Effect of shock wave therapy on acute fractures of the tibia: a study in a dog model

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.

The effects and underlying mechanism of extracorporeal shockwave therapy on fracture healing

The clinical efficacy of ESWT in treating bone non union has been widely recognized, but the biological mechanism of ESWT promoting bone non union healing is still unclear. ESWT can make old callus micro fracture through mechanical conduction, form subperiosteal hematoma, promote the release of bioactive factors, reactivate the fracture healing mechanism, rebalance the activities of osteoblasts and osteoclast, promote the angiogenesis of fracture site, and accelerate the healing of bone nonunion.Over recent years, great efforts have been made by both scientists and clinicians to explore the underlying mechanism behind the healing effect of ESWT on bone fractures. In this review, we introduced the growth factors during osteogenesis induced by ESWT hoping to provide new insights in the clinical use of ESWT.

Selected Techniques for Physiotherapy in Dogs

Simple Summary

Animal physiotherapy is widely addressed in many scientific reports. Although the effectiveness of physiotherapy has been repeatedly proven in both human and animal models, a small percentage of animal keepers decide to implement physiotherapy as part of treatment programs for their pets. After horses, dogs are the second group of animals that are most frequently subjected to physiotherapy treatments. The present study compiles the current knowledge of canine physiotherapy methods. An attempt was made to systematize this knowledge through selection and description of the most important aspects of canine physiotherapy. Most of the physiotherapeutic methods have been transferred from human treatment protocols. A key issue in the achievement of therapy success is the proper selection of physiotherapeutic procedures and close cooperation between the veterinarian and the physiotherapist.

Abstract

Physiotherapy is a new dynamically developing field of science in which the original idea was to improve the care for convalescent patients. Its positive effects observed in humans suggested the need for the adaptation and implementation of human physiotherapy techniques in animal care. Dogs are the second group of animals that undergo physiotherapy most frequently. These animals are diagnosed with a number of locomotor system problems, which may be congenital and are often related to the breed or acquired. The aim of the study was to collect and systematize knowledge of animal physiotherapy with emphasis on the selection and description of the most important aspects of canine physiotherapy. The review material consisted of 59 publications, with 230 selected for the review. Physiotherapeutic treatments are applied not only for rehabilitation of animals but also in healthy animals to upgrade their sports performance and improve their welfare. A majority of physiotherapeutic approaches have been transferred from human protocols. A key issue in the achievement of therapy success is the proper selection of physiotherapeutic procedures and close cooperation between the veterinarian and the physiotherapist.

The Effects of the Exposure of Musculoskeletal Tissue to Extracorporeal Shock Waves

Extracorporeal shock wave therapy (ESWT) is a safe and effective treatment option for various pathologies of the musculoskeletal system. Many studies address the molecular and cellular mechanisms of action of ESWT. However, to date, no uniform concept could be established on this matter. In the present study, we perform a systematic review of the effects of exposure of musculoskeletal tissue to extracorporeal shock waves (ESWs) reported in the literature. The key results are as follows: (i) compared to the effects of many other forms of therapy, the clinical benefit of ESWT does not appear to be based on a single mechanism; (ii) different tissues respond to the same mechanical stimulus in different ways; (iii) just because a mechanism of action of ESWT is described in a study does not automatically mean that this mechanism is relevant to the observed clinical effect; (iv) focused ESWs and radial ESWs seem to act in a similar way; and (v) even the most sophisticated research into the effects of exposure of musculoskeletal tissue to ESWs cannot substitute clinical research in order to determine the optimum intensity, treatment frequency and localization of ESWT.

Extracorporeal shock wave therapy mechanisms in musculoskeletal regenerative medicine

Extracorporeal shockwave therapy (ESWT) is a popular non-invasive therapeutic modality in the medical field for the treatment of numerous musculoskeletal disorders. This technique first emerged around the 1980s as extracorporeal shockwave lithotripsy and has been studied since then for its application towards orthopedics and traumatology. ESWT works by the emission of acoustic waves (shockwaves) that carry energy and can propagate through tissues. Shockwaves can generate interstitial and extracellular responses, producing many beneficial effects such as: pain relief, vascularization, protein biosynthesis, cell proliferation, neuro and chondroprotection, and destruction of calcium deposits in musculoskeletal structures. The combination of these effects can lead to tissue regeneration and significant alleviation of pain, improving functional outcomes in injured tissue. Considering these facts, ESWT shows great potential as a useful regenerative medicine technique for the treatment of numerous musculoskeletal injuries.

Extracorporeal shock wave therapy improves short-term limb use after canine tibial plateau leveling osteotomy

OBJECTIVE

To determine the influence of postoperative extracorporeal shock wave therapy (ESWT) on hind limb use after tibial plateau leveling osteotomy (TPLO).

STUDY DESIGN

Randomized, prospective clinical trial.

ANIMALS

Sixteen client-owned dogs, 2 to 10 years old weighing 18 to 75 kg.

METHODS

Dogs were randomly assigned to treatment cohorts, TPLO with ESWT (ESWT, n = 9) or TPLO without ESWT (control, n = 7). Treatment consisted of 1000 pulses at 0.15 mJ/mm² immediately and 2 weeks after surgery. Subjective pain, stifle goniometry, stifle circumference, peak vertical force (PVF) and vertical impulse (VI) were measured before surgery, prior to ESWT, and 2 and 8 weeks after surgery. Measures were compared between treatments at each time point and among time points for each treatment (P < .05).

RESULTS

The PVF (5.5 ± 1.0 N/kg, mean ± SD) and VI (0.67 ± 0.14 N-s/kg) of surgically treated limbs in the ESWT cohort were higher 8 weeks after surgery compared with preoperative (3.8 ± 1.1 N/kg, P < .0001 and 0.47 ± 0.21 N-s/kg, P = .0012, respectively) values. In the control cohort, PVF (2.9 ± 1.3 N/kg, P = .0001) and VI (0.33 ± 0.20 N-s/kg, P = .0003) 2 weeks after surgery and VI (0.42 ± 0.2 N-s/kg, P = .0012) 8 weeks after surgery were lower (4.59 ± 2.33 N/kg and 0.592 ± 0.35 N-s/kg, respectively) than before surgery. Other parameters did not differ between groups.

