eswt in orthopeadics

EXTRACORPOREAL SHOCK WAVE THERAPY

IN ORTHPEADICS

Ahmed Ashour dr.

ESWT IN ORTHOPEADICS

- ESWT in orthopeadics was introduced in Germany and Austria more than

a decade ago. - In Germany, the number of patients

treated with ESWT for orthopaedic disorders estimated 60,000 to 100,000 patients annually>>>>>> exceeds even the number of patients treated with urologic lithotripsy.


Uses:1- ONFH Stage- I, II, or III i.e. (pre-

collapse stages).

2- Insertion Tendinopathies : A- Supraspintaus Tendinitis. B- Lateral Epicondylitis. C- Plantar Fasciits.3- Fracture Non union.


ESWT or

Core Decompression for ONFH ?

Ching-Jen Wang et al, J Bone Joint Surg Am. 2005;87:2380-2387.

ESWT or Core Decompression ?

ESWT: For early-stages ONFH.- Other Joint-preserving options:-1- Protected weight bearing. 2- Core decompression with or without

vascularized or nonvascularized bone-graft.

3- Muscle pedicle grafting.4- Rotational osteotomy.5- Electropulsed magnetic field.

ESWT or Core Decompression?

Methods:1- Stage-I, II, or III Osteonecrosis were

randomly assigned.2- Shock-wave group consisted of 23

pts (29 hips).3- Surgical group consisted of 25 pts

(28 hips).4- Shock-wave group received a single

treatment with 6000 impulses of shock waves at 28 kV to the affected hip, (1.500 impulse for 4 points)


Criteria of follow up:-1- Clinical assessment of pain with:- A- visual analog pain scale, B- Harris

hip scores, C- assessment of activities of daily living and work capacity.

2- Radiographic assessment was performed with serial plain radiographs and MRI’s.


Technique of ESWT (23 pts):- 1- patient under general anesthesia. 2- supine position. 3-The affected hip was positioned in adduction, internal rotation. 4-The femoral artery was identified by digital palpation, confirmed with an ultrasound Doppler scan to avoid any direct shock-wave contact with it during the course of treatment..


The Junctional Zone:-1- Stage-II or III: between avascular and vascular bone of the femoral head was delineated under c-arm. 4 focal points, approximately 1.0 cm apart, within the junctional zone were selected.2-the corresponding locations on the skin in the groin were marked with a marker. 3- Stage-I lesion: the junctional zone was selected on the basis of findings on magnetic resonance imaging


- Chung and Wiley et al classified ESWT according to energy categories:

- Low : (<0.08 mJ/mm2).- Medium: (0.08 to 0.28 mJ/mm2).- High: (>0.6 mJ/mm2).

ESWT or Core Decompression ?

- Each of the 4 points was treated with 1500 impulses of shock waves at 28 kV (equivalent to 0.62 mJ/mm2 energy flux density).

-Total of 6000 impulses of shock waves.

-The integrity of the femoral artery was checked with the Doppler ultrasound before and after the procedure.


Core Decompression(25 pts):-1- Lateral approach. 2-The location of the Osteonecrosis of

the femoral head was verified with c-arm, 10 mm reamer.

3-The necrotic bone and its margins were removed.

4-Cancellous bone grafts.

5- Cortical fibular strut graft.


Evaluation:-1- Follow-up at 1, 3,6,12 months and

then once a year. 2- Pain scores and Harris hip scores,

evaluation of the ability to carry out activities of daily living and work capacity.

3- The intensity of pain was recorded on a visual analog scale ranging from 0 to 10.


Evaluation cont.:-4- The Harris hip score measures

pain, function, activity, and motion of the hip10.

5- The evaluation of activities of

daily living included determination of the level of activity, walking capacity with or without support, the length of time that the patient could walk; and the ability to ascend and descend stairs.


Clinical outcome : defined as:

1- “Improved” if the patient had :

a ≥50% reduction in hip pain and a ≥50% improvement in hip

function in activities of daily living,


2- “Unchanged” if the patient had a <50% reduction in hip pain and a <50% improvement in hip

function in activities of daily living.

3- “Worse” if the patient had more hip pain and less hip function compared with the pretreatment status.


