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Arthroscopic Treatment of Calcific Tendonitis

Open AccessPublished:March 17, 2014DOI:https://doi.org/10.1016/j.eats.2013.11.003

      Abstract

      Calcific tendonitis, or calcifying tendonitis, is a common disorder characterized by the multifocal accumulation of basic calcium phosphate crystals within the rotator cuff tendons. In most cases, the multifocal calcifications are located 1 to 2 cm from the insertion of the supraspinatus tendon on the greater tuberosity. The initial treatment should be nonoperative including oral anti-inflammatory medication and physical therapy. If this is unsuccessful, arthroscopic debridement of the deposit is effective. The technique used is an arthroscopic localization and debridement without associated subacromial decompression. The rotator cuff should be evaluated for partial- and full-thickness tears before and after the debridement of calcifications. If a partial- or full-thickness rotator cuff tendon tear is identified, it should be treated in a fashion consistent with those without associated calcium deposits. In our hands, tears 5 mm or greater in depth are repaired using a tendon-to-tendon or tendon-to-bone technique. Tears with less depth are debrided and then left alone. Arthroscopic debridement of calcific tendonitis can yield excellent functional results and high patient satisfaction.

      Technique Video

      See video under supplementary data.

      Calcific tendonitis, or calcifying tendonitis, is a common disorder characterized by the multifocal accumulation of basic calcium phosphate crystals within the rotator cuff tendons. In most cases, the multifocal calcifications are located 1 to 2 cm from the insertion of the supraspinatus tendon on the greater tuberosity. Gärtner and Heyer
      • Gärtner J.
      • Heyer A.
      Calcific tendinitis of the shoulder.
      analyzed calcific deposits and found that they consist of hydroxyapatite crystals (Ca10[PO4]6[OH]2). Various etiologies including tendon hypoxia, genetics, or an endocrine disorder have been proposed; however, a conclusive etiology is not yet indentified.
      This reactive calcification is cell mediated and believed to occur in 3 distinct stages: precalcific, calcific, and postcalcific. During the precalcific stage, the tendon undergoes fibrocartilaginous transformation with metaplasia of tenocytes into chondrocytes. Areas of generally avascular fibrocartilaginous metaplasia are present. The calcific stage is broken down further into a formative phase (during which calcium crystals are deposited in matrix vesicles that coalesce to form large deposits), a resting phase (during which calcium deposition ceases), and a resorptive phase (during which spontaneous resorption of the calcium deposit occurs). The greatest pain is believed to be experienced during the resorptive phase.
      The initial treatment should be nonoperative including oral anti-inflammatory medication and physical therapy. The injection of corticosteroids may be temporarily helpful. In unresponsive cases or in patients who experience significant worsening of their symptoms, arthroscopic debridement provides excellent results.
      • Ark J.W.
      • Flock T.J.
      • Flatow E.L.
      • et al.
      Arthroscopic treatment of calcific tendinitis of the shoulder.
      • Seil R.
      • Litzenburger H.
      • Kohn D.
      • et al.
      Arthroscopic treatment of chronically painful calcifying tendinitis of the supraspinatus tendon.
      A subacromial decompression is not considered by some authors to be an appropriate accompanying procedure,
      • Tillander B.M.
      • Norlin R.O.
      Change of calcifications after arthroscopic subacromial decompression.
      • Marder R.A.
      • Heiden E.A.
      • Kim S.
      Calcific tendonitis of the shoulder: is subacromial decompression in combination with removal of the calcific deposit beneficial?.
      although others report that an additional subacromial decompression seems to reduce postoperative pain.
      • Balke M.
      • Bielefeld R.
      • Schmidt C.
      • et al.
      Calcifying tendinitis of the shoulder: midterm results after arthroscopic treatment.
      The technique starts with a thorough arthroscopic inspection of the glenohumeral and bursal areas including both an articular and bursal evaluation of the rotator cuff, lancing the lesion with a large-bore needle, additional arthroscopic debridement as needed, and a repeat evaluation of the cuff. Any remaining calcium deposit or significant rotator cuff tearing should be addressed. An arthroscopic technique is illustrated in which a 14-gauge needle is used to identify the lesion, open it, and facilitate the evacuation of the calcium deposit.

