Enhancement of bone fracture healing by ultrasound ...

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 175-182

ISSN 0009-479X

OPIS PRZYPADKU Kończyna górna i dolna

Enhancement of bone fracture healing by ultrasound stimulation – 4 case reports Wspomaganie zrostu tkanki kostnej za pomocą ultradźwięków – studium 4 przypadków Mateusz Stolarz1,2,3, Robert Hawranek1,2, Grzegorz Wrzask1, Marek Hawranek1, Jakub Hawranek1, Zygmunt Wróbel3, 1

Department of Orthopedics and Traumatology, City Hospital in Zabrze, Poland Medict, Gliwice, Poland 3 Department of Computer Biomedical Systems, University of Silesia, Institute of Computer Science, Sosnowiec, Poland 2

Abstract The problems associated with treating bone fractures as well as frequently accompanying complications are still a challenge for modern orthopedics and traumatology. The duration of the healing process is different and depends on numerous individual circumstances. Various methods of accelerating these processes are currently being used; as well, alternative methods of treatment are being sought. Among the ones currently in use, invasive, related to surgery or local injection of various substances, and non-invasive methods, related to physiotherapeutic procedures, can be distinguished. One of the non-invasive methods is low-intensity pulsed ultrasound (LIPUS). This article discusses the use of LIPUS in four cases: nonunion fracture of the clavicle, prolonged healing of a femoral fracture, a tibial stress fracture, and ipsilateral talus and calcaneal fracture. Summing up the discussed cases, the use of ultrasound is a positive and safe method of promoting bone healing. It is worth considering its use, especially in bone nonunion as an alternative to surgical treatment. Key words: bone fracture, nonunion, low-intensity pulsed ultrasound, LIPUS,

Streszczenie Problematyka leczenia złamań kości i nierzadkich powikłań wciąż stanowi wyzwanie dla współczesnej ortopedii i traumatologii. Szybkość procesu gojenia jest różna i zależna od wielu uwarunkowań osobniczych. Obecnie wykorzystywane są różne metody przyspieszenia gojenia. Wśród stosowanych można wyróżnić inwazyjne lub nieinwazyjne. Jedną z metod są ultradźwięki o niskim natężeniu (LIPUS). W niniejszym artykule omówiono zastosowanie LIPUS w czterech przypadkach: brak zrostu obojczyka, przedłużający się zrost kości udowej, złamanie przeciążeniowe kości piszczelowej, złamanie ipsilateralne kości skokowej i piętowej. Podsumowując, użycie ultradźwięków stanowi dobrą i bezpieczną metodę wspomagania gojenia kości. Warto rozważyć ich zastosowanie szczególnie przy braku zrostu kości, jako alternatywę do leczenia operacyjnego. Słowa kluczowe: złamanie kości, brak zrostu, ultradźwięki o niskim natężeniu, LIPUS

Author’s address: Mateusz Stolarz, Department of Orthopedics and Traumatology, City Hospital in Zabrze, Zamkowa 4, 41-803 Zabrze, Poland, tel.: +48500793030, e-mail: [email protected],

Received: 05.09.2017 Accepted: 29.09.2017 Published: 03.11.2017

© Polskie Towarzystwo Ortopedyczne i Traumatologiczne Chirurgia Narządów Ruchu i Ortopedia Polska / Polish Orthopaedics and Traumatology

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Mateusz Stolarz et al., Enhancement of bone fracture healing by ultrasound stimulation – 4 case reports