Before treatment, the 2 groups had similar pain and Harris hip scores, but at an average of 25 months after treatment

After 25 m. Improve-d

Unchanged

Worse

Shock wave 79% 10% 10%

Core -decompression

29% 36% 36%


Results:- Shock-wave group, imaging

studies showed: 1- 5 of 13 lesions that had been

designated as stage I or II before treatment >>>>>> regression.

2- No regression of a stage-III . 3- 2 stage-II and 2 stage-III

lesions progressed.


Results:- Surgical group:- 1- 4 lesions regressed 2- 15 (of the 19 graded as stage I

or II) progressed. 3- The remaining 9 lesions were

unchanged.


Conclusion:- 1- ESWT appeared to be more

effective than core decompression and nonvascularized fibular grafting in patients with early-stage ONFH.

BUT………..

Long-term results (after 36 months) ? ?

ESWT of the Femoral Head Osteonecrosis in Systemic

Lupus Erythematosis

a case report

Po-Chun Lin et al, The Journal of Arthroplasty Vol. 21 No. 6 2006

ESWT of ONFH in SLE

A 19-year-old lady was diagnosed to have -SLE 2 years ago with recurrent bleeding

episodes due to thrombocytopenia. Initial treatments consisted of analgesics and dexamethasone 10 mg QID, tapered down to 10 mg/d when the symptoms were brought under control,

-Ortho.,: Intermittent bilateral hip pain for nearly 12 months’ duration, progressively worse especially on distance walking and stairs climbing.

ESWT of ONFH in SLE

- Range of hip motion steadily decreased.

- Conservative treatments including analgesics, increase of dexamethasone were ineffective.

-The intensity of pain was 8 right hip , 5 left hip based on visual analogue scale (from 0 to 10 with 0 for no pain and 10 for severe pain )

-The Harris hip scores were 73 points right hip, 74 points left hip.

ESWT of ONFH in SLERadiographs, MRI of the hips

showed stage III ONFH in both hips.

Involved total surface area

Weight bearing area

Right 15% 72%

Left 13% 95%

ESWT of ONFH in SLE

MRI’s: showed grade 4 bone marrow edema on

the right hip and grade 2 on the left hip.

Bone marrow edema ?? : 5 grades 0 => no edema, 1 => perinecrotic, 2 => edema extending to the femoral

head, 3=> edema extending to the femoral neck, 4=> edema extending to the intertrochanteric region.

ESWT of ONFH in SLE

Technique:-The junctional zone was delineated with C-arm.

- 4 points 1.0 cm apart were selected with a metallic guide, and the corresponding locations were marked on the skin in the groin area.

- Each of the 4 points of interest was treated with 1000 impulses of shockwaves at 28 kV (equivalent to 0.62 mJ/mm2 energy flux density), and a total of 4000 impulses of shockwaves was delivered to the affected femoral head.

Left hip before and after treatment:

- No changes in the stages of the disease

- No further collapse of the femoral heads.

Left hip before and after treatment:

- Resolution of bone marrow edema

- No further collapse of the femoral head.

ESWT of ONFH in SLE

Mechanism of action:

Wang et al, shockwave treatment induced:

1- In growth of neovascularization. 2-Increased expressions of angiogenic

growth factors including endothelial nitric oxide synthase, vessel endothelial growth factor,

3- Increased expression of proliferating cell nuclear antigen at the tendon-bone junction in rabbits.

ESWT of ONFH in SLE

Mechanism of action:

4- Neovascularization may play a role in the improvement in blood supply and tissue repair.

5- Dose-dependent enhancement of shock waves on bone mass and bone strength in a rabbit model

ESWT of ONFH in SLENatural course ONFH:-Koo et al, reported a correlation with hip

pain and bone marrow edema in hips affected by ONFH.

- Merle d’Aubigne et al, >>> collapse of the femoral head in 20% within 1 year and 75% within 3 years from the onset of the disease in the follow-up of 90 cases.

-Takatori et al, >>>a 44% collapse in 25 high-risk patients on glucocorticoids or alcoholism with positive MRI for AVN of bone, but X-ray normal and asymptomatic in an average follow-up of 15 months.

