Percutaneous ultrasound-guided treatment of shoulder tendon calcifications: Clinical and radiological follow-up at 6 months()

Ultrasound guided lavage with corticosteroid injection versus sham lavage with and without corticosteroid injection for calcific tendinopathy of shoulder: randomised double blinded multi-arm study

OBJECTIVE

To compare treatment effects between ultrasound guided lavage with corticosteroid injection and sham lavage with and without corticosteroid injection in patients with calcific tendinopathy of the shoulder.

DESIGN

Pragmatic, three arm, parallel group, double blinded, sham controlled, randomised, superiority trial with repeated measurements over 24 months.

SETTING

Six hospitals in Norway and Sweden.

PARTICIPANTS

220 adults with calcific tendinopathy of the shoulder, persistent for at least three months.

INTERVENTIONS

Ultrasound guided deposit lavage plus subacromial injection of 20 mg triamcinolone acetonide and 9 mL 1% lidocaine hydrochloride (lavage+steroid); sham lavage plus subacromial injection of 20 mg triamcinolone acetonide and 9 mL 1% lidocaine hydrochloride (sham lavage+steroid); or sham lavage plus subacromial injection of 10 mL 1% lidocaine hydrochloride (sham). All patients received a physiotherapeutic treatment regimen consisting of four home exercises.

MAIN OUTCOME MEASURES

The primary outcome was the result on the 48 point scale (0=worst; 48=best) of the Oxford Shoulder Score (OSS) at four month follow-up. Secondary outcomes included measurements on the short form of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) and of pain intensity up to 24 months. The influence of the size of the deposit at baseline and of the persistence or disappearance of the deposit was investigated.

RESULTS

Data from 218 (99%) participants were included in the primary analysis. Differences between groups on the OSS at four months were not significant: lavage+steroid versus sham 0.2 (95% confidence interval -2.3 to 2.8; P=1.0); sham lavage+steroid versus sham 2.0 (-0.5 to 4.6; P=0.35); lavage+steroid versus sham lavage+steroid -1.8 (-4.3 to 0.7; P=0.47). After four months, 143 patients with insufficient treatment effect received supplementary treatment. At 24 months, none of the study procedures was superior to sham. No serious adverse events were reported.

CONCLUSIONS

This study found no benefit for ultrasound guided lavage with a corticosteroid injection or for sham lavage with a corticosteroid injection compared with sham treatment in patients with calcific rotator cuff tendinopathy of the shoulder.

TRIAL REGISTRATION

NCT02419040EudraCT 2015-002343-34; Ethical committee Norway 2015-002343-34; Ethical committee Sweden 2015/79-31; Clinicaltrials.gov NCT02419040.

Treatment of calcific tendinopathy of the rotator cuff with ultrasound-guided puncture and aspiration

OBJECTIVE

Calcific tendinopathy of the rotator cuff is a common condition caused by the deposition of calcium crystals in the tendons of the rotator cuff. This study aimed to analyze the effectiveness of ultrasound-guided puncture and aspiration in calcific tendinopathy of the should in 86 patients treated at our center and to determine the factors associated with poor prognosis after this treatment.

MATERIAL AND METHODS

This retrospective descriptive study included 86 patients with calcific tendinopathy of the rotator cuff treated with ultrasound-guided puncture and aspiration between 2015 and 2019 for whom clinical and radiological variables were collected 1, 3, 6, and 12 months after the procedure.

RESULTS

One year after treatment, 81.4% patients showed clinical improvement and 96.5% showed radiological improvement. Complications were observed in 34.9%; all complications were mild.

CONCLUSIONS

Ultrasound-guided puncture and aspiration is an effective treatment for calcific tendinopathy of the shoulder, resulting in a high rate of clinical and radiological improvement and a low rate of minor complications. This technique has additional advantages, such as interaction with the patient and the lack of ionizing radiation.

