The intraoperative use of ultrasound facilitates significantly the arthroscopic debridement of calcific rotator cuff tendinitis

Could intraoperative ultrasound improve clinical and radiological outcomes during arthroscopic calcification evacuation of rotator cuff?

Background

Martinel et al described an intraoperative ultrasound technique to easier identify calcification (CA) under arthroscopy. Our hypothesis was that intraoperative ultrasound monitoring allowed better evacuation of calcific tendinopathy. Our aim was to determine whether ultrasound monitoring improved the short-term clinical and radiological outcomes of calcific tendinopathy.

Methods

A prospective, single-center, single-operator, consecutive study conducted between February 2020 and June 2023. The inclusion criterion was surgical treatment for evacuation of symptomatic macro-centimetric CA type A or B. The first 20 patients were operated on using the standard surgical technique and the next 20 under ultrasound control. The mean age at surgery was 49.8 years (minimum: 28 years; maximum: 64 years). Patients were reviewed at 6 weeks and 3 months. The evacuation of the CA was checked at 6 weeks by X-ray.

Results

In the standard technique group, the mean preoperative Constant score was 41.4/100 (±15.07). Postoperatively, the Constant score was 58.88/100 (±15.28) at 6 weeks and 69.16/100 (±13.86) at 3 months. The mean preoperative Subjective Shoulder Value (SSV) was 39.0% (±18.61). Postoperatively, the SSV was 64.0% (±17.21) at 6 weeks and 79.47% (±16.06) at 3 months. In the ultrasound control group, the preoperative Constant score was 44.48/100 (±14.28) and 58.18/100 (±15.64) at 6 weeks and 66.87/100 (±18.45) at 3 months postoperatively. The mean preoperative SSV was 40.0% (±16.54) and 61.75% (±18.59) at 6 weeks and 76.05% (±19.62) at 3 months postoperatively. There was no significant postoperative difference in Constant score (P = .732) or SSV (P = .566) between the 2 groups. There was a significant difference (P = .004) between the 2 groups in terms of complete evacuation of the CA with the standard technique in 65% of cases (13 patients out of 20) and with intraoperative ultrasound monitoring in 95% of cases (19 patients out of 20).

Conclusion

There was no significant postoperative difference in Constant score and SSV between the 2 groups in the short term. Evacuation of calcification was significantly better with ultrasound monitoring.

Intraoperative checking of the first ray rotation and sesamoid position through sonographic assistance

INTRODUCTION

Hallux valgus (HV) deformity affects the orientation of the metatarsophalangeal (MTP) joint in three planes. Displacement in the coronal plane results in axial rotation of the first metatarsal, with progressive subluxation of the first MTP joint. Multiple techniques have been described to correct the malrotation itself. However, none of them have checked intraoperatively the final position of the first metatarsal head and sesamoids previous to the fixation of the Lapidus procedure or first metatarsal bone osteotomies. The aim of this article is to describe a novel technique to check the first ray rotation and sesamoids position through sonographic assistance.

MATERIALS AND METHODS

Before fixation of the Lapidus procedure, with the ankle in maximal dorsiflexion, the surgeon takes the linear ultrasound probe and places it on the sole to visualize the sesamoids, which should be viewed at the same level, with the flexor hallucis longus (FHL) centered between both. Once the ideal position of the head of the first ray has been achieved, temporary fixation with K-wires is performed over the first TMT joint and M1-M2 joint for further sonographic verification of the sesamoids beneath the first metatarsal head. The height of the sesamoids relative to the second metatarsal head should be checked by sonographic control too.

RESULTS

Four patients were included. Three females and one male. Their mean age was 76.4 years (R 61-72). Their mean BMI was 29 (R 27.5-32.24). The mean IMA (intermetatarsal angle) was 18.2 (R 17.2-19) degrees and the mean MPA (metatarsophalangeal angle) was 50 (R 36-63) degrees.

CONCLUSIONS

Sonographic assistance, is a widely available, inexpensive, and comparative imaging technique that can guide the first ray rotation and sesamoids position in HV surgery, theoretically improving radiological outcomes.