ESWT of ONFH in SLE

- Ohzono et al, reported collapse of the femoral head in 94% to 100% if the lesions at the weight-bearing surface on the femoral head within 5 years.

- Mont et al, reported that the average interval from core decompression to THA was only 14 months and recommended that core decompression should not be performed in SLE patients with stage III lesion of ONFH.

Low-Energy ESWT for Treatment of Chronic

Plantar Fasciitis

Jan D. Rompe et al, J Bone Joint Surg Am. 2002;84:335-341.

ESWT for Plantar Fasciitis

- Rompe et al did a prospective, randomized, controlled trial to assess whether 3 applications of 1000 impulses of low-energy shock waves (Group I) led to a superior clinical outcome when compared with 3 applications of 10 impulses of shock waves (Group II) in patients with intractable plantar heel pain.( sample 112 pt)


- Painful heel, often combined with an inferior calcaneal spur, is a common orthopaedic complaint.

-The cause of this clinical entity remains enigmatic.

-The use of conservative methods, with a stretching protocol regarded as the mainstay of nonoperative treatment, alleviates the condition in most patients.

- When conservative treatment has failed, surgical release of the plantar fascia has been undertaken with variable results.


Patient criteria:- 119 patients (51 female and 68 male;

mean age 46 years) who had had pain for a mean of 9 m (range 6-12 m) were eligible for the study.

- All 119 patients had been previously treated unsuccessfully.

- 80 patients given medication, mostly NSAIDs.

- 110 had worn shock-absorbing shoe inserts.

- 42 had performed some kind of stretching exercises on a regular basis.

- 19 had used night splints.


Patient criteria:- 81 treated with a cast for at least 2

weeks. - Average of 1.9 corticosteroid

injections (range 1-5 injections) had been given to the 119 patients.

- Average of 3 different physical therapy regimens (range,1-5 different regimens), such as icing, ultrasound, magnetic field therapy, iontophoresis or phonophoresis, contrast baths, and radiation therapy, had been tried.


Group1:- Received a total of 3000 impulses of

an energy flux density of 0.08 mJ/mm2, (No: 50 pts)

-The mean duration of pain beofre trial was 8m (range 6-19ms).

Group II-A total of 30 impulses of an energy flux

density of 0.08 mJ/mm2, (No: 50 pts)-The mean duration of pain was 10ms

(range, 6-12ms).

ESWT for Plantar FasciitisEvaluation at 6 ms :-Pain rating, according to modified

criteria of the Roles and Maudsley score, was defined as:

- Excellent (no pain, patient satisfied with the treatment outcome, and unlimited walking without pain).

- Good (symptoms substantially decreased, patient satisfied with the treatment outcome, and ability to walk without pain for more than one hour).

ESWT for Plantar FasciitisEvaluation at 6m con.:- Acceptable (symptoms somewhat

decreased, pain at a more tolerable level than before treatment, and patient slightly satisfied with the treatment outcome).

- Poor (symptoms identical or worse and patient not satisfied with the treatment outcome).

- Treatment was considered successful when the patient had an excellent or good score.

ESWT for Plantar FasciitisEvaluation at 5 years:- Extent of pain at night, at rest, and on

manual pressure on a visual analog scale ranging from 0 (no pain) to 100 (worst imaginable pain) >>(at 6m and at 5 yrs)

-To assess pain on manual pressure, the physician used his thumb to gradually increase pressure on the patient’s contralateral unaffected heel until pain began.


-Walking ability without a need for rest to relieve pain in the heel was rated as :

-0 (less than 5 min) -1 (less than 15 min)

-2 (less than 30 min) -3 (less than 45 min)

-4 (less than 60 min) - 5 (unlimited).

- All patients had a radiograph made of the heel before treatment and at 6ms follow-up.

Percentage of patients with a good or excellent outcome

Visual analog scale for pain on manual pressure before and after ESWT for chronic heel pain.

Subjective pain in Patients Receiving 3000 Impulses ( I),Those Receiving 30 Impulses ( II)

1-Night Pain 2- Resting pain

Grades for walking ability before and after ESWT for chronic heel pain.