Introduction The problem of bone fracture treatment is the subject of numerous studies. The treatment uses conservative and operational methods. Occurring complications, among others, include nonunions, pseudarthrosis in the place of fracture, delayed healing, and others still whose enigmatic etiologies pose a challenge for modern orthopedics and traumatology [1, 2]. A holistic view of the fracture healing process involves both systemic processes and local inflammation processes. Fracture healing can take place directly and indirectly [2]. Subsequent physiological steps combining a junction of broken bone elements include: hematoma formation, recruitment and accumulation of stem cells, angiogenesis, and extracellular matrix formation which is a scaffold for new bone cells that creates a bone scar [3]. The healing process is dependent on biochemical (including pro-inflammatory factors and hormones), nervous and physical regulators [1]. Factors influencing the osseointegration processes also include: sex, age, BMI, nicotine, chronic diseases such as osteoporosis, diabetes as well as genetic predisposition [4, 5]. The duration of the healing process of a bone fracture varies individually between patients. Currently, many enhancement techniques are described in the literature, both invasive and noninvasive. Noninvasive techniques include low-intensity pulsed ultrasound (LIPUS) [6, 7], low-dose laser therapy [8], extracorporeal shock wave therapy (ESWT) [9], and supplementation of parathormon (PTH) [10] or calcium and vitamin D. Minimally invasive techniques are usually associated with local injection of bone marrow [11], FGF-2 factor [15], BMP-2 protein [12], BMP-7 protein [13]. Low intensity ultrasound, which is commercially available, has been proven in many studies to enhance bone healing [6, 14, 15]. Currently it is particularly recommended in the absence or delay of bone healing in stable fixation [16, 17]. Indications also include accelerating the healing of fresh bone fractures treated surgically or conservatively [6, 18], [19]. However, some authors have questioned the use of LIPUS, indicating moderate to low quality of healing enhancement and contradictory literature data [20]. In the presented article, we have described the use of LIPUS using the system Exogen in 4 medical cases: two patients with nonunion fractures and two with acute fractures. Case studies Medical case 1 A woman, 27 years old, presented with a multifragmentary, unstable fracture of the left clavicle as a result of high-energy trauma. The patient presented with no preexisting diseases and a high level of physical activity. The attempt at fracture

repositioning as an application of conservative treatment failed. The patient was approved for an urgent procedure and operated on. An intramedullary nail was implanted (Fig. 1a). Due to the relatively high activity of the patient, it was decided that a Dessault’s plaster dressing would be used. At the follow-up examinations at 1 month (Fig. 1b), 7 months (Fig. 1c), 8 months (Fig. 1d), and 9 months (Fig. 1e) after surgery, no satisfactory bone union was achieved. An ache was continuously present in the area surrounding the fracture and a strong pain was felt upon palpation of the clavicle. It was decided that LIPUS would be used for 30 days. A satisfactory bone union (Fig. 1f) was observed a year after injury, and 1,5 months after LIPUS treatment. Complete elimination of pain was achieved. The patient returned to her daily activities. Medical case 2 A 36 year old patient, male, with no chronic diseases, no allergy and no addiction, suffered a fracture of the left femur as a result of a fall. The patient was operated on with a minimally invasive technique using an intramedullary nail (Fig. 2). Early postoperative follow up showed no complications during the postoperative period . Rehabilitation began two days postoperatively. Along with the subsiding of pain, starting the third week after surgery, he gradually increased the load on the limb. Unfortunately, the pain only decreased to a certain level, afterwards plateauing, which interfered with normal daily activity. The radiological examinations were carried out 2 months, 3 months, 4 months and 6 months (Fig. 3) after the operation, and showed bone nonunion. It was decided that performing revision surgery was necessary, carried out 7 months after the initial operation. In one step, the existing fixation material was removed and with the open technique, the fracture was refreshed, and existing fibrous tissue was removed. The fractured part was covered locally with allogeneic bone grafts and a reconstruction plate was fastened (Fig. 4). Postoperative protocol remained the same as after the initial surgery. Postoperatively, the patient complained of stronger pain than that following the first operation which may have been due to more extensive perioperative soft tissue injury. Control tests, including X-rays were taken: 1 month, 3 months and 5 months (Fig. 5) after surgery, showing no satisfactory bone union. Radiographs showed slight signs of bone union and absorption of allografts, after 5 months. Fixation was assessed as stable. When the patient tried to walk, he suffered strong pain, which made his daily activities difficult. Despite intensive rehabilitation and attempts to move with a single crutch, the patient required two elbow crutches. In the fifth month after the operation, LIPUS was applied in 30 cycles at one-day intervals and rehabilitation was continued. Control studies at 8 months (Fig. 6), 10 months, and 18 months (Fig. 7) showed progressive bone union

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observed a year after injury, and 1,5 months after LIPUS treatment. Complete elimination of Stolarz et al., Enhancement of bone fracture healing by ultrasound stimulation – 4 case reports pain was achieved. The patient returnedMateusz to her daily activities.

Fig. 2. Plain radiograph after surgery, a) AP proj

Rehabilitation began two days postopera starting the third week after surgery, he graduall Unfortunately, the pain only decreased to a certa interfered with normal daily activity. The radiolo Fig. 1. Plain radiograph of left clavicle, inof AP projection. a) 1 day after b) 1 month after surgery, c) 7 months surgery, d) b) 8 months surgery, Fig. 1. Plain radiograph left clavicle, insurgery, AP projection. a)31 months, day afterafter 1 month months, 4surgery, months and 6aftermonths (Fig. e) 9 months after surgery, f ) 12 months after surgery, and 1,5 month after LUPIS treatment. after surgery, c) 7 months after surgery, d) 8 months after surgery, e) 9 months after surgery, f) nonunion. 12 months after surgery, and 1,5 month after LUPIS treatment.