CONCLUSION

Weight bearing increased faster after TPLO in dogs treated with postoperative ESWT.

CLINICAL SIGNIFICANCE

This study provides evidence to consider adjunct ESWT after TPLO.

Comparison of autogenous cancellous bone grafting and extra-corporeal shock wave therapy on osteotomy healing in the tibial tuberosity advancement procedure in dogs

Objectives: To compare optical values in the osteotomy gap created after a tibial tuberosity advancement (TTA) treated with autogenous cancellous bone graft, extracorporeal shock wave therapy, a combination of auto-genous cancellous bone graft and extra -corporeal shock wave therapy, and absence of both autogenous cancellous bone graft and extracorporeal shock wave therapy using densitometry.

Methods: Dogs that were presented for surgical repair of a cranial cruciate ligament rupture were randomly assigned to one of four groups: TTA with autogenous cancellous bone graft (TTA-G), TTA with autogenous cancellous bone graft and extracorporeal shock wave therapy (TTA-GS), TTA with extracorporeal shock wave therapy (TTA-S), and TTA with no additional therapy (TTA-O). Mediolateral radiographs at zero, four and eight weeks after surgery were evaluated to compare healing of the osteotomy gap via densitometry. An analysis of variance was used to compare the densitometric values between groups.

Results: At four weeks after surgery, a significant difference in osteotomy gap density was noted between TTA-GS (8.4 millimetres of aluminium equivalent [mmAleq]) and TTA-S (6.1 mmAleq), and between TTA-GS (8.4 mmAleq) and TTA-O (6.4 mmAleq). There were no significant differences noted between any groups at the eight week re-evaluation.

Clinical significance: There were no significant differences in the osteotomy gap density at eight weeks after surgery regardless of the treatment modality used. The combination of autogenous cancellous bone graft and extracorporeal shock wave therapy may lead to increased radiographic density of the osteotomy gap in the first four weeks after surgery. Densitometry using an aluminium step wedge is a feasible method for comparison of bone density after TTA in dogs.

High energy focused shock wave therapy accelerates bone healing

Objectives: To evaluate the influence of shock wave therapy (SWT) on radiographic evidence of bone healing after tibial plateau leveling osteotomy (TPLO).

Methods: Healthy dogs between two to nine years of age that underwent TPLO were randomly assigned to receive either electro- hydraulic SWT (1,000 shocks) or sham treatment (SHAM). Treatment or SHAM was administered to the osteotomy site immediately postoperatively and two weeks postoperatively. Three blinded radiologists evaluated orthogonal radiographs performed eight weeks postoperatively with both a 5-point and a 10-point bone healing scale. Linear regression analysis was used to compare median healing scores between groups.

Results: Forty-two dogs (50 stifles) were included in the statistical analysis. No major complications were observed and all osteo -tomies healed uneventfully. The median healing scores were significantly higher at eight weeks postoperatively for the SWT group compared to the SHAM group for the 10-point (p <0.0002) and 5-point scoring systems (p <0.0001).

Clinical significance: Shock wave therapy applied immediately and two weeks post -operatively led to more advanced bone healing at the eight week time point in this study population. The results of this study support the use of electro-hydraulic SWT as a means of accelerating acute bone healing of canine osteotomies. Additional studies are needed to evaluate its use for acceleration of bone healing following fracture, or with delayed union.

Low-energy extracorporeal shockwave therapy (ESWT) improves metaphyseal fracture healing in an osteoporotic rat model

Purpose

As result of the current demographic changes, osteoporosis and osteoporotic fractures are becoming an increasing social and economic burden. In this experimental study, extracorporeal shock wave therapy (ESWT), was evaluated as a treatment option for the improvement of osteoporotic fracture healing.

Methods

A well-established fracture model in the metaphyseal tibia in the osteoporotic rat was used. 132 animals were divided into 11 groups, with 12 animals each, consisting of one sham-operated group and 10 ovariectomized (osteoporotic) groups, of which 9 received ESWT treatment. Different energy flux intensities (0.15 mJ/mm², 0.35 mJ/mm², or 0.55 mJ/mm²) as well as different numbers of ESWT applications (once, three times, or five times throughout the 35-day healing period) were applied to the osteoporotic fractures. Fracture healing was investigated quantitatively and qualitatively using micro-CT imaging, quantitative real-time polymerase chain reaction (qRT-PCR) analysis, histomorphometric analysis and biomechanical analysis.

Results

The results of this study show a qualitative and quantitative improvement in the osteoporotic fracture healing under low-energy (energy flux intensity: 0,15 mJ/mm²) ESWT and with fewer treatment applications per healing period.

Conclusion

In conclusion, low-energy ESWT seems to exhibit a beneficial effect on the healing of osteoporotic fractures, leading to improved biomechanical properties, enhanced callus-quantity and -quality, and an increase in the expression of bone specific transcription factors. The results suggest that low-energy ESWT, as main treatment or as adjunctive treatment in addition to a surgical intervention, may prove to be an effective, simple to use, and cost-efficient option for the qualitative and quantitative improvement of osteoporotic fracture healing.

Efficacy of extracorporeal shockwave therapy and low-intensity pulsed ultrasound in a rat knee osteoarthritis model: A randomized controlled trial

OBJECTIVE

This study aims to assess the efficacy of extracorporeal shockwave therapy (ESWT) and low-intensity pulsed ultrasound (LIPUS) on osteoarthritic rat knees.

MATERIAL AND METHODS

Twenty-four rats were divided into 3 groups: group 1-control (n=8), group 2-LIPUS (n=8) and group 3-ESWT (n=8). Cartilage degeneration was provided using mono-iodo-asetate (MIA). One milligram of MIA was delivered to the right knees in group 1 and both knees in group 2 and 3. A 0.09% saline solution was delivered to the left knees in group 1 for control. Twenty-four hours after the delivery, ESWT was applied once on the right knees in the group 2 rats to the medial tibia plateu with a 1 Hz frequency and 800 impulses. LIPUS was applied to the right knees in the group 2 rats to the medial tibia plateu with a 3 mHz frequency and 40 mW/cm2 intensity for 20 minutes over a period of 15 days. Pain scores were measured with a knee bend test. Bone mineral density measurements and scintigraphic bone scans were performed. Histopathological examination was done using a modified Mankin scale.