Arthroscopic treatment and subacromial decompression of calcific tendinitis without removal of the calcific deposit results in rapid resolution of symptoms and excellent clinical outcomes in commercial airline pilots and cabin crew

PURPOSE

The purpose of this study was to report the results of subacromial arthroscopic decompression (SAD) without removal of the calcific deposits in patients with calcifying tendinitis.

METHODS

All patients between 2016 and 2019 were included if they were aged between 18 and 60 years and had an isolated calcific deposit. The Constant-Murley score (CMS), Disabilities of the Arm, Shoulder and Hand (Quick DASH) score, the Shoulder Pain and Disability Index (SPADI), the simple shoulder test (SST), and the single assessment numeric evaluation (SANE) were used for assessment. Time to return to work was recorded.

RESULTS

24 patients (13 pilots, 11 cabin crew) with a mean age of 47.1 ± 7.8 years were included. Quick Dash improved from 68.8 preoperative, to 8.4 at 3 months, and 0.1 at 24 months. CMS improved from 37.4 preoperative, to 83 at 3 months, and 94 at 24 months. SPADI improved from 73.8 preoperative, to 5.4 at 3 months, and 1 at 24 months. SST improved from 22.5 preoperative, to 94.2 at 3 months, and 100 at 24 months. SANE improved from 33.5 preoperative, to 78.7 at 3 months, and 95.6 at 24 months. MCID, SCB, and PASS reached values above 83% at 3 months and 100% at 6 months, with the exception of SANE which reached 29% at 3 months and plateaued to 96% at 6 months. The mean time to return to work was 7.1 ± 2.1 weeks. Pilots returned at a mean of 6.9 ± 1.8 weeks; cabin crew returned to work at a mean of 7.8 ± 2.5 weeks.

CONCLUSIONS

The results of this study suggest excellent short- and mid-term clinical outcomes can be achieved in patients with calcific tendinitis undergoing arthroscopic debridement and subacromial decompression without removal of calcific deposits. In this patient population, early surgical intervention was a potentially viable alternative to nonoperative treatment, and allowed early return to work.

Clinical evaluation and management of calcific tendinopathy: an evidence-based review

Calcific tendinopathy (CT) is an important musculoskeletal condition most commonly seen in the shoulder girdle, accounting for 10-42% of all shoulder pain. Despite the high prevalence within the shoulder region, CT has been demonstrated in many tendons throughout the axial and appendicular skeleton. Unlike degenerative tendinopathies, CT appears to be a self-limiting condition that affects otherwise-healthy tendon with deposition of calcium hydroxyapatite crystals between healthy tenocytes. In patients with functionally limiting symptoms or pain, the clinical course may be accelerated through a multitude of treatments including physical therapy and pain management, extracorporeal shock wave therapy, ultrasound-guided percutaneous lavage (UGPL), and operative debridement. Currently, the most efficacious and frequently utilized treatment for shoulder CT is UGPL due to its ability to effectively reduce calcium burden and pain while limiting soft-tissue damage. However, more evidence regarding the treatment and course of CT is needed before determining the most appropriate treatment at all potential sites of CT.

Arthroscopic Ultrasound-Guided Needling: An Effective Technique for the Treatment of Calcific Rotator Cuff Tendinopathy

Calcifying tendinopathies of the rotator cuff that do not respond to conservative treatment may require arthroscopic removal. Intraoperative localization of calcifications can be difficult and is usually performed by bursal needle probing. We present a surgical technique combining arthroscopy and intraoperative ultrasonography based on the ultrasound-guided needle technique to precisely and rapidly locate even small calcium deposits. The modalities may differ depending on tendon topography. This nonirradiating technique with this compact device should be more widely used.

Does intraoperative ultrasound help the surgeon in arthroscopic excision of rotator cuff tendon calcifications ?

PURPOSE

Arthroscopic excision of rotator cuff tendon calcifications is a common procedure in cases where medical treatment has failed. The objective of this study was to evaluate how intraoperative ultrasound contributes to improving the interventional procedure. Our hypothesis was that through the use of ultrasonography the frequency of postoperative residual calcium deposits could be reduced without increasing operating time.

