SLR - October 2011 - C. Keith McSpadden

Extracorporeal Shock Wave Therapy for Nonunion of the Tibia

Reference: Elster EA, Stojadinovic A, Forsberg J, Shawen S, Andersen RC, Schaden W. (2010). Extracorporeal Shock Wave Therapy for Nonunion of the Tibia. J Orthop Trauma, 24, 133-141.             

Scientific Literature Review

Reviewed by: C. Keith McSpadden, DPM
Residency Program: The Western Pennsylvania Hospital, Pittsburgh, PA

Podiatric Relevance:
Nonunion of fracture and arthrodesis sites can be a frustrating complication for the foot and ankle surgeon. Revisional surgery can lead to further patient morbidity and increased complications. In cases of nonunion without malalignment, non-invasive techniques, including electromagnetic, ultrasonic, and extracorporeal shock wave therapy (ESWT), can offer distinct advantages over revisional surgery. Furthermore, ESWT does not require the daily patient compliance of self-administration involved with other bone stimulation modalities.

One hundred ninety-two patients were treated with ESWT at a single referral trauma center for treatment for tibia nonunion. Nonunion was determined by radiographic or CT analysis at least six months following operative or nonoperative treatment, with at least three months of no radiographic changes. Fractures were treated with up to 12,000 pulses (median, 4000 pulses) using an energy flux density ranging 0.38 to 0.40 mJ/mm2. Fluoroscopy was used to confirm the focal point targeted the fracture site. Duration and type of immobilization, for up to 12 weeks, were not standardized. Fracture healing was determined by radiographic or CT analysis.

At the time of last follow up, 138 of 172 (80.2%) patients demonstrated complete fracture healing. Mean time from first shock wave therapy to complete healing of the tibia nonunion was 4.8 months. Associated factors influencing fracture healing included number of orthopedic operations (P = 0.003), shock wave treatments (P = 0.002), and pulses delivered (P = 0.04). Patients requiring multiple (more than one) shock wave treatments versus a single treatment had a significantly lower likelihood of fracture healing (P = 0.003).

This study concludes that high energy ESWT may be used successfully in the treatment of tibia nonunions. The reported healing rate of 80% is consistent with previous literature, reporting bony union rates ranging from 55% to 87% following ESWT. The large sample size gives this study relevance; however, limitations include retrospective design and lack of a control group using immobilization alone. Although this study evaluated nonunion of tibia fractures, there is potential for future investigation of ESWT in the treatment of fracture and arthrodesis nonunion in the foot and ankle.


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