Interventional Radiology Procedures of the Shoulder

Using imaging guidance to perform procedures around the shoulder girdle has become established practice in musculoskeletal radiology. Whether it be therapeutic injections for intra-articular pathology, rotator cuff or subacromial/subdeltoid bursal pathology, or injections for diagnostic purposes, such as magnetic resonance or computed tomography arthrography, a range of techniques and imaging modalities can be used. This article discusses the techniques for commonly performed procedures.

Treatment of calcific tendinopathy of the rotator cuff with ultrasound-guided puncture and aspiration

OBJECTIVE

Calcific tendinopathy of the rotator cuff is a common condition caused by the deposition of calcium crystals in the tendons of the rotator cuff. This study aimed to analyze the effectiveness of ultrasound-guided puncture and aspiration in calcific tendinopathy of the should in 86 patients treated at our center and to determine the factors associated with poor prognosis after this treatment.

MATERIAL AND METHODS

This retrospective descriptive study included 86 patients with calcific tendinopathy of the rotator cuff treated with ultrasound-guided puncture and aspiration between 2015 and 2019 for whom clinical and radiological variables were collected 1, 3, 6, and 12 months after the procedure.

RESULTS

One year after treatment, 81.4% patients showed clinical improvement and 96.5% showed radiological improvement. Complications were observed in 34.9%; all complications were mild.

CONCLUSIONS

Ultrasound-guided puncture and aspiration is an effective treatment for calcific tendinopathy of the shoulder, resulting in a high rate of clinical and radiological improvement and a low rate of minor complications. This technique has additional advantages, such as interaction with the patient and the lack of ionizing radiation.

Factors Associated With Clinical Improvement and the Disappearance of Calcifications After Ultrasound-Guided Percutaneous Lavage of Rotator Cuff Calcific Tendinopathy: A Post Hoc Analysis of a Randomized Controlled Trial

BACKGROUND

Calcific tendinitis of the rotator cuff is a frequent cause of shoulder pain. Ultrasound-guided percutaneous lavage (UGPL) is an effective treatment, but factors associated with good clinical and radiological outcomes still need to be identified.

PURPOSE

To study the clinical, procedural, and radiological characteristics associated with improved shoulder function and the disappearance of calcification on radiograph after UGPL.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This is a post hoc analysis of the CALCECHO trial, a double-blinded randomized controlled trial conducted on 132 patients. The trial assessed the effect of corticosteroid injections after UGPL, and patients were randomly assigned to receive either corticosteroid or saline solution in the subacromial bursa. We analyzed all patients included in the randomized controlled trial as 1 cohort. We collected the patients' clinical, procedural, and radiological characteristics at baseline and during follow-up (3, 6, and 12 months). Univariable analysis, followed by multivariable stepwise regression through forward elimination, was performed to identify the factors associated with clinical success (Disabilities of the Arm, Shoulder and Hand [DASH] score <15) or the disappearance of calcification.

RESULTS

Good clinical outcomes at 3 months were associated with steroid injections after the procedure (odd ratio [OR], 3.143; 95% CI, 1.105-8.94). At 6 months, good clinical evolution was associated with a lower DASH score at 3 months (OR, 0.92; 95% CI, 0.890-0.956) and calcium extraction (OR, 10.7; 95% CI, 1.791-63.927). A lower DASH at 6 months was also associated with a long-term favorable outcome at 12 months (OR, 0.939; 95% CI, 0.912-0.966). Disappearance of calcification at 3 and 12 months occurred more frequently in patients in whom communication was created between the calcification and the subacromial bursa during the procedure (OR, 2.728 [95% CI, 1.194-6.234] at 3 months; OR, 9.835 [95% CI, 1.977-48.931] at 12 months). Importantly, an association between calcification resorption and good clinical outcome was found at each time point.

CONCLUSION

Assessing patients at 3 months seems to be an essential part of their management strategy. Calcium extraction and creating a communication between the calcific deposits and subacromial bursa are procedural characteristics associated with good clinical and radiological evolution.

Ultrasound-Guided Percutaneous Irrigation of Rotator Cuff Calcific Tendinopathy (US-PICT): Patient Experience

Purpose

To assess patients' experience of ultrasound-guided percutaneous irrigation of rotator cuff calcific tendinopathy (US-PICT).