RESULTS

There was no difference among the right knee subchondral bone osteoblastic activities (p>0.05). The left knee osteoblastic activities in the LIPUS and extracorporeal shockwave therapy (ESWT) groups were higher than those in the control group (p<0.05), but there was no difference between the LIPUS and ESWT groups. There was no difference among the groups for both knee subchondral bone BMD values (p>0.05). The modified Mankin scores of both the right and left knees of the ESWT and LIPUS groups were lower than those of the control group (p<0.05), but there was no difference between the ESWT and LIPUS groups. The pain scores of both knees of the ESWT and LIPUS groups at day 7 were higher than those of the control group (p<0.05), but there was no difference between the ESWT and LIPUS groups. There was no difference among the pain scores of the right knees at day 14 (p<0.05).

CONCLUSION

ESWT and LIPUS have systemic proliferative and regenerative effects on cartilage and tissue.

Tarsal navicular stress fractures

PURPOSE OF REVIEW

Navicular stress fractures are common in athletes and management is debated. This article will review the evaluation and management of navicular stress fractures.

RECENT FINDINGS

Various operative and non-operative adjunctive treatment modalities are reviewed including the relevance of vitamin D levels, use of shock wave therapy and bone marrow aspirate concentrate (BMAC), and administration of teriparatide. Surgical treatment may be associated with earlier return to sports. The author's preferred treatment algorithm with corresponding images is presented which allows for safe and rapid return to activities in the athletic patient. Future research is needed in evaluating the preventative effects of vitamin D and use of other adjunctive treatments to increase the healing rates of this fracture.

Prostaglandin E2 and Connexin 43 crosstalk in the osteogenesis induced by extracorporeal shockwave

As a type of mechanical stimulation, extracorporeal shockwave (ESW) has been widely used in the clinic to treat bone fracture delayed union and non-unions. A large number of studies have shown beneficial effects of ESW in promoting fracture healing by inducing bone regeneration; however, the underlying mechanisms remain unclear. ESW has been shown to induce the production of prostaglandin E2 (PGE2), which is essential for gap junction intercellular communication in response to mechanical stress. Among the 19 known gap junction subunits, connexin43 (Cx43) is the most prevalent for mediating the response of mechanical stress. However, to our knowledge, the effect of ESW on Cx43 expression has not been reported before. Herein, we propose that a crosstalk between PGE2 and Cx43 is involved in the enhancement of osteogenesis induced by ESW. We review the currently available data to propose an unrevealed, but important mechanism via which ESW treatment affects osteogenic differentiation of bone marrow stromal cells.

The influence of platelet-rich fibrin on angiogenesis in guided bone regeneration using xenogenic bone substitutes: a study of rabbit cranial defects

PURPOSE

The purpose of this study was to investigate the influence of platelet-rich fibrin (PRF) on angiogenesis and osteogenesis in guided bone regeneration (GBR) using xenogenic bone in rabbit cranial defects.

MATERIALS AND METHODS

In each rabbit, 2 circular bone defects, one on either side of the midline, were prepared using a reamer drill. Each of the experimental sites received bovine bone with PRF, and each of the control sites received bovine bone alone. The animals were sacrificed at 1 week (n = 4), 2 weeks (n = 3) and 4 weeks (n = 3). Biopsy samples were examined histomorphometrically by light microscopy, and expression of vascular endothelial growth factor (VEGF) was determined by immunohistochemical staining.

RESULTS

At all experimental time points, immunostaining intensity for VEGF was consistently higher in the experimental group than in the control group. However, the differences between the control group and the experimental group were not statistically significant in the histomorphometrical and immunohistochemical examinations.

CONCLUSIONS

The results of this study suggest that PRF may increase the number of marrow cells. However, PRF along with xenogenic bone substitutes does not show a significant effect on bony regeneration. Further large-scale studies are needed to confirm our results.

Does extracorporeal shock wave therapy enhance healing of osteochondritis dissecans of the rabbit knee?: a pilot study

BACKGROUND

Severe osteochondritis dissecans (OCD) in children and adolescents often necessitates surgical interventions (ie, drilling, excision, or débridement). Since extracorporeal shock wave therapy (ESWT) enhances healing of long-bone nonunion fractures, we speculated ESWT would reactivate the healing process in OCD lesions.

QUESTIONS/PURPOSES

We asked whether ESWT would enhance articular cartilage quality, bone and cartilage density, and histopathology of osteochondral lesions compared to nontreated controls in an OCD rabbit model.

METHODS

We harvested a 4-mm-diameter plug of the weightbearing osteochondral surface on the medial femoral condyle of each knee in 20 skeletally immature (8-week-old) female rabbits. We placed a piece of acellular collagen-glycosaminoglycan matrix into the cavity and then replaced the plug. Two weeks after surgery, we sedated each rabbit and treated the right knee in a single setting with shock waves: 4000 impulses at 4 Hz and 18 kV. The left knee was a sham control. Ten weeks after surgery, we assessed cartilage morphology of the lesion using a modified Outerbridge Grading System, bone and cartilage density using histologic imaging, bone and cartilage morphology using the histopathology assessment system, and radiographic bone density and union and compared these parameters between ESWT-treated and control knees.

RESULTS

Histologically, we observed more mature bone formation and better healing (1.1 versus 3.4) and density of the cartilage (60 versus 49) on the treated side. Radiographically, we noted an increase in bony density (154 versus 138) after ESWT.

CONCLUSIONS

ESWT accelerated the healing rate and improved cartilage and subchondral bone quality in the OCD rabbit model.

CLINICAL RELEVANCE

This therapeutic modality may be applicable in OCD treatment in the pediatric population. Future research will be necessary to determine whether it may play a role in healing of human osteochondral defects.