      Surgical Technique

      Radiographs should be available at the time of surgery to facilitate the localization and assessment of the calcium deposition. Large lesions (Fig 1) can have multiple calcium deposits.
      Fig 1
      Fig 1Large calcific tendonitis lesions can have multiple calcium deposits (arrow) (anteroposterior view of right shoulder, lateral decubitus position). (© F. Alan Barber)
      With the patient under a general hypotensive anesthetic and using the lateral decubitus position, posterior and anterior viewing portals are established and a standard 15-point diagnostic examination of the glenohumeral joint is performed. Areas of increased vascularity in the rotator cuff are noted if present. These may be associated with the final phase of the calcific stage, which includes vascular proliferation at the margins of the lesion. Once the diagnostic glenohumeral arthroscopy is completed, the subacromial space is entered.
      In addition to the established anterior and posterior portals, a lateral portal is established slightly anterior to the lateral midline. An 8-point bursal examination is performed. A subacromial bursectomy is performed to ensure complete visualization of the rotator cuff tendon. This includes removal of the posterior bursal curtain. The rotator cuff is inspected for areas of swelling, neovascularity, or calcium deposits (Fig 2). If a calcium deposit is not readily apparent, a probe is used to palpate the tendon for inconsistencies in texture suggesting a hidden deposit. Once an area of calcification is located, a 14-gauge needle from an infusion catheter is used to puncture the lesion (Fig 3). This usually results in the release of the calcification. The released calcification can resemble either “toothpaste” or “chalk dust.” Using a probe or the needle, the lesion can be milked to express the rest of the calcium deposit from the area (Fig 4, Video 1). As the calcified material enters the subacromial space, the shaver suction is used to remove the debris.
      Fig 2
      Fig 2The rotator cuff tendon is inspected for areas of swelling, neovascularity, or calcium deposits (arrow) (arthroscopic view through posterior portal of left shoulder, lateral decubitus position, instrumentation through lateral portal). (© F. Alan Barber)
      Fig 3
      Fig 3A 14-gauge Jelco needle can be used to identify and release the area of calcification (arthroscopic view through posterior portal of left shoulder, lateral decubitus position, instrumentation through lateral portal). (© F. Alan Barber)
      Fig 4
      Fig 4Using a probe or the needle, the lesion can be milked to express the rest of the calcium out of the deposit (arthroscopic view through posterior portal of left shoulder, lateral decubitus position). (© F. Alan Barber)
      Sometimes removal of the calcific deposit creates a cavity in the rotator cuff tendon. This cavity should be inspected and any remaining calcium debrided. If a significant rotator cuff tendon disruption exists, a limited tendon repair may be required. A final inspection and palpation of the entire bursal surface of the rotator cuff tendon are then performed by externally and internally rotating the humerus and palpating the cuff with a probe. If none is found, the procedure is terminated and the patient treated with a sling for comfort followed by physical therapy. A summary of pearls and pitfalls is listed in Table 1.
      Table 1Pearls and Pitfalls
      • Patients present very much like someone with acute subacromial bursitis, rotator cuff tendonitis, or an impingement syndrome.
      • Closely review the plain radiographs for any evidence of a calcium deposit.
      • For needle localization during injection, fluoroscopy may be more helpful than ultrasound.
      • Locating the deposit may be a challenge. During an arthroscopic evaluation of the glenohumeral joint, mark any areas in the rotator cuff with increased vascularity using a spinal needle as a reference.
      • Avoid making deep cuts into the rotator cuff while exploring for deposits. A small residual deposit will not impair the clinical outcome.
      • Repair any significant defects in the rotator cuff tendon.
      • Most series have not shown acromioplasty to be of benefit in calcific tendonitis surgery.

