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Alternative pseudarthrosis therapy? A field report by Dr Raul Borgmann

2021-01-07_news_Dr_Raul_Borgmann

In this article, the author presents a case in which focused shock wave therapy combined with ultrasound-guided platelet-rich plasma (PRP) injection achieved favourable results in the treatment of pseudarthrosis of the femur.

In early April 2020, a young 34-year-old man with femoral shaft pseudarthrosis came to me for an orthopaedic consultation – ten months after a serious traffic accident involving a quad bike. The fracture had been osteosynthesised with a long proximal femoral nail in May 2019 and had not yet healed in the shaft region (Fig. 1).

Fig. 1: Femoral shaft before shock wave therapy.

Fig. 1: Femoral shaft before shock wave therapy.

At the check-up in the university hospital at the beginning of March, the patient was told that the pseudarthrosis had to be revised, the osteosynthesis material had to be removed, the fracture gap had to be refreshed and filled with iliac crest spongiosa and it all had to be refixed with a ring fixator. He would then be released postoperatively, initially confined to a wheelchair, and would have to prepare himself for a rehabilitation phase lasting several months.

Impact of the corona pandemic on therapy decisions
The patient was also informed that, due to the onset of the corona pandemic, surgical treatment could not take place at that time and would only be possible in June/July at the earliest, as soon as the corona situation could be better assessed. For the patient, however, this would have had additional far-reaching consequences. Because he was unable to work due to his severe injury, he wanted to begin a retraining programme in September 2020. If his surgery date was not until July then he would not have been able to attend. This would have meant that his return to work would have been delayed by yet another entire year.

Due to this situation, the patient and his wife began searching for possible alternatives and came across my practice regarding conservative pseudarthrosis treatment. After studying the medical history of the patient and his pictures, I had to inform the patient that the attempt at conservative therapy using shock waves needed to be performed in the clinic using large-scale equipment. My hands were also tied in this case due to the corona pandemic; as an external consultant, I was not allowed to access the large-scale equipment in the clinic.

Combination therapy with shock wave device in practice
On account of this situation and in view of the lack of alternatives, the patient and I agreed to try a therapy programme using my electromagnetic practice shock wave device in combination with an ultrasound-guided PRP injection into the pseudarthrosis gap. Subsequently, in April, I performed four focused shock wave treatments after ultrasound localisation of the pseudarthrosis gap from two directions with 3000 pulses each, i.e. a total of 6000 pulses with an energy flux density of 0.55 mJ/mm² per treatment. In addition, a PRP injection was performed under visual control, as well as ultrasound-guided, into the pseudarthrosis gap (Fig. 2).

Fig. 2: Platelet-rich plasma injection for femoral shaft pseudarthrosis.

Fig. 2: Platelet-rich plasma injection for femoral shaft pseudarthrosis.

There were no issues whatsoever with the treatment appointments; it was virtually pain-free for the patient and there were no undesirable side effects observed. At the subsequent check-up in the university clinic on 11.05.2020 – just four weeks after starting treatment in my practice – the X-ray showed callus formation for the first time as well as initial signs of consolidation. Due to these developments, the colleagues at the university hospital treating the patient initially refrained from further surgical intervention and advised the patient to continue the conservative therapy approach. We then performed two additional shock wave therapy sessions according to the above regimen as well as another ultrasound-guided PRP injection. The follow-up examinations performed afterwards at the end of June and the beginning of August 2020 continued to show a slow but steadily increasing consolidation of the fracture (Fig. 3).

Fig. 3: Femoral shaft 3 months after shock wave therapy and PRP injection.

Fig. 3: Femoral shaft 3 months after shock wave therapy and PRP injection.

Conclusion and outlook
In this case, the patient was spared additional major surgical intervention. I would therefore like to suggest that this therapy regimen – in combination with ultrasound-guided PRP injection and focused shock wave therapy (ideally with large-scale equipment for the long tubular bones ) – also be considered as a treatment option in the future for pseudarthrosis of the long tubular bones prior to surgical intervention. The two procedures appear to have a synergistic effect in this case. In my literature search on this subject, I only came across one study on combining the two methods that I used1,2. There are, however, numerous studies3–7 on the individual procedures that demonstrate their effectiveness. Since both procedures achieve their effects in the tissue due to the cytokines, this also makes perfect sense.

Author: Raul Borgmann, MD
Privatpraxis für Orthopädie & Osteopathie
Gartenstrasse 1, 79098 Freiburg
E-mail:

References:
1. Rughetti A, Flamini S, Colafarina O et al. Closed surgery: autologous platelet gel for the treatment. Blood Transfus 004;2:37-43.
2. Großner T, Schmidmaier G. Konservative Therapieoptionen der Pseudarthrosen [Conservative therapy options for pseudarthroses]. Unfallchirurg 2020;123:705–710.
3. Wang L, Yang JY, Zhang BW et al. Plateletrich plasma injection for the treatment of atrophic fracture nonunion. Zhongguo Gu Shang 2020;33(3):261–264. [Article in Chinese] https://pubmed.ncbi.nlm.nih.gov/32233256/
4. Mahadik SK, Mehta S, Deshpande S et al.Autologous platelet injection in the treatment of long bone nonunion: A prospective interventional study. Int J Orthop Sci 2018;4(3).
5. Bielecki T, Gazdzik TS, Szczepanski T. Benefit of percutaneous injection of autologous platelet-leukocyte-rich gel in patients with delayed union and nonunion.Eur Surg Res 2008;40(3):289–296.
6. Ghaffarpasand F, Shahrezaei M, Dehghankhalili M. Effects of Platelet Rich Plasma on Healing Rate of Long Bone Non-union Fractures: A Randomized Double-Blind Placebo Controlled Clinical Trial.Bull Emerg Trauma 2016;4(3):134–140.
7. Haffner N, Smolen D, Dahm F et al. Significance of extracorporeal shockwave therapy in fracture treatment. In: Wang CJ, Schaden W, Ko JY (eds.): Shockwave Medicine. Transl Res Biomed 2018;6:42–63, Basel, Karger.

*Published in Orthopädischen Nachrichten 10/2020

 

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