Optimal intensity shock wave promotes the adhesion and migration of rat osteoblasts via integrin β1-mediated expression of phosphorylated focal adhesion kinase

To search for factors promoting bone fracture repair, we investigated the effects of extracorporeal shock wave (ESW) on the adhesion, spreading, and migration of osteoblasts and its specific underlying cellular mechanisms. After a single period of stimulation by 10 kV (500 impulses) of shock wave (SW), the adhesion rate was increased as compared with the vehicle control. The data from both wound healing and transwell tests confirmed an acceleration in the migration of osteoblasts by SW treatment. RT-PCR, flow cytometry, and Western blotting showed that SW rapidly increased the surface expression of α5 and β1 subunit integrins, indicating that integrin β1 acted as an early signal for ESW-induced osteoblast adhesion and migration. It has also been found that a significant elevation occurred in the expression of phosphorylated β-catenin and focal adhesion kinase (FAK) at the site of tyrosine 397 in response to SW stimulation after the increasing expression of the integrin β1 molecule. When siRNAs of integrin α5 and β1 subunit were added, the level of FAK phosphorylation elevated by SW declined. Interestingly, the adhesion and migration of osteoblasts were decreased when these siRNA reagents as well as the ERK1/2 signaling pathway inhibitors, U0126 and PD98059, were present. Further studies demonstrated that U0126 could inhibit the downstream integrin-dependent signaling pathways, such as the FAK signaling pathway, whereas it had no influence on the synthesis of integrin β1 molecule. In conclusion, these data suggest that ESW promotes the adhesion and migration of osteoblasts via integrin β1-mediated expression of phosphorylated FAK at the Tyr-397 site; in addition, ERK1/2 are also important for osteoblast adhesion, spreading, migration, and integrin expression.

Extracorporeal shockwave therapy in musculoskeletal disorders

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

Effects of ultrasound on osteotomy healing in a rabbit fracture model

This study investigated the effects of ultrasound (US) at different frequencies on fracture healing over a three-week period in a rabbit fibular fracture model. Forty-five adult New Zealand White rabbits were divided into five groups: a control group and four groups treated with US frequencies of 0.5, 1.0, 1.5 and 2.0 MHz (0.5 W/cm(2), 200-μs burst, pulsed 1:4). After anesthesia, transverse osteotomy was performed on the fibula bone. This was followed by intravital staining and fluorescence microscopic examination of new bone formation and biomechanical tests of torsional stiffness at the osteotomy site. Results showed that total new bone formation and torsional stiffness of the fibula were greater in all US-treated groups than in the control group. No significant difference was found between any of the four US-treated groups. The US treatment also enhanced bone growth of the sham-treated contralateral fracture site. These results suggest that US treatment at 0.5, 1.0, 1.5 or 2.0 MHz can enhance fracture healing in a rabbit model. Furthermore, the effects of US on fracture healing at present parameters might not be confined locally.

Unfocused extracorporeal shock waves induce anabolic effects in rat bone

BACKGROUND

Extracorporeal shock waves are known to stimulate the differentiation of mesenchymal stem cells toward osteoprogenitors and induce the expression of osteogenic-related growth hormones. The aim of this study was to investigate if and how extracorporeal shock waves affected new bone formation, bone microarchitecture, and the mechanical properties of bone in a healthy rat model, in order to evaluate whether extracorporeal shock wave therapy might be a potential treatment for osteoporosis.

METHODS

Thirteen rats received 1000 electrohydraulically generated unfocused extracorporeal shock waves to the right tibia. The contralateral, left tibia was not treated and served as a control. At two, seven, twenty-one, and forty-nine days after administration of the shock waves, in vivo single-photon-emission computed tomography (SPECT) scanning was performed to measure new bone formation on the basis of uptake of technetium-labeled methylene diphosphonate ((99m)Tc-MDP) (n = 6). Prior to and forty-nine days after the extracorporeal shock wave therapy, micro-computed tomography (micro-CT) scans were made to examine the architectural bone changes. In addition, mechanical testing, microcrack, and histological analyses were performed.

RESULTS

Extracorporeal shock waves induced a strong increase in (99m)Tc-MDP uptake in the treated tibia compared with the uptake in the untreated, control tibia. Micro-CT analysis showed that extracorporeal shock waves stimulated increases in both trabecular and cortical volume, which resulted in higher bone stiffness compared with that of the control tibiae. Histological analysis showed intramedullary soft-tissue damage and de novo bone with active osteoblasts and osteoid in the bone marrow of the legs treated with extracorporeal shock waves. Microcrack analysis showed no differences between the treated and control legs.

CONCLUSIONS

This study shows that a single treatment with extracorporeal shock waves induces anabolic effects in both cancellous and cortical bone, leading to improved biomechanical properties. Furthermore, treatment with extracorporeal shock waves results in transient damage to the bone marrow, which might be related to the anabolic effects. After further examination and optimization, unfocused extracorporeal shock waves might enable local treatment of skeletal sites susceptible to fracture.

Bone morphogenetic protein-2 expression in spinal fusion masses enhanced by extracorporeal shock wave treatment: a rabbit experiment

PURPOSE

Extracorporeal shock wave (ESW) has been introduced to enhance spinal fusion. This study was conducted to assess the effect of ESW on bone morphogenetic protein-2 (BMP-2) expression in a spinal fusion experiment.

METHODS

Twelve rabbits underwent fusion at bilateral L5-6 intertransverse spaces. They were evenly divided into two groups. In the study group, bilateral L5 and L6 transverse processes were treated with 1,000 impulses of ESW at 14 kV at 12 weeks. In the control group, the rabbits did not receive ESW treatment. All rabbits were sacrificed at 16 weeks, and their lumbar spines were harvested for radiographic and molecular biological study.

RESULTS

In the study group (n = 6), the radiographs showed good fusion in all six rabbits, while in the control group (n = 6), good fusion was found only in three rabbits (50%). Although more rabbits in the study group had a good fusion result, the inter-group difference was not statistically significant (P = 0.182). In the molecular biological examination, the mean value of the normalized expression of BMP-2 mRNA in the fusion masses of the study group was 90 ± 8.4 while that of the control group was 77.33 ± 6.74. Statistical analysis showed the study group had a significantly higher BMP-2 mRNA expression in the fusion masses than the control group (P = 0.018).

CONCLUSIONS

The current study showed that ESW treatment enhances BMP-2 mRNA expression in spinal fusion masses.

