Non-union is a regular complication of arthrodeses. Standard treatment includes revision surgery with frequent need for re-revision due to persistent non-union. Particularly patients with concomitant diseases are at risk of secondary complications. There is a need for evaluation of alternative treatment options. The aim of this study is to provide first evidence on union-rate and pain course after focussed extracorporeal shock-wave therapy of arthrodesis non-unions.
Patients and methods
In a retrospective single-centre study, 25 patients with non-union following arthrodesis received one session of focussed extracorporeal shock-wave therapy (energy flux density 0.36 mJ/mm2, 3000 impulses, 23 kV, 4 Hz). Radiographic and clinical results were recorded 6, 12 and 24 weeks after treatment.
24 patients were followed-up. After 24 weeks arthrodeses of the hand healed in 80%, of the upper ankle in 50%, of subtalar joint in 27.2% and of the midfoot in 0% of the cases. Pain decreased from 4.8 (± 2.8) points on the visual analogue scale to 3.4 (± 2.3), 2.9 (± 2.5) and 2.4 (± 2.8) points after 6, 12 and 24 weeks, respectively (p < 0.0001).
Our data indicate that the effect of focussed, high-energy shock wave therapy depends on body region and is effective for the treatment of non-unions of the hand as well as for pain relief.
Level of evidence
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Cook JJ, Summers NJ, Cook EA (2015) Healing in the new millennium: bone stimulators: an overview of where we’ve been and where we may be heading. Clin Podiatr Med Surg 32:45–59. https://doi.org/10.1016/j.cpm.2014.09.003
Dujela M, Hyer CF, Berlet GC (2017) Rate of subtalar joint arthrodesis after retrograde tibiotalocalcaneal arthrodesis with intramedullary nail fixation: evaluation of the RAIN database. Foot Ankle Spec 463:1938640017740674. https://doi.org/10.1177/1938640017740674
Zanolli DH, Nunley JA, Easley ME (2015) Subtalar fusion rate in patients with previous ipsilateral ankle arthrodesis. Foot Ankle Int 36:1025–1028. https://doi.org/10.1177/1071100715584014
Dickson DR, Mehta SS, Nuttall D, Ng CY (2014) A systematic review of distal interphalangeal joint arthrodesis. J Hand Microsurg 6:74–84. https://doi.org/10.1007/s12593-014-0163-1
Johnson JT, Schuberth JM, Thornton SD, Christensen JC (2009) Joint curettage arthrodesis technique in the foot: a histological analysis. J Foot Ankle Surg 48:558–564. https://doi.org/10.1053/j.jfas.2009.05.008
Charnley J, Baker SL (1952) Compression arthrodesis of the knee: a clinical and histological study. J Bone Joint Surg Br 34-B:187–199
Thevendran G, Shah K, Pinney SJ, Younger AS (2017) Perceived risk factors for nonunion following foot and ankle arthrodesis. J Orthop Surg (Hong Kong) 25:2309499017692703. https://doi.org/10.1177/2309499017692703
Myerson M, Li S, Taghavi C, Tracey T (2016) Management of nonunion following subtalar arthrodesis: an analysis of the methods of revision surgery, and the risk factors in achieving arthrodesis. Bone Joint J 98-B:21
Easley ME, Montijo HE, Wilson JB et al (2008) Revision tibiotalar arthrodesis. J Bone Joint Surg Am 90:1212–1223. https://doi.org/10.2106/JBJS.G.00506
Everding J, Freistühler M, Stolberg-Stolberg JA et al (2016) Extracorporal shock wave therapy for the treatment of pseudarthrosis: new experiences with an old technology. 120:1–10. https://doi.org/10.1007/s00113-016-0238-5
Haffner N, Antonic V, Smolen D et al (2016) Extracorporeal shockwave therapy (ESWT) ameliorates healing of tibial fracture non-union unresponsive to conventional therapy. Injury 47:1506–1513. https://doi.org/10.1016/j.injury.2016.04.010
