Dataset Information

Focused Extracorporeal Shock Wave Therapy for Painful Delayed Union or Nonunion of Fractures of Interphalangeal Coalition.

ABSTRACT:

Background

Interphalangeal coalition is characterized by fusion of interphalangeal joint between the middle and distal phalanges. Interphalangeal coalition fractures often result in delayed union or nonunion. The purpose of this study was to evaluate the results of focused extracorporeal shock wave therapy (ESWT) for painful delayed union or nonunion of fractures of the interphalangeal coalition.

Methods

The study group consisted of 9 patients (9 feet) diagnosed with painful delayed union or nonunion due to persistent pain and no tendency toward bony union for at least 3 months after the interphalangeal coalition fracture on plain radiographs between 2021 and 2023 were included. The mean age was 51.3 years (23-64). Focused ESWT was performed in all patients. The mean time from the date of injury to the start of ESWT was 16.1 weeks (12-15). ESWT was performed every 2 weeks, with each session consisting of 3000 impulses (0.15-0.25 mJ/mm²). Plain radiographs were used to confirm bone union, and visual analog scale (VAS) scores were used for pain assessment.

Results

Complete bony union was documented in all 9 patients. The application of focused ESWT was performed a mean of 2.7 times (2-4), and the mean duration from the initiation of treatment to the confirmation of bony union was 7.4 weeks (3.6-12.7). In all cases, the symptoms of swelling and pain were alleviated. The VAS scores exhibited significant improvement, with the mean VAS score decreasing from 3.8 (2-6) before ESWT to 0 after the achievement of union (P < .001).

Conclusion

In this small cohort, all patients with painful delayed union or nonunion of fractures at the interphalangeal coalitions achieved complete bony fusion after focused ESWT. Moreover, bony union was observed within 2 months of ESWT initiation. These findings suggest that focused ESWT may be a valuable treatment option for painful delayed union or nonunion of interphalangeal coalition fractures.

Level of evidence

Level IV, case series.

SUBMITTER: Shimozono Y

PROVIDER: S-EPMC11339734 | biostudies-literature | 2024 Jul

REPOSITORIES: biostudies-literature

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Publications

Focused Extracorporeal Shock Wave Therapy for Painful Delayed Union or Nonunion of Fractures of Interphalangeal Coalition.

Shimozono Yoshiharu Y Mori Daisuke D Mizuno Yasuyuki Y Funakoshi Noboru N Kobayashi Masahiko M Matsuda Shuichi S Yamashita Fumiharu F

Foot & ankle orthopaedics 20240701 3

<h4>Background</h4>Interphalangeal coalition is characterized by fusion of interphalangeal joint between the middle and distal phalanges. Interphalangeal coalition fractures often result in delayed union or nonunion. The purpose of this study was to evaluate the results of focused extracorporeal shock wave therapy (ESWT) for painful delayed union or nonunion of fractures of the interphalangeal coalition.<h4>Methods</h4>The study group consisted of 9 patients (9 feet) diagnosed with painful delay ...[more]

