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Objectives: The aim of this article is to provide a concise review of the basic science of extracorporeal shock wave therapy (ESWT) and to perform a systematic review of the literature for the use of ESWT in the treatment of fractures and delayed unions/nonunions., Data Sources: Articles in the English or German language were identified for the systematic review by searching PubMed-MEDLINE from 1966 until 2008, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, and relevant meeting abstracts from 2007 to 2008. Moreover, the bibliographies of the identified articles were reviewed., Study Selection: We included clinical outcome studies of ESWT in the treatment of fractures and delayed unions/nonunions. Reports with less than 10 patients were excluded. Nonunions after corrective osteotomies or arthrodeses were excluded., Data Extraction: Sample size, level of evidence, definition of delayed union, definition of nonunion, time from injury to shock wave treatment, location of fracture, union rate, and complications were extracted from the identified articles., Data Synthesis: Data of 924 patients undergoing ESWT for delayed union/nonunion were extracted from 10 studies. All articles were graded as level 4 studies. The overall union rate was 76% (95% confidence interval 73%-79%). The union rate was significantly higher in hypertrophic nonunions than in atrophic nonunions., Conclusion: Data from level 4 studies suggest that shock wave therapy seems to stimulate the healing process in delayed unions/nonunions. However, further investigations are required.

Objectives: Biomechanical study on cadaveric bones using physiological loading conditions to quantify interfragmentary movements in a tibial shaft fracture model fixed by intramedullary nailing., Methods: Six fresh frozen human cadaveric tibiae were sequentially tested in axial, torsional, 4-point bending, and shear loading configurations. Tests were performed in intact specimens and osteotomized specimens equipped with interlocked intramedullary nails. The amount of clearance of the nail within the intramedullary canal was measured on computed tomography scans. Linear and angular deformations of the fragments were continuously measured in all directions to obtain the exact interfragmentary movements., Results: The amount of movement at the site of the fracture was substantial. Especially shear and torsion resulted in gap movements of up to 10 mm. Movements in the transverse plane were significantly larger than axial movements for all loading conditions. For torsion and bending, a significant portion of the movement of the fracture gap resulted from the flexibility of the intramedullary nail; for compression and shear, the majority of the movement was related to the clearance of the nail within the bone., Conclusions: Clearance of the implant within the medullary canal, the flexibility of the implant itself, and the compliance of the implant (nail and locking screws) within the bone determine the extent of movement. The implant flexibility and the clearance are strongly dependent on the thickness of the intramedullary nail.

Study Design: Case report, operative technique., Objectives: Vertebral osteomyelitis is frequently associated with elderly and debilitated patients who have significant medical comorbidities. If surgical debridement is contemplated, an open anterior approach like a thoracotomy can be associated with significant complications in this patient population. Thus, patients with vertebral osteomyelitis who need surgery may benefit from minimal invasive techniques that avoid the complications of more extensive open approaches. We performed thoracoscopic spinal surgery in patients with pyogenic vertebral osteomyelitis, attempting to reduce the morbidity attributable to standard open thoracotomy surgery., Methods: The technique and results of minimally invasive thoracoscopic spinal surgery for pyogenic vertebral osteomyelitis in three patients, including radical debridement and anterior spinal reconstruction, are presented., Results: Radical debridement and anterior spinal reconstruction are feasible via endoscopic approach. Standard thoracotomy or thoracoabdominal approaches associated with high morbidity can be avoided, even for fusion across multiple levels. Conversion to open technique was not necessary in this study. There was no recurrence of infection or loss of reduction during the follow-up period. Operative time and blood loss of endoscopic technique were comparable to open technique., Conclusions: The cases clearly demonstrate the feasibility and efficacy of thoracoscopic spinal surgery in the management of pyogenic vertebral osteomyelitis. Debridement, decompression of the spinal canal, interbody fusion, and anterior spinal fixation can be performed via endoscopic approach.