Aims. To explore the efficacy of extracorporeal shockwave therapy (ESWT) in the treatment of osteochondral defect (OCD), and its effects on the levels of transforming growth factor (TGF)-β, bone morphogenetic protein (BMP)-2, -3, -4, -5, and -7 in terms of cartilage and bone regeneration. Methods. The OCD lesion was created on the trochlear groove of left articular cartilage of femur per rat (40 rats in total). The experimental groups were Sham, OCD, and ESWT (0.25 mJ/mm. 2. , 800 impulses, 4 Hz). The animals were euthanized at 2, 4, 8, and 12 weeks post-treatment, and histopathological analysis, micro-CT scanning, and immunohistochemical staining were performed for the specimens. Results. In the histopathological analysis, the macro-morphological grading scale showed a significant increase, while the histological score and cartilage repair scale of ESWT exhibited a significant decrease compared to OCD at the 8- and 12-week timepoints. At the 12-week follow-up, ESWT exhibited a significant improvement in the volume of damaged bone compared to OCD. Furthermore, immunohistochemistry analysis revealed a significant decrease in type I collagen and a significant increase in type II collagen within the newly formed hyaline cartilage following ESWT, compared to OCD. Finally, SRY-box transcription factor 9 (SOX9), aggrecan, and TGF-β, BMP-2, -3, -4, -5, and -7 were significantly higher in ESWT than in OCD at 12 weeks. Conclusion. ESWT promoted the effect of TGF-β/BMPs, thereby modulating the production of extracellular matrix proteins and transcription factor involved in the regeneration of articular cartilage and subchondral bone in an OCD rat model. Cite this article: Bone Joint Res 2024;13(7):342–352

The April 2024 Foot & Ankle Roundup³⁶⁰ looks at: Safety of arthroscopy combined with radial extracorporeal shockwave therapy for osteochondritis of the talus; Bipolar allograft transplantation of the ankle; Identifying risk factors for osteonecrosis after talar fracture; Balancing act: immediate versus delayed weightbearing in ankle fracture recovery; Levelling the field: proximal supination osteotomy’s efficacy in severe and super-severe hallux valgus; Restoring balance: how adjusting the tibiotalar joint line influences movement after ankle surgery.

Aims. We conducted a study to identify factors that are prognostic of the outcome of extracorporeal shockwave therapy (ESWT) for calcific tendinitis of the shoulder. Patients and Methods. Since 1998, patients with symptomatic calcific tendinitis of the rotator cuff have been treated with ESWT using an electrohydraulic mode shockwave device. One year after ESWT, patients were grouped according to the level of resorption of calcification. Results. Of 241 symptomatic shoulders, complete resorption (CR) of calcification occurred in 134 (CR group). The remaining 107 shoulders had incomplete resorption (ICR) (ICR group). Gartner type I calcification was most common (64.5%) in the ICR group. The mean duration of symptoms before ESWT was significantly longer in the ICR group. Overall, 81% of the CR group and 23.4% of the ICR group were symptom free. There was a strong relationship between subsidence of symptoms and remission of calcification. Poor prognosis was significantly related to Gartner type I calcification, calcification extent > 15 mm and duration of symptoms > 11 months. Conclusion. Patients with calcific tendinitis of the shoulder who have the factors identified for a poor outcome after ESWT should undergo a different procedure. Cite this article: Bone Joint J 2017;99-B:1643–50