PMID: 39175667

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Project description:BackgroundThe Radiographic Union Score for Hip (RUSH) is a previously validated outcome instrument designed to improve intra- and interobserver reliability when describing the radiographic healing of femoral neck fractures. The ability to identify fractures that have not healed is important for defining nonunion in clinical trials and predicting patients who will likely require additional surgery to promote fracture healing. We sought to investigate the utility of the RUSH score to define femoral neck fracture nonunion.Questions/purposes(1) What RUSH score threshold yields at least 98% specificity to diagnose nonunion at 6 months postinjury? (2) Using the threshold identified, are patients below this threshold at greater risk of reoperation for nonunion and for other indications?MethodsA representative sample of 250 out of a cohort of 725 patients with adequate 6-month hip radiographs was analyzed from a multinational elderly hip fracture trial (FAITH). All patients had a femoral neck fracture and were treated with either multiple cancellous screws or a sliding hip screw. Two reviewers independently determined the RUSH score based on the 6-month postinjury radiographs and interrater reliability was assessed with the interclass correlation coefficient (ICC). There was substantial reliability between the reviewers assigning the RUSH scores (ICC, 0.81; 95% confidence interval [CI], 0.76-0.85). The RUSH score is a checklist-based system that quantifies four measures of healing: cortical bridging, cortical fracture disappearance, trabecular consolidation, and trabecular fracture disappearance.. Fracture healing was determined by two independent methods: (1) concurrently by the treating surgeon using both clinical and radiographic assessments as per routine clinical care; and (2) retrospectively by a Central Adjudication Committee using complete obliteration of the fracture line on radiographs alone. Receiver operating characteristic tables were used to define a RUSH threshold score that was > 98% specific for fracture nonunion.ResultsA threshold score of < 18 was associated with a 100% specificity (95% CI, 97%-100%) and a positive predictive value of 100% (95% CI, 73%-100%) for radiographic nonunion. In contrast, using the fracture healing assessments of the treating surgeons failed to identify a useful discriminatory nonunion threshold and the highest positive predictive value was 43%. With respect to complications, patients with RUSH scores below 18 had greater risk of undergoing reoperation for nonunion (reoperation when < 18: six of 13 [46%]; reoperation when ≥ 18: 11 of 237 [54%]; relative risk [RR], 9.9 [95% CI, 4.4-22.7]; p < 0.001) and for all indications (reoperation when < 18: eight of 13 [62%]; reoperation when ≥ 18: 54 of 237 [38%]; RR, 2.7 [95% CI, 1.7-4.4]; p = 0.004).ConclusionsThe 6-month RUSH score is a reliable method for assessing radiographic healing. Our results highlight the discordance between radiographic determinations and clinician assessments of fracture healing and stress the need for clinical data to be incorporated in research studies evaluating fracture healing.Level of evidenceLevel III, diagnostic study.

Project description:BackgroundExtracorporeal shock wave therapy (ESWT) has shown benefits in patients with nonunion or delayed bone healing, pseudarthrosis, and avascular necrosis of bone. Until now, these effects were explained by the release of growth factors, activation of cells, and microfractures occurring after ESWT. Microcirculation is an important factor in bone healing and may be compromised in fractured scaphoids because its blood supply comes from the distal end. Due to this perfusion pattern, the scaphoid bone is prone to nonunion after fracture. The ability of ESWT to enhance microcirculation parameters in soft tissue was of interest to determine if it improves microcirculation in the scaphoid.Questions/purposes(1) Does capillary blood flow increase after a single session of ESWT in the scaphoid? (2) Do oxygen saturation in the bone and postcapillary venous filling pressure increase after a single session of ESWT in the scaphoid?MethodsESWT (0.3 mJ/mm, 8Hz, 1000 impulses) was applied to the intact scaphoid of 20 volunteers who were without wrist pain and without any important metabolic disorders. Mean age was 43 ± 14 years, 12 men and eight women (40% of total). Volunteers were recruited from January 2017 to May 2017. No anesthetic was given before application of ESWT. An innovative probe designed for measurements in bone by compressing soft tissue and combining laser-Doppler flowmetry and spectrophotometry was used to noninvasively measure parameters of microcirculation in the scaphoid. Blood flow, oxygenation, and venous filling pressure were assessed before and at 1, 2, 3, 5, 10, 15, 20, 25, and 30 minutes after ESWT application. Room temperature, humidity, ambient light and measuring sequences were kept consistent. A paired t-test was performed to compare experimental data with baseline (p < 0.05 taken as significant).ResultsAt baseline, capillary blood flow of the bone was 108 ± 46 arbitrary units (AUs) (86 to 130). After treatment with ESWT, it was 129 ± 44 AUs (106 to 150; p = 0.011, percentage change of 19 %) at 1 minute, 138 ± 46 AUs (116 to 160; p = 0.002, percentage change of 28%) at 2 minutes, 146 ± 54 AUs (121 to 171; p = 0.002, percentage change of 35%) at 3 minutes and 150 ± 52 AUs (126 to 174; p < 0.001, percentage change of 39%) at 5 minutes. It remained elevated until the end of the measuring period at 30 minutes after treatment at 141 ± 42 AUs (121 to 161; p = 0.002) versus baseline). Oxygen saturation and postcapillary venous filling pressure in bone showed no change, with the numbers available.ConclusionsA single session of ESWT increased capillary blood flow in the scaphoid during measuring time of 30 minutes. Bone oxygenation and postcapillary venous filling pressure, however, did not change. Because increased oxygenation is needed for improved bone healing, it remains unclear if a sole increase in capillary blood flow can have clinical benefits. As the measuring period was limited to only 30 minutes, bone oxygenation and postcapillary filling pressure may subsequently show change only after the measuring-period ended.Clinical relevanceFurther studies need to evaluate if increased capillary blood flow can be sustained for longer periods and if bone oxygenation and postcapillary venous filling pressure remain unchanged even after prolonged or repetitive ESWT applications. Moreover, clinical studies must validate if increased microcirculation has a positive impact on bone healing and to determine if ESWT can be therapeutically useful on scaphoid fractures and nonunions.

