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Extracorporeal Shock Wave Treatment for Delayed Union and Nonunion Fractures

A Systematic Review

Willems, Annika, MSc*; van der Jagt, Olav P., MD, PhD; Meuffels, Duncan E., MD, PhD*

doi: 10.1097/BOT.0000000000001361
Review Article

Objectives: Nonunions after bone fractures are usually treated surgically with risk of infections and failure of osteosynthesis. A noninvasive alternative is extracorporeal shock wave treatment (ESWT), which potentially stimulates bone regeneration. Therefore this review investigates whether ESWT is an effective and safe treatment for delayed unions and nonunions.

Data Sources:, MEDLINE ovid, Cochrane, Web of Science, PubMed publisher, and Google Scholar were systematically searched.

Study Selection: Inclusion criteria included studies with patients with delayed union or nonunion treated with ESWT; inclusion of ≥10 patients; and follow-up period ≥6 weeks.

Data Extraction: Assessment for risk of bias was conducted by 2 authors using the Cochrane tool. Union rates and adverse events were extracted from the studies.

Data Synthesis: Two RCTs and 28 nonrandomized studies were included. One RCT was assessed at medium risk of bias and reported similar union rates between ESWT-treated patients (71%) and surgery-treated patients (74%). The remaining 29 studies were at high risk of bias due to poor description of randomization (n = 1), nonrandomized allocation to control groups (n = 2), or absence of control groups (n = 26). The average union rate after ESWT in delayed unions was 86%, in nonunions 73%, and in nonunions after surgery 81%. Only minor adverse events were reported after ESWT.

Conclusions: ESWT seems to be effective for the treatment of delayed unions and nonunions. However, the quality of most studies is poor. Therefore, we strongly encourage conducting well-designed RCTs to prove the effectiveness of ESWT and potentially improve the treatment of nonunions because ESWT might be as effective as surgery but safer.

Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

*Department of Orthopaedic Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands; and

Department of Orthopaedic Surgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.

Reprints: Annika Willems, MSc, Erasmus MC, Department of Orthopaedic Surgery (NC-424), Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands (e-mail:

The authors report no conflict of interest.

Presented as a poster at the International Society for Medical Shockwave Treatment Congress, San Sebastian, Spain, 20th until 24th of June 2017.

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Accepted October 09, 2018

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