Medical case 2 A 36 year old patient, male, with no chronic diseases, no allergy and no addiction, suffered a fracture of the left femur as a result of a fall. The patient was operated on with a minimally invasive technique using an intramedullary nail (Fig. 2). Early postoperative follow up showed no complications during the postoperative period .

Fig. 3. Plain radiograph 6 months after operation: a) AP projection, b) lateral Fig. 2. Plain radiograph after surgery, a) AP projection, b) lateral projection. projection.

Fig. 2. Plain radiograph after surgery, a) AP projection, b) lateral projection.

It was decided that performing revision s after the initial In one step, the existin Rehabilitation began two days postoperatively. Along withoperation. the subsiding of pain, © Polskie Towarzystwo Ortopedyczne i Traumatologiczne open technique, theonfracture and startingChirurgia the Narządów third week afterPolska surgery, he gradually increased the load the limb.was refreshed, Ruchu i Ortopedia / Polish Orthopaedics and Traumatology 177 fractured part wasplateauing, covered locally Unfortunately, the pain only decreased to a certain level, afterwards whichwith allogene

bone union. Radiographs showed slight signs of bon 5 months. Fixation was assessed as stable. When th Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 175-182 OPIS PRZYPADKU pain, which made his daily activities difficult. Desp Mateusz Stolarz et al., Enhancement of bone fracture healing by ultrasound stimulation – 4 case reports move with a single crutch, the patient required two

Fig. 5. RTG months after revision surgery, projection, b)surgery, lateral Fig. 4. Plain radiograph, one day after revision surgery months after firsta) AP operation) , a)proAPa) AP p Fig. 5.5(7 RTG 5 months after revision jection. Radiographs showed slight signs of bone union and absorption of projection, b)lateral projection. Radiographs showed slight signs of bone union and allografts.

Fig. 4. Plain radiograph, one day after revision surgery (7 months after first operation) , a) AP projection, b)lateral projection.

Postoperative protocol remained the same as afterInthe surgery. Postoperatively, theinitial fifth month after the operation, LIPUS

with properly formed bone scarring. At the follow-up after patient complained of stronger pain than that intervals followingand therehabilitation first operationwas which may have continued. Control 8the months, the patient moved about using his own strength/ bearing his full the injured leg, without crutches, been due toweight moreonextensive perioperative soft tissue Control including X-rays bone un and injury. 18 months (Fig.tests, 7) showed progressive slightly limping. were taken: 1 month, 3 months and 5 months (Fig. surgery,after showing no satisfactory At5) theafter follow-up 8 months, the patient moved At 18 months, basic treatment was completed. The pabone union. Radiographs showed slight signs of bone union on andthe absorption of allografts, after slig full weight injured leg, without crutches, tient reported periodic “discomfort associated with weather 5 months. Fixation was assessed as stable. When the patient tried to walk, he suffered strong changes”, but could move without the aid of elbow crutches.

pain, which made his daily activities difficult. Despite intensive rehabilitation and attempts to Medical case 3 a single crutch, the patient required two elbow crutches. move with

The patient, male, 49 years old, overweight, presented without additional diseases, with no current addictions and a history of cigarette use. After a few months without any Fig. 6. Radiograph 8 months after surgery, a) AP pr sport activity other than daily activities, he started intensive bon union formation. running, every 2-3 days. During one run, he felt a sudden, sharp pain in the distal part of the right leg preventing full At 18 months, basic treatment was complete weight bearing of the traumatic limb. After a clinical exami“discomfort associated with weather changes, but c nation and a RTG study (Fig. 8), a stress fracture of the right tibia was diagnosed. crutches. Fig. 6. Radiograph 8 months after b)surgery, Fig. 6. Radiograph 8 months after surgery, a) AP projection; lateral projec-a) AP pr tion. Satisfactory bon union formation. Plaster immobilization bandages were used for a month, bon union formation. without weight bearing on the limb, along with the use of 2 elbow crutches. During the immobilization period, antiAt 18 months, basic treatment was complete thrombotic prophylaxis was used (deltaparin, 1x1 sc). After “discomfort associated with weather changes, but c 3.5 weeks of immobilization, the plaster brace was removed crutches. and replaced with an orthosis (“Walker type”) and 30 cycles of LIPUS were used at one day intervals, along with intensive rehabilitation. In follow-up exams less than 3 months after satisfactory bone union achievedsurgery, (Fig. 9). a) AP projection, b) lateral projection. Fig.injury, 5. RTG 5 months after was revision After this period, the patient returned to daily activities, Radiographs showed slight signs of bone union and absorption of allografts. without pain.