Project description:BACKGROUND:Extracorporeal shock wave therapy (ESWT) has been used as a safe alternative treatment for refractory musculoskeletal diseases, such as plantar fasciitis, Achilles tendinopathy and gluteal tendinopathy, and various forms of fibromatosis including palmar or penile fibromatosis. However, there is limited published data for clinical and sonographic features of plantar fibromatosis after ESWT. The purpose of this study was to evaluate the long-term clinical outcome of ESWT in ultrasonography-confirmed plantar fibromatosis and ultrasonographic changes of plantar fibroma after ESWT. METHODS:Medical charts of 26 patients (30 feet) with plantar fibromatosis confirmed by ultrasonography were reviewed. Finally, a total of 10 feet who underwent ESWT for "Poor" or "Fair" grade of Roles-Maudsley Score (RMS) and symptoms persisted for >6 months were included in this study. Short-term follow-up was conducted one week after ESWT and long-term follow-up time averaged 34.0 months. The Numerical Rating Scale (NRS) and RMS were collected for the evaluation of clinical features. Follow-up ultrasonography was conducted at long-term follow-up and changes of plantar fibroma was assessed. A greater than 50% reduction in the NRS and achievement of a "good" or "excellent" grade in the RMS were regarded as treatment success. Additionally, medical charts of 144 patients (168 feet) with plantar fasciitis confirmed by ultrasonography were reviewed and subsequently, 42 feet who underwent ESWT with the same protocol were included for the comparison of clinical features. RESULTS:In plantar fibromatosis, baseline NRS (6.2 ± 1.3) and RMS (3.5 ± 0.5) were significantly improved at short-term follow-up (NRS, 1.8 ± 1.0; RMS, 2.0 ± 0.8, P < .001, respectively) and long-term follow-up (NRS, 0.6 ± 1.1; RMS, 1.4 ± 0.8, P < .001, respectively). Treatment success was recorded in seven feet (70.0%) at short-term follow-up and 8 feet (80%) at long-term follow-up, which is comparable to that of the plantar fasciitis group (28 feet, 66.7%; 35 feet, 83.3%, respectively). In long-term follow-up ultrasonography, mean fibroma thickness was reduced from 4.4±1.0 to 2.6±0.8 mm (P = .003); however, length and width were not significantly changed. There were no serious adverse effects. CONCLUSION:While these are preliminary findings, and must be confirmed in a randomized placebo control study, ESWT can have a beneficial long-term effect on pain relief and functional outcomes in painful plantar fibromatosis. However, ESWT is unlikely to affect the ultrasonographic morphology of plantar fibroma, with the exception of reducing the thickness. LEVEL OF EVIDENCE:Level III, retrospective cohort study.

Dataset Information

Focused Extracorporeal Shock Wave Therapy for Painful Delayed Union or Nonunion of Fractures of Interphalangeal Coalition.

Background

Methods

Results

Conclusion

Level of evidence

Publications

Focused Extracorporeal Shock Wave Therapy for Painful Delayed Union or Nonunion of Fractures of Interphalangeal Coalition.

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