Osteointegration of soft tissue grafts within the bone tunnels in anterior cruciate ligament reconstruction can be enhanced

Anterior cruciate ligament reconstruction with a soft tissue autograft (hamstring autograft) has grown in popularity in the last 10 years. However, the issues of a relatively long healing time and an inferior histological healing result in terms of Sharpey-like fibers connection in soft tissue grafts are still unsolved. To obtain a promising outcome in the long run, prompt osteointegration of the tendon graft within the bone tunnel is essential. In recent decades, numerous methods have been reported to enhance osteointegration of soft tissue graft in the bone tunnel. In this article, we review the current literature in this research area, mainly focusing on strategies applied to the local bone tunnel environment. Biological strategies such as stem cell and gene transfer technology, as well as the local application of specific growth factors have been reported to yield exciting results. The use of biological bone substitute and physical stimulation also obtained promising results. Artificially engineered tissue has promise as a solution to the problem of donor site morbidity. Despite these encouraging results, the current available evidence is still experimental. Further clinical studies in terms of randomized control trial in the future should be conducted to extrapolate these basic science study findings into clinical practice.

Extracorporeal shock wave therapy: current evidence

OBJECTIVES

The aim of this article is to provide a concise review of the basic science of extracorporeal shock wave therapy (ESWT) and to perform a systematic review of the literature for the use of ESWT in the treatment of fractures and delayed unions/nonunions.

DATA SOURCES

Articles in the English or German language were identified for the systematic review by searching PubMed-MEDLINE from 1966 until 2008, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and relevant meeting abstracts from 2007 to 2008. Moreover, the bibliographies of the identified articles were reviewed.

STUDY SELECTION

We included clinical outcome studies of ESWT in the treatment of fractures and delayed unions/nonunions. Reports with less than 10 patients were excluded. Nonunions after corrective osteotomies or arthrodeses were excluded.

DATA EXTRACTION

Sample size, level of evidence, definition of delayed union, definition of nonunion, time from injury to shock wave treatment, location of fracture, union rate, and complications were extracted from the identified articles.

DATA SYNTHESIS

Data of 924 patients undergoing ESWT for delayed union/nonunion were extracted from 10 studies. All articles were graded as level 4 studies. The overall union rate was 76% (95% confidence interval 73%-79%). The union rate was significantly higher in hypertrophic nonunions than in atrophic nonunions.

CONCLUSION

Data from level 4 studies suggest that shock wave therapy seems to stimulate the healing process in delayed unions/nonunions. However, further investigations are required.

VEGF modulates angiogenesis and osteogenesis in shockwave-promoted fracture healing in rabbits

OBJECTIVE

Strong vascular endothelial growth factor (VEGF) expression of osteoprogenitors was found in callus site during fracture healing. The aim of this study was to investigate whether VEGF modulates the angiogenesis and osteogenesis in shockwave-promoted fracture healing in rabbits.

MATERIALS AND METHODS

Twenty-seven Japanese rabbits were used in the study. A fracture of left tibia with 5 mm gap was created, and the fracture was stabilized with an external fixator. The rabbits were randomly divided into three groups. Group I was the control group and received no shockwave therapy. Group II received shockwave therapy, and group III was pretreated with bevacizumab, a monoclonal antibody against VEGF, before receiving shockwave. Radiographs of the tibia were obtained at 1, 4, and 8 wk. Bone mineral density was performed at 8 wk. The rabbits were euthanized at 8 wk, and the bone specimens were subjected to histomorphological examination and immunohistochemical analysis.

RESULTS

At 8 wk, radiographs showed considerably better bone healing and remodeling of the fracture in group II compared with groups I and III, whereas no discernable difference was noted between group I and group III. The BMD values were significantly higher in group II than groups I and III, but no difference noted between group I and group III. In histomorphological examination, significant increases in bone tissue was were noted in group II compared with groups I and III, but no difference was noted between group I and group III. In immunohistochemical analysis, significant increases in VEGF, vWF, PCNA, BMP-2 and osteocalcin, and a decrease in TUNEL expression were observed in group II compared with groups I and III, but no statistical difference was noted between group I and group III.

CONCLUSION

Significant increases in VEGF and angiogenic and osteogenic growth factors were noted in shockwave-promoted bone healing. Pre-treatment with bevacizumab inhibited VEGF and in turn, attenuated the effect of shockwave. It appears that VEGF modulates angiogenesis and osteogenesis in shockwave-promoted bone healing in rabbits.

Preoperative shock wave therapy reduces ischemic necrosis in an epigastric skin flap model

Extracorporeal shock wave therapy (ESWT) has recently been demonstrated to improve skin flap survival. In all these studies EWST was applied immediately after the surgical intervention. Thus, the purpose of this study was to determine the preoperative effect of ESWT as a noninvasive technique to precondition flap tissue in a rat epigastric skin flap model. EWST and control groups each contained 10 animals. ESWT was applied 7 days before the surgical intervention, whereas the control group received no treatment. Follow-up evaluation was performed on postoperative day 5. The mean area of flap necrosis, expressed as a percentage of the total flap area, was calculated. A significant reduction of the average flap necrosis area was observed in the ESWT group (27.2% +/- 9.6%) compared with the control group (46.1% +/- 7.9% (P < 0.05). In summary, this study indicates that preoperative ESWT may enhance skin flap survival in a rodent model.

Cocktail therapy for femoral head necrosis of the hip

INTRODUCTION

Cocktail therapy consists of extracorporeal shock wave treatment (ESWT), hyperbaric oxygen therapy (HBO) and alendronate. We hypothesized that this combined therapy may produce better results than ESWT alone when treating hip necrosis.

METHODS

This prospective, randomized study evaluated the effectiveness of cocktail therapy in early hip necrosis, and then compared it to shock wave treatment alone. Sixty-three patients (98 hips) were randomly divided into two groups. Group A consisted of 28 patients (50 hips) who received cocktail therapy, and group B consisted of 35 patients (48 hips) who received only ESWT. Each affected hip was treated with 6,000 shocks of ESWT at 28 kV (equivalent to 0.62 mJ/mm2) in a single session. Cocktail patients also received HBO therapy performed in a multi-place chamber daily for 20 treatments, and they were administered 70 mg of alendronate orally per week for 1 year. The evaluations included clinical assessment, radiograph and MRI.

