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. 2025 Jan 1;111(1):1144-1153.
doi: 10.1097/JS9.0000000000001836.

Extracorporeal shock wave therapy with imaging examination for early osteonecrosis of the femoral head: a systematic review

Han Tan  1   2 , Peiyuan Tang  1   3 , Hua Chai  2 , Wenbo Ma  2 , Yangbin Cao  2 , Bin Lin  2 , Ying Zhu  2 , Wenfeng Xiao  1   3 , Ting Wen  1   3 , Yusheng Li  1   3
Affiliations

Extracorporeal shock wave therapy with imaging examination for early osteonecrosis of the femoral head: a systematic review

Han Tan et al. Int J Surg. .

Abstract

Background: Extracorporeal shockwave therapy (ESWT) is a traditional noninvasive therapy to treat osteonecrosis of the femur head (ONFH). This systematic review aims to investigate whether ESWT can improve the clinical function of ONFH and whether differences in improvement can be observed in radiographic outcomes.

Materials and methods: Two authors independently searched PubMed, Embase, Cochrane Library, and Web of Science for English articles until 21 October 2023. After screening and reading the literature, the two authors independently used corresponding scales to evaluate the quality of the included articles and extracted data. The key data extracted included the Harris Hip Score (HHS), Visual Analog Scale (VAS), changes in lesion size, the change in the Association Research Circulation Osseous (ARCO) stage, and bone marrow edema (BME) stage.

Results: Nine articles included 468 males and 248 females. The average age was 43.29 years and the mean follow-up time was 15.19 months. After receiving ESWT, five studies involving 146 hips showed a higher HHS (MD=-33.38; 95% CI: -46.31, -20.45), and the difference was statistically significant ( P <0.00001). The average VAS before treatment was above 5, but it dropped to 1.2 after ESWT (MD=4.64; 95% CI: 3.63-5.64), and the difference was statistically significant ( P <0.00001). Three studies found no significant differences in the areas of femoral head necrosis before and after treatment with ESWT(MD=9.66; 95% CI: -0.36, 19.67; P =0.06; I2 =84%). Two articles showed that the use of ESWT had no significant effect on the change in the ARCO stage (MD=1.11; 95% CI: 0.76-1.62; P =0.60; I2 =0%). Three studies indicated that using ESWT could improve the BME symptom in the early stage of ONFH (MD=4.35; 95% CI: 1.32-14.37; P =0.02; I2 =62%).

Conclusion: Based on the current evidence, ESWT shows promise as a therapy to enhance hip function and alleviate pain in the early stage of ONFH. With the advancement of more precise imaging techniques, ESWT can potentially reduce the area affected by ONFH. However, such reduction was not found to be statistically significant at the imaging level. Additionally, ESWT could improve symptoms of BME in the early stage. However, no significant change in ARCO grade was observed with ESWT treatment.

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Conflict of interest statement

All authors declare that there are no conflicts of interest.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Figures

Figure 1
Figure 1
Flow chart of study selection using PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines.
Figure 2
Figure 2
The quality analysis of randomized controlled trials.
Figure 3
Figure 3
The Harris Hip Score before and after extracorporeal shockwave therapy.
Figure 4
Figure 4
The Visual Analog Scale before and after extracorporeal shockwave therapy.
Figure 5
Figure 5
The lesion size before and after extracorporeal shockwave therapy.
Figure 6
Figure 6
The Association Research Circulation Osseous change before and after extracorporeal shockwave therapy.
Figure 7
Figure 7
The grade of bone marrow before and after extracorporeal shockwave therapy.
Figure 8
Figure 8
The bone marrow edema of the left femur head on T1-weighted images before and after extracorporeal shockwave therapy treatment (reproduced with permission from Springer Nature).
Figure 9
Figure 9
The bone marrow edema of the left femur head on T2-weighted images before and after extracorporeal shockwave therapy treatment (reproduced with permission from Springer Nature).
See this image and copyright information in PMC

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