Cacchio A, Giordano L, Colafarina O et al (2009) Extracorporeal shock-wave therapy compared with surgery for hypertrophic long-bone nonunions. J Bone Joint Surg Am 91:2589–2597. https://doi.org/10.2106/JBJS.H.00841
Notarnicola A, Moretti L, Tafuri S et al (2010) Extracorporeal shockwaves versus surgery in the treatment of pseudoarthrosis of the carpal scaphoid. Ultrasound Med Biol 36:1306–1313. https://doi.org/10.1016/j.ultrasmedbio.2010.05.004
Furia JP, Juliano PJ, Wade AM et al (2010) Shock wave therapy compared with intramedullary screw fixation for nonunion of proximal fifth metatarsal metaphyseal-diaphyseal fractures. J Bone Joint Surg Am 92:846–854. https://doi.org/10.2106/JBJS.I.00653
Stojadinovic A, Kyle Potter B, Eberhardt J et al (2011) Development of a prognostic naive bayesian classifier for successful treatment of nonunions. J Bone Joint Surg Am 93:187–194. https://doi.org/10.2106/JBJS.I.01649
Ogden JA, Tóth-Kischkat A, Schultheiss R (2001) Principles of shock wave therapy. Clin Orthop Relat Res 387:8–17
Xu J-K, Chen H-J, Li X-D et al (2012) Optimal intensity shock wave promotes the adhesion and migration of rat osteoblasts via integrin β1-mediated expression of phosphorylated focal adhesion kinase. J Biol Chem 287:26200–26212. https://doi.org/10.1074/jbc.M112.349811
Wang FS, Yang KD, Chen RF et al (2002) Extracorporeal shock wave promotes growth and differentiation of bone-marrow stromal cells towards osteoprogenitors associated with induction of TGF-beta1. J Bone Joint Surg Br 84:457–461
Maier M, Averbeck B, Milz S et al (2003) Substance P and prostaglandin E2 release after shock wave application to the rabbit femur. Clin Orthop Relat Res. https://doi.org/10.1097/01.blo.0000030173.56585.8f
Hausdorf J, Lemmens MAM, Kaplan S et al (2008) Extracorporeal shockwave application to the distal femur of rabbits diminishes the number of neurons immunoreactive for substance P in dorsal root ganglia L5. Brain Res 1207:96–101. https://doi.org/10.1016/j.brainres.2008.02.013
Mittermayr R, Pusch M, Schwab C, Fischer A Moreira Jr Editora|RBM Revista Brasileira de Medicina. moreirajr.com.br
Calori GM, Phillips M, Jeetle S et al (2008) Classification of non-union: need for a new scoring system? Injury 39(Suppl 2):S59–S63. https://doi.org/10.1016/S0020-1383(08)70016-0
Einhorn TA, Gerstenfeld LC (2015) Fracture healing: mechanisms and interventions. Nat Rev Rheumatol 11:45–54. https://doi.org/10.1038/nrrheum.2014.164
Einhorn TA (1998) The cell and molecular biology of fracture healing. Clin Orthop Relat Res S7–21
Wang FS, Wang C-J, Huang HJ et al (2001) Physical shock wave mediates membrane hyperpolarization and Ras activation for osteogenesis in human bone marrow stromal cells. Biochem Biophys Res Commun 287:648–655. https://doi.org/10.1006/bbrc.2001.5654
Wang C-J, Huang H-Y, Pai C-H (2002) Shock wave-enhanced neovascularization at the tendon-bone junction: an experiment in dogs. J Foot Ankle Surg 41:16–22
Wang FS, Yang KD, Kuo Y-R et al (2003) Temporal and spatial expression of bone morphogenetic proteins in extracorporeal shock wave-promoted healing of segmental defect. Bone 32:387–396
Wang C-J, Wang F-S, Yang KD (2008) Biological effects of extracorporeal shockwave in bone healing: a study in rabbits. Arch Orthop Trauma Surg 128:879–884. https://doi.org/10.1007/s00402-008-0663-1
Park SH, O’Connor K, Sung R et al (1999) Comparison of healing process in open osteotomy model and closed fracture model. J Orthop Trauma 13:114–120
Klein M, Stieger A, Stenger D et al (2015) Comparison of healing process in open osteotomy model and open fracture model: delayed healing of osteotomies after intramedullary screw fixation. J Orthop Res 33:971–978. https://doi.org/10.1002/jor.22861
Stern PJ, Fulton DB (1992) Distal interphalangeal joint arthrodesis: an analysis of complications. J Hand Surg Am 17:1139–1145