RESULTS

After a minimum of 2-years of follow-up, the overall results showed 74% improved, 16% unchanged and 10% worsened in group A; and 79.2% improved, 10.4% unchanged and 10.4% worsened in group B (P = 0.717). Total hip replacement (THR) was performed for 10% of group A and 10.4% of group B (P = 0.946). MRI showed significant reduction in bone marrow edema and a trend of decrease in the size of the lesions in both groups, however, no difference was noted between the two groups. Cocktail therapy is effective for early hip necrosis, but the results are comparable to ESWT in short-term follow up. The joint effects of HBO and alendronate over EWST were not observed.

CONCLUSION

Long-term results are needed to determine whether or not the synergistic effects of ESWT, HBO and alendronate over ESWT alone exist in early hip necrosis.

Unfocused extracorporeal shock wave therapy as potential treatment for osteoporosis

Extracorporeal shock wave therapy (ESWT) influences the differentiation of bone marrow stroma cells towards osteoprogenitors and increases the expression of several growth factors. To assess whether unfocused ESWT might serve as a treatment for osteoporosis, we examined the bone architecture dynamics of ESWT-treated and untreated rat tibiae using in vivo micro-computed tomography (CT) scanning. In addition, the effects of ESWT on fracture healing, using a bilateral fibula osteotomy, were examined. Unilateral unfocused ESWT with 2,000 pulses and an energy flux density of 0.16 mJ/mm(2) was applied to the hind leg of ovariectomized and sham-ovariectomized rats. A single treatment with unfocused ESWT resulted in a higher trabecular bone volume fraction (BV/TV) in the proximal tibia of the sham-ovariectomized animals. Three weeks after ESWT, BV/TV was 110% of baseline BV/TV in treated legs versus 101% in untreated contralateral control legs (p = 0.001) and 105% of baseline BV/TV versus 95% at 7 weeks after ESWT (p = 0.0004). In ovariectomized rats, shock wave treatment resulted in a diminished bone loss. At 7 weeks, the BV/TV of the treated legs was 50% of baseline BV/TV, whereas in untreated control legs this was 35% (p = 0.0004). ESWT did not influence acute fracture healing. This study shows that bone microarchitecture can be affected by unfocused shock waves, and indicates that unfocused ESWT might be useful for the treatment of osteopenia and osteoporosis.

The challenge of establishing preclinical models for segmental bone defect research

A considerable number of international research groups as well as commercial entities work on the development of new bone grafting materials, carriers, growth factors and specifically tissue-engineered constructs for bone regeneration. They are strongly interested in evaluating their concepts in highly reproducible large segmental defects in preclinical and large animal models. To allow comparison between different studies and their outcomes, it is essential that animal models, fixation devices, surgical procedures and methods of taking measurements are well standardized to produce reliable data pools and act as a base for further directions to orthopaedic and tissue engineering developments, specifically translation into the clinic. In this leading opinion paper, we aim to review and critically discuss the different large animal bone defect models reported in the literature. We conclude that most publications provide only rudimentary information on how to establish relevant preclinical segmental bone defects in large animals. Hence, we express our opinion on methodologies to establish preclinical critically sized, segmental bone defect models used in past research with reference to surgical techniques, fixation methods and postoperative management focusing on tibial fracture and segmental defect models.

Extracorporeal shockwave therapy: A systematic review of its use in fracture management

Extracorporeal shockwave therapy is increasingly used as an adjuvant therapy in the management of nonunions, delayed unions and more recently fresh fractures. This is in an effort to increase union rates or obtain unions when fractures have proven recalcitrant to healing. In this report we have systematically reviewed the English language literature to attempt to determine the potential clinical efficacy of extracorporeal shockwave therapy in fracture management. Of 32 potentially eligible studies identified, 10 were included that assessed the extracorporeal shockwave therapy use for healing nonunions or delayed unions, and one trial was included that assessed its use for acute high-energy fractures. From the included, studies' overall union rates were in favor of extracorporeal shockwave therapy (72% union rate overall for nonunions or delayed unions, and a 46% relative risk reduction in nonunions when it is used for acute high-energy fractures). However, the methodologic quality of included studies was weak and any clinical inferences made from these data should be interpreted with caution. Further research in this area in the form of a large-scale randomized trial is necessary to better answer the question of the effectiveness of extracorporeal shockwave therapy on union rates for both nonunions and acute fractures.

Osteogenic effects of low-intensity pulsed ultrasound, extracorporeal shockwaves and their combination - an in vitro comparative study on human periosteal cells

Our previous studies have shown that on human periosteal cells, low-intensity pulsed ultrasound (LIPUS) has an immediate stimulatory effect whereas extracorporeal shockwaves (ESW) have an delayed stimulatory effect. Therefore, we hypothesized that a combined ESW and LIPUS treatment might provide additive or synergistic effects on periosteal cells, by using ESW to trigger a biological activity while using LIPUS to maintain the stimulated activity. Human periosteal cells were subjected to a single session of ESW treatment on day 0 and/or daily LIPUS treatments or no treatment (control). The cell viability, proliferation, and alkaline phosphatase activity on day 6 and day 18 as well as matrix mineralization on day 35 were measured. Results revealed that LIPUS alone had early positive effects on the activities on day 6 only. In contrast, ESW alone had an early destructive effect but exerted delayed stimulatory effects on the cellular activities on day 18. The combined treatment of ESW plus LIPUS produced effects that were comparable to the ESW treatment alone. Although these findings suggest that ESW and LIPUS stimulate the periosteal cells in two different ways and at different times, their additive or synergistic effects could not be proven.

Biological effects of extracorporeal shockwave in bone healing: a study in rabbits

INTRODUCTION

This study is an investigation of the biological effects of extracorporeal shockwave treatment (ESWT) on bone healing in a rabbit model.

MATERIALS AND METHODS

Sixteen 12-month-old New Zealand white rabbits with body weight ranging from 2.5 to 3.5 kg were used in the study. An intra-medullary pin was inserted retrograde into the femur canal. A closed fracture of the femur was created with a three-point bend method. The animals were randomly divided into the study group and the control group with eight rabbits in each group. The study group received shockwave treatment, whereas the control group did not. The animals were killed at 12 weeks, and a 5-cm long femur bone including the callus was harvested. The specimens were subjected to biomechanical study, histomorphological examination, and immunohistochemical analysis.