In the fifth month after the operation, LIPUS was applied in 30 cycles at one-day

Medical case 4 intervals and 54 rehabilitation wasfrom continued. The patient, male, years old, had fallen about 2 me-Control studies at 8 months (Fig. 6), 10 months, ters left lower limb.7) Theshowed Patient suffered from hy- boneFig. andonto 18 his months (Fig. progressive union formed bone 7. Radiograph 18properly months after18 surgery, a) AP projection; b) lateral proFig. 7. with Radiograph months afterscarring. surgery, jection. Complete bone union.

At the follow-up after 8 months, the patient moved about using his own strength/ bearing his bone union. full weight on the injured leg, without crutches, slightly limping.

a) AP p


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Medical case 3 18 months after surgery, a) AP p Fig. 7. Radiograph


OPIS PRZYPADKU Mateusz Stolarz et al., Enhancement of bone fracture healing by ultrasound stimulation – 4 case reports

pain and swelling after intense physical activity. In the X-ray, bone union in the place of the fractures (Fig. 13) was evident. Additionally, there were symptoms of minor osteoarthritis.

Fig. 8. Radiograph of stress fracture of right tibia , a) AP projection; b) lateral projection; c) magnification of AP projection; d) magnification of lateral projection. Plaster immobilization bandages were used for a month, without weight bearing on the limb, along with the use of 2 elbow crutches. During the immobilization period, antithrombotic prophylaxis was used (deltaparin, 1x1 sc). After 3.5 weeks of immobilization, the plaster brace was removed and replaced with an orthosis (“Walker type) and 30 cycles of LIPUS were used atofone intervals, with ,intensive rehabilitation. In follow-up exams Fig. 8. Radiograph of stress fracture of stress rightday tibia fracture , a) AP projection; b) late- tibia Fig. 8. Radiograph of along right a) AP projection; b) lateral projection; c) ral projection; c) magnification of AP projection; d) magnification of lateral less than 3 months injury, satisfactory bone union wasprojection. achieved (Fig. 9). After this magnification of APafter projection; d) magnification of lateral projection. period, the patient returned to daily activities, without pain. Fig. 10. Plain radiograph od ankle joint, with lateral projection, Fracture of

talus for and calcaneal bone. without weight bearing on the Plaster immobilization bandages were used a month, Fig. 10. Plain radiograph od ankle joint, with lateral limb, along with the use of 2 elbow crutches. During the immobilization period, bone. antithrombotic prophylaxis was used (deltaparin, 1x1 sc). After 3.5 weeks of immobilization, the plaster brace was removed and replaced with an orthosis (“Walker type) and 30period, cycles antithrom of During the immobilization LIPUS were used at one day intervals, along with intensive In the follow-up exams treat used. In the rehabilitation. first month after injury, LIPUS less than 3 months after injury, satisfactory bonepartial union weight was achieved 9).injured After this bearing(Fig. on the limb. After 4 w period, the patient returned to daily activities, without pain. ankle orthosis. After control examinations two mont gradual loading of the limb was permitted. The X-ra was confirmed (Fig. 12). Fig. 9. Radiograph of right tibia, inof the time less tibia, than 3 months after fractuthe follow-up, foura)months Fig. 9. Radiograph right in the time less than 3 On months after fracture. AP after the traum re. a) AP projection; b) lateral projection. crutches and reported periodic pain and swelling aft projection; b) lateral projection. bone union in the place of the fractures (Fig. 13) wa pertension, without additional chronic diseases, without adsymptoms of minor osteoarthritis.

