELECTION

Inclusion criteria included studies with patients with delayed union or nonunion treated with ESWT; inclusion of ≥10 patients; and follow-up period ≥6 weeks.

DATA EXTRACTION

Assessment for risk of bias was conducted by 2 authors using the Cochrane tool. Union rates and adverse events were extracted from the studies.

DATA SYNTHESIS

Two RCTs and 28 nonrandomized studies were included. One RCT was assessed at medium risk of bias and reported similar union rates between ESWT-treated patients (71%) and surgery-treated patients (74%). The remaining 29 studies were at high risk of bias due to poor description of randomization (n = 1), nonrandomized allocation to control groups (n = 2), or absence of control groups (n = 26). The average union rate after ESWT in delayed unions was 86%, in nonunions 73%, and in nonunions after surgery 81%. Only minor adverse events were reported after ESWT.

CONCLUSIONS

ESWT seems to be effective for the treatment of delayed unions and nonunions. However, the quality of most studies is poor. Therefore, we strongly encourage conducting well-designed RCTs to prove the effectiveness of ESWT and potentially improve the treatment of nonunions because ESWT might be as effective as surgery but safer.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Demethylation of ITGAV accelerates osteogenic differentiation in a blast-induced heterotopic ossification in vitro cell culture model

Trauma-induced heterotopic ossification is an intriguing phenomenon involving the inappropriate ossification of soft tissues within the body such as the muscle and ligaments. This inappropriate formation of bone is highly prevalent in those affected by blast injuries. Here, we developed a simplified cell culture model to evaluate the molecular events involved in heterotopic ossification onset that arise from the shock wave component of the disease. We exposed three subtypes of human mesenchymal cells in vitro to a single, high-energy shock wave and observed increased transcription in the osteogenic master regulators, Runx2 and Dlx5, and significantly accelerated cell mineralisation. Reduced representation bisulfite sequencing revealed that the shock wave altered methylation of gene promoters, leading to opposing changes in gene expression. Using a drug to target ITGAV, whose expression was perturbed by the shock wave, we found that we could abrogate the deposition of mineral in our model. These findings show how new therapeutics for the treatment of heterotopic ossification can be identified using cell culture models.

Exposure of zebra mussels to extracorporeal shock waves demonstrates formation of new mineralized tissue inside and outside the focus zone

The success rate of extracorporeal shock wave therapy (ESWT) for fracture nonunions in human medicine (i.e. radiographic union at 6 months after ESWT) is only approximately 75%. Detailed knowledge regarding the underlying mechanisms that induce bio-calcification after ESWT is limited. We analyzed the biological response within mineralized tissue of a new invertebrate model organism, the zebra mussel Dreissena polymorpha, after exposure with extracorporeal shock waves (ESWs). Mussels were exposed to ESWs with positive energy density of 0.4 mJ/mm² (A) or were sham exposed (B). Detection of newly calcified tissue was performed by exposing the mussels to fluorescent markers. Two weeks later, the A-mussels showed a higher mean fluorescence signal intensity within the shell zone than the B-mussels (P<0.05). Acoustic measurements revealed that the increased mean fluorescence signal intensity within the shell of the A-mussels was independent of the size and position of the focal point of the ESWs. These data demonstrate that induction of bio-calcification after ESWT may not be restricted to the region of direct energy transfer of ESWs into calcified tissue. The results of the present study are of relevance for better understanding of the molecular and cellular mechanisms that induce formation of new mineralized tissue after ESWT.

Radial extracorporeal shock wave therapy is efficient and safe in the treatment of fracture nonunions of superficial bones: a retrospective case series

BACKGROUND

A substantial body of evidence supports the use of focused extracorporeal shock wave therapy (fESWT) in the non-invasive treatment of fracture nonunions. On the other hand, virtually no studies exist on the use of radial extracorporeal shock wave therapy (rESWT) for this indication.

METHODS

We retrospectively analyzed 22 patients treated with rESWT for fracture nonunions of superficial bones that failed to heal despite initial surgical fixation in most cases. Radial extracorporeal shock wave therapy was applied without anesthesia in three rESWT sessions on average, with one rESWT session per week and 3000 radial extracorporeal shock waves at an energy flux density of 0.18 mJ/mm² per session. Treatment success was monitored with radiographs and clinical examinations.

RESULTS

Six months after rESWT radiographic union was confirmed in 16 out of 22 patients (73%), which is similar to the success rate achieved in comparable studies using fESWT. There were no side effects. The tibia was the most common treatment site (10/22) and 70% of tibia nonunions healed within 6 months after rESWT. Overall, successfully treated patients showed a mean time interval of 8.8 ± 0.8 (mean ± standard error of the mean) months between initial fracture and commencement of rESWT whereas in unsuccessfully treated patients the mean interval was 26.0 ± 10.1 months (p < 0.05). In unsuccessful tibia cases, the mean interval was 43.3 ± 13.9 months.

CONCLUSIONS

Radial extracorporeal shock wave therapy appears to be an effective and safe alternative in the management of fracture nonunions of superficial bones if diagnosed early and no fESWT device is available. The promising preliminary results of the present case series should encourage the implementation of randomized controlled trials for the early use of rESWT in fracture nonunions.