Methods

Ninety-one patients (58 females; mean age: 50.5 ± 8.3 years) treated by US-PICT (local anesthesia, single-needle lavage, and intrabursal steroid injection) answered to a list of questions regarding their experience of the procedure before treatment, immediately after treatment, and three months later. The Borg CR10 scale was used to evaluate perceived pain, discomfort during anesthetic injection, and anxiety. The Wilcoxon, Spearman's rho, linear regression, and chi-square statistics were used.

Results

81/91 patients complained mild discomfort during the injection of anesthetics (2, 1-2). Pain scores during US-PICT were very low (0, 0-1), with 70% patients having not experienced pain. After treatment, we found a significant reduction of pain (before: 8, 7-8; 3-month: 3, 1-6; p < .001) and anxiety (before: 5, 2-7; during treatment: 2, 1-7; p = 0.010), with high overall satisfaction (immediately after: 10, 9-10; 3-month: 9, 7-10) and confidence in the possibility of recovery (immediately after: 9, 8-10; 3-month: 10, 8-10), respectively. Treatments performed before US-PICT were not statistically associated with pain relief (p = 0.389) and clinical improvement (p = 0.937). We found a correlation between satisfaction immediately postprocedure and confidence in the possibility of recovery (p = 0.002) and between satisfaction three months after treatment and clinical improvement (p < 0.001) and patients' reminds about the description of the procedure (p = 0.005) and of the potential complications (p = 0.035).

Conclusions

US-PICT is a mildly painful, comfortable, and well-tolerated procedure, regardless of any previous treatments. Patients' satisfaction is correlated with clinical benefit and full explanation of the procedure and its complications.

An orthopaedic surgeon's guide to ultrasound imaging of the healthy, pathological and postoperative shoulder

Ultrasound (US) imaging is an efficient, easy to use and inexpensive tool allowing for facilitated diagnosis and management of the painful shoulder. It remains primarily used by radiologists and rheumatologists, despite having shown excellent diagnostic accuracy when used by different medical specialities in their office-based consultation. It also has advantages over other imaging modalities in the evaluation of the postoperative shoulder for rotator cuff integrity and correct anchor and suture placement, as well as rotator cuff analysis following arthroplasty. Integration of US imaging into the orthopaedic surgeon's toolbox can be aided by a basic understanding of US principles, accompanied by a guide outlining basic techniques for evaluation of the healthy, pathological and postoperative shoulder as well as US-guided treatment possibilities.

Efficacy of triamcinolone acetate and methylprednisolone acetonide for intrabursal injection after ultrasound-guided percutaneous treatment in painful shoulder calcific tendonitis: a randomized controlled trial

Background Ultrasound-guided percutaneous irrigation of calcific tendinopathy (US-PICT) with intrabursal steroid injection is an elective treatment for painful rotator cuff calcific tendinopathy. Purpose To compare the efficacy of post-US-PICT intrabursal 40 mg injection of triamcinolone acetonide (TA) versus methylprednisolone acetate (MA). Material and Methods Forty patients (22 women; mean age 48.7 ± 7.2 years) with painful shoulder calcific tendinopathy, treated with TA or MA injected intrabursally after US-PICT, were included in this randomized controlled trial. At baseline and after 1, 7, 15, 30, 45, and 180 days, patients underwent US and clinical examination, using Constant (CS) and VAS (VS) scores. Complications and analgesic use were also recorded. Results Compared to baseline, at the 45-day follow-up, TA and MA group showed a similar improvement (Δ) in CS (42 ± 10 versus 36 ± 9 points) and VS (-4.4 ± 1.3 versus -3.6 ± 1.3 points). At the 180-day follow-up, the improvement was higher in TA versus MA (ΔCS: 53 ± 7 versus 44 ± 7 points; ΔVS: -4.9 ± 1.1 versus -3.9 ± 1 points). Multivariate analysis showed a mean CS higher ( P = 0.02) in TA versus MA group, while VS was similar. TA had a 5 × higher ( P = 0.007) chance of reaching complete remission (CS = 100 points) than MA group. A progressive decrease in analgesic use, concomitant to a significant and similar reduction of bursitis and calcifications, was observed in both groups. No major complications occurred. Conclusion Two-needle US-PICT with intrabursal steroid injection is safe and effective. The chance of reaching better scores and, even more important for a clinical perspective, of functional recovery, is higher in patients treated with TA than MA.

