Arthroscopic Treatment of Calcific Tendinitis

Stephen C. Weber, M.D.

I. Historical Review.

Common problem since reported by Codman and others in the 1930’s (6) affecting up to 10% of individuals (20). It can often be asymptotic (5), but usually presents with relatively abrupt onset as an acute inflammatory process with severe pain (6,12,14,17,18). While some get better spontaneously (12), many will require treatment. Heat, nonsteroidal medication, and gentle range of motion provide the mainstays of treatment, but other options are available.

A. Injection of corticosteroid. Reported effective by virtually all authors

B. Needle aspiration. Described by many authors (10,14,16,17,18,23,24). Can be successful, but often very painful. Fluoroscopic control can be helpful (4,7,16) in identifying the deposit, but does not decrease pain. In my experience, few “happy customers” with this technique due to pain.

C. Acetic acid iontophoresis. Published widely in the physical therapy literature (19). Anecdotal short term results reported to be good, but hard to correlate with the basic science of iontophoresis showing penetration of most substances is marginal.

D. Treatment described using lithotripsy. Most experience in Europe. Reports by Loew, et. al. (11) described treatment with few side effects, other than subcutaneous hematoma. Success was not universal, with 8 of 20 showing no change in calcifi-cation, and an improvement of only 30% in the mean Constant scores (11). No damage to soft tissue or osseous structures was noted.

E. Open removal described since the 1930’s.

1. some with acromioplasty (15,20)

2. some without (14,17)

3. all retrospective small studies show good results, but Neer’s advice perhaps the most honest. Recovery is “longer that expected” and patients are warned of a “lengthy exercise program following surgery” (14). It was Neer’s feeling that acromioplasty was not indicated in the treatment of calcific tendonitis..

4. Uhthoff and Loehr (23) recently reviewed arthroscopic and open treatment feeling that they were equivalent, again recommending failure of conservative management first. Wittenberg et. al. (26) also found outcomes equivalent, but improvement in cosmesis with a trend to improvement in pain and function with arthroscopic treatment..

F. Acromioplasty without calcium removal. Some studies showed poor result without excision. Columbia group (2) showed no correlation with amount or completeness of calcium removal and outcome.

G. Arthroscopic Removal

I. Dr. ElIman first described arthroscopic excision in 1987 as an anecdotal treatment in five patients in his first report on arthroscopic acromioplasty (8). Technique involved blind needle aspiration to locate deposit, followed by excision, followed by acromioplasty.

2. Other reports followed by the Columbia group (1), Zarins (18) Snyder et. al. (22) and others. Acromioplasty issue not resolved as some studies recommended acromioplasty, while others did not.

3. Blind arthroscopic needling still difficult. Weber (25) presented augmentation of technique previously described by Ellman with the addition of fluoroscopic control using intraoperative image intensification, as had been previously described to assist in needling under local. First series in which all deposits were identified at surgery and resolved radiographically at final follow-up.

4. American Multi-Center study presented at the 5th International Conference on Surgery of the Shoulder in 1992 by Dr. Ellman. Included results of Esch, ElIman, Bigliani, Flatow, Oglivie-Harris, Weber, and Snyder in the American group (9). European Multi-Center experience presented by Moke-Nancy and Walch et. al.(13).

 

American       European

cases                                                  131                 275
age                                                     45.8                46.8
duration of symptoms (months)       29.5                43.4
preoperative injections                     2.7                   5.28
size of calcification (mm2)              115                 119
calcium not found @ surgery           18.6                16
acromioplasty (%)                            74                    74
release of CA ligament                    7.6%               12%
constant score, unaffected              91.3                85.4
extremity
constant score, affected                   85.3                83.6
extremity p op
results with acromioplasty               85.3                86.7

5. No complications found in either group. Did not compare open excision, but little reason to support it given the excellent results of arthroscopic treatment. Dr. Eliman suggested that based on this data unless obvious radiographic or arthroscopic evidence of impingement was evident, acromioplasty could be omitted. However, there was a 10% reoperation rate in the group in which acromioplasty was omitted. Associated rotator cuff tears in 4%.

II. Current treatment decisions

A. Conservative management still the treatment of choice. Uhthoff and Loehr (23) noted distinct phases of development, with formative and resorptive phases, recommendinginjection of corticosteroid in the formative and needle aspiration in the resorptive phases. The number of injections and duration of conservative management in the Combined series should be noted

B. Acromioplasty without removal. Some patients in the Combined series did show improvement with acromioplasty alone, but more recent work suggests this is to be avoided, if possible.

C. Acromioplasty with removal. Still up for debate, as no comparative studies are available. Combined series suggest that this is generally unnecessary, but reoperation to pefform an acromioplasty will be required in 10% if not concomitantly performed. Dr. Ellman’s recommendation to perform only with evidence of impingement as good as any. In addition, I would recommend excluding patients with multidirectional instability from acromioplasties, limiting their surgery to simple removal of the deposit. Another perspective is that acromioplasty did not adversely affect outcome either.

D. Management of resultant cuff defect. While most recommend leaving the defect, including the Combined Study, trouble with failure of the defect to heal or progression to a complete rotator cuff tear has been present in my experience, and other authors have suggested closure of the defect (23) at least as an open procedure. There is no data, but placing simple sutures arthroscopically to close a large defect created by calcium removal may avoid problems later, with little increase in morbidity.

E. Localization with fluoroscopy. While it does increase the radiation risk for both patient and surgeon, the time averages only 2 minutes. The only surgeon in the Combined Series who always identified the calcium at surgery was the subset of my patients using fluoroscopic control. Removing the deposit clearly improves the predictability of the procedure; the 18% failure to identify the deposit at surgery in both the European and American experience bears remembering.

REFERENCES

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