      Discussion

      The cause of these rotator cuff calcifications is still unclear. Relative ischemia from hypovascularity in the “critical zone,” metabolic disturbances, and rotator cuff tendon degeneration are suggested etiologies. Although the different stages of the disease are well described, what triggers the metaplasia is not as yet identified. Hypoxia may be the primary factor, but this remains unclear.
      • Uhthoff H.K.
      • Sarkar K.
      • Maynard J.A.
      Calcifying tendinitis: a new concept of its pathogenesis.
      Calcific tendonitis can present as a single localized deposit, several separate deposits, or 1 large deposit with septations creating several compartments, each requiring release for complete evacuation. The guiding principle is to continue probing for deposits even after the satisfying release of a large deposit. Alternative treatments to surgery exist. A recent randomized controlled study looked at the effectiveness of ultrasound-guided corticosteroid injection in the subacromial bursa with and without ultrasound-guided needling and lavage of the calcific deposit.
      • de Witte P.B.
      • Selten J.W.
      • Navas A.
      • et al.
      Calcific tendinitis of the rotator cuff: a randomized controlled trial of ultrasound-guided needling and lavage versus subacromial corticosteroids.
      Although there was improvement in both groups at 1 year, the clinical and radiographic results were significantly better in the group receiving ultrasound-guided needling and lavage of the calcific deposit.
      It is unclear what the impact of a persistence calcific deposit postoperatively is on the clinical outcome. Most authors stress the importance of the complete removal of all calcific deposits. A strong correlation exists between the complete disappearance of these deposits and good outcomes.
      • Rompe J.D.
      Shock wave therapy for calcific tendinitis of the shoulder: a prospective clinical study with two-year follow-up.
      Some authors report that residual deposits result in lower postoperative Constant scores. Patients with complete or partial elimination of the calcific deposits report significantly better outcomes than those who had no radiographic improvement.
      • Jerosch J.
      • Strauss J.M.
      • Schmiel S.
      Arthroscopic treatment of calcific tendinitis of the shoulder.
      However, a recent study looked at a series of patients with calcific tendonitis whose resection was focused on preserving the integrity of the rotator cuff.
      • Maier D.
      • Jaeger M.
      • Izadpanah K.
      • et al.
      Rotator cuff preservation in arthroscopic treatment of calcific tendinitis.
      A complete deposit removal was achieved in 82 of 99 patients, and 17 of 99 had some minor residual calcium remaining. Preserving the integrity of the rotator cuff while removing as much of the calcium deposit as possible yielded good to excellent results in 90% of both groups of patients and avoided iatrogenic tendon defects. The minor residual deposits did not impair clinical outcomes and spontaneously resolved at follow-up.
      • Maier D.
      • Jaeger M.
      • Izadpanah K.
      • et al.
      Rotator cuff preservation in arthroscopic treatment of calcific tendinitis.
      In contrast, Tillander and Norlin
      • Tillander B.M.
      • Norlin R.O.
      Change of calcifications after arthroscopic subacromial decompression.
      reported 2 matched-pair groups with 25 patients each with and without radiographic calcium undergoing arthroscopic subacromial decompression while the calcium deposit was left untouched. At 2 years, radiographs showed the disappearance or decrease in size of the calcific deposits in 79%. On occasion, tuberosity osteolysis has been associated with calcific tendonitis. This is a distinctive form of calcific tendonitis and associated with significantly lower Constant scores.
      • Porcellini G.
      • Paladini P.
      • Campi F.
      • et al.
      Osteolytic lesion of greater tuberosity in calcific tendinitis of the shoulder.
      The potential for this procedure to create a significant rotator cuff tendon defect must be recognized. As a final step, a careful inspection of both the bursal and articular sides of the rotator cuff tendon should be made to determine if a significant tear exists. The decision whether or not to repair a residual defect in the rotator cuff tendon is based on the size of the defect. Maier et al.
      • Maier D.
      • Jaeger M.
      • Izadpanah K.
      • et al.
      Rotator cuff preservation in arthroscopic treatment of calcific tendinitis.
      reported that preserving the integrity of the rotator cuff during arthroscopic calcium deposit removal yielded good or excellent results in 90% of patients and avoided iatrogenic tendon defects in all patients. Minor rotator cuff tendon tears did not impair the clinical outcome at follow-up.
      Another study reported a higher rate of partial supraspinatus tendon tears than the contralateral control using ultrasound at a mean follow-up of 6 years after the procedure.
      • Balke M.
      • Bielefeld R.
      • Schmidt C.
      • et al.
      Calcifying tendinitis of the shoulder: midterm results after arthroscopic treatment.
      This raises the issue of whether repairing a significant tendon defect is worthwhile. Yoo et al.
      • Yoo J.C.
      • Park W.H.
      • Koh K.H.
      • et al.
      Arthroscopic treatment of chronic calcific tendinitis with complete removal and rotator cuff tendon repair.
      evaluated the clinical results after the complete removal of calcific deposits with or without repair of the rotator cuff tendon in 35 consecutive patients. They found that repair provided good clinical results and earlier pain relief.
      Arthroscopic debridement of calcific tendonitis can yield excellent functional results and high patient satisfaction. The rotator cuff should be evaluated for partial- and full-thickness tears before and after the debridement of calcifications. If a partial- or full-thickness rotator cuff tendon tear is identified, it should be treated in a fashion consistent with those without associated calcium deposits. In our hands, tears 5 mm or greater in depth are repaired using a tendon-to-tendon or tendon-to-bone technique. Tears with less depth are debrided and then left alone.

      Supplementary Data

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