Treatment of scaphoid waist nonunion by one, two headless compression screws or plate with or without additional extracorporeal shockwave therapy.

INTRODUCTION: Scaphoid nonunion remains challenging for hand surgeons. Several treatment options are available such as: non-vascularized or vascularized bone grafting, with or without additional stabilization. In the last few decades, extracorporeal shockwave therapy (ESWT) has become an established procedure for treating delayed and nonunions. Purpose of this retrospective follow-up study was (a) to investigate union rate and clinical outcome of the different implants [either one/two headless compression screws (HCS) or a plate] and (b) union rate and clinical outcome using only surgery, or a combination of surgery and ESWT. MATERIALS AND METHODS: The study included 42 patients with scaphoid nonunions of the waist with a mean follow-up of 52 months. All patients received a non-vascularized bone graft from the iliac crest and stabilization was achieved by using one, two HCS or a plate. ESWT was performed with 3000 impulses, energy flux density per pulse 0.41 mJ/mm2 within 2 weeks after surgery. Clinical assessment included range of motion (ROM), pain according to the Visual Analog Scale (VAS), grip strength, Disability of the Arm Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O'Brien (Mayo) Wrist Score. In addition, each patient had a CT scan of the wrist. RESULTS: A total of 33/42 (79%) patients showed union at the follow-up investigation. Patients treated with additional ESWT showed bony healing in 21/26 (81%) and without ESWT in 12/16 (75%). Patients that were stabilized using one HCS showed bony healing in 6/10 (60%), with two HCS 10/12 (83%) and by plate 17/20 (85%). The ESWT group had a significantly lower pain score according to the VAS and better modified Green O'Brien (Mayo) Score. No differences could be found in respect of ROM, grip strength, functional outcome score depending of which stabilization method was used. CONCLUSIONS: Stabilization of scaphoid waist nonunions with two HCS or plate showed higher union rates than a stabilization using only one HCS. In addition, ESWT combined with a nonvascularized bone graft from the iliac crest seems a suitable option for treating scaphoid nonunions.

Unfocused extracorporeal shock waves induce anabolic effects in rat bone.

BACKGROUND: Extracorporeal shock waves are known to stimulate the differentiation of mesenchymal stem cells toward osteoprogenitors and induce the expression of osteogenic-related growth hormones. The aim of this study was to investigate if and how extracorporeal shock waves affected new bone formation, bone microarchitecture, and the mechanical properties of bone in a healthy rat model, in order to evaluate whether extracorporeal shock wave therapy might be a potential treatment for osteoporosis. METHODS: Thirteen rats received 1000 electrohydraulically generated unfocused extracorporeal shock waves to the right tibia. The contralateral, left tibia was not treated and served as a control. At two, seven, twenty-one, and forty-nine days after administration of the shock waves, in vivo single-photon-emission computed tomography (SPECT) scanning was performed to measure new bone formation on the basis of uptake of technetium-labeled methylene diphosphonate ((99m)Tc-MDP) (n = 6). Prior to and forty-nine days after the extracorporeal shock wave therapy, micro-computed tomography (micro-CT) scans were made to examine the architectural bone changes. In addition, mechanical testing, microcrack, and histological analyses were performed. RESULTS: Extracorporeal shock waves induced a strong increase in (99m)Tc-MDP uptake in the treated tibia compared with the uptake in the untreated, control tibia. Micro-CT analysis showed that extracorporeal shock waves stimulated increases in both trabecular and cortical volume, which resulted in higher bone stiffness compared with that of the control tibiae. Histological analysis showed intramedullary soft-tissue damage and de novo bone with active osteoblasts and osteoid in the bone marrow of the legs treated with extracorporeal shock waves. Microcrack analysis showed no differences between the treated and control legs. CONCLUSIONS: This study shows that a single treatment with extracorporeal shock waves induces anabolic effects in both cancellous and cortical bone, leading to improved biomechanical properties. Furthermore, treatment with extracorporeal shock waves results in transient damage to the bone marrow, which might be related to the anabolic effects. After further examination and optimization, unfocused extracorporeal shock waves might enable local treatment of skeletal sites susceptible to fracture.

Effects of low-energy shock waves on oral bacteria.