- Maier et al. reported good or excellent results in 36 of 48 patients (75%) heels at 29 m

- Wang et al, reported that 33of 41 patients (80%)were either free of symptoms or substantially better at 12 w after shock-wave therapy.


- Ogden et al. performed a randomized, placebo-controlled study:

- 119 pts >> treatment group- 116 pts>> placebo group. - 12 w after a single application of

1500 shock waves at 18 kV. - the result was successful in 47% of

the patients.


- This study led the United States Food

and Drug Administration (FDA) To

approve shock-wave therapy for

painful heels


Conclusion:- ESWT effective for plantar fascitis- Dose dependent; 3 applications

of 1000 impulses appeared to be a useful, noninvasive, negligible side effects that reduced the necessity for a surgical procedure.


Nevertheless !!! -low-energy shock-wave cannot be recom-

mended as a first-line procedure for chronic heel pain.

-Although the United States (FDA) approved ESWT for heel pain, additional controlled studies are still needed to verify the results of this study and to define the precise role of this new modality in the treatment of chronic plantar fasciitis.

Extracorporeal Shock Wave Therapy in the Treatment of Lateral

Epicondylitis

M. Haake et al J Bone Joint Surg Am. 2002;84:1982-1991.

ESWT for Lateral EpicondylitisMethods: - A randomized multicenter trial (Germany,

Austria) local anesthesia (No: 272 Pts).- ESWT with 3 treatments of 2000 pulses

each.- placebo was applied on an outpatient

basis.- The rate of success as determined with

the Roles and Maudsley score and whether additional treatment was required 12 W after the intervention.

- Subjective pain rating, and grip strength after 6 , 12 W and 12 M.

ESWT for Lateral Epicondylitis

Inclusion criteria:- A patient had to have a clinical

diagnosis of lateral epicondylitis based on at least 2 positive clinical tests:

1- local pain above the lateral epicondyle

2- Thomson test 3-the middle-finger extension test 4 - the Mill test.

ESWT for Lateral Epicondylitis - ESWT with 3 treatments of 2000 pulses

each was applied with 1 w interval between, (ED+) of 0.07 to 0.09 mJ/mm2

- After administration of local anesthesia (3 mL of 1% mepivacaine).

- Positioning: ultrasound imaging to focus the

shock waves at the insertion of the muscles at the lateral epicondyle of the humerus

Self-Administered Roles and Maudsley Pain Score Used in the Trial

Grip strength, black>> ESWT, red>> Placebo

Success Rates 12w After Intervention


Results: - The success rate was 25.8% in the

group treated with ESWT.- 25.4% in the placebo group. (ONLY

difference of 0.4%)- Improvement was observed in 2/3 of

the patients from both groups 12 M after the intervention. Few side effects were reported.


Conclusion: ESWT as applied in the present study was ineffective in the treatment of lateral

epicondylitis.

Humeral Head Osteonecrosis

After ESWT for Rotator Cuff Tendinopathy

A case report

Hon-Man Liu et al, J Bone Joint Surg Am. 2006;88:1353-1356.

Humeral head ON after ESWT

49year-old woman underwent serial

MRI’S of the left shoulder over a period of 10 months to evaluate pain, which had begun after she pulled a heavy object.


- The first MRI revealed: - Shoulder impingement with partial

tear of the supraspinatus tendon on the humeral side.

- Subacromial and subdeltoid bursitis.- Biceps tenosynovitis.- No evidence of osteonecrosis of the

humeral head.


- The patient then received 1 shock-wave treatment each week for 3 consecutive weeks.

- The impulse rate was 3000 shocks per session with an energy of 0.78 mJ/mm2.


- 3ms after ESWT, the follow-up MRI showed a newly developed area of osteonecrosis in the left humeral head in addition to the previous findings.

- Geographic subchondral lesions of the humeral head with preservation of its

cortical outline.


- 7 ms after ESWT, another follow up MRI revealed a “crescent sign” in the humeral head.

- This sign was not present on the study performed at 3ms and was considered to demonstrate progression of the osteonecrosis.


- The shoulder pain became intolerable, and the patient also noted progressive limitation of the range of motion of the

shoulder. - 2m later, she therefore, underwent

surgical core decompression of the humeral head two months later.


