Callus formation and bone remodeling in a tibial nonunion after minimal invasive percutaneous screw fixation followed by extracorporeal shockwave therapy 17-months after initial trauma – A case report

Introduction: The treatment of tibial nonunion is challenging and treatment may be conservative or surgical. Conservative strategies include functional braces and weight bearing, or focused extracorporeal shockwave therapy (fESWT).

Case description: A 45-year-old male patient sustained spiral tibial shaft fractures and was treated surgically within 24 hours after the initial accident with intramedullary nails. The tibial fracture was later classified as nonunion after 11 months. Radiologic evaluation 17 months after the initial trauma demonstrated clinical nonunion, and subsequently the patient was offered a conservative approach with fESWT to facilitate an increase in callus formation. The handpiece was fitted with a stand-off II (long), penetration depth of 15 mm. Three cycles were administered in month 17, 19 and 20 after baseline. Each cycle consisted of three treatments sessions spaced with 6-8 days apart, and consisted of 3000 to 4000 impulses each given at 0.25-0.84 mJ/mm2. The number of impulses and the power at the focus point varied according to the pain response.

Outcomes: The patient achieved union 23 months after fracture. A clinical important improvement was observed with both Lower Extremity Functional Scale (LEFS) (18-point difference) and Patient Specific Functional Scale (PSFS) (average: 4.7 points,) The "worst pain last 24 hours" was reduced by 5 points. These values express minimal clinically important difference (MCID) values in these functional patient-reported outcome measures.

Conclusion: This treatment strategy may be viable in a broader setting, including private practice physiotherapy thereby treating the patient in close proximity to the patient's everyday life.