Paul G. Peters, MD
Dr. Peters is Resident Advisory Board Member of The American Journal of
Orthopedics; and Associate Faculty, Wright State University School of
Medicine, Dayton, Ohio.
There may be another good alternative for the treatment of nonunions and delayed unions other than surgery. A study just published in The American Journal of Orthopedics by Vulpiani and colleagues, reported that extracorporal shock wave therapy (ESWT) is safe and effective for the treatment of fracture nonunions.
Overall, 143 patients were treated with high-energy shock wave therapy. Complete healing occurred in 80 patients (55.9%). The success rate increased to 89.1% when atrophic nonunions were excluded. An electromagnetic shock wave generator was used to apply 2500 to 3000 impulses given at 0.25-0.84 mL/mm(2) in 3-5 sessions. No significant adverse events were reported.
The results reported by this medical center further add to the body of evidence supporting the use of ESWT as an alternative for treatment of fracture nonunion. Two points that I was able to take away from this paper are a positive treatment effect is typically evident in the first 3 months and the importance of exclusion criteria, which include open and neoplastic fractures, infection, gross instability and bone gap greater than 0.5 cm. The exclusion of atrophic nonunions is likely prudent based on the success rate reported here.
ESWT is a very interesting treatment modality with a wide array of attempted applications from its initial FDA approval for the treatment of plantar fasciitis to many off-label uses such as fracture nonunion, lateral epicondylitis of the elbow, calcific tendinitis of the shoulder, patellar tendinopathy, Achilles tendinopathy and more recently diabetic ulcers. Reported success rates are variable and likely related to patient selection criteria and variable treatment protocols. Complication rates are low with the most common reported being local swelling, petechiae, and hematoma. The low risk profile is even more prominent as our knowledge of the deleterious effects of cortisone expands.
My personal experience relates predominantly to the treatment of plantar fasciitis and Achilles tendonosis. The majority of my patients have appreciated a clinical improvement and often have avoid surgical intervention. I have found that ESWT is a viable treatment in a select patient population, including patients that did not have good outcomes in standard nonoperative treatment, are not good surgical candidates, or that desire an alternative to surgery.
To read the full study, see:
Vulpiani MC, Vetrano M, Conforti F, et al. Effects of Extracorporeal Shock Wave Therapy on Fracture Nonunions. Am J Orthop. 2012;41(9):E122-E127.