Predictive factors for failure of conservative management in the treatment of calcific tendinitis of the shoulder

Comparing midterm clinical outcome of surgical versus ultrasound guided needle aspiration of the calcific deposits for therapy resistant calcifying tendinitis of the shoulder. A comparative cohort study

PURPOSE

Comparing the midterm clinical outcome of surgical treatment versus ultrasound guided needle aspiration of the calcific deposits (NACD) treatment for conservative therapy resistant calcifying tendinitis (CT) of the shoulder. The hypothesis is that both surgical treatment and NACD treatment led to a comparable good clinical outcome.

METHODS

A comparative cohort study was performed (n = 76). The allocation to surgical group (n = 35) or NACD group (n = 41) was the result of a shared decision-making strategy. Primary outcome was decrease in VAS for pain (pVAS). Secondary outcomes were EQ-5D index, DASH score, ASES, VAS for satisfaction, recommendation of treatment, adverse events, cross-over between groups, additional treatments, and symptomatology after care as usual.

RESULTS

At midterm follow-up (5.5 years, SD 0.5 years) decrease in pVAS did not differ (p = 0.20) between two groups (60.6 mm, SD 23.3 mm vs 53.4 mm, SD 24.2 mm). Secondary clinical outcomes were also comparable. In 68.3% surgical treatment was avoided. At final follow-up none of the outcome scores differed significantly between the crossed-over patients (n = 13, 31.7%) and the initial surgical group.

DISCUSSION

At midterm follow-up surgical and NACD treatment result in comparable clinical outcomes. In 68.3% a surgical treatment could be avoided. In 31.7% the patient eventually needed a surgical treatment after failed NACD treatment. After midterm follow-up these patients showed comparable good clinical outcomes. In our opinion, both NACD and surgical treatment could be considered as a next step treatment option for conservative therapy resistant CT of the shoulder. Though, one should be aware that after a midterm follow-up a high number of patients cross-over to surgical treatment after a NACD treatment.

[Calcific tendinitis]

CLINICAL ISSUE

Calcific tendinitis (TC) is a common-usually self-limiting-musculoskeletal disease, histopathologically characterized by both deposition and subsequent inflammatory breakdown of calcium crystals in tendons. The disease can cause acute, sometimes excruciating pain and restricted movement in the shoulder joint. Furthermore, 10-30% of patients have a complicated course of the disease.

STANDARD RADIOLOGICAL METHODS

Imaging-based assessment by X‑ray and ultrasound is required to establish the initial diagnosis and differential diagnosis as well as for follow-up.

METHODOLOGICAL INNOVATIONS

Magnetic resonance imaging (MRI) and, to a lesser degree, computed tomography (CT) complete the imaging work-up for establishing differential diagnoses and detecting complications.

PRACTICAL RECOMMENDATIONS

The combined evaluation of clinical symptoms and imaging findings is crucial to assess prognosis, plan therapy and detect potential complications. This article provides an overview of imaging-based morphology as related to the different stages of TC, relevant complications and potential pitfalls with respect to comorbidities and differential diagnoses.

Arthroscopic Surgery Versus Nonoperative Treatment for Calcific Tendinitis of the Shoulder: A Retrospective Cohort Study

BACKGROUND

Treatment options for calcific tendinitis (CT) of the shoulder remain controversial. A consensus for an operative indication for this condition is lacking.

PURPOSE

To compare nonoperative versus operative treatment for shoulder CT and analyze factors affecting the prognosis after treatment.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 180 patients diagnosed with symptomatic CT between January 2017 and September 2021 were evaluated in this retrospective cohort study. There were 103 patients treated nonoperatively at our institution, which included the use of nonsteroidal anti-inflammatory drugs, acupuncture, steroid injections, extracorporeal shock wave therapy, and ultrasound-guided needle aspiration/percutaneous irrigation. However, 77 patients were treated with arthroscopic surgery after 6 months of failed nonoperative treatment. The visual analog scale (VAS) for pain, the Constant-Murley score, and imaging were used to assess and evaluate outcomes. Descriptive data, functional outcomes, and imaging findings were compared between the operative and nonoperative groups before and after propensity score matching. Additionally, prognostic factors including calcium deposit size, tendon infiltration by calcium deposits, involvement of single or multiple tendons, and occurrence of rotator cuff tears were analyzed by comparing the groups to determine their effect on treatment options and recovery.

RESULTS

Magnetic resonance imaging showed that the supraspinatus tendon (66.7%) was most commonly involved, followed by the infraspinatus (42.8%) and subscapularis (21.1%) tendons. Tendon infiltration by calcium deposits was observed in 84.4% of the patients, and rotator cuff tears occurred in 30.0% of the patients. After propensity score matching, there was no significant difference in changes in the Constant-Murley score (48.1 ± 25.4 vs 49.0 ± 22.8, respectively; P = .950) and VAS score (4.9 ± 2.3 vs 4.5 ± 1.9, respectively; P = .860) between the operative and nonoperative groups at the final follow-up. However, for patients with shoulder CT and without rotator cuff tears, there was a significant difference in changes in the Constant-Murley score (52.93 ± 25.18 vs 42.13 ± 22.35, respectively; P = .012) and VAS score (5.21 ± 2.06 vs 3.81 ± 1.98, respectively; P < .001) between the operative and nonoperative groups, but the recovery time in the operative group was longer than that in the nonoperative group (86.92 ± 138.56 vs 30.42 ± 54.97 days, respectively; P = .016). The results also showed that calcium deposit size, involvement of multiple tendons, and tendon infiltration by calcium deposits did not affect the recovery time after treatment. The survival analysis showed that rotator cuff tears affected the complete recovery of shoulder function.

