Is There A Role For ESWT In Wound Care?

By John S. Steinberg, DPM, Lt. Col. Alexander Stojadinovic, MD, LCDR Eric Elster, MD, Lt. Col.(P) George Peoples, MD, and Chris E. Attinger, MD

   Over the past several years, there has been a developing body of knowledge regarding the clinical applications of extracorporeal shockwave therapy (ESWT). The latest area of clinical investigation for this technology is in the arena of wound healing. Researchers are now studying ESWT as a new approach to wound healing with a particular emphasis on complex soft tissue wounds with and without underlying bone disruption. Hopefully, this article will serve as an introduction to this new topic and we hope the evidence-based data will soon follow as the ongoing clinical trials progress.    Preliminary clinical trials show that the core technology of unfocused ESWT (Tissue Regeneration Technologies) significantly enhances and accelerates the healing of complex soft tissue wounds in comparison to standard methods of treatment. Experience to date with ESWT indicates it is uniquely suited to the challenge of efficiently and effectively treating a variety of complex wound types, including military combat wounds. If proven in the proposed definitive field testing, such a system would offer new treatment options for some of our most challenging non-healing wound types.    Clinicians have used ESWT successfully to disintegrate kidney stones since 1981. The high efficacy and few adverse effects associated with this treatment made it the standard of care worldwide. Then shockwave therapy became a standard treatment for various common orthopedic conditions such as plantar fasciitis, tendinosis calcarea of the shoulder and tennis elbow.1 Further research has demonstrated shockwave therapy’s effectiveness in treating nonunion fractures in long bones and aseptic bone necrosis in humans.2-4 Unlike the treatment of kidney stones, the fundamental therapeutic objective of orthopedic shockwave application is not to destroy tissue but to stimulate tissue regeneration.5,6    Researchers have shown that treatment with ESWT increases the release of critical wound growth factors and promotes vessel in-growth. The resulting improved circulation within the wound can have certain benefits in a variety of wound etiologies. Animal studies indicate that local delivery of shockwave therapy stimulates early expression of angiogenesis-related growth factors, including endothelial nitric oxide synthase, vessel endothelial growth factor and proliferating cell nuclear antigen. This results in new vessel in-growth that improves blood supply, increases cell proliferation and accelerates tissue regeneration and healing.1,7-9    Ludwig, et. al., described the beneficial effect of ESWT on wound healing in 1990.10 During the course of treating nonunion or delayed osseous union of bone fractures, researchers discovered that both the disrupted bone as well as overlying soft tissue wounds healed rapidly.3 Subsequently, an extensive body of peer-reviewed literature emerged, demonstrating that one could apply ESWT safely and with minimal risk to treat patients with a variety of complex surgical problems, including nonunion of long bone fractures with or without osteomyelitis, aseptic femoral head necrosis, pseudoarthroses and osteochondritis dissecans.10-15 The observed antibacterial effects of extracorporeal shockwaves are highly relevant to the increased risk of infection common to non-healing wounds.

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