Shockwave Therapy for Nonunion of Fractures: Report of Two Uncommon Cases and Review of the Literature

Fracture non-unions are still a challenging problem in orthopedics. The standard of care is surgical, with debridement of bone at the fracture site, and stable internal fixation, with or without bone graft. Shockwave therapy (ESWT) has gained popularity as an alternative treatment modality for delayed union and nonunion of fractures, as well as for nonunion of arthrodesis. However, ESWT for nonunion of calcaneal fracture has not been reported.

A 64 years old male have had a comminuted intraarticular fracture of the calcaneus, treated by ORIF. X-rays and CT scans at 1 year follow up demonstrated nonunion of the fracture. The patient was treated by a single session of 3000 high-energy shockwaves (Orthospec, Medispec). Full union was achieved at 3 months and at 5 years follow up the patient is asymptomatic.

A 68 years old male had bilateral calcaneal fracture 20y ago. In 2018 he had Lt subtalar arthrodesis. Follow up CT scan demonstrated nonunion of the arthrodesis, and he was offered a revision surgery. 3000 high-energy shockwaves therapy yielded full recovery.

Shockwaves induce angiogenesis and osteogenesis by means of up-regulation and expression of various pro-angiogenic and pro-osteogenic growth factors, and bone healing is strongly stimulated. This non-invasive modality does not compromise the bone blood supply, a major disadvantage of surgery. Long bones are usually treated by several sessions but for small bones one session is recommended. Union is achieved in about 75% of cases, rates comparable to surgery with only few minor side effects. Shockwave therapy is very cost-effective. In Austria, ESWT proved to decrease costs of fractures non-union treatment by 65%-85%.

ESWT should be considered progressively as “therapy of first choice” for the treatment of suitable non-union of fractures and arthrodesis.