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Predictive Value Of Follow-Up 3-Phase Bone Scintigraphy For The Results Of ESWT Treatment In Nonunions
Wojciech Marks1, Monika Czarnocka2, Zbigniew Witkowski1, Jacek Teodorczyk3, Marek Białko1, Aleksandra Kawecka1, Włodzimierz Deja1, Jerzy Lasek1, Michał Studniarek2,

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.
Tel/Fax: +48583492402


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 ESWT.
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 ESWT therapy.
Key words: ESWT, bone scintigraphy, nonunion, pseudoarthrosis

J.Orthopaedics 2006;3(3)e2


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 :

ESWT Methodology:

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. 

Scintigraphy Methodology:

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).

Case reports:

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.

Results :

Table. 1 Comparison of success and failure in the nonunion treatment by means  of ESWT monitored by quantitative scinthigraphy. 


AP(21 year old)

MS (19 year old)

Initial diagnosis

Femur fracture

Femur fracture

Initial treatment

AO plate

Intramedullar nailing

Time since accident to ESWT

10 months

14 months

X-ray (6 weeks after ESWT)

No fusion progress

Callus formation

X-ray (6 months after ESWT)

No fusion progress

Fracture consolidation

X-ray(10 months after ESWT)

No fusion progress new osteosynthesis (AO plate, bone grafting)

Fracture consolidation

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

- 5,5 %

+ 27,5 %

Delay of definitive treatment

9 months

No delay

Discussion :

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 initial scintigraphy.

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.                                                                      

Reference :

  1. Haupt G. Use of extracorporeal shock waves in the treatment of pseudoarthrosis, tendinopathy and other orthopaedic diseases. J Urol 1997; 158: 4-11.

  2. Rompe JD, Hopf C, Kullmer K, et al. Analgesic effect of extracorporeal shock wave therapy on chronic tennis elbow. J Bone Joint Surg (Br) 1999; 78-B: 233-7.

  3. Speed CA. Extracorporeal shock-waves therapy in the management of chronic soft-tissue conditions. J Bone Joint Surg (Br) 2004; 86: 165-171.

  4. Rompe J.D., Kullmer K., Vogel J., Eckhardt A., Wahlmann U., Eysel P., Hopf C., Kirkpatrick C.J., Burger R., Nafe B. Extracorporale Stoswellentherapie. Der Orthopade 1997; 26: 215-228.

  5. Brander H., Spath K. Extrakorporale Stoswelletherapie bei Knochenheilungsstorungen. Trauma und Berufskrankheit  2001; 3; Suppl 2: 253-261.

  6. Schoellner C., Rompe J.D., Decking J., Heine J. Die hochenenergetische extracorporale Stoswellentherapie (ESWT) bei pseudoarthrose. Der Orthopade 2002; 31; 7: 658-662.

  7. Maier M., Tischner T., Schmitz C., Refior H.J. Influence of extracorporeal shock wave application normal bone in an in-vivo animal model. J Bone Joint Surg (Br) 2004;86-B: Suppl III: 365.

  8. R. Wen-Wei Hsu, Ching-Luang Tai, Ch. Yu-Chih chen, Wei-Hsiu Hsu, Swei Hsueh. Enhencing mechanical strength during early fracture healing via shockwave treatment: animal study. Clinical Biomechanics 2003; 18: 33-39.

  9. Ching-Jen Wang, Kuender D. Yang, Feng-Sheng Wang, Chia-Chen Hsu, Hsiang-Ho Chen. Shock wave treatment shows dose-dependent enhancement of bone mass and bone strength after fracture of the femur. Bone 2004; 34: 225-230.

  10. Beutler S., Regel G., Pape H.C., Machtens S., Weinberg A.M., Kremeike I., Jonas U., Tscherne H. Die extracorporale Stoswellentherapie (ESWT) in der Behandlung von Pseudoarthrosen des rohrenknochens. Unfallchirurg 1999; 102: 839-847.

  11. Schaden W. Extracorporale Stoswellentherapie (ESWT) bei Pseudoarthrosen und verzorgerter Fracturheilung, Trauma Berufskrankh 2000; 2(Suppl 3):5333-5339.

  12. Biedermann R., Handle G., Auckenthaler T., Bach C., Krismer M. Extracorporeal shock waves in the treatment of nonunions. J Bone Joint Surg (Br) 2004;86-B; Suppl III: 364.

This is a peer reviewed paper 

Please cite as : Wojciech Marks: Predictive Value Of Follow-Up 3-Phase Bone Scintigraphy For The Results Of ESWT Treatment In Nonunions

J.Orthopaedics 2006;3(3)e2





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