Background. Greater trochanteric pain syndrome (GTPS) is a common problem affecting 10–25% of the population. Physiotherapy, anti-inflammatories, corticosteroid injections and surgery have all been described in the management of GTPS, all with limited, temporal success. Extracorporeal shockwave therapy (ESWT) has been proposed as a potential management option for this difficult presentation. Method. We ran a prospective, 2 arm, single blinded, randomised control trial comparing focused shockwave therapy to an ultrasound guided corticosteroid injection. The primary outcome measure was the visual analogue pain score. Secondary outcome measures included the Harris hip score and Trendelenburg test for function; the SF-36 for quality of life (QoL); and a Likert scale question for a subjective assessment of symptom improvement. Results. 104 patients (10 males and 94 females), of mean age 61.5 years were recruited. 53 were randomised to receive ESWT and 51 to receive an image guided injection. 11 patients were lost to follow up. Baseline scores were equal between the groups. At 3 months, pain, function and QoL scores had improved in both groups. The Trendelenburg test was significantly improved in the ESWT group with 80% patients being negative compared to 80% positive at baseline (p<0.001). At 12 months, the improvement in Trendelenburg test was maintained in the ESWT group, but the injection group had reverted to baseline. Across all outcomes, the ESWT group had significantly improved scores compared to the injection group; VAS 3.71 versus 5.50 (p=0.007, 95% confidence interval 0.63 to 3.08), HHS 69.7 vs 57.5 (p=0.002, 95% confidence interval −20.0to −4.6) and SF-36 52.4 vs 47.7 (p=0.048, 95% confidence interval −9.31 to −0.04). Conclusions. We have shown focused ESWT is an effective treatment for patients with GTPS. We hope to advocate ESWT as an effective non-invasive treatment modality for this challenging patient population

Background. Previous studies have individually shown extracorporeal shockwave therapy (ESWT) to be beneficial for mid-substance Achilles tendinopathy, insertional Achilles tendinopathy or plantar fasciitis. The purpose of this pragmatic study was to determine the efficacy of ESWT in managing the three main causes of refractory heel pain in our routine clinical practice. Methods. 236 patients (261 feet) aged between 25 – 81 years (mean age 50.4) were treated in our NHS institute with ESWT between April 2014 and May 2016. They all underwent a clinical and radiological assessment (ultrasonography +/− magnetic resonance imaging) to determine the primary cause of heel pain. Patients were subsequently categorized into three groups, mid-substance Achilles tendinopathy (55 cases), insertional Achilles tendinopathy (55 cases) or plantar fasciitis (151 cases). If their symptoms were recalcitrant to compliant first line management for 6 months, they were prescribed three consecutive ESWT sessions at weekly intervals. All outcome measures (foot & ankle pain score, EQ-5D) were recorded at baseline and 3-month follow-up (mean 18.3 weeks, range 11.4 to 41). Results. Complete data sets were obtained for 41% of the ESWT treatments (107/261). EQ-5D scores showed a statistically significant improvement between baseline and follow-up in all three-treatment groups; mid-substance Achilles tendinopathy 0.681 to 0.734, insertional Achilles tendinopathy 0.687 to 0.742 and plantar fasciitis 0.684 to 0.731 (p< 0.05). The foot & ankle pain scores grouped for all causes of heel pain also showed a statistically significant reduction from 6.78 at baseline to 5.36 at follow-up (p< 0.05). Conclusion. Overall our results showed that ESWT is an effective tool for the management of all refractory heel pain in an NHS foot & ankle clinical practice

Introduction. Greater trochanteric pain syndrome (GTPS) is a common and disabling condition characterised by pain and tenderness at or around the trochanteric area. Extracorporeal shockwave therapy (ESWT) has been described as a method of treatment. The National Institute for Clinical Excellence (NICE, UK) guidance suggests a possible benefit but with limited evidence. Materials and Methods. We retrospectively identified 71 consecutive patients who underwent ESWT for refractory GTPS over a period of 16 months. The diagnosis was made clinically. ESWT was offered to patients with refractory symptoms despite conservative treatment. Telephone interviews were used to collect data including pain scores (0–10), change in symptoms, discomfort of the procedure, and complications. Results. Fifty-nine patients (83%) were followed up. The mean time to follow up was 8 months (3 to 19). The mean age was 59 (29 to 88) with 86% females. Two-thirds had improvement in their symptoms with a significant drop of 6 points in their pain score (p<0.05); however, symptoms recurred in 60% at a mean of 3.7 months. Most patients (60%) had mild or no discomfort from the treatment. Two patients (3.3%) could not tolerate the treatment. One complication was reported; an exacerbation of sciatica symptoms which settled spontaneously. Conclusion. This study shows an improvement in the symptoms of 67% of patients with refractory GTPS, for up to 15 months, but with frequent relapsed. Further research is required to confirm whether MRI may be useful in selecting patients for ESWT