Rotator Cuff Calcific Tendinopathy: Randomized Comparison of US-guided Percutaneous Treatments by Using One or Two Needles

Purpose To determine whether the use of one or two needles influences procedure performance and patient outcomes for ultrasonography (US)-guided percutaneous irrigation of calcific tendinopathy. Materials and Methods Institutional review board approval and written informed patient consent were obtained. From February 2012 to December 2014, 211 patients (77 men and 134 women; mean age, 41.6 years ± 11.6; range, 24-69 years) with painful calcific tendinopathy diagnosed at US were prospectively enrolled and randomized. Operators subjectively graded calcifications as hard, soft, or fluid according to their appearance at US. US-guided percutaneous irrigation of calcific tendinopathy (local anesthesia, needle lavage, intrabursal steroid injection) was performed in 100 patients by using the single-needle procedure and in 111 patients by using the double-needle procedure. Calcium dissolution was subjectively scored (easy = 1; intermediate = 2; difficult = 3). Procedure duration was recorded. Clinical evaluation was performed by using the Constant score up to 1 year after the procedure. The occurrence of postprocedural bursitis was recorded. Mann-Whitney U, χ², and analysis of variance statistics were used. Results No difference in procedure duration was seen overall (P = .060). Procedure duration was shorter with the double-needle procedure in hard calcifications (P < .001) and with the single-needle procedure in fluid calcifications (P = .024). Ease of calcium dissolution was not different between single- and double-needle procedures, both overall and when considering calcification appearance (P > .089). No clinical differences were found (Constant scores for single-needle group: baseline, 55 ± 7; 1 month, 69 ± 7; 3 month, 90 ± 5; 1 year, 92 ± 4; double-needle group: 57 ± 6; 71 ± 9; 89 ± 7; 92 ± 4, respectively; P = .241). In the single-needle group, nine of 100 cases (9%) of postprocedural bursitis were seen, whereas four of 111 cases (3.6%) were seen in the double-needle group (P = .180). Conclusion The only difference between using the single- or double-needle procedure when performing US-guided percutaneous irrigation of calcific tendinopathy is procedure duration in hard and fluid calcifications. Clinical outcomes are similar up to 1 year. ^© RSNA, 2017.

Smoking and morphology of calcific deposits affect the outcome of needle aspiration of calcific deposits (NACD) for calcific tendinitis of the rotator cuff

INTRODUCTION

Although NACD has proven to be an effective minimal invasive treatment for calcific tendinitis of the rotator cuff, little is known about the factors associated with treatment failure or the need for multiple procedures.

METHODS

Patients with symptomatic calcific tendinitis who were treated by NACD were evaluated in a retrospective cohort study. Demographic details, medical history, sonographic and radiographic findings were collected from patient files. Failure of NACD was defined as the persistence of symptoms after a follow-up of at least six months. NACD procedures performed within six months after a previous NACD procedure were considered repeated procedures. Multivariate logistic regression analysis was used to determine factors associated with treatment failure and multiple procedures.

RESULTS

431 patients (277 female; mean age 51.4±9.9 years) were included. Smoking (adjusted odds ratio (AOR): 1.7, 95% CI 1.0-2.7, p=0.04) was significantly associated with failure of NACD. Patients with Gärtner and Heyer (GH) type I calcific deposits were more likely to need multiple NACD procedures (AOR: 3.4, 95% CI 1.6-7.5, p<0.01) compared to patients with type III calcific deposits. Partial thickness rotator cuff tears were of no influence on the outcome of NACD or the number of treatments necessary.

CONCLUSION

Smoking almost doubled the chance of failure of NACD and the presence of GH type I calcific deposits significantly increased the chance of multiple procedures. Partial thickness rotator cuff tears did not seem to affect the outcome of NACD. Based on the findings in this study, the importance of quitting smoking should be emphasized prior to NACD and partial thickness rotator cuff tears should not be a reason to withhold patients NACD.