RESULTS

The shockwave group showed significantly better bone strength in biomechanical study, more cortical bone formation in histomorphological examination and higher number of neo-vessels and angiogenic and osteogenic growth markers including VEGF, eNOS, PCNA, and BMP-2 on immunohistochemical stains than the control group.

CONCLUSION

ESWT significantly improved bone healing after fracture of the femur in rabbit. ESWT promoted the formation of cortical bone what might have been associated with increased biomechanical results. ESWT-promoted bone healing was associated with increased neovascularization and up-regulation of angiogenic and osteogenic growth factors.

Extracorporeal Shock Wave Therapy Induces Alveolar Bone Regeneration

Periodontal inflammation with alveolar bone resorption is a hallmark of periodontitis. We hypothesized that extracorporeal shock wave therapy (ESWT) could promote the regeneration of alveolar bone following Porphyromonas gingivalis-induced periodontitis in rats. Rats were infected with P. gingivalis for 10 wks, which caused alveolar bone resorption. The rats were then treated with a single episode of 100, 300, or 1000 impulses of shock wave on both cheeks at energy levels 0.1 mJ/mm2. Alveolar bone levels were determined at 0, 3, 6, and 12 wks following ESWT and compared with those in untreated controls. Infected rats treated with 300 and 1000 impulses demonstrated significantly improved alveolar bone levels at 3 wks compared with untreated controls, and the improved levels remained for at least 6 wks in most rats. The results demonstrated effective regeneration of alveolar bone by ESWT and suggested that ESWT should be evaluated as an adjunct in the regeneration of periodontal tissues following periodontal disease. Abbreviations: ESWT, extracorporeal shock wave therapy; PCR, polymerase chain-reaction.

Vulnerability of the spinal cord to injury from extracorporeal shock waves in rabbits

We studied the vulnerability of the spinal cord to extracorporeal shock wave treatment (ESWT). In this experiment, 12 rabbits were divided into three groups (4 in each group). All animals underwent a preceding lumbar laminectomy at L4 1 week before ESWT. In group 1, 2000 impulses of high dose (0.62 mJ/mm2 energy flux density) shockwave energy were applied to the spinal cord at the laminectomy site. In group 2, 2000 impulses of low dose (0.18 mJ/mm2 energy flux density) shockwave energy were applied to the same site as group 1. Group 3 did not receive ESWT and served as a control. None of the rabbits in the study groups (groups 1 and 2) showed weakness or paralysis of the hind limbs throughout the entire post-ESWT period. The spinal cord at the L4 level of all animals was harvested on day 13 after laminectomy. On gross morphology, the cord from the study groups and the control group showed normal surface appearance. On microscopic examination, the cord from the control group was normal, whereas the cords from the study groups showed varying degrees of myelin damage and neuronal loss. These microscopic findings were dose-dependent. For the low-energy group (group 2), neuronal loss was insignificant compared to that in the control group. ESWT produced varying degrees of microscopic changes of the treated cords, but no neurological symptoms. The neuronal injury was dose-dependent and mild in the low-energy group.

Extracorporeal shockwave for chronic patellar tendinopathy

BACKGROUND

Chronic patellar tendinopathy is an overuse syndrome with pathologic changes similar to tendinopathies of the shoulder, elbow, and heel. Extracorporeal shockwave was shown effective in many tendinopathies.

HYPOTHESIS

Extracorporeal shockwave therapy may be more effective than conservative treatment for chronic patellar tendinopathy.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 2.

METHODS

This study consisted of 27 patients (30 knees) in the study group and 23 patients (24 knees) in the control group. In the study group, patients were treated with 1500 impulses of extracorporeal shockwave at 14 KV (equivalent to 0.18 mJ/mm(2) energy flux density) to the affected knee at a single session. Patients in the control group were treated with conservative treatments including nonsteroidal anti-inflammatory drugs, physiotherapy, exercise program, and the use of a knee strap. The evaluation parameters included pain score, Victorian Institute of Sports Assessment score, and ultrasonographic examination at 1, 3, 6, and 12 months and then once a year.

RESULTS

At the 2- to 3-year follow-up, the overall results for the study group were 43% excellent, 47% good, 10% fair, and none poor. For the control group, the results were none excellent, 50% good, 25% fair, and 25% poor. The mean Victorian Institute of Sports Assessment scores were 42.57 +/- 10.22 and 39.25 +/- 10.85, respectively, before treatment (P = .129) and 92.0 +/- 10.17 and 41.04 +/- 10.96, respectively, after treatment (P < .001). Satisfactory results were observed in 90% of the study group versus 50% of the control group (P < .001). Recurrence of symptoms occurred in 13% of the study group and 50% of the control group (P = .014). Ultrasonographic examination showed a significant increase in the vascularity of the patellar tendon and a trend of reduction in the patellar tendon thickness after shockwave treatment compared with conservative treatments. However, no significant difference in the appearance, arrangement, and homogeneity of tendon fibers was noted between the 2 groups. There were no systemic or local complications or device-related problems.

CONCLUSION

Extracorporeal shockwave therapy appeared to be more effective and safer than traditional conservative treatments in the management of patients with chronic patellar tendinopathy.

The effects of extracorporeal shockwave on acute high-energy long bone fractures of the lower extremity

INTRODUCTION

High-energy long bone fractures of the lower extremity are at risk of poor fracture healing and high rate of non-union. Extracorporeal shockwave was shown effective to heal non-union of long bone fracture. However, the effect of shockwave on acute fractures is unknown. The purpose of this study was to investigate the effects of shockwave on acute high-energy fractures of the lower extremity.

MATERIALS AND METHODS

Between January and October 2004, 56 patients with 59 acute high-energy fractures were enrolled in this study. Patients were randomly divided into two groups with 28 patients with 28 fractures in the study group and 28 patients with 31 fractures in the control group. Both groups showed similar age, gender, type of fracture and follow-up time. Patients in the study group received open reduction and internal fixation and shockwave treatment immediately after surgery on odd-numbered days of the week, whereas, patients in the control group received open reduction and internal fixation without shockwave treatment on even-numbered days of the week. Postoperative managements were similarly performed in both groups including crutch walking with non-weight bearing on the affected limb until fracture healing shown on radiographs. The evaluation parameters included clinical assessments of pain score and weight bearing status of the affected leg and serial radiographs at 3, 6 and 12 months. The primary end-point is the rate of non-union at 12 months, and the secondary end point is the rate of fracture healing at 3, 6 and 12 months.

