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

Abstract

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).

Figure 1.

Type 1 calcification of the sopraspinatus [(a), arrows] with radiological appearance [(b), arrowhead]. Needling [(c), broken arrows indicating needles] and lavage [(d), star] of the calcification with 1-month follow-up ultrasound examination show none to minimal remains (e).

Figure 2.

Soft calcification of the sopraspinatus at ultrasound [(a), arrows] with previous radiographic finding [(b), arrowhead] and lavage of the calcification [(c), stars show liquids swelling the calcification “room”]. Elastosonographic appearance of the calcification immediately before treatment, enhancing the characterization of the calcification and highlighting its softness [(d) broken arrows] images of 1-month follow-up examination (e and f).

Figure 3.

Some of the typical conditions that might be present in rotator cuff calcific tendinitis: subacromial/subdeltoid bursitis [with acute inflammation and power Doppler positivity (a), arrows], calcification fragments migrated to the bursa enhancing bursitis and effusion [(b), broken arrow] and acute biceps tenosynovitis [(c, arrowhead].