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Table 6 Imaging outcome measures for osteonecrosis of the femoral head (ONFH)

From: The effects of shockwave therapy on musculoskeletal conditions based on changes in imaging: a systematic review and meta-analysis with meta-regression

Author (year) SWT type Comparator Imaging outcome Follow-up
Period Baseline - F/U
Mean ± SD
P value
Within group Between group
Algarni (2018) [61] F-SWT None Anteroposterior and lateral radiographs were obtained to assess the size of the lesion, the extent of subchondral bone collapse, and the presence of degenerative changes in the hip joint. MRI was performed to evaluate BME, the size of the lesion, femoral head congruency, the presence of a crescent sign, and degenerative changes in the hip joint 6,12,24 months The mean size of the lesion (%) over the femoral head pre-SWT was 59 ± 32 and post-SWT was 28 ± 16.
Significant reduction in BME was noted following SWT
p = 0.24 NA
Chen (2009) [62] F-SWT Total hip arthroplasty MRI were assessed for the congruency of the femoral head, crescent sign, the size and stage of the lesion and bone marrow edema 41 ± 7.4 month The mean size of the lesion (%) over the femoral head pre-SWT was 23.1 ± 22.2 and post-SWT was 22 ± 23.3.
Significant reduction in BME was noted after treatment
lesion size =0.466
BME =0.031
NA
D’Agostino (2014) [59] F-SWT None MRI examination was performed and calculated the edema area using the Sectra PACS software 2,3,6 months Pre-treatment, the mean edema area (mm2) was 981.9 ± 453.2. After 2 months was 469.5 ± 306.8. At 6 months, the mean edema area had reduced to 107.8 ± 248.1. < 0.01 NA
Hsu (2010) [63] F-SWT Cocktail therapy (SWT, hyperbaric oxygen therapy (HBO), alendronate) Radiographs were used to assess the size and location of the lesion, congruency of the femoral head, the presence of a crescent sign and degenerative changes of the hip joint. MRI was used to evaluate the changes in the size of the lesion, the congruency of the articular surface of the femoral head and BME 6,12 months The mean size of the lesion (%) over the total femoral head surface was 28.9 ± 14.9 and 27.4 ± 18 before treatment, and 27.6 ± 14.5 and 26.2 ± 18.5 after treatment for the Cocktail therapy group and SWT alone group, respectively =0.373 for the lesion size, =0.033 for the BME =0.344
Ludwig (2001) [64] F-SWT None Radiography and MRI were used to classify the lesions on the ARCO scale 1 year complete healing in 4 patients, a significant decrease in the size of the area of poor circulation in 6 patients, and unchanged in 4 patients NR NA
Vulpiani (2012) [60] F-SWT None Antero-posterior and lateral radiographs were used to evaluate the size of the lesion, the extent of collapse of subchondral bone and degenerative changes of the hip joint. MRI was used to measure the size of the lesion, assess the congruency of the femoral head, the presence of a crescent sign and/or degenerative changes, with the aim to stage the lesion according to ARCO scale 3,6,12,24 months At all follow-up time points, the lesions show no or only minimal changes. Neither regression nor progression of lesions that had been graded before treatment as ARCO stage I and II were seen. NR NA
Wang (2016) [65] F-SWT Low vs medium vs high dosage SWT The necrotic areas of femoral heads on MRI were estimated on a high resolution monitor via the PACS system. The percentage of the infarcted femoral head volume (IFHV) was measured by the infarcted femoral head volume divided by total femoral head volume. BME around the necrotic regions were graded on MRI as follows: grade 0: no BME; grade 1: peri-necrotic; grade 2: edema extending to femoral head; grade 3: edema extending to femoral neck and grade 4: edema extending to intertrochanteric region 6 months The mean size of the lesion (%) in group A pre-SWT was 35.1 ± 9.4 and post-SWT was 34.2 ± 5.9, group B pre-SWT was 36.2 ± 8.6 and post-SWT was 36.6 ± 7.7 and group C pre-SWT was 30.5 ± 13.1 and post-SWT was 30.2 ± 7.3.
