Aims

Biofilm formation is one of the primary reasons for the difficulty in treating implant-related infections (IRIs). Focused high-energy extracorporeal shockwave therapy (fhESWT), which is a treatment modality for fracture nonunions, has been shown to have a direct antibacterial effect on planktonic bacteria. The goal of the present study was to investigate the effect of fhESWT on Staphylococcus aureus biofilms in vitro in the presence and absence of antibiotic agents.

Achilles tendinopathy is characterised by chronic degeneration of the Achilles tendon, usually secondary to injury or overuse. Extracorporeal shockwave treatment (ESWT) is of potential benefit in refractory cases where conservative management with analgesia, physiotherapy and corticosteroid injection have been unsuccessful. Patients with refractory Achilles tendinopathy enrolled between October 2010 and October 2011 received three sessions of ESWT over three weeks. Patients completed visual analogue scale (VAS) scores for pain at rest and on activity and the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire pre-treatment. These outcome measures and a six-point Likert satisfaction scale were reassessed at six and 16 weeks post treatment. 51 patients completed follow up. Mean age was 56 (34–80) years and mean length of symptoms 34 (4–252) months. Significant improvement (p<0.05) in VAS scores (rest and activity) and VISA-A scores was observed between baseline and 16 weeks. Mean Likert score was 3 (somewhat improved) at 16 weeks. Patients suffering Achilles tendinopathy for longer than 25 months had significantly less improvement than those affected for a shorter period. This study suggests that ESWT improves subjective and objective outcomes in patients with refractory Achilles tendinopathy

This study compared the functional outcomes of total hip arthroplasty (THA) in one hip and extracorporeal shockwave (ESWT) in the other hip in patients with bilateral hip necrosis. Seventeen patients with bilateral hip necrosis were treated with THA for late stage ONFH in one hip and ESWT for early lesion in the other hip. In THA, only one type of prosthesis was used and all components were cementless. In EWST, each hip received 6000 shocks at 28 Kv (equivalent to 0.62 mJ/mm. 2. energy flux density) in a single session. The evaluations included pain score, Harris hip score, radiographs and MR images at 6 and 12 months and then yearly. Significant improvements in pain score and Harris hip score were noted after treatment in both hips. However, the magnitudes of improvement showed significant differences between the two sides favoring the ESWT side. On subjective assessment, 13 patients rated ESWT better than THA; 4 patients reported comparable results of THA and ESWT, and none graded THA better than ESWT. In THA side, abnormal radiographs were noted in 47% (8 of 17) including component mal-position, nonprogressive radiolucency, and suspected component loosening. In ESWT side, significant reduction of bone marrow edema and a trend of decrease in the size of the lesion were observed after treatment. ESWT and THA are effective for early and late stages of ONFH respectively. However, better functional outcomes were observed in ESWT-treated hips than hips treated with THA in patients with bilateral hip disease in short-term

Achilles tendinopathy is chronic degeneration of the Achilles tendon, usually secondary to injury or overuse. It involves a triad of pain, swelling and impaired function. Primary treatment is rest, analgesia, corticosteroid injections and physiotherapy (eccentric training and heel pads to correct gait). Some patients remain symptomatic and further treatment options need considering. NICE produced a document from the Interventional Procedures Advisory Committee in 2009 which reviewed the literature and evidence for extracorporeal shockwave treatment (ESWT). Low energy shock wave treatment (SWT) is thought to stimulate soft tissue healing, inhibit pain receptors and promote angiogenesis. NICE guidance was that ESWT could be used in refractory Achilles tendinopathy if used for clinical governance, audit or research. Patients with refractory Achilles tendinopathy were enrolled between October 2010 and 2011. They received three sessions of ESWT over three week. Patients completed visual analogue scale (VAS) scores for pain at rest and on activity and the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire pre-treatment. These outcome measures and a six-point Likert satisfaction scale (six points, high is worsening) were reassessed at 6 and 16 weeks post treatment. 51 patients completed follow up. The mean age was 56 (34–80) years and mean length of symptoms 34 (4–252) months. There was a significant improvement (p<0.05) in VAS scores observed from baseline and 16 weeks post treatment. This was also the case in the VISA-A scores. The mean Likert score was 3 (somewhat improved) at 16 weeks but there was no statistical significance. This study suggests that ESWT improves subjective and objective outcomes in patients with refractory Achilles tendinopathy. Patients over 60 possibly have a worse outcome along with patient who had symptoms for over 25 months. Follow up scores at one year are due to be collected and the data will be submitted to NICE

Introduction:

Plantar Fasciitis is an extremely common and challenging problem that presents itself to foot and ankle practitioners. Many different treatment modalities are available for this condition, with little proven benefit. ECSWT was approved for use by the FDA for the treatment of chronic proximal plantar fasciitis in 2002 and NICE published guidance in 2009 recommending its use in refractory cases.

The effect of shockwave in osteonecrosis of the femoral head (ONFH) is poorly understood. The purpose of this study was to investigate the regeneration effects of shockwave in ONFH.