Ultrasound-guided percutaneous irrigation in rotator cuff calcific tendinopathy: what is the evidence? A systematic review with proposals for future reporting

OBJECTIVES

We performed a systematic review of current evidence regarding ultrasound-guided percutaneous irrigation of calcific tendinopathy (US-PICT) in the shoulder aimed to: assess different published techniques; evaluate clinical outcome in a large combined cohort; and propose suggestions for homogeneous future reporting.

METHODS

Cochrane Collaboration for Systematic Reviews of Interventions Guidelines were followed. We searched MEDLINE/MEDLINE In-Process/EMBASE/Cochrane databases from 1992-2013 using the keywords 'ultrasound, shoulder, needling, calcification, lavage, rotator cuff' combined in appropriate algorithms. References of resulting papers were also screened. Risk of bias was assessed with a modified Newcastle-Ottawa Scale.

RESULTS

Of 284 papers found, 15 were included, treating 1,450 shoulders in 1,403 patients (females, n = 838; mean age interval 40-63 years). There was no exclusion due to risk of bias.

CONCLUSIONS

US-PICT of rotator cuff is a safe and effective procedure, with an estimated average 55% pain improvement at an average of 11 months, with a 10% minor complication rate. No evidence exists in favour of using a specific size/number of needles. Imaging follow-up should not be used routinely. Future studies should aim at structural uniformity, including the use of the Constant Score to assess outcomes and 1-year minimum follow-up. Alternatives to steroid injections should also be explored.

KEY POINTS

• US-PICT of rotator cuff is a safe and effective procedure. • On average 55% pain improvement with 10% minor complication rate. • No evidence exists in favour of using a specific size/number of needles. • Future need to assess outcome using Constant Score with 1-year minimum follow-up.

Sports medicine ultrasound (US) beyond the musculoskeletal system: use in the abdomen, solid organs, lung, heart and eye

The use of point-of-care ultrasound (US) by non-radiologists is not new and the expansion into sports medicine practice is relatively young. US has been used extensively to evaluate the musculoskeletal system including the diagnosis of muscle, tendon and bone injuries. However, as sports medicine practitioners we are responsible for the care of the entire athlete. There are many other non-musculoskeletal applications of US in the evaluation and treatment of the athlete. This paper highlights the use of US in the athlete to diagnose pulmonary, cardiac, solid organ, intra-abdominal and eye injuries.

Evidence for minimally invasive therapies in the management of chronic calcific tendinopathy of the rotator cuff: a systematic review and meta-analysis

BACKGROUND

This meta-analysis assessed the short-term to midterm effectiveness of minimally invasive treatments in the management of calcifying tendinopathy of the shoulder cuff, a common source of chronic shoulder pain that leads to pain, a decreased active range of motion, and loss of muscular strength. When conservative therapies fail, minimally invasive treatment options can be considered before resulting to surgery.

MATERIALS AND METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to conduct this review. A systematic literature search was conducted in May 2013 to identify all studies that examined the short-term to midterm effectiveness of minimally invasive treatments for chronic calcifying tendinopathy. The primary end points were identified as function, pain, and total resorption rates. Grades of Recommendation Assessment, Development and Evaluation (GRADE) was used to assess the quality of evidence.

RESULTS

Included were 20 studies (1544 participants). Common methodological flaws were related to randomization. In general, there is moderate-quality GRADE evidence that high-energy extracorporeal shockwave therapy has a significant effect on pain relief and functional status compared with other interventions. There is variable-quality GRADE evidence on the efficiency of other interventions.

CONCLUSION

High-energy extracorporeal shockwave therapy is the most thoroughly investigated minimally invasive treatment option in the short-term to midterm and has proven to be a safe and effective treatment. Ultrasound-guided needling is safe but has not been proven to be more effective than an ultrasound-guided subacromial corticosteroid injection in recent level I research, and further research will have to prove its effectiveness.