The Effect of High Energy Shock Waves Focused on Cortical Bone: An in Vitro Study

Abstract

Extracorporeal shock wave lithotripsy has become an accepted alternative for the management of nephrolithiasis and cholelithiasis. Direct impact of shock waves cause tear and shear forces at transition sites between tissues with divergent acoustic impedances leading to stone fragmentation. The aim of this study was to determine whether shock waves can cause cortical bone damage at all and, if so, what the relationship is, if any, between the energy density of the shock waves, the number of shock waves applied, and the resulting cortical bone damage. With the Siemens Lithostar Plus with overhead module, electromagnetic shock waves, generated under water with energy densities of 0.23, 0.33, 0.42, or 0.54 mJ/mm 2, corresponding with power settings 2, 4, 6, and 8, were applied to bone specimens, i.e., of rabbit femurs and tibiae. Prior to exposure to the shock waves, the bones were mounted on a specially constructed perspex holder which could be placed in a water-filled test basin with an elastic membrane in the front through which the shock waves propagate without loss of energy. This setup made it possible not only to induce complete fractures, but also to detect the existence of a linear relationship with a Spearman rank correlation coefficient of -0.72 ( P ⩽ 0.01) between the energy level of the shock waves and the severity of the cortical bone defects. The latter findings are especially of great importance because this means that the process can be controlled and that the cortical effects will be predictable and reproducible. This study should be considered a preliminary test concerning the effects of high energy shock wave on bone. The resulting fragmentation and decortication of cortical bone could be the basis for the nonoperative treatment of some disturbances of bone healing, such as delayed unions and established nonunions.