dictions. X-ray examination was performed (Fig. 10) and an ipsilateral fracture of the left talus and calcaneus bone were MedicalTocase 4 illustrate the fracture, computed todiagnosed. precisely The patient, male, 54 years old, had fallen from about 2 meters onto his left lower limb. The mography was performed (Fig. 11). Despite recommendations, the patient did not consent to surgery and decided to additional chronic diseases, without addictions. Patient suffered from hypertension, without undergo conservative treatment - immobilization in a plaster X-ray wasright performed 10) and ipsilateral of the left talus and Fig.with 9.examination Radiograph of tibia, in(Fig. the time less an than 3 monthsfracture after fracture. a) AP boot, no weight bearing. calcaneus were projection. diagnosed. To precisely projection; b) lateral During the bone immobilization period, antithrombotic prophy- illustrate the fracture, computed tomography laxis (deltaparin, 1x1 sc) was used. In the first month after the was performed (Fig. 11). Despite recommendations, the patient did not consent to surgery and injury, LIPUS treatment was applied. Rehabilitation included decided to undergo conservative treatment - immobilization in a plaster boot, with no weight partial weight bearing on the injured limb. After 4 weeks the bearing. plaster was changed to a hard ankle orthosis. After control exMedicaltwo case 4 later, the orthesis was removed, and aminations months The patient, old, gradual loading ofmale, the limb54 wasyears permitted. Thehad X-rayfallen was tak-from about 2 meters onto his left lower limb. The en, and satisfactory bone union was confirmed (Fig. 12). Patient suffered from hypertension, without additional chronic diseases, without addictions. On the follow-up, four months after the trauma, the paX-ray examination was performed (Fig. 10) and Fig. an ipsilateral fracture of the leftof talus and 11. Computed tomography oftomography left angle after injury, a,b) AP projections; Fig. 11. Computed left angle after tient moved without elbow crutches and reported periodic c,d) lateral projections; e,f) oblique projections.

calcaneus bone were diagnosed. To precisely illustrate the fracture, computed tomography projections; e,f) oblique projections. was performed (Fig. 11). Despite recommendations, the patient did not consent to surgery and decided to undergo conservative treatment - immobilization in a plaster boot, with no weight © Polskie Towarzystwo Ortopedyczne i Traumatologiczne Chirurgia Narządów Ruchu i Ortopedia Polska / Polish Orthopaedics and Traumatology bearing. 179

in

Fig. 11. projections; c,d) lateral Narzadow Ruchu Ortop. Pol., 82(5) 175-182 OPIS PRZYPADKU Fig. 11. Computed Computed tomography tomography of of left left angle angle after after injury, injury, a,b) a,b)Chir.AP AP projections; c,d)2017; lateral projections; e,f) projections. projections; e,f) oblique oblique projections. Mateusz Stolarz et al., Enhancement of bone fracture healing by ultrasound stimulation – 4 case reports

Fig. 12. Plain radiographradiograph of ankle 2 months after ankle injury, a) AP projection; b) Fig. 12. Fig. 12. Plain Plain radiograph of of ankle 2 2 months months lateral projection.

Fig. 13. Plain of 4 months Fig. 13. Plain of ankle 4 months after injury, a) AP b) Fig. 13.radiograph Plain radiograph radiograph of ankle ankle 4projection; months lateral projection.

Discussion Low-intensity pulsed ultrasound has been use in orthopedics and traumatology for less than two decades. In many scientific studies, the authors conclude their effectiveness in promoting treatment with moderate or considerable enthusiasm [6, 16-19, 21]. It is worth noting that there are authors who do not recommend using LIPUS [20, 22]. In the first medical case, there was no union after fracture and operative treatment of the clavicle. Despite the young age, lack of chronic diseases and relatively high healing potential, after eight months there was no progressive bone adhesion. This was confirmed by chronic pain, increasing with the movements of the limb and local palpation. Surgical treatment of clavicular fracture, both with plate reconstruction [23], and intramedullary nail [24], decreases healing time and reduces complications. Total treatment time lasts on average 4 months, which is usually radiologically verified [25]. In the absence of union in the presented patient, LIPUS was chosen as an alternative therapy. As in one article [26] which depicts support for clavicular fracture healing after conservative treatment, a satisfactory union and complete elimination of pain was achieved. The complete healing was radiologically confirmed within a month and a half after LIPUS treatment.

