[Open surgical procedures in calcifying tendinitis of the shoulder - concomitant pathologies affect clinical outcome]

Surgery for calcifying tendinitis of the shoulder: A systematic review

AIM

To systematically search literature and determine a preferable surgical procedure in patients with failed conservative treatment of calcifying tendinitis of the shoulder.

METHODS

The electronic online databases MEDLINE (through PubMed), EMBASE (through OVID), CINAHL (through EB- SCO), Web of Science and Cochrane Central Register of Controlled Trials were systematically searched in May 2016. Eligible for inclusion were all available studies with level II and level III evidence (LoE). Data was assessed and extracted by two independent review authors using a specifically for this study designed data extraction form.

RESULTS

Six studies (294 surgically treated shoulders) were included in this review. No significant differences between the three available treatment options (acromioplasty with the removal of the calcific deposits, acromioplasty or solely the removal of the calcific deposits) were detected regarding the functional and clinical outcome. The follow-up ranged from 12 mo to 5 years. Complication rates were low. No reoperations were necessary and the only reported complication was adhesive capsulitis, which in all cases could be treated conservatively with full recovery.

CONCLUSION

We found that all three available treatment options show good functional and clinical outcomes in the short and midterm. However, a favorable procedure is difficult to determine due to the lack of high-quality comparing studies.

Calcific tendinitis of the rotator cuff

Calcific tendinitis within the rotator cuff tendon is a common shoulder disorder that should be differentiated from dystrophic calcification as the pathogenesis and natural history of both is totally different. Calcific tendinitis usually occurs in the fifth and sixth decades of life among sedentary workers. It is classified into formative and resorptive phases. The chronic formative phase results from transient hypoxia that is commonly associated with repeated microtrauma causing calcium deposition into the matrix vesicles within the chondrocytes forming bone foci that later coalesce. This phase may extend from 1 to 6 years, and is usually asymptomatic. The resorptive phase extends from 3 wk up to 6 mo with vascularization at the periphery of the calcium deposits causing macrophage and mononuclear giant cell infiltration, together with fibroblast formation leading to an aggressive inflammatory reaction with inflammatory cell accumulation, excessive edema and rise of the intra-tendineous pressure. This results in a severely painful shoulder. Radiological investigations confirm the diagnosis and suggest the phase of the condition and are used to follow its progression. Although routine conventional X-ray allows detection of the deposits, magnetic resonance imaging studies allow better evaluation of any coexisting pathology. Various methods of treatment have been suggested. The appropriate method should be individualized for each patient. Conservative treatment includes pain killers and physiotherapy, or “minimally invasive” techniques as needling or puncture and aspiration. It is almost always successful since the natural history of the condition ends with resorption of the deposits and complete relief of pain. Due to the intolerable pain of the acute and severely painful resorptive stage, the patient often demands any sort of operative intervention. In such case arthroscopic removal is the best option as complete removal of the deposits is unnecessary.

Intraarticular lesions in calcifying tendinitis: incidence and association with the acromion index

INTRODUCTION

Intraarticular pathologies are a common finding during arthroscopy for rotator cuff lesions. Both rotator cuff tears as well as cartilage lesions have been described as correlating with the acromion index.

METHODS

In the current study, we aimed to determine the incidence of intraarticular lesions in calcifying tendinitis, to compare the incidence in patients with partial- and full-thickness tears of the rotator cuff, and to determine the acromion index in these groups. The incidence and type of accompanying intraarticular lesions were compared between three consecutive, age-matched groups of 64 patients each: those with calcifying tendinitis (group A), and those with partial- (group B) and full-thickness rotator cuff tears (group C). Also, the acromion index was measured from plain radiographs and compared between the groups.

RESULTS

The incidence of intraarticular pathology was 43% in group A, 41% in group B and 84% in group C. The differences between groups A and C as well as B and C were significant (p < 0.0001), but not between groups A and B (p = 0.858). Even though the acromion index was larger in group C than in the other two groups, the difference was not significant (A vs. B, p = 0.505; A vs. C, p = 0.180; and B vs. C p = 0.446). The incidence and type of intraarticular lesions in calcifying tendinitis are comparable to age-matched shoulders with partial- rather than full-thickness rotator cuff tears.

CONCLUSION

The acromion index is not different between shoulders with calcifying tendinitis, and partial- or full-thickness rotator cuff tears.

Symptomatic calcification of the medial collateral ligament of the knee joint: a report about five cases

Symptomatic calcifications of the rotator cuff tendons is well-known pathologic condition. However, pathologic calcifications may involve other structures of the locomotor system as well. We report about five patients (age 52-66 years) with a painful calcification at the proximal part of the medial collateral ligament of the knee joint. All five patients presented with load-dependent pain pretending meniscus symptoms, but manual valgus stress provoked severe pain at the medial side of the knee. Conventional X-ray examination showed a dense rounded deposit at the proximal part of the medial collateral ligament. Initially all patients were treated conservatively by needling and infiltration with a local anaesthetic. Open resection of the deposit was performed in four patients after unsuccessful conservative treatment. Postoperatively all patients were immediately free of pain. After a mean follow-up of 6 years (patient 1-4) (range=2.5-9.5 years), all patients were still free of pain. Histological evaluation of biopsies obtained during surgery showed nodular deposition of calcium at the collagen fibres, vascular proliferations and inflammative changes. Soft tissue calcifications have to be considered as a rare differential diagnosis in patients presenting with medial knee joint pain. Open resection reduces symptoms immediately. The histological changes seen were comparable to that reported about pathological tendon calcifications of the shoulder. Therefore, both conditions might be of the same aetiology.

Atypical pattern of acute severe shoulder pain: contribution of sonography

A patient presented with an atypical pattern of acute severe shoulder pain. Sonography elucidated the mechanism of the pain and allowed effective treatment. The patient was unable not only to move her shoulder but also to flex and to extend her elbow. Sonography showed a calcific deposit in the subscapularis tendon with local edema displacing the long head of the biceps tendon out of the bicipital groove. Local injection of a glucocorticoid under ultrasonographic control was followed within 7 days by subsidence of the subscapularis tendon edema and by a return of the long head of the biceps tendon to its normal position in the bicipital groove.