We have recently demonstrated that extracorporeal shock-wave therapy (ESWT) is effective in promoting the healing of dermal wounds and in regenerating alveolar bone lost through periodontal disease. The objective of the present study was to determine any antibacterial effect of ESWT on oral bacteria. Monoculture suspensions of 6 bacterial species were treated with 100 to 500 pulses of ESWT at energy flux densities (EFD) of 0.12 mJ/mm(2), 0.22 mJ/mm(2), and 0.3 mJ/mm(2). Following treatment, aliquots were plated for viability determination and compared with untreated controls. ESWT showed a significant microbicidal effect for Streptococcus mutans and an unencapsulated strain of Porphyromonas gingivalis following as few as 100 pulses at 0.3 mJ/mm(2) (p 0.05). These findings suggest that low-energy ESWT may be bactericidal for selected oral bacteria.

Extracorporeal shock wave therapy induces alveolar bone regeneration.

UNLABELLED: Periodontal inflammation with alveolar bone resorption is a hallmark of periodontitis. We hypothesized that extracorporeal shock wave therapy (ESWT) could promote the regeneration of alveolar bone following Porphyromonas gingivalis-induced periodontitis in rats. Rats were infected with P. gingivalis for 10 wks, which caused alveolar bone resorption. The rats were then treated with a single episode of 100, 300, or 1000 impulses of shock wave on both cheeks at energy levels 0.1 mJ/mm(2). Alveolar bone levels were determined at 0, 3, 6, and 12 wks following ESWT and compared with those in untreated controls. Infected rats treated with 300 and 1000 impulses demonstrated significantly improved alveolar bone levels at 3 wks compared with untreated controls, and the improved levels remained for at least 6 wks in most rats. The results demonstrated effective regeneration of alveolar bone by ESWT and suggested that ESWT should be evaluated as an adjunct in the regeneration of periodontal tissues following periodontal disease. ABBREVIATIONS: ESWT, extracorporeal shock wave therapy; PCR, polymerase chain-reaction.

[How long is a musculocutaneous microvascular transplant flap dependent on its vascular pedicle?]. / Wie lange ist ein mikrovaskulär transplantierter muskulokutaner Lappen von seinem Gefässstiel abhängig?

Two cases of open fractures of the lower leg with microvascular flap reconstruction for soft-tissue coverage illustrate the time span necessary for neovascularisation of the flap. In the first case, the supplying artery of the flap had to be ligated due to a septic aneurysm 17 days after operation. Because of sufficient blood circulation between the flap margin and the surrounding tissue, there was no ischemic damage to the flap. A similar observation was made in a second case, where more than one year postoperatively, venous congestion was managed with leeches. Careful consideration must be given to incisions of these microvascular flaps prior to any further surgical procedure, particularly if the traumatised region is badly vascularised and the flap consists only of a split thickness skin grafted muscle.

[Questionable hyperparathyroidism: diagnostic value of thallium-technetium subtraction scintigraphy]. / Fraglicher Hyperparathyreoidismus: Diagnostischer Stellenwert der Thallium-Technetium-Subtraktions-Szintigraphie.

The diagnostic exclusion of hyperparathyroidism belongs to the standard repertoire of a practicing urologist involved in stone prophylaxis. Primary indicators of hyperparathyroidism are increases in serum calcium and in parathyroid hormone. Additional diagnostic methods are needed, since the methods most often used so far are inadequate, especially insofar as adenomas and ectopic tumors or recurrences can remain unrecognized. Exploratory surgical intervention means a difficult and traumatizing operation. Therefore, a sensitive technique for localization of adenomas is an urgent necessity. Thallium-pertechnetate subtraction scintigraphy was first introduced for localization of an adenoma of the parathyroid by Ferlin's group. This technique yielded better results than any previously known methods, with a success rate of 92%. The object of the present paper is not only to present a method that is not yet sufficiently well accepted among urologists, but also to offer a critical evaluation of the examination results known so far. The method cannot yet make exploratory surgery unnecessary, even when clinical and biochemical examinations give rise to a strong suspicion. However, since ectopic adenomas and possible relapse can be recognized with 90-100% accuracy, which is important in deciding on the surgical strategy, the method should be included in the preoperative diagnostic armamentarium.