Dosage effects of extracorporeal shockwave therapy in early hip necrosis.
BACKGROUND
This study investigated the effects of different dosages of extracorporeal shockwave therapy (ESWT) in early osteonecrosis of the femoral head (ONFH).


METHODS
Thirty-three patients (42 hips) were randomly divided into three groups. Group A (10 patients with 16 hips) received 2000 impulses of ESWT at 24 Kv to the affected hip. Group B (11 patients with 14 hips) and Group C (12 patients with 12 hips) received 4000 and 6000 impulses of ESWT respectively. The evaluations included clinical assessment, radiographs, dynamic contrast-enhanced MRI for microcirculation (Ktrans) and plasma volume (Vp), and blood tests for biomarker analysis (NO3, VEGF, BMP-2, osteocalcin, TNF-α, IL-6, substance P, CGRP, DKK-1 and IGF).


RESULTS
Significant differences of pain and Harris hip scores were noticed between Group A and C in 6 months after ESWT (all P < 0.05). The pain score decreased, but not Harris hip score improved over the observation time period from 6 to 24 months. Total hip arthroplasty was performed in 3 patients (4 hips) in Group A, but none in Groups B and C. Group C showed significant changes in serum biomarkers for angiogenesis, osteogenesis, anti-inflammation, pain threshold and tissue regeneration between one week and one month after treatment (all P < 0.05). However, no significant changes in the infarction volume in image studies were noted in all groups (all P > 0.05). The post-treatment Ktransand Vp in the peri-necrotic areas of Group B and C were significantly greater than pre-treatment data (both P < 0.05).


CONCLUSIONS
High dosage ESWT is more effective in early stage ONFH. The systemic beneficial effects of ESWT may ultimately enhance angiogenesis with improvement of microcirculation of the peri-necrotic areas, that in turn, can improve subchondral bone remodeling and prevent femoral head collapse.
Center for Shockwave Medicine and Tissue Engineering, Department of Medical Research, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taiwan; Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taiwan.
Ching-Jen
CJ
Wang
Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taiwan. Electronic address: cch2269@gmail.com.
Chung-Cheng
CC
Huang
Center for Shockwave Medicine and Tissue Engineering, Department of Medical Research, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taiwan; Department of Cardiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taiwan.
Hon-Kan
HK
Yip
Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taiwan.
Ya-Ju
YJ
Yang
D000293:Adolescent; D000328:Adult; D043925:Angiogenesis Inducing Agents / Q000528:radiation effects; D018771:Arthralgia / Q000209:etiology / Q000628:therapy; D019644:Arthroplasty, Replacement, Hip; D015415:Biomarkers / Q000097:blood; D001861:Bone Regeneration / Q000528:radiation effects; D016723:Bone Remodeling / Q000528:radiation effects*; D005260:Female; D005271:Femur Head Necrosis / Q000097:blood / Q000150:complications / Q000503:physiopathology / Q000628:therapy*; D019220:High-Energy Shock Waves / Q000627:therapeutic use*; D006801:Humans; D007249:Inflammation / Q000209:etiology / Q000628:therapy; D008297:Male; D008875:Middle Aged; D010012:Osteogenesis / Q000528:radiation effects; D011829:Radiation Dosage; D055815:Young Adult
D043925:Angiogenesis Inducing Agents; D015415:Biomarkers
Angiogenesis; Anti-inflammation; ESWT dosage; Hip necrosis; Osteogenesis; Pain threshold; Tissue regeneration