Extracorporeal shockwave therapy in osteonecrosis of femoral head: A systematic review of now available clinical evidences

Zhang, Qingyu; Liu, Lihua; Sun, Wei; Gao, Fuqiang; Cheng, Liming; Li, Zirong

In 2001, Ludwig and his coauthors [13] first suggested that highenergy extracorporeal shockwave might provide a noninvasive alternative for treating ONFH. In this study, a total of 22 patients with ONFH of ARCO I-III stage received 1 (or 2 if necessary) session of ESWT and were followed up for 1 year. The results revealed obvious therapeutic success in 14 patients, in which group patients scored statistically differently at ARCO scale and showed slightly heterogeneous (though not statistically significant) age distribution compared with those resistant to ESWT. Meanwhile, 4 cases of complete healing were observed on MRI. Kong et al [22] supported this conclusion. In their study, 36 ONFH patients involving 42 hips were enrolled and at 1-year follow-up, they declared that cure was observed in 6 hips, marked effect in 13 hips, effectiveness in 16 hips, and ineffectiveness in 7 hips. It must be pointed out that in this study they did not undertake MRI examination and the definition of cure was disappearance of clinical symptoms. In 2012, Vulpiani et al [23] performed a further study by including 36 patients with unilateral ONFH and grouping them according to the ARCO scale. At the same time, [29] also divided patients on the basis of ARCO stage and obtained similar results. Kusz et al [24] demonstrated considerable enhancement of quality of life in ONFH patients after ESWT; however, they only followed up patients for 6 weeks. In the study reported by Gao et al, [26] they presented the largest patient population on this topic. A total of 335 patients involving 528 hips were divided into 2 groups according to whether the lateral pillar of femoral head was preserved and both groups showed amelioration of pain, increase of Harris hip scores and slowing of disease progression. They pointed out that the improvement of Harris hip scores was mainly due to the reduction of pains and the lesion decrease on MRI after ESWT was not statistically significant (at the same time, a significant reduction of bone marrow edema was indeed observed). Above-mentioned studies used focused shockwave while in 2016, Ma et al [28] described a case of advanced ONFH opt not to THA and treated with radial ESWT, in which a satisfactory result was obtained. Larger-scale clinical trials are needed to confirm this conclusion.