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Nonunion Fractures and PRP/Shockwave

By April 23, 2024No Comments

There are millions of reported bone fractures in the United States yearly. Most heal without any problems. However, even with the best surgical or nonsurgical treatment, some fractures do not heal. When fractures fail to heal, they are called a nonunion fracture.

Bone Healing

For a fracture to heal, the bone needs a proper blood supply and overall stability. These are the major factors that dictate the regeneration of the bone itself.

Stability- All broken bones must be realigned to their anatomic position and stabilized until the healing occurs. Casting and splinting are the typical methods of realignment and stabilization however, in severe compound fractures, internal or external fixation with metal screws and pins is used.

Blood supply- Blood delivers the components required for bone, a living tissue, to heal and unite. If the blood supply is damaged, growth factors, cytokines and bioactive proteins cannot be delivered to the injury for regeneration.

Other significant causes for nonunion are infections which can prevent healing, poor alignment, and separation after setting properly.

Any broken bone can develop into a nonunion, but several bones are notorious for the development of nonunion. The reason is the blood flow to these bones is poor in normal life, therefore in damaged tissues and bones where an increased flow is needed for repair and regeneration, the blood flow cannot meet the demand needed.

These bones are:

  • Scaphoid
  • Fifth metatarsal
  • Femoral neck
  • Talus

Risk Factors for Nonunion

  • Smoking or tobacco use of any kind
  • Age- higher incidence in ages greater than 50 years old
  • Severe anemia- oxygen is poorly delivered to the tissues.
  • Diabetes
  • Low vitamin D
  • Hypothyroidism
  • Overall poor nutritional status
  • Medications including steroids, aspirin, NSAID and other immune modulators.

Symptoms of Nonunion

The major complaint is persistent pain at the fracture site. This can be diagnosed through Xray. Typically, nonunion is diagnosed after a period of healing and as much as a six-month period of immobility.

Non-Surgical Treatment

The most common non-surgical treatment is a bone stimulator. This device delivers ultrasonic or pulsed electromagnetic waves that are employed to stimulate the regenerative process. The device is placed externally over the fractured site. This treatment must be used repeatedly and daily to be effective.

Surgical Treatment

Surgical options include bone grafting, bone graft substitute, internal and or external fixation.

Bone grafting where a bone from another part of the body is placed at the fracture site. Typically, a piece of bone is harvested from the pelvic area then transplanted to the non-union site. Harvesting bone from the pelvis is painful but does not cause a functional impairment.

Cadaver bone may be used and can decrease the painful aftereffects of the allograft. Grafting provides a scaffold to heal over the non-union area and ultimately the bone replaces the cadaver bone.

Bone graft substitutes avoid the use of the allograft or cadaver bone but these osteobiologics do not provide fresh bone cells needed for normal growth patterns.

Bone grafts alone provide no increased stability to the fracture site. Therefore, internal or external fixation devices are commonly placed surgically. These consist of pins and screws placed internally or outside the body. A second surgery is needed to remove the hardware externally. Some pins or screws are left inside the body unless there are side effects dictating their removal.

Platelet Rich Plasma is an autologous blood concentrate, rich in cytokines, growth factors and bioactive proteins. PRP has been used in all fields of medicine to regenerate and revive injured tissue. It can stimulate immune mediators to aid in fighting infection and phagocytosis of damaged necrotic tissues. PRP is instrumental in the regenerative cascade of inflammation, proliferation and remodeling. It can attract the bodies own mesenchymal stem cells to rebuild tissues. Therefore, PRP seem to be advantageous in the healing of non-union fractures.

Shockwave therapy was invented in the late 1960’s in Germany. It was originally used in the treatment of kidney stones. Then, shockwave was used in coronary artery disease. In the 1990, scientists began to study shockwave therapy on musculoskeletal injuries. This therapy increases circulation around injured tissues. It also breaks down scar and calcified deposits. Shockwave can stimulate new bone growth and connective tissues and reduce pain by overstimulating nerve tissues.