In the second case, the patient presented with a stable fixation with an intramedullary nail. Six months after the surgery, the patient felt persistent pain, and could not bear full weight on the limb. The radiographs showed at the edges of bone fragments no progressive bone healing. Due to the incomplete anatomical fixation, as well as a persistent fracture gap in radiological images, it was decided that revision surgery would be performed. The use of an additional fixing plate or a larger diameter intramedullary nail was considered. In the first case the patient would have had a large amount of foreign bodies implanted; in the second case, the fracture gapa)would have been refreshed and the projection. removal of after injury, AP projection; b) lateral afterfibrous injury, a) AP projection; b) lateral projection. tissue would have been difficult. Finally, a single stage operation was performed – the fixation nail was removed and then using the open technique, existing fibrous scar was resected. The reconstruction plate and allogeneic bone grafts were implanted. The operation, as well as the postoperative recovery were without complications, with the wound healing well. In spite of this, the patient was not healing properly. In subsequent visits 1, 3 and 5 months after surgery, the pain was reduced but not to a satisfactory level. Sequentially performed X-rays showed bone graft resorption, but a properly progressive union in the place of the fracture gap could not beinjury, seen. After discussing the possibility of furtherprojection. treatment after a) AP projection; b) lateral afterwith injury, a) AP projection; b) lateral projection. the patient, LIPUS was decided upon. The Exogen system was used for a month, then two months later, a control radiograph was performed (Fig. 6). Radiologically visualized, progressive union of the bone, in particular on the AP projections, was seen. The patient reported pain regression. Subsequent control studies showed a satisfactory union. Ultrasound LIPUS was repeatedly used to stimulate healing of nonunion or delay in the union of the post fracture femoral bone [27, 28]. Authors of the cited publications, as in this case, have used LIPUS for stable fractures with no union, achieving positive results. In this patient, the lack of union after revision surgery was a disturbing symptom. In this and other similar cases, the spectrum of treatment methods is decreasing. In our opinion, the use of ultrasound encouraged the initiation of union at the fracture site. The final effect of the treatment was satisfactory. The advantage of this method is its noninvasive character and that in instances in which it is ineffective, it does not interfere with other treatment methods. The third case concerns a stress fracture of the tibia. This type of fracture is a result of chronic overloading of the skeleton over a given period of time, which prevents proper adaptation of the skeleton to this overload [29, 30]. Recovery time after stress fracture is approximately 12 weeks on average and can be extended up to 19 weeks [31]. Moreover, the risk of re-fracture is as high as 29% [32]. The process is based on conservative treatment, combined with several weeks of immobilisation followed by rehabilitation [31]. Treatment may be supported by physiotherapeutic procedures, such as electrical stimulation [33], shock wave therapy (ESWT) [9]


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or low intensity ultrasound (LIPUS) [34]. The literature presents conflicting studies on the effectiveness of work in the context of the LIPUS treatment of tibia fracture. Some authors in randomized trials have demonstrated that there is no significant reduction in healing time with LIPUS compared to placebo [22], Other authors point to significant acceleration of healing [34]. In the present case the healing process proceeded correctly. Recovery and the return to daily activities lasted 11 weeks, which is a good result, slightly below average. It is difficult to assess whether the use of ultrasound in this case significantly affected the healing process, but certainly the convalescence process was not disturbed and no complications were reported. Ipsilateral fractures of the talus and calcaneus bones are relatively rare and occur in 1% of fractures of the calcaneus and 6% of fractures of the talus [35]. The treatment is still controversial with a lack of generally accepted standards [35-38]. Usually surgical treatment is chosen to reconstruct broken bones or arthrodesis.In rare instances, lower leg/ shin limb amputation is deemed necessary [35, 38, 39]. Conservative treatment, involving immobilisation is least used, only in selected cases [39]. In the fourth case, the patient suffered a fracture of the talus, type 1 by Hawkins and fractures of the calcaneus with preservation of the Bohler angle. Surgery to fixate the fracture was recommended, but the patient did not consent. Due to the fact that the fractures were not significantly displaced, immobilisation, rehabilitation and healing using LIPUS were used. Two months after the injury, the result of the treatment was successful. The control X-ray (Fig. 12) illustrated the progressive union of the bone, along with significant reduction in pain. After 4 months the patient was fully active and returned to pre-injury daily activities. In similar cases the healing and convalescence process lasted from 3 to 20 months [39]. In the absence of prolonged healing and other complications, given the relatively short recovery time, it can be concluded that the use of LIPUS was valuable and effective in the present case. In the cases discussed above, the use of LIPUS bone healing augmentation system was effective in the treatment of union failure or prolonged bone union. Exogen system was used for stable lesions that did not show progressive bone healing. The presented cases are evidence of the effectiveness of acting in accordance with the indications [14, 16, 17]. In the case of healing these fresh fractures, evaluation of the effectiveness of healing is difficult. The course of treatment and recovery was normal. It is not known whether treatment without LIPUS would be similar. In conclusion, the use of low-frequency ultrasound is a positive and safe method to promote the healing of bone. It is worth considering its use, especially in the absence of bone adhesion, as an alternative to surgical treatment. The presented group of cases is small and heterogeneous, but the hypothesis has been confirmed as in many published studies.

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