Wojciech Marks1, Monika
Czarnocka2, Zbigniew Witkowski1, Jacek Teodorczyk3, Marek Białko1,
Aleksandra Kawecka1, Włodzimierz Deja1, Jerzy Lasek1, Michał
Department of Trauma Surgery, Medical University of Gdańsk1
Department of Radiology, Medical University of Gdańsk2
Department of Nuclear Medicine, Medical University of Gdańsk3
Address for Correspondence
Zbigniew Witkowski M.D.
Medical University of Gdańsk,
Department of Trauma Surgery,
Dębinki 7 street,
80-211 Gdańsk, Poland.
Nonunions occur in 5 % of long bone
fractures. ESWT seems to be less costly and safe alternative
for an operative treatment of nonunions. There is still no
wildly accepted inclusion criteria for ESWT treatment and
monitoring modality established for assessment of the effects of
3-phase bone scintigraphy before ESWT was done to exclude
hypotrophic (nonactive) pseudoarthrosis. Follow-up scintigraphy
was performed 2 weeks after ESWT to assess the level of reaction
on shockwave therapy and then to predict long term effect of it.
It seems that proper inclusion criteria and follow-up
quantitative scintigraphy may shorten the delay of effective
treatment in cases of patients with initial poor reaction to
Key words: ESWT, bone scintigraphy, nonunion,
Nonunions (delayed unions and pseudoarthroses)
occur in ca. 5 % of long bone fractures. Nonunion still remains
a major complication after skeletal trauma or elective surgery.
ESWT is a well-known method which was first introduced in the
treatment of renal calculi about three decades ago. Later ESWT
was also used in the treatment of delayed bone unions and
pseudoarthroses (1). Nowadays it has become an alternative
method in the management of some soft tissue complaints as
well. Detailed indications, contraindications and technical
parameters of ESWT in soft tissue complaints treatment are not
established yet (2,3).
ESWT is reported to be the last alternative
before an operative procedure (4). ESWT is applied in
pseudoarthroses of different locations. No delay of definitive
treatment longer than 12 weeks was observed. 66,7% of patients
qualified to ESWT healed completely but including distinct
improvements – 84,8% (5).
The attempts to find out prognostic factors
for ESWT treatment in patients with pseudoarthroses that
persisted for at least 9 months have been made. To
differentiate active from nonactive pseudoarthrosis a bone
scintigraphy was compulsory. Clinical and radiological follow-up
was done at 4-week intervals starting 8 weeks after ESWT for 9
months. Bone fusion was assessed 4 to 6 months after ESWT. Of
patients with an initial positive scintigraphy (active
pseudoarthrosis in qualitative assessment) 82,9 % had bony
healing compared to 25% with initial negative scintigraphy (nonactive
pseudoarthrosis in qualitative assessment) (6). ESWT effects
were investigated by bone scintigraphy in animal model
(rabbits). Local blood flow and metabolism were decreased at 10
day after but were increased 28 days after ESWT (7). Attempts of
monitoring the effects of ESWT by the BMD (bone mineral density)
measurement were carried out as well but the BMD value may not
represent the degree of structural organization, which is
essential to the mechanical strength (8).
Patients received ESWT (0,5 to 0,9 mJ/mm2)
with 3000 impulses in one session under local anesthesia (6,7).
The effect of shock wave treatment on bone mass and bone
strength appears to be dose dependent in acute fracture healing
in rabbits (9)
The most important problems of ESWT seems to
be the value of classification method (lack of quantitative
assessment) and the delay of definite treatment in case of
unsuccessful conservative therapy.
The aim of presented case reports is to show
a possibility of qualification and monitoring ESWT treatment by
means of repeated (follow-up) quantitative scintigraphy.
Material and Methods :
We used standard urological lithotriptor,
Econolith 2000; 3000 shocks of 22 kV. The precise positioning
were made with fluoroscopic targeting. The waves were focused on
an area 8 mm in diameter and 50 mm in length.
The dynamic scintigraphy was done after iv
injection of 600-800 MBq 99m-Tc-methylene-diphosphonate
compound. Images were acquired with dual-head gammacamera
Multispect-2 (Siemens, Erlangen, Germany).
Patient 1 (AP)
21 year old male has sustained MVA,
comminuted femur fracture was diagnosed on admission. He was
initially treated with AO plate osteosynthesis. Pseudoarthrosis
has develop. Patient was qualified to our study 10 months after
the accident. New osteosynthesis has been done 10 months after
ESWT (AO plate, bone grafting).
Patient 2 (MS)
19 year old male sustained MVA, femur
fracture was diagnosed. He was initially treated with
intramedullar osteosynthesis. Pseudoarthrosis has occured.
Patient was qualified to our study 14 months after the accident.
Table. 1 Comparison of success and
failure in the nonunion treatment by means of ESWT monitored by
AP(21 year old)
MS (19 year old)
Time since accident to ESWT
X-ray (6 weeks after ESWT)
No fusion progress
X-ray (6 months after ESWT)
No fusion progress
X-ray(10 months after ESWT)
No fusion progress – new osteosynthesis (AO plate, bone
X-ray (12 months after ESWT)
Quantitative scintigraphy before ESWT (mean uptake)
Quantitative scintigraphy 2 weeks after ESWT (mean uptake)
Change of mean uptake after ESWT
Delay of definitive treatment
ESWT has been postulated as an additional therapeutic option in
nonunion after fracture treatment (10). If no improvement
occurs, the maximum delay of operative treatment is supposed to
be three to six months (6, 10). Bony consolidation was achieved
in 75,7% cases, mean follow-up 31 months, range 5-50 months
(11). Assessment of change between initial (before ESWT) and
follow-up quantitative scintigraphy could substantially shorten
the period of observation.
How to tell the difference between natural history of healing
and the process stimulated by ESWT ? In our opinion we could
clearly indicate the difference using follow-up quantitative
scintigraphy. The really important seems to be not the metabolic
activity assessed as the inclusion criteria but reaction to
ESWT measured by the change of uptake between the follow-up and
No prospective, randomized trial was conducted to show
efficiency of ESWT till now. Before such studies would be
possible the proper metodology should be established to assess
changes connected with application of ESWT. We think that this
aim is achievable by means of 3-phase quantitative scintigraphy
but applied before ESWT (as a main criteria for ESWT
application) and then after ESWT (to assess reaction to ESWT and
predict final result).
Clinical studies reporting acceleration of union seem to
misinterpret natural history of union (12). We tried to document
changes of bone metabolism after ESWT by scintigraphy and to
find out changes connected only with applied treatment. Positive
scintigraphy (presence of active nonunion) was compulsory to
include patient to the study. The next important criteria to
continue conservative treatment after ESWT seems to be follow-up
quantitative scintigraphy assessing reaction to the ESWT.
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