Although he acknowledges the study's success, he suggests that shock wave treatment is rather intensive. "There were four extracorporeal shock wave therapy treatments over four weeks, each requiring the use of regional anesthesia," he notes. "All fractured limbs were immobilized for six to twelve weeks and, if the nonunion was in a lower extremity, a long leg cast was applied. Many surgeons would argue, and at least some patients would agree, that this intensive treatment program should not be considered 'conservative'."

Another fact to consider for a future study was the difference in enrollment rates for those with hypertrophic nonunions and atrophic ones. Hypertrophic breaks, although non-healing, have calluses, and are vascular enough for new bone growth, while atrophic fractures usually feature some sort of blood supply impairment, and often require grafts to heal. Drop out among atrophic patients in the study was high: 32 percent quit before therapy was over, compared with only 4 percent in the hypertrophic group.

Nonetheless, Dr. Marsh finds the results largely encouraging. "Despite these disadvantages, for selected patients with a nonunion, a nonoperative treatment option that results in similar healing time, faster return to function, and quicker relief of pain than what can be expected after surgery would be a welcome addition," he writes.

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