**Author details**

Carlos Vinícius Buarque de Gusmão1\*, José Marcos Alves2 and William Dias Belangero1

\*Address all correspondence to: vigusmao@yahoo.com

1 Department of Orthopedics and Traumatology, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil

2 Department of Electrical Engineering, College of Engineering og São Carlos, University of São Paulo (USP), São Carlos, São Paulo, Brazil

## **References**

histological analysis revealed increased number of chondrocytes in the proliferative zone and increased thickness of the epiphyseal plaque, suggesting a possible role for growth stimulation. No studies were found for LIPUS that could suggest a possible role for growth stimulation in

Patients who develop avascular necrosis of the femoral head experience groin pain and disability, and further may necessitate joint replacement. A novel possible approach for initial stages of that condition, when bone collapse and osteoarthritis have not established yet, is acoustic therapy. Experimental studies with avascular necrosis of the femoral head models showed that LIPUS and electrohydraulic ESWT increase neovascularization, osteogenesis, osteogenic differentiation of bone marrow cells, decreased size of fat cells—which substitute dead bone—and biomechanical strength of bone. Increased expression of proliferative factors, such as BMP-2, FGF, IGF-1, NO and VEGF, was also found. Furthermore, a clinical and an experimental research revealed that electrohydraulic ESWT may be more effective than core decompression and non-vascularized fibular grafting in patients with early-stage disease; reverts osteonecrosis by one stage; decelerates, or stops, disease' progression; and decreases

Undoubtedly, acoustic devices are useful tools to stimulate osteogenesis. Nevertheless, there is a wide list of topics that require further investigations: physical phenomena elicited by acoustic forces need to be proved in vivo, signalling molecules need to be assigned to specific signalling pathways, the control of cellular response to acoustic loads needs to be clarified, RPWT and piezoelectric ESWT influence on bone biology lack investigations, clinical protocols for ESWT and RPWT should be established and, finally, randomized controlled trials address‐ ing acoustic therapy should be performed. As a conclusion, a lot of research is expected within the next years to clarify the unanswered questions about the relationship of bone tissue and

1 Department of Orthopedics and Traumatology, State University of Campinas (UNICAMP),

2 Department of Electrical Engineering, College of Engineering og São Carlos, University of

and William Dias Belangero1

skeletally immature individuals [96, 97].

50 Advanced Techniques in Bone Regeneration

*6.3.4. Avascular necrosis of the femoral head*

pain and functional disability [10, 38, 149, 159, 160].

Carlos Vinícius Buarque de Gusmão1\*, José Marcos Alves2

\*Address all correspondence to: vigusmao@yahoo.com

São Paulo (USP), São Carlos, São Paulo, Brazil

**7. Future directions**

acoustic forces.

**Author details**

Campinas, São Paulo, Brazil


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