RESULTS

At 12 months, the rate of non-union was 11% for the study group versus 20% for the control group (P < 0.001). Significantly, better rate of fracture healing was noted in the study group than the control group at 3, 6 and 12 months (P < 0.001).

CONCLUSION

Extracorporeal shockwave is effective on promoting fracture healing and decreasing the rate of non-union in acute high-energy fractures of the lower extremity.

Extracorporeal shock wave treatment for defective nonunion of the radius: a rabbit model

PURPOSE

To investigate the effect of extracorporeal shock wave treatment (ESWT) on bony union using volume analysis of the callus mass by computed tomography and histology.

METHODS

Both radii of 13 rabbits were osteotomised and a defective bony nonunion created by placing a polyethylene pad between the osteotomy site for 40 days. Nonunion was confirmed by radiography using Lane-Sandhu criteria. ESWT (14 kW, 0.46 mJ/mm(2), 1000 shock waves) was applied to the right radius of the rabbits. The left radius served as a control. Five rabbits were killed 4 weeks after ESWT (group 1) and 8 after 6 weeks (group 2). Volume analysis of the callus mass was performed using computed tomography and the bone healing process was assessed by histology.

RESULTS

In group 1, callus volume on the treated side was invariably greater than that on the control side; the difference being statistically significant (p=0.032). In group 2, the callus volume of the treated side was greater than that of the control side, except in rabbits 4 and 9. Only after excluding the findings from the latter did the difference attain statistical significance (p=0.020). Histology confirmed that the bone-healing process was faster in the treated side.

CONCLUSION

ESWT enhanced the bone-healing process by increasing both volume and speed of callus formation.

Assessment of scintigraphic and thermographic changes after focused extracorporeal shock wave therapy on the origin of the suspensory ligament and the fourth metatarsal bone in horses without lameness

OBJECTIVE

To monitor the effect of focused extra-corporeal shock wave therapy (ESWT) on bone and bone-tendon junction of horses without lameness by use of nuclear scintigraphy and thermography.

ANIMALS

6 warmblood horses without lameness.

PROCEDURE

The origin of the suspensory ligament at the metacarpus (OSL-MC) and the fourth metatarsal bone were treated at 2 time points (days 0 and 16) with 2,000 shocks applied by a focused ESWT device at an energy flux density of 0.15 mJ/mm2. One forelimb and 1 hind limb were treated, and the contralateral limbs served as controls. To document the effect of focused ESWT, nuclear scintigraphy was performed on days -1, 3, 16 (before second ESWT), and 19. Thermography was performed on days -1, 0 (1 hour after first ESWT), 1, 3, 8, 16 (twice; before and 1 hour after second ESWT), and 19. On days 3, 16 (first scans), and 19, thermography was performed before scintigraphy.

RESULTS

Scintigraphically, significant variations in radiopharmaceutical activity at the OSL-MC were detected in treatment and control limbs. No significant differences, however, in mean temperature or radiopharmaceutical activity could be detected by use of thermography or nuclear scintigraphy, respectively, between the treatment and control limbs at any time point in response to ESWT.

CONCLUSIONS AND CLINICAL RELEVANCE

After 2 treatments of focused ESWT, no physiologic effect on the studied structures could be demonstrated by use of nuclear scintigraphy or thermography. Results of this study indicate that at currently used ESWT settings, no damage to the bone or bone-tendon junction should occur.

Histomorphologic evaluation of extracorporeal shock wave therapy of the fourth metatarsal bone and the origin of the suspensory ligament in horses without lameness

OBJECTIVE

To determine via histologic examination and scintigraphy the effect of focused extracorporeal shock wave therapy (ESWT) on normal bone and the bone-ligament interface in horses.

ANIMALS

6 horses without lameness.

PROCEDURE

Origins of the suspensory ligament at the metacarpus (35-mm probe depth) and fourth metatarsal bone (5-mm probe depth) were treated twice (days 0 and 16) with 2,000 shocks (energy flux density, 0.15 mJ/mm2). One forelimb and 1 hind limb were randomly treated, and the contralateral limbs served as nontreated controls. Bone scans were performed on days -1 (before ESWT), 3, 16, and 19. Histomorphologic studies of control and treated tissues were performed on day 30.

RESULTS

ESWT significantly increased the number of osteoblasts but caused no damage to associated soft tissue structures and did not induce cortical microfractures. A significant correlation between osteoblast numbers and radiopharmaceutical uptake was noticed on lateral views of the hind limb on days 3 and 16 and on caudal views of the forelimb on day 3.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that ESWT has the potential to increase osteoblast numbers in horses. The correlation between increased osteoblast numbers and radio-pharmaceutical uptake 3 days and 16 days after the first ESWT suggested that stimulation of osteogenesis occurred soon after ESWT. No damage to bone or the bone-ligament interface should occur at the settings used in this study, and ESWT can therefore be administered safely in horses.

Bone and Lean Tissue Changes Following Cranial Cruciate Ligament Transection and Stifle Stabilization

Following cranial cruciate ligament transection and extracapsular stabilization, dual-energy X-ray absorptiometry was used to analyze bone mineral content and lean tissue mass in the surgical and nonsurgical legs (n=14) at 0, 2, 4, and 8 weeks, and to evaluate bone mineral content and bone mineral density (BMD) of the proximal, mid-, and distal tibia of both the surgical and nonsurgical legs (n=15) at 0, 5, and 10 weeks. There was significant loss of bone mineral content and lean tissue in the surgical leg compared to the nonsurgical leg. Significant loss in bone mineral content and BMD was detected in the tibia of the surgical leg and was most pronounced in the metaphyseal region.

Emerging Modalities in Veterinary Rehabilitation

Many new modalities have been introduced in human and veterinary physical rehabilitation. In many instances, there is sound theory of how they may impact the physiology of various cells, tissues, or organs. This article reviews some of the modalities that have been introduced recently in human and veterinary rehabilitation. Topics include low-level laser, phototherapy, and extracorporeal shock wave treatment.