Could Platelet Rich Plasma together with Shockwave therapy provide a synergistic treatment for non-union fractures?


Orthop Traumatol Surg Res 2024 Feb;110(1):103417 PMID 37010140

Introduction: Union of long bone fractures is a complicated biological mechanism affected by numerous systemic and local variables. Disruption of any of these components may result in fracture nonunion. There are various types of clinically available treatment strategies for aseptic nonunion. Both activated platelet rich plasma and extracorporeal shock waves play important roles in fracture healing. This study aimed to investigate the interaction of platelet rich plasma and extracorporeal shock wave in bone healing of nonunion.

Conclusion: 55 patients were included in this study. PRP combined with shockwave has a certain synergistic effect in treating aseptic nonunion after fracture surgery. It can significantly improve the formation of new bone; it is minimally invasive and effective strategy to treat aseptic nonunion in a clinical setting.

Cureus 2024 Mar 10;16(3): e55877 PMID 38595890

Introduction: Stress fractures of the proximal phalanx of the great toe are one of the overuse injuries occurring in the lower limb. Conservative therapy mainly from rest from sports activities and resting the affected area, aiming for bone union is commonly chosen first in these patients. If conservative therapy fails, surgery may be considered.

While it is possible to enable athletes to return to competition through conservative treatment, it may take some time and, in some cases, the delayed union may necessitate surgery.

To date, there have been no reports of conservative treatment combining extracorporeal shock wave and platelet rich plasma injections to promote the healing of stress fractures of the proximal phalanx of the great toe that was treated with a combination of ESWT and PRP injection.

Conclusion: In this case, the combination of shockwave and PRP injection for stress fracture of the proximal phalanx of the great toe led to an exceptionally rapid bone union and return to competition. The combined use of ESWT and PRP injections, both beneficial for bone healing, may prove to be a potentially effective treatment for delayed union of the stress fracture of the proximal phalanx of the great toe.

Zhongguo Gu Shang 2019 May 25;32(5):434-439 PMID 31248238

Objective: To investigate the methods and clinical effects of autologous iliac bone transplantation, platelet rich plasma and extracorporeal shock wave in the treatment of nonunion.

Conclusion: 55 patients were included. Autologous iliac bone transplantation combined with platelet rich plasma and extracorporeal shock wave has a certain effect in the treatment of bone nonunion after fracture surgery. It can significantly improve the formation of new bone. It is a comprehensive and useful way to treat nonunion after fracture surgery in clinical work.

Juventix Regenerative Medical is an industry leader in the regenerative medical field. Our Platelet Rich Plasma Kits are FDA cleared and designed for safety, sterility and effectiveness. Our kits are scientifically manufactured to provide a platelet concentrate, devoid of red blood cells with a minimum number of leukocytes that are critical to the regenerative process.

Juventix Regenerative Medical offers a LED Activator to activate the platelets and begin the regenerative process. The activation is a critical step in the release of cytokines, growth factors and bioactive proteins from the alpha granules on the platelets and is accomplished with LED light. This negates the use of chemical additives such as Calcium Chloride, Thrombin or Collagen. This mode of activation by LED light provides sustained growth factor release versus older methods of activation while adhering to the minimal manipulation guidelines of the FDA.

Juventix Regenerative Medical supplies a Bio-Incubator to transform the Platelet Rich Plasma into an Injectable Platelet Rich Fibrin. The Platelet Rich Fibrin, commonly called the “second generation of platelet products” has different cytokines and growth factors than the original PRP. These different cytokines provide an anti-inflammatory microenvironment and can be used confidently in inflammatory conditions.

Juventix Regenerative Medical is proud to offer the PhysioPro Shockwave System. This is a clinical grade shockwave therapy system that induces intracellular and extracellular reactions to assist in the healing of soft tissue and musculoskeletal injures. The deep penetrating waves activate cellular pathways involved in the proliferation and remodeling of damaged tissues. This low-cost device is lightweight, easy to use and complimentary to other regenerative treatments.


Regenerative Regards,


Dr. Robert McGrath

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