In a prospective study to evaluate the benefits of radial extracorporeal shockwave therapy (ESWT) in patients with longstanding chronic Achilles tendonitis. 34 cases of non-insertional Achilles tendonitis were treated in 32 patients, using radial shockwave treatment. Symptoms had been present for at least ten months and were resistant to conservative treatments. Patients received three shockwave sessions at weekly intervals. Evaluation was performed prior to treatment, at six weeks and three months after the final session. Patients completed a visual analogue score (VAS) for maximal pain (0–100), the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot Scale and the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A). At short-term review all patients reported an improvement in symptoms. The VAS fell from a pre-treatment value of 74 (+/−15) to 22 (+/−17). An improvement in the AOFAS from of 64 (+/−10) to a post-treatment value of 90(+/−7) was seen, and an average from 30 to 70 in the VISA-A score. No complications from the treatment were reported. Four patients previously listed for surgery have improved sufficiently to be removed from the waiting list. Conclusion: Short-term results using ESWT for the treatment of longstanding non-insertional Achilles tendonitis are encouraging. Longer-term follow-up subsequent to this prospective pilot study is underway to assess if results are reproducible over a greater time period

Aims: A prospective study to evaluate the beneþts of extracorporeal shockwave therapy (ESWT) in patients with chronic Achilles tendonitis. Methods: 34 cases of non-insertional Achilles tendonitis were treated in 32 patients, using radial shockwave treatment. Symptoms had been present for at least ten months and were resistant to conservative treatments. Patients received three shockwaves sessions at weekly intervals. Evaluation was performed prior to treatment, at six weeks and three months after the þnal session. Patients completed a visual analogue score (VAS) for maximal pain (0–100), the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot Scale and the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A). Results: At short term review all patients reported an improvement in symptoms. The VAS fell from a pre-treatment value of 74 (±15) to 22(±17). An improvement in the AOFAS from of 64 (±10) to a post-treatment value of 90(±7) was seen, and an average from 30 to 70 in the VISA-A score. No complications from the treatment were reported. Four patients previously listed for surgery have improved sufþciently to be removed from the waiting list. Conclusion: Shortterm results using ESWT for the treatment of longstanding non-insertional Achilles tendonitis are encouraging. Longer Ðterm follow-up subsequent to this prospective pilot study is underway to assess if results are reproducible over a greater time period

Introduction. The pathophysiology of osteonecrosis of femoral head (ONFH) is uncertain for most cases with speculation of vascular impairment and changes in cell biology due to multi-factorial etiologies including corticosteroid, alcohol, smoking, trauma, radiation or caisson disease and genetic. Extracorporeal shockwave therapy (ESWT) began with an incidental observation of osteoblastic response pattern during animal studies in the mid-1980 that generated an interest in the application of ESWT to musculoskeletal disorders. The mechanism of shockwave therapy is not fully understood but several reports showed better clinical outcomes and promoted bone remodelling and regeneration effect of the femoral head after ESWT in ONFH. Therefore, we compared the clinical results of the use of extracorporeal shock wave therapy (ESWT) on the patients with ONFH in radiographic staging. Methods. We evaluated 24 patients with 32 hip joints diagnosed ONFH treated with ESWT from 1993 to 2012. Average follow-up period was 27 months, and patients were average 47.8 aged. Association Research Circulation Osseous (ARCO) staging system was used to grade radiographic stage before treatment. All the patients were divided to two groups; group 1 (ARCO stage I,II), group 2 (ARCO stage III). Comparative analysis was done between two groups with visual analogue scale (VAS) score and Harris hip score (HHS) at pre-treatment, 3, 6, 12 and 24 months after treatments. The failure was defined when radiographic stage was progressed or arthroplasty surgery was needed due to clinical exacerbation. Results. Two groups showed all clinical improvements with VAS scoring at final follow-up (group 1: mean 6.3 to 1.6, p < 0.001; group 2: mean 7.1 to 3.3, p < 0.001). With HHS, group 1 showed a significant improvement from 64.4 to 95.4 (p < 0.001), while no significance in group 2 (p = 0.280). At final-follow-up, 3 hips of group 1 and 1 hip of group 2 showed radiographic improvement, but 2 patients were performed total hip arthroplasty due to persistent pain and dysfunction. Discussion and Conclusion. ESWT could be considered as an alternative option before surgical treatment in patients not only with early stage of ONFH but also with mid stage