Shockwaves Inhibit Chondrogenic Differentiation of Human Mesenchymal Stem Cells in Association with Adenosine and A2B Receptors

Extracorporeal shockwave therapy (ESWT) has emerged as the important choice for the treatment of many orthopedic disorders. Our previous mechanistic studies suggest that ESWT promoted osteogenesis of human mesenchymal stem cells (hMSCs) through mechanisms that involve adenosine 5'-triphosphate (ATP) release. In this study, we investigated the effect of ESWT on chondrogenesis of hMSCs. We demonstrate that ESWT treatment caused a significant release of adenosine from hMSCs; ESWT treatment increased the levels of A2B receptor (A2BR) in hMSCs under 3-D culture conditions. ESWT, exogenous adenosine and specialized A2BR agonist suppressed hMSC chondrogenic differentiation through downregulating the expressions of aggrecan (ACAN), Collagen Type I alpha 2(COL1A2), Collagen Type II alpha 1(COL2A1), Sex-Determining Region YBox 9 (SOX9) and Sex-Determining Region YBox 6 (SOX6). Selective A2BR antagonists induced chondrogenic differentiation of hMSCs. This study indicated that shockwave therapy inhibits hMSC chondrogenic differentiation through or partially through regulation of adenosine release and activation of A2B receptor under 3-D culture conditions.

Mechanobiology of bone remodeling and fracture healing in the aged organism

Bone can adapt to changing load demands by mechanically regulated bone remodeling. Osteocytes, osteoblasts, and mesenchymal stem cells are mechanosensitive and respond to mechanical signals through the activation of specific molecular signaling pathways. The process of bone regeneration after fracture is similarly and highly regulated by the biomechanical environment at the fracture site. Depending on the tissue strains, mesenchymal cells differentiate into fibroblasts, chondrocytes, or osteoblasts, determining the course and the success of healing. In the aged organism, mechanotransduction in both intact and fractured bones may be altered due to changed hormone levels and expression of growth factors and other signaling molecules. It is proposed that altered mechanotransduction may contribute to disturbed healing in aged patients. This review explains the basic principles of mechanotransduction in the bone and the fracture callus and summarizes the current knowledge on aging-induced changes in mechanobiology. Furthermore, the methods for external biomechanical stimulation of intact and fractured bones are discussed with respect to a possible application in the elderly patient.

Historical ESWT Paradigms Are Overcome: A Narrative Review

Extracorporeal Shock Wave Therapy (ESWT) is a conservative treatment modality with still growing interest in musculoskeletal disorders. This narrative review aims to present an overview covering 20-year development in the field of musculoskeletal ESWT. Eight historical paradigms have been identified and put under question from a current perspective: energy intensity, focus size, anesthesia, imaging, growth plates, acuteness, calcifications, and number of sessions. All paradigms as set in a historical consensus meeting in 1995 are to be revised. First, modern musculoskeletal ESWT is divided into focused and radial technology and the physical differences are about 100-fold with respect to the applied energy. Most lesions to be treated are easy to reach and clinical focusing plays a major role today. Lesion size is no longer a matter of concern. With the exception of nonunion fractures full, regional, or even local anesthesia is not helpful in musculoskeletal indications. Juvenile patients can also effectively be treated without risk of epiphyseal damage. Further research is needed to answer the question about if and which acute injuries can be managed effectively. Treatment parameters like the number of sessions are still relying on empirical data and have to be further elucidated.

Extracorporeal shockwave therapy (ESWT) ameliorates healing of tibial fracture non-union unresponsive to conventional therapy

Tibial non-unions are common cause of demanding revision surgeries and are associated with a significant impact on patients' quality of life and health care costs. Extracorporeal shockwave therapy (ESWT) has been shown to improve osseous healing in vitro and in vivo. The main objective of present study was to evaluate the efficacy of ESWT in healing of tibial non-unions unresponsive to previous surgical and non-surgical measures. A retrospective multivariant analysis of a prospective open, single-centre, clinical trial of tibia non-union was conducted. 56 patients with 58 eligible fractures who met the FDA criteria were included. All patients received 3000-4000 impulses of electrohydraulic shockwaves at an energy flux density of 0.4mJ/mm(2) (-6dB). On average patients underwent 1.9 times (±1.3SD) surgical interventions prior to ESWT displaying the rather negatively selected cohort and its limited therapy responsiveness. In 88.5% of patients receiving ESWT complete bone healing was observed after six months irrespective of underlying pathology. The multivariant analysis showed that time of application is important for therapy success. Patients achieving healing received ESWT earlier: mean number of days between last surgical intervention and ESWT (healed - 355.1 days±167.4SD vs. not healed - 836.7 days±383.0SD; p<0.0001). ESWT proved to be a safe, effective and non-invasive treatment modality in tibial non-unions recalcitrant to standard therapies. The procedure is well tolerated, time-saving, lacking side effects, with potential to significantly decrease health care costs. Thus, in our view, ESWT should be considered the treatment of first choice in established tibial non-unions.