Additional file 1: of Enzymatic debridement for the treatment of severely burned upper extremities – early single center experiences

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Low-energy extracorporeal shockwave therapy (ESWT) improves metaphyseal fracture healing in an osteoporotic rat model

<div><p>Purpose</p><p>As result of the current demographic changes, osteoporosis and osteoporotic fractures are becoming an increasing social and economic burden. In this experimental study, extracorporeal shock wave therapy (ESWT), was evaluated as a treatment option for the improvement of osteoporotic fracture healing.</p><p>Methods</p><p>A well-established fracture model in the metaphyseal tibia in the osteoporotic rat was used. 132 animals were divided into 11 groups, with 12 animals each, consisting of one sham-operated group and 10 ovariectomized (osteoporotic) groups, of which 9 received ESWT treatment. Different energy flux intensities (0.15 mJ/mm², 0.35 mJ/mm², or 0.55 mJ/mm²) as well as different numbers of ESWT applications (once, three times, or five times throughout the 35-day healing period) were applied to the osteoporotic fractures. Fracture healing was investigated quantitatively and qualitatively using micro-CT imaging, quantitative real-time polymerase chain reaction (qRT-PCR) analysis, histomorphometric analysis and biomechanical analysis.</p><p>Results</p><p>The results of this study show a qualitative and quantitative improvement in the osteoporotic fracture healing under low-energy (energy flux intensity: 0,15 mJ/mm²) ESWT and with fewer treatment applications per healing period.</p><p>Conclusion</p><p>In conclusion, low-energy ESWT seems to exhibit a beneficial effect on the healing of osteoporotic fractures, leading to improved biomechanical properties, enhanced callus-quantity and -quality, and an increase in the expression of bone specific transcription factors. The results suggest that low-energy ESWT, as main treatment or as adjunctive treatment in addition to a surgical intervention, may prove to be an effective, simple to use, and cost-efficient option for the qualitative and quantitative improvement of osteoporotic fracture healing.</p></div

Biomechanical analysis results.

<p>Biomechanical analysis results regarding the average A) stiffness in N/mm and B) yield load in N. Both are shown against the different treatment groups (number of treatment(s) and applied energy flux intensity (mJ/mm²)). Values are shown as means ± standard error of the mean (SEM). Adjusted p-values were considered statistically significant at p < 0.05 (One-way analysis of variance (SPSS Statistics Version 23; IBM Corp., New York, NY, USA), Welch-Test adjusted, and Bonferroni post hoc test for stiffness; Two- way analysis of variance ((SPSS Statistics Version 23; IBM Corp., New York, NY, USA) and Bonferroni post hoc test for the other parameters). * p < 0.05 vs. 3 x 0.55 mJ/mm². N: Newton, mm: milli-meter, mJ: milli-Joule.</p

Gene expression analysis of osteoblast and osteoclast specific transcripts.

<p>Gene expression analysis through qRT-PCR of the osteoblast and osteoclast markers with regards to the respective treatment group (number of treatment(s) and energy flux intensity (mJ/mm²)) and shown in relative expression units. Portrayed values are shown as means ± standard error of the mean (SEM). Adjusted p-values were considered statistically significant at p < 0.05 (One-way analysis of variance (SPSS Statistics Version 23; IBM Corp., New York, NY, USA), Welch-Test adjusted, and Bonferroni post hoc test). Please see Supplement 2 for details on the numerous significances. qRT-PCR: Quantitative real-time Polymerase Chain Reaction, Coll1α1: Collagen 1-alpha-1, ERα: Estrogen Receptor-α, IGF-1: Insulin-like Growth Factor 1, OC: Osteocalcin, TRAP: Tartrate-resistant Acid Phosphatase, mJ: milli-Joule, mm: millimeter.</p

Specific primer sequences used for the quantitative real-time polymerase chain reaction (qRT-PCR) amplification.

<p>Specific primer sequences used for the quantitative real-time polymerase chain reaction (qRT-PCR) amplification.</p

Fracture osteosynthesis of the tibia.

<p>Completed osteosynthesis of the tibia with a 5-hole mini Y-plate and 4 screws, with the plate spanning the fracture gap located in the metaphyseal area of the tibia.</p

Extracorporeal shock wave therapy application scheme.

<p>Extracorporeal shock wave therapy application scheme.</p

Average formed callus.

<p>Average total callus formed including simultaneous depiction of the average callus formed individually by Calcein green (white part of bar graph) and Alizarin red (grey part of bar graph). The amount of callus was measured in mm² and is shown according to respective treatment group (number of treatment(s) and applied energy flux intensity (mJ/mm²)). Portrayed is the average total callus of the dorsal, the endosteal and the ventral aspect of the fracture callus. Values are shown as means ± standard error of the mean (SEM) of the total callus. Adjusted p-values were considered statistically significant at p < 0.05 (One-way analysis of variance (SPSS Statistics Version 23; IBM Corp., New York, NY, USA), Welch-Test adjusted, and Bonferroni post hoc test). * p < 0.05 vs. SHAM, Δ p < 0.05 vs. 1 x 0.35 mJ/mm2. mm: milli-meter, mJ: milli-Joule.</p