The purpose of this study was to assess the clinical outcome of two non-invasive techniques used in the treatment of calcific tendinitis of the shoulder. Over the eight month period April 2000 to November 2000 sixty patients who were referred to this hospital with symptomatic calcific tendonitis were treated either with extracorporeal shockwave therapy (ESWT) using the Storz Medical Minilith (Storz Medical AG, Kreuzlingen, Germany) or by barbotage (needle puncture, aspiration and lavage under ultrasound control). All the patients had a long history of shoulder pain (average 42 months), caused by a radiographically evident calcific deposit, that had been unresponsive to conservative treatment including physiotherapy, steroid injections and non-steroidal anti-inflammatory tablets. 15 patients were treated with ESWT and 45 with ultrasound guided barbotage. The patients undergoing ESWT had the application head positioned under real time ultrasound or flouroscopic control. Patients had from one to three treatments with up to 2,500 shocks per treatment at incremental energy levels from 0.1 to 0.2 mJ/ mm2. Patients undergoing real time ultrasound guided barbotage had a single treatment. Clinical outcome was evaluated after a three month period with a postal questionnaire. Thirty-two of 45 patients (71%) in the barbotage group had a marked reduction in symptoms at three months compared to nine out of 15 (64%) of the ESWT group. Shockwave therapy (ESWT) and ultrasound guided barbotage are simple non invasive outpatient procedures which are effective in 64% to 71% of patients. These simple outpatient techniques should be considered for chronic pain due to calcific deposits that have been unresponsive to conservative treatments, and surgery reserved for those who fail to benefit

Aims: To evaluate the inßuence of simultaneous local anesthesia (LA) on the clinical outcome after repetitive low-energy extracorporeal shock wave application (ESWT) for chronic plantar fasciitis. Methods: A prospective randomized observer-blinded pilot trial was performed in 48 painful heels (40 patients), having been resistant to various conservative treatment procedures for more than 6 months. 24 heels (20 patients) received 3 applications of 1500 impulses of 0.4 mJ/mm2 without LA (Group I)on 3 consecutive days with a conventional ultrasound-guided orthopaedic shock wave device (Sonocur plus, Siemens AG, Erlangen, Germany). 24 heels (20 patients) received 3 applications of 1500 impulses of 0.04 mJ/mm2 with LA on 3 consecutive days (Group II). Main outcome measure was the number of good or excellent outcomes needing no further therapy at three month follow-up. Secondary outcome measure was pain after weightbearing assessed on a visual analog scale (VAS; range, 0–10). Both groups did not differ signiþcantly before the start of the trial. Results: In Group I 16 of 24 (67%) heels reached a good or excellent result, in Group II 7 of 24 heels (29%) at three-month follow-up (p= 0.0199 for difference between groups; difference= 0.38; 95%CI= 0.09 to 0.66). Pain after weightbearing was 2.2±2.6 on a VAS in Group I, and 3.8±2.5 on a VAS in Group II (p= 0.0318 for difference between groups; mean difference= 0.16; 95%CI= 0.01 to 0.30). Conclusions: The simultaneous use of local anesthesia has a negative inßuence on repetitive low-energy shock wave therapy for chronic plantar fasciitis. Further prospective studies should be performed to evaluate more exactly the extent of this negative inßuence

Aims

Arthroscopic microfracture is a conventional form of treatment for patients with osteochondritis of the talus, involving an area of < 1.5 cm². However, some patients have persistent pain and limitation of movement in the early postoperative period. No studies have investigated the combined treatment of microfracture and shortwave treatment in these patients. The aim of this prospective single-centre, randomized, double-blind, placebo-controlled trial was to compare the outcome in patients treated with arthroscopic microfracture combined with radial extracorporeal shockwave therapy (rESWT) and arthroscopic microfracture alone, in patients with ostechondritis of the talus.