This study consisted of 14 femoral heads from 14 patients undergoing total hip arthroplasty for ONFH. Seven patients with seven hips who received shockwave prior to surgery were designated as the study group, whereas, seven patients with seven hips who did not receive shockwave were assigned to the control group. Both groups showed similar demographic characteristics. The femoral heads were investigated with histopathological examination and immunohistochemical analysis with von Willebrand factor (vWF), VEGF, platelet endothelial cell adhesion molecule-1 (PECAM-1) also referred to as (CD 31) and vascular cell adhesion molecule (VCAM) for angiogenesis, and with proliferation cell nuclear antigen (PCNA), Dickkopf-1 (DKK1) and Winless 3a (Wnt 3) for bone remodelling and regeneration.

In histopathological examination, the study group showed significantly more viable bone and less necrotic bone, higher cell concentration and more cell activities including phagocytosis than the control group. In immunohistochemical analysis, the study group showed significant increases in vWF (P< 0.01), VEGF (P¼0.0012) and CD 31 (P¼0.0023), Wnt3 (P¼0.008) and PCNA (P¼0.0011), and decreases in VCAM (P¼0.0013) and DKK1 (P¼0.0007) than the control group.

Shockwave treatment significantly promotes angiogenesis and bone remodelling than the control. It appears that application of shockwave results in regeneration effects in hips with ONFH.

PURPOSE OF THE STUDY: We reported of eleven cases of early spontaneous osteonecrosis (SO) of the knee successfully treated with an extracorporeal shock-wave treatment (ESWT).

Traumatic and vascular theories have been proposed as the cause of the SO, lack of blood in some critical areas, such as subchondral bone of femoral condyles or tibial plateaus, has been considered the underlying condition of this pathology.

ESWT can be suggested as an effective conservative treatment for SO of the knee.

MATERIALS AND METHODS: Ten patients with medial femoral condyle osteonecrosis of the knee (one bilateral) were evaluated. Exclusion criteria was evidence of a structural collapse of subchondral bone. Two patients had received a femoro-popliteal by-pass within the last year, while others five presented a deficit of the vascular axis of the homolateral lower limb documented by an eco-colordoppler. A clinical evaluation was taken at the diagnosis using KSS, PPI, NRS and VAS. Plain radiographs and MRI confirmed the diagnosis of osteonecrosis.

Patients were treated with a cycle of three ESWT performed with 2000 pulses of 0,28 mJ/mm2 with Wolf Piezoson 300 with 6,5 MHz ultrasounds for three times in a month.

Clinical evaluation was performed at first and at third month after treatment and a MRI evaluation was performed at fourth month after treatment.

RESULTS: Clinical evaluation showed a significant improvement of symptoms and articular functionality. MRI of all cases revealed the continuity of the cartilage with a reduction in bone marrow edema and no collapse of lesion.

DISCUSSION: In our study, a single cycle of ESWT produced an improvement of the clinical and MRI aspects in eleven cases of SO of the knee. The neo-angiogenetic effect of the ESWT appears to accelerate the time for the symptom remission.

ESWT might have the potential to avoid the need for surgical treatment.

Bone is one of the most highly adaptive tissues in the body, possessing the capability to alter its morphology and function in response to stimuli in its surrounding environment. The ability of bone to sense and convert external mechanical stimuli into a biochemical response, which ultimately alters the phenotype and function of the cell, is described as mechanotransduction. This review aims to describe the fundamental physiology and biomechanisms that occur to induce osteogenic adaptation of a cell following application of a physical stimulus. Considerable developments have been made in recent years in our understanding of how cells orchestrate this complex interplay of processes, and have become the focus of research in osteogenesis. We will discuss current areas of preclinical and clinical research exploring the harnessing of mechanotransductive properties of cells and applying them therapeutically, both in the context of fracture healing and de novo bone formation in situations such as nonunion.

Cite this article: Bone Joint Res 2019;9(1):1–14.

In a prospective randomised trial of calcifying tendinitis of the rotator cuff, we compared the efficacy of dual treatment sessions delivering 2500 extracorporeal shock waves at either high- or low-energy, via an electromagnetic generator under fluoroscopic guidance. Patients were eligible for the study if they had more than a three-month history of calcifying tendinitis of the rotator cuff, with calcification measuring 10 mm or more in maximum dimension. The primary outcome measure was the change in the Constant and Murley Score.

A total of 80 patients were enrolled (40 in each group), and were re-evaluated at a mean of 110 (41 to 255) days after treatment when the increase in Constant and Murley score was significantly greater (t-test, p = 0.026) in the high-energy treatment group than in the low-energy group. The improvement from the baseline level was significant in the high-energy group, with a mean gain of 12.5 (−20.7 to 47.5) points (p < 0.0001). The improvement was not significant in the low-energy group. Total or subtotal resorption of the calcification occurred in six patients (15%) in the high-energy group and in two patients (5%) in the low-energy group.

High-energy shock-wave therapy significantly improves symptoms in refractory calcifying tendinitis of the shoulder after three months of follow-up, but the calcific deposit remains unchanged in size in the majority of patients.