Clinical history: -No predisposing factors such as: - Injury, use of steroid medication,

blood disorders such as sickle cell disease, excessive alcohol use, Gaucher disease, pancreatitis.

- Radiation treatment, chemotherapy, decompression disease, connective tissue diseases, or dyslipoproteinemia.

Humeral head ON after ESWT RENAL COMPLICATIONS:- Are thought to be the result of:- Cell damage - Cavitation produced by the shock waves,- Rupture of small blood vessels (with an

inner diameter of <300 μm), - Complete detachment of endothelial cells

in defined regions.- Cell damage after ischemic-reperfusion

injury, vasoconstriction. - Free-radical production.


- According to a cadaveric study by Duparc et al.- The diameter of the anterior humeral

circumflex artery ranges between 0.3 and 2 mm in adults.

- Some patients with a small artery may be more susceptible to the development of osteonecrosis after ESWT.

ESWT for defective nonunion

a rabbit model

O Bulut et al, Journal of Orthopaedic Surgery 2006;14(2):133-7


-The management of long-bone defective nonunion is difficult and costly.

- ESWT has been used in the treatment of pseudarthrosis since 1988 with a success rate ranging from 60 to 85%.

- More satisfactory results have been obtained in hypertrophic than atrophic nonunion.


-Schaden et al. reported a 76% success rate with ESWT in 115 pts with nonunion caused by fractures that were treated nonoperatively.

- They suggested that ESWT was a better method for treating nonunion with a defect

smaller than 5 mm.


Method:-- 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. - Then ESWT (14 kW, 0.46 mJ/mm2, 1000

shock waves) was applied to the right radius of the rabbits.

- The left radius served as a control.


Method con.:-- 5 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.

Photo. and X-ray showing osteotomy of the radius, insertion of polyethylene pads to

create abone defect.


-After 40 days, the polyethylene pads were removed under general anaesthesia.

- Plain radiographs were taken on both radii after a further 10 days.

- Bone defects were evaluated according to the Lane-Sandhu radiographic criteria.

A radiograph taken 40 days after osteotomy with polyethylene pads removed showing a defective nonunion.


- ESWT was performed under general anaesthesia on the same day.

- ESWT (14 kW, 0.46 mJ/mm2, 1000 shock waves) was applied to the right radius by focusing the shock waves on the bone defect.

- The left side of each animal served as a control.


- 5 animals were randomly selected, killed 4 ws after ESWT (group 1) and the remaining 8 animals were killed 2 ws later (group 2).

- Callus formation was analysed using CT scan by taking 2-mm axial sections of the callus mass.

- The callus mass in every section with the border drawn using a ‘free hand technique’ was measured in cm2 on the CT scan.


-This value was multiplied by 0.2 cm (the distance between sections) to determine the section volume.

- Total callus volume was then calculated by combining the volume measurements of all callus areas.

Analysis of the callus volume by free handtechnique on computed tomographic scan.


- Bone and callus tissue specimens from both the treated and control sides of groups 1 and 2 were examined under photomicroscopy, by taking 5 to 7 μm sections and staining them with hematoxylin and eosin

“Callus analysis of 5 animals after 4 w”

“Callus analysis of 8 animals after 6 w”


This study:- A simple method for analysis of callus

volume was used.- Callus volume analysis is used,

because it is superior for quantitative assessment of bone healing.

- Callus density measurement was not needed because callus density indicates the mechanical strength of callus tissue.1


Wang et al.: demonstrated a great deal of cortical

bone formation on the treated side, and a great deal of fibrous and fibro-cartilaginous tissue formation on the control side 12 weeks after ESWT.


- Rompe et al.: suggested that ESWT was more effective

in fractures caused by osteotomy than those caused by injury

- McCormack et al.: did not observe faster bone-healing

process and remodelling phase, even though a greater callus volume was seen.


Moreover,- negative effects of ESWT such as:

reduced mechanical stability and delayed fracture healing in a sheep

Model.- and delayed bone healing and

epiphyseal dysplasia in a rat model, have also been

reported.

eswt in orthopeadics

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