Levine SE, Myerson MS, Lucas P, Schon LC (1997) Salvage of pseudoarthrosis after tibiotalar arthrodesis. Foot Ankle Int 18:580–585. https://doi.org/10.1177/107110079701800910
Kirkpatrick JS, Goldner JL, Goldner RD (1991) Revision arthrodesis for tibiotalar pseudarthrosis with fibular onlay-inlay graft and internal screw fixation. Clin Orthop Relat Res (268):29–36
Easley ME, Trnka HJ, Schon LC, Myerson MS (2000) Isolated subtalar arthrodesis. J Bone Joint Surg Am 82:613–624
Zarutsky E, Rush SM, Schuberth JM (2005) The use of circular wire external fixation in the treatment of salvage ankle arthrodesis. J Foot Ankle Surg 44:22–31. https://doi.org/10.1053/j.jfas.2004.11.004
Wang C-J, Chen HS, Chen CE, Yang KD (2001) Treatment of nonunions of long bone fractures with shock waves. Clin Orthop Relat Res (387):95–101
Alvarez RG, Cincere B, Channappa C et al (2011) Extracorporeal shock wave treatment of non- or delayed union of proximal metatarsal fractures. Foot Ankle Int 32:746–754. https://doi.org/10.3113/FAI.2011.0746
Quadlbauer S, Pezzei C, Beer T et al (2019) Treatment of scaphoid waist nonunion by one, two headless compression screws or plate with or without additional extracorporeal shockwave therapy. Arch Orthop Trauma Surg 139:281–293. https://doi.org/10.1007/s00402-018-3087-6
Melzack R (1995) Folk medicine and the sensory modulation of pain. In: Wall PD, Melzack R (eds) Textbook of pain, 3rd edn. Churchill Livingstone, Edinburgh, pp 1209–1217
Takahashi N, Wada Y, Ohtori S et al (2003) Application of shock waves to rat skin decreases calcitonin gene-related peptide immunoreactivity in dorsal root ganglion neurons. Auton Neurosci 107:81–84. https://doi.org/10.1016/S1566-0702(03)00134-6
Jones CP, Coughlin MJ, Shurnas PS (2006) Prospective CT scan evaluation of hindfoot nonunions treated with revision surgery and low-intensity ultrasound stimulation. Foot Ankle Int 27:229–235. https://doi.org/10.1177/107110070602700401
Midis N, Conti SF (2016) Revision ankle arthrodesis. Foot Ankle Int 23:243–247. https://doi.org/10.1177/107110070202300309
Saltzman C, Lightfoot A, Amendola A (2004) PEMF as treatment for delayed healing of foot and ankle arthrodesis. Foot Ankle Int 25:771–773. https://doi.org/10.1177/107110070402501102
Bassett CAL, Mitchell SN, Gaston SR (1982) Pulsing electromagnetic field treatment in ununited fractures and failed arthrodeses. JAMA 247:623–628. https://doi.org/10.1001/jama.1982.03320300027017
Zura R, Rocca Della GJ, Mehta S et al (2015) Treatment of chronic (> 1 year) fracture nonunion: heal rate in a cohort of 767 patients treated with low-intensity pulsed ultrasound (LIPUS). Injury 46:2036–2041. https://doi.org/10.1016/j.injury.2015.05.042
Buckley RE (2018) Aseptic nonunion. In: Buckley R, Moran C (eds) AO principles of fracture management, vol 2, 3rd edn. Georg Thieme Verlag, Stuttgart
Alkhawashki HMI (2015) Shock wave therapy of fracture nonunion. Injury 46:2248–2252. https://doi.org/10.1016/j.injury.2015.06.035
We thank PD Dr. Patric Garcia for initiation of structured study and follow-up of patients treated with fESWT. Furthermore, we thank Dr. Britta Wieskötter for the cooperation and advice for patients with non-unions of the hand and Dr. Moritz Freistühler for the calculation of the treatment costs.
Conflict of interest
The authors declare that they have no conflict of interest.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Everding, J., Stolberg-Stolberg, J., Pützler, J. et al. Extracorporal shock wave therapy for the treatment of arthrodesis non-unions. Arch Orthop Trauma Surg (2020). https://doi.org/10.1007/s00402-020-03361-2
- Shock wave
- Tissue regeneration