In the field of orthopedics, nonunions are among the most challenging problems faced in practice.
Generally, nonunion occurs when the bone lacks stability and/or blood flow. That said, they are increasingly common if a bone breaks due to a high-impact injury or trauma. The incidence rate of nonunions is said to be between 5 – 50% depending on the study, and each nonunion varies greatly depending upon location, type of fracture, and whether it involves an open or closed wound.
A systematic review was recently published in The Journal of Clinical Medicine, titled “Extracorporeal Shockwave Therapy in the Treatment of Nonunion in Long Bones: A Systematic Review and Meta-Analysis.” The purpose of this study was to perform a systematic review of the clinical literature to evaluate the effectiveness of extracorporeal shockwave therapy (ESWT) in the treatment of nonunion in long bones. Review the study in its entirety for a full breakdown of all the findings.
Methodology of the Study
Researchers conducted an exhaustive search of three databases: PubMed, Scopus, and Web of Science. In all, they found 646 total publications, and of those, only twenty-three met their inclusion criteria.
What is a Nonunion Fracture?
Typically, broken bones heal without incident. In some cases, patients experience difficulty healing a broken bone despite treatment. Fractures that do not heal within expected time frames are known as nonunions.
Nonunions are often associated with long bone fractures of the forearm, humerus, femur, tibia, and clavicle. The impact on patients includes pain, impaired functioning, loss of quality of life, and psychological suffering that can accompany the frustrating condition.
The Course of Treatment with ESWT
It is said that ESWT has an 80% success rate from improving sports performance to delaying the progression of osteoarthritis. Patients ordinarily undergo a course of five treatments, each lasting approximately 30 minutes.
With the focused and precise energy and pinpoint accuracy, the maximum treatment depth is 12 centimeters.
Upon completion, there is also a 12-week post-treatment, and during this period, tissue remodeling and regeneration occur. Prior to the advent of shockwave therapy, physicians relied upon physical therapy, electrical stimulation, and rehabilitation when treating musculoskeletal pain and injuries. While those methods are still used, they are often utilized in conjunction with shockwave.
Differentiating Between Types of Nonunion Fractures
Typically, nonunion is identified by radiological characteristics and biological indicators.
- Hypertrophic Nonunion – characterized by abundant bone callus formation, noted lack of stability, and considered to have excessive motion. The healing potential is strong due to good blood supply to the area.
- Atrophic Nonunion –impaired bony healing due to inadequate blood supply or metabolic causes, such as diabetes or smoking. Blood flow must be stimulated to facilitate healing.
- Oligotrophic Nonunion – minimal callus formation and considered to have excessive motion and adequate biology for proper healing.
Atrophic nonunions are notoriously challenging to treat and exceptionally resistant to treatment due to the lack of vascularization.
Current Protocols for Nonunion Fractures
Many surgical techniques are used to treat nonunions, and there is a high success rate of 80%, but as with any surgery, there are inherent risks. Success with surgical rates is significantly lower in the case of atrophic nonunion due to the complexity. Surgery is a necessary part of the solution, especially in the case of dislocated nonunion.
Stem cell therapies and Extracorporeal Shockwave Therapy (ESWT) are among the conservative treatments to be considered by medical practitioners. ESWT is non-invasive and effectively fosters neovascularization and promotes bone repair.
Due to the enormous biological potential for healing, it is said that ESWT could be as effective as surgery in achieving the union, particularly of long bone hypertrophic nonunions.
In cases of long bone fracture nonunions treated with ESWT, the data indicates success rates ranging from 54% to 90%, dependent upon the site location and nature of the nonunion, along with the elapsed time after injury before treatment.
In the research, five studies differentiated results for hypertrophic and atrophic or oligotrophic cases. It was revealed that the probability that bone healing would occur with ESWT was three times higher in hypertrophic cases than in oligotrophic or atrophic nonunion patients.
Variations in Healing Rates Based on Location of Nonunion Fractures
Depending upon the anatomic location of the nonunion, healing rates seem to vary. While most studies reported outcomes for all long bones together, others reported separately by anatomical location, see below:
Despite variations by location, the overall healing rate was 73%.
Conclusions of the Systematic Review and Meta-Analysis
This review and analysis demonstrated that extracorporeal shockwave therapy is a promising approach to treating nonunions successfully. The impressive healing rates achieved with ESWT are comparable to surgery but do not carry the associated risk of potential complications. Medical practitioners should consider ESWT at the top of the list as a viable alternative to surgery in the treatment of nonunion.
Brief periods between injury and treatment lead to higher healing rates Also, 6 months of follow-up post-treatment appears to be too short a time to evaluate the full impact of healing. In fact, several studies demonstrated that healing rates continued to increase at follow-ups beyond 6 months after the last ESWT treatment was received.
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