METHODS

In a non-randomized single-operator comparative study, 56 patients who underwent arthroscopic excision of calcification were retrospectively included: group 1 (n = 20) without ultrasound guidance and group 2 (n = 36) with guidance. Operating time was measured and localization failures noted. Radiological follow-up was carried out with x-ray images at conventional angles and ultrasound at 1.5, 3 and 6 months postoperatively. Clinical follow-up was based on the Constant score (CS) at 6 months.

RESULTS

The mean operating time was 18 min in group 1 (9-33 ± 8.1) and 22 min in group 2 (10-48 ± 7.7) (p = 0.03). The rate of failure to identify calcifications was 8% and 2% in groups 1 and 2, respectively (p = 0.22). At 6 months, four calcifications were still visible on radiography in group 1 vs 1 in group 2 (20% vs 2.7%, p = 0.03). The mean CS increased from 35 to 81 points in group 1 (p < 0.001) and from 34 to 82 points in group 2 (p < 0.001).

CONCLUSION

Despite an increase in operating time, intraoperative ultrasound improves the process of excising rotator cuff intratendinous calcifications, prevents localization failures and enables a more complete extraction.

Calcific tendinopathy of the rotator cuff: a review of operative versus nonoperative management

Calcific tendinopathy of the shoulder involves calcification and degeneration of the rotator cuff tendon near its insertion point on the greater tuberosity. The purpose of this review is to analyze recent literature evaluating the clinical outcomes of non-operative and operative treatment for calcific tendinopathy of the shoulder. Conservative management, extracorporeal shockwave therapy (ESWT), ultrasound-guided percutaneous irrigation of calcific tendinopathy (US-PICT), and surgical intervention will be reviewed.

Pilot randomized controlled trials in the orthopaedic surgery literature: a systematic review

BACKGROUND

The primary objective of this systematic review is to examine the characteristics of pilot randomized controlled trials (RCTs) in the orthopaedic surgery literature, including the proportion framed as feasibility trials and those that lead to definitive RCTs. This review aim to answer the question of whether pilot RCTs lead to definitive RCTs, whilst investigating the quality, feasibility and overall publication trends of orthopaedic pilot trials.

METHODS

Pilot RCTs in the orthopaedic literature were identified from three electronic databases (EMBASE, MEDLINE, and Pubmed) searched from database inception to January 2018. Search criteria included the evaluation of at least one orthopaedic surgical intervention, research on humans, and publication in English. Two reviewers independently screened the pool of pilot trials, and conducted a search for corresponding definitive trials. Screened pilot RCTs were assessed for feasibility outcomes related to efficiency, cost, and/or timeliness of a large-scale clinical trial involving a surgical intervention. The quality of the pilot and definitive trials were assessed using the Checklist to Evaluate a Report of a Non-Pharmacological Trial (CLEAR NPT).

RESULTS

The initial search for pilot RCTs yielded 3857 titles, of which 49 articles were relevant for this review. 73.5% (36/49) of the orthopaedic pilot RCTs were framed as feasibility trials. Of these, 5 corresponding definitive trials (10.2%) were found, of which four were published and one ongoing. Based on author responses, the lack of a definitive RCT following the pilot trial was attributed to a lack of funding, inadequacies in recruitment, and belief that the pilot RCT sufficiently answered the research question.

CONCLUSIONS

Based on this systematic review, most pilot RCTs were characterized as feasibility trials. However, the majority of published pilot RCTs did not lead to definitive trials. This discrepancy was mainly attributed to poor feasibility (e.g. poor recruitment) and lack of funding for an orthopaedic surgical definitive trial. In recent years this discrepancy may be due to researchers saving on time and cost by rolling their pilot patients into the definitive RCT rather than publish a separate pilot trial.