The August 2024 Foot & Ankle Roundup³⁶⁰ looks at: ESWT versus surgery for fifth metatarsal stress fractures; Minimally invasive surgery versus open fusion for hallux rigidus; Diabetes and infection risk in total ankle arthroplasty; Is proximal medial gastrocnemius recession useful for managing chronic plantar fasciitis?; Fuse the great toe in the young!; Conservative surgery for diabetic foot osteomyelitis; Mental health and outcome following foot and ankle surgery.

The February 2024 Foot & Ankle Roundup³⁶⁰ looks at: Survival of revision ankle arthroplasty; Tibiotalocalcaneal nail for the management of open ankle fractures in the elderly patient; Accuracy of a patient-specific total ankle arthroplasty instrumentation; Fusion after failed primary ankle arthroplasty: can it work?; Treatment options for osteochondral lesions of the talus; Managing hair tourniquet syndrome of toe: a rare emergency; Ultrasound-guided collagenase therapy for recurrent plantar fibromatosis: a promising line of therapy?.

The December 2014 Shoulder & Elbow Roundup³⁶⁰ looks at: cuff tears and plexus injury;

corticosteroids and physiotherapy in SAI; diabetes and elbow arthroplasty; distal biceps tendon repairs; shockwave therapy in frozen shoulder; hydrodilation and steroids for adhesive capsulitis; just what do our patients read?; and what happens to that stable radial head fracture?

Non-traumatic osteonecrosis of the femoral head is a potentially devastating condition, the prevalence of which is increasing. Many joint-preserving forms of treatment, both medical and surgical, have been developed in an attempt to slow or reverse its progression, as it usually affects young patients.

However, it is important to evaluate the best evidence that is available for the many forms of treatment considering the variation in the demographics of the patients, the methodology and the outcomes in the studies that have been published, so that it can be used effectively.

The purpose of this review, therefore, was to provide an up-to-date, evidence-based guide to the management, both non-operative and operative, of non-traumatic osteonecrosis of the femoral head.

Cite this article: Bone Joint J 2017;99-B:1267–79.

It has been suggested that extracorporeal shockwave therapy is a safe and effective treatment for pain relief from recalcitrant plantar fasciopathy (PF). However, the changes in gait and associated biomechanical parameters have not been well characterised. We recruited 12 female patients with recalcitrant PF who had a mean age of 59 years (50 to 70) and mean body mass index of 25 kg/m² (22 to 30). The patients reported a mean duration of symptoms of 9.3 months (6 to 15). Shockwave therapy consisting of 1500 impulses (energy flux density 0.26 mJ/mm²) was applied for three sessions, each three weeks apart. A pain visual analogue scale (VAS) rating, plantar pressure assessment and motion analysis were carried out before and nine weeks after first shock wave therapy. It was demonstrated that patients increased their walking velocity and cadence as well indicating a decrease in pain after shockwave therapy. In the symptomatic foot, the peak contact pressure over the forefoot increased and the contact area over the digits decreased. The total foot impulse also decreased as did stance duration. The duration the centre of pressure remained in the hindfoot increased in the symptomatic foot after shockwave therapy. The differences in centre of pressure trajectory at baseline decreased at final follow-up. In conclusion, shockwave therapy not only decreased the pain VAS rating but also improved the gait parameters of the symptomatic foot in PF patients.

Cite this article: Bone Joint J 2013;95-B:1088–93.