The IFHV of lesion (%) in group A at pre-SWT was 20.8 ± 18.7 and post-SWT was 19.3 ± 19, group B at pre-SWT was 23 ± 14.1 and post-SWT was 22.5 ± 16.4, and group C at pre-SWT was 22.3 ± 15.7 and post-SWT was 18.9 ± 12.5.
The stage of the lesion showed no significant differences in all groups. However, BME on MRI was significantly reduced after SWT in group C (P = 0.039).
> 0.05 except for the IFHV of lesion in group C = 0.028 > 0.05
Wang (2012) [66] F-SWT Core decompression MRI was used to examine the size of the lesion, congruency of the femoral head, the presence of a crescent sign, BME and degenerative changes of the hip joint. The percentage of IFHV was measured by IFHV divided by total femoral head volume. 1,2,9–8 years The mean size of the lesion (%) over the femoral head pre-SWT was 21 ± 41 and post-SWT was 30 ± 20, 30 ± 20, 26 ± 18 at 1,2, 8–9 years respectively. In the pre-surgical group was 40 ± 23, and post-surgical was 42 ± 15, 41 ± 27, 41 ± 4 at 1,2, 8–9 years respectively. > 0.05 < 0.05 for the size of the lesion and reduction of BME after SWT
Wang (2009) [67] F-SWT None Radiographs were used to assess the size of the lesion, congruency of the femoral head, the presence of a crescent sign and degenerative changes. MRI was used to evaluate the changes in lesion size, the congruency of the articular surface and BME. 1,3,6,12,24 months The mean size of the lesion (%) over the femoral head pre-SWT in the SLE group was 34.8 ± 21.1 and 28.7 ± 14.2 post-SWT, in the Non-SLE group, pre-SWT was 32.9 ± 22.4 and post-SWT was 26.7 ± 12.9. both groups showed significant reduction of BME following SWT > 0.05 > 0.05 for the size of lesion and < 0.05 for reduction of BME
Wang (2005) [68] F-SWT core decompression and bone-grafting Radiographs of the hip joint were used to evaluate the size of the lesion, the extent of collapse of subchondral bone, and degenerative changes of the hip joint. MRI was used to examine the size of the lesion, the congruency of the femoral head, the presence of a crescent sign, BME, and degenerative changes of the hip joint 3,6,12,24 months The mean size of the lesion (%) over the femoral head pre-SWT was 61 ± 41 and post-SWT was 30 ± 20 at 24 months follow-up. In contrast, the pre-surgical was 40 ± 23 and post-surgical was 41 ± 27.
In the SWT group, 5 lesions (3 stage I and 2 stage II) regressed and 4 (2 stage II and 2 stage III) progressed. In the surgical group, 4 lesions regressed, 15 (14 stage II and 1 stage I) progressed, and 9 were unchanged
=0.282 < 0.01
Wang (2008) [69] F-SWT SWT + alendronate Radiographs of the hip joint were used to assess the size of the lesion, congruency of the femoral head, the presence of a crescent sign and degenerative changes of the hip joint. MRI was used to examine the size of the lesion, the congruency of the femoral head, the presence of a crescent sign, BME, and degenerative changes of the hip joint 3,6,12,24 months The mean size of the lesion (%) over the femoral head pre-SWT was 27.7 ± 15.5 and post-SWT was 25.7 ± 16.2 at 6 months follow-up. In contrast, the pre-SWT+ alendronate group was 32.6 ± 19.9 and post- SWT+ alendronate was 29.32 ± 21.99.
Significant reduction in BME was noted in both groups.
=0.679 0.145
Wang (2011) [70] F-SWT None Radiographs in AP and lateral views were used to assess the size of the lesion, congruency of the femoral head, the presence of a crescent sign and degenerative changes. MRI was used to evaluate the size of the lesion, the collapse of femoral head and BME. 6,12 months The mean size of the lesion (%) over the femoral head pre-SWT was 27.23 ± 18.9 and 27.04 ± 19.17 post-SWT. Significant improvement in BME was noted following SWT > 0.05 for the size of lesion and = 0.04 for reduction of BME NA
  1. BME bone marrow edema, F-SWT focused SWT, R-SWT radial SWT, NR not reported, NS not significant, NA not applicable