The Effectiveness of High-Energy Extracorporeal Shockwave Therapy Versus Ultrasound-Guided Needling Versus Arthroscopic Surgery in the Management of Chronic Calcific Rotator Cuff Tendinopathy: A Systematic Review

PURPOSE

The objectives of this comprehensive quantitative review of the treatment of calcific tendinopathy of the rotator cuff were to investigate if there is a sustainable positive effect on outcomes after treatment with high-energy extracorporeal shockwave therapy (ESWT) or ultrasound (US)-guided needling and to compare these results with those of treatment with arthroscopic surgery.

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to conduct this review. A systematic literature search was conducted in December 2014 to identify relevant clinical articles in peer-reviewed journals with at least 6 months' follow-up. Each article was scored using the Coleman Methodology Score. The primary endpoints were functional outcome and radiologic change in the size of the calcific deposit.

RESULTS

Twenty-two studies were included (1,258 shoulders). The mean Coleman Methodology Score for the included studies was 77.1 ± 9.1. Overall, good to excellent clinical outcomes were achieved after treatment with either high-energy ESWT, US-guided needling, or arthroscopic surgery, with an improvement in the Constant-Murley score ranging between 26.3 and 41.5 points after 1 year. No severe side effects or long-term complications were encountered.

CONCLUSIONS

Patients can achieve good to excellent clinical outcomes after high-energy ESWT, US-guided needling, and arthroscopy for calcific tendinopathy of the shoulder. Side effects and post-treatment complications should be taken into account when a decision is being made for each individual patient. Physicians should consider high-energy ESWT and US-guided needling as minimally invasive treatment options when primary conservative treatment fails. Arthroscopy can safely be used as a very effective but more invasive secondary option, although the extent of deposit removal and the additional benefit of subacromial decompression remain unclear.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I, II, and IV studies.

Ultrasound imaging-guided percutaneous treatment of rotator cuff calcific tendinitis: success in short-term outcome

OBJECTIVE

Rotator cuff calcific tendinitis (RCCT) is a common cause of shoulder pain in adults and typically presents as activity-related shoulder pain. Between non-surgical and surgical treatment options, today a few minimal invasive techniques are available to remove the calcific deposit, and they represent a cornerstone in the management of this painful clinical condition. The aim of the work was a retrospective evaluation of double-needle ultrasound-guided percutaneous fragmentation and lavage (DNL), focused on understanding the factors which are of major importance in determining a quick and good response at 1 month.

METHODS

A series of 147 patients affected by RCCT and suitable for DNL were evaluated. A systematic review of anamnestic, clinical and imaging data was performed in 144 shoulders treated in a single-centre setting. Clinical reports and imaging examinations were revisited. The inclusion criteria were submission to DNL, therefore fitness for the percutaneous procedure, and following 1-month follow-up. There was no exclusion owing to risk of bias. The treatment was defined as successful for constant shoulder modified score (CSS) improvement of >50% at 1 month.

RESULTS

In 70% of shoulders, the treatment resulted in a quick and significant reduction of symptoms (successful). On the whole, CSS increase at 1 month was estimated at 91.5 ± 69.1%. CSS variations were significantly related to age of patients (better results between 30 and 40 years old), calcification size (more relevant improvement for middle-sized calcifications, 12-17 mm), sonographic and radiographic features of calcific deposits (softer calcifications) and thickening of subacromial/subdeltoid bursa walls. In the final model of stepwise regression for CSS variation, ultrasound score pre-treatment and post-treatment, the distance between bursa and calcification before treatment and the size of post-treatment calcification area were shown to be independently correlated to success. Numeric rating scale score for pain showed similar results. Pain at admission was also related to age, calcification size, ultrasound and Gärtner score, power Doppler positivity, bursal wall thickening and biceps tenosynovitis.

CONCLUSION

The success of the procedure with quick improvement in function and symptoms is warranted in soft and middle-sized calcifications, in young adults.

ADVANCES IN KNOWLEDGE

Ultrasound-guided percutaneous procedures for RCCT must be safe, effective and with prompt pain relief and function restoration. This study shows which clinical picture is more favourable to this purpose and actual prognostic factors for DNL (soft and middle-sized calcifications, in young adults, are more favourable).