CONCLUSION

This study demonstrated no significant difference between nonoperative and operative treatment for patients with shoulder CT, on the whole. However, for patients with shoulder CT and without rotator cuff tears, the effect of operative treatment was better than that of nonoperative treatment; yet, operative treatment was shown to prolong the recovery time. Calcium deposit size, tendon infiltration by calcium deposits, and involvement of multiple tendons did not correlate with recovery time or the recovery of function. A rotator cuff tear was the only factor affecting the complete recovery of shoulder function.

Treatment of Calcific Tendonitis of the Rotator Cuff: An Updated Review

Rotator cuff calcific tendonitis (RCCT) is a disorder that can greatly impair patients' quality of life. A literature review was conducted to find the most effective and newest treatments for RCCT. PubMed and Cochrane Review databases were searched, without strict inclusion/exclusion criteria, for peer-reviewed articles between 1941 and 2021 that discussed RCCT etiology and treatments. If nonoperative measures (non-steroidal anti-inflammatory drugs, physical therapy, and corticosteroids) are unsuccessful, other options include extracorporeal shockwave therapy, ultrasound-guided injection techniques, and minimally invasive surgery. Because RCCT can resolve spontaneously, patients should progress to invasive options only if conservative first-line treatments have failed. [Orthopedics. 2023;46(6):e326-e332.].

Comparison of clinical and radiological outcomes after three different surgical treatments for resistant calcifying tendinitis of the shoulder: a short-term randomized controlled trial

Background

A preferable surgical treatment for patients with conservative therapy-resistant calcifying tendinitis of the shoulder is still a matter of debate. Therefore, the purpose of this study was to evaluate and compare short-term clinical and radiological results of three surgical treatment options for these patients.

Methods

A multicenter randomized trial was conducted. Sixty-nine patients were randomly assigned to receive 1. subacromial decompression (Group SAD), 2. debridement of calcifications (Group D), or 3. debridement of calcifications with SAD (Group D + SAD). Stringent inclusion and exclusion criteria were used. The primary outcome was an improvement in VAS for pain (pVAS) 6 months postoperatively. Secondary outcomes were an improvement in pVAS 6 weeks postoperatively, functional outcomes (CMS, DASH, ASES), radiological outcome, additional treatments, and complications.

Results

The improvement in pVAS was significant in all groups (p < 0.001) and did not differ between the groups after 6 months. Six weeks postoperatively, the improvement in pVAS was significantly (p = 0.03) less in Group SAD compared to Group D + SAD (16.5 mm, SD 19.3 mm vs 33.1 mm, SD 19.7 mm, respectively). The mean size of calcifications decreased significantly in all groups (p < 0.0001). In Group SAD, the size of the calcifications decreased less (p = 0.04) compared to Group D and Group D + SAD after 6 weeks. Group SAD received more additional treatments (p = 0.003) compared to Group D + SAD (9 vs 1), which were mainly subacromial cortisone injections.

Conclusions

All patient groups showed significant pain relief and an improvement in shoulder function 6 months after surgery. However, patients in Group SAD showed inferior pain relief and less improvement in DASH score after 6 weeks. Furthermore, this group required more postoperative additional treatments. No significant differences in clinical and radiological outcomes were observed between patients in Group D compared to Group D + SAD. Therefore, an arthroscopic debridement without subacromial decompression seems to be advisable for patients with therapy-resistant calcifying tendinitis of the shoulder.

Level of evidence 2, Open-Label Randomized Clinical Trial.

IRB METC Zuyderland MC. Number: 14-T-112.

Registered at trialregister.nl NL 4947.

Intraosseous calcific tendinitis of the rotator cuff yields similar outcomes to those of intratendinous lesions despite worse preoperative scores

PURPOSE

To evaluate the surgical outcomes of arthroscopic removal of intraosseous deposits in patients with intraosseous calcific tendinitis of the rotator cuff.

METHODS

This study involved a retrospective review of 96 patients operated on from 2004 to 2019. Patients were divided into two groups according to the location of calcific deposits. Group I had pure tendinous involvement (n = 71), and Group II had tendinous and intraosseous involvement (n = 25). The mean follow-up time was 6.4 ± 3.9 years. There were 71 patients (46 women, 25 men) in Group I, and the mean age was 49.3 ± 8.2 years (range 30-65 years). In group II, there were 25 patients (18 women, 7 men); the mean age was 47.3 ± 11.2 years (range 28-70 years).

RESULTS

The mean preoperative VAS pain score was 8.8 ± 1.4 in Group I compared to 9.5 ± 0.5 in group II (p = 0.017). The median preoperative Constant and Oxford scores were 42 (20-65) and 22 (8-34) in Group I and 25.5 (22-46) and 10 (8-16) in group II, respectively (p < 0.001). There was no difference in postoperative pain scores (Group I: 0.7 ± 1.6 and group II: 0.5 ± 0.6, p = 0.926), Constant scores [Group I: 100 (80-100) and group II: 100 (90-100), (n.s).] and Oxford scores [Group I: 48 (28-48) and group II: 46.5 (4-48), (n.s.)] between the two groups. The number of preoperative injections was higher in Group II (p = 0.05). There was no correlation between the size of the soft tissue calcific deposit and the preoperative pain, Constant, and Oxford scores (n.s.).

CONCLUSION

Arthroscopic debridement of calcific tendinitis with intraosseous involvement is a safe and effective treatment method similar to that of pure tendinous involvement.

LEVEL OF EVIDENCE

III.