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Revista Chilena de Radiología. Vol. 23 Nº 3, año 2017; 109-115. ARTÍCULO ORIGINAL - MUSCULOESQUELÉTICO Calcific tendinitis of the and its lavage using ultrasound

Stefan Guiloff P1, Juan Pablo Niedmann E2, Esteban Hebel N1, Fabián Villacres C1.

1. Radiology resident. Faculty of Medicine, Universidad del Desarrollo - Clínica Alemana. Santiago, Chile. 2. Radiologist. Clínica Alemana de Santiago. Santiago, Chile.

Calcific tendinitis of the rotator cuff and its lavage using ultrasound

Abstract. Purpose: The objective of this study is to describe the technique of lavage and aspiration of calcifications under ultrasound in patients affected by this entity and to evaluate their results in the short term. Experimental design: Retrospective, descriptive study, with approval from the Ethics Committee of the Institution. Material and Methods: We performed a retrospective search of patients who underwent lavage as well as shoulder aspiration under ultrasound for calcific tendinitis at the Clínica Alemana in Santiago. 94 patients were identified between the years 2011 and 2015, of which 23 were excluded due to incomplete data. The electronic clinical record was reviewed and the data was recorded in RedCap v6 and statistical analyzes were performed using StataSE v12. Results: The sample consisted of 71 patients, the median age being 50.1 years (IQR: 41.6-57.7) and 45.1% were women. 70.4% affected the right shoulder. The mean evolution of the symptoms was 5 months (IQR: 2-24 months). 22.5% received one or more previous infiltrations and 47.9% attended kinesiotherapy. The calcifications corresponded mainly to type 1 according to the Gartner and Heyer classification (73.3%), with a median size of 14 mm on their major axis (IQR: 10-18 mm). They affected one in 74.7%, two in 18.3% and three tendons in 7.0%, the supraspinatus being the tendon most frequently affected (90.1%). 85.9% presented complete or significant improvement of the symptoms, only 8.5% requiring surgical resolution with arthroscopy. The final improvement had no significant association with the Gartner and Heyer type (p= 0.3), size (p= 0.16), or with the evolution time of the symptoms (p= 0.7). Conclusions: Patients with calcific tendinitis who underwent lavage and aspiration under ultrasound had, in most cases, a significant or total resolution of the symptoms at two months follow-up, with only a minor percentage requiring arthroscopy. It was not possible to identify predictors of poor evolution for this procedure. Further studies are needed to determine its advantages over medical treatment. Key words: Tendinitis, calcific tendinitis, Rotator cuff, Ultrasonic lavage.

Resumen. Propósito: El objetivo de este estudio es describir la técnica de lavado y aspirado de cal- cificaciones bajo ultrasonido en pacientes afectados por esta entidad y evaluar sus resultados a corto plazo. Diseño experimental: Estudio retrospectivo, descriptivo, con aprobación del Comité de Ética de la Institución. Material y Métodos: Se realizó una búsqueda retrospectiva de los pacientes sometidos a lavado más aspirado de hombro bajo ultrasonido por tendinitis cálcica en Clínica Alemana de Santiago. Se identificaron 94 pacientes entre los años 2011 y 2015, de los cuales 23 fueron excluidos por presentar datos incompletos. Se revisó la ficha clínica electrónica y los datos fueron registrados en RedCap v6 y los análisis estadísticos se realizaron usando StataSE v12. Resultados: La muestra se compuso por 71 pacientes, siendo la mediana de edad de 50,1 años (Rango Intercuartil, RIC: 41,6-57,7) y un 45,1% correspondió a mujeres. El 70,4% afectó el hombro derecho. La evolución media de los síntomas fue de 5 meses (RIC: 2-24 meses). Un 22,5% recibió una o más infiltraciones previas y 47,9% asistió a kinesio- terapia. Las calcificaciones correspondieron principalmente al tipo 1 según la clasificación de Gartner y Heyer (73,3%), con una mediana de tamaño de 14 mm en su eje mayor (RIC: 10-18 mm). Afectaron un tendón en 74,7%, dos tendones en 18,3% y tres tendones en 7,0%, siendo el tendón más frecuentemente afectado el supraespinoso (90,1%). El 85,9% presentó mejoría completa o significativa de los síntomas,

109 Revista Chilena de Radiología. Vol. 23 Nº 3, año 2017; 109-115. requiriendo resolución quirúrgica con artroscopía tan sólo un 8,5%. La mejoría final no tuvo asociación significativa con el tipo de Gartner y Heyer (p= 0,3), tamaño (p= 0,16), ni con el tiempo de evolución de los síntomas (p= 0,7). Conclusiones: Los pacientes con tendinitis cálcica que son sometidos a lavado y aspirado bajo ultrasonido tuvieron en su mayoría una resolución significativa o total de los síntomas a los dos meses de seguimiento, requiriendo artroscopia en un porcentaje menor. No se lograron identificar factores predictores de mala evolución de este procedimiento. Se requieren de más estudios para deter- minar sus ventajas por sobre el tratamiento médico. Palabras clave: Tendinitis, tendinitis cálcica, manguito rotador, lavado por ultrasonido.

Guiloff S., et al. Tendinitis cálcica del manguito rotador y su lavado por ultrasonido. Rev Chil Radiol 2017; 23(3): 109-115. Correspondence: Esteban Hebel N. / [email protected] Paper sent 15 March 2017. Accepted for publication 12 September 2017.

Introduction Prior to the treatment, all patients underwent radio- Calcific tendinitis is a frequent cause of shoulder graphs that included at least two planes of the space in adults, which can be highly disabling, affecting (anteroposterior and axial projection of the scapula) their independence and quality of life. It is caused by and/or ultrasound of the compromised shoulder. The deposition of hydroxyapatite crystals in the tendons of calcifications of the rotator cuff were recognized, their the rotator cuff with a reported prevalence in 2.5-7.5% number, size and location, and with this information of radiographs in asymptomatic adults1. Approxima- the morphological classification according to Gartner tely half of these will present symptoms, being more and Hayer7 was used, which defines the calcifica- frequent in women (70%) and in those older than 40 tions as of dense appearance (type I), translucent years1,2. One of the difficulties in the management appearance and cloudiness (type III). and those of of calcific tendinitis is that, since it is a self-limiting non-classifiable morphology (type II). The size was entity, where calcification resolves spontaneously, classified according to Bosworth8, as small (barely the treatment seeks to improve the quality of life and visible), medium (<15 mm) and large (>15 mm). accelerate recovery through symptomatic relief, so Description of the technique: The procedure is it must be effective, uncomplicated and minimally performed with the patient in the supine position and invasive2. the affected arm in contact with the body. The degree Traditionally, the treatment of first choice is con- of rotation of the shoulder will depend on the location servative management, which includes the use of of the calcification, trying to leave the shortest path and a short course of nonsteroidal and the best approach angle between the skin and anti-inflammatory drugs3. An alternative approach calcification. Local antisepsis was performed with a is to extract the calcification via ultrasound guided sterile technique (Figures 1a and 1b) and the access procedures. Previous studies have shown promising route and the subacromial-subdeltoid bursa were results with lavage of calcifications via ultrasound as a anesthetized using a 25G needle (lidocaine 2%) (Figure therapeutic option, with multiple techniques described, 1). For our study, a multifrequency linear transducer however, none of these have been applied universa- (12-5 or 18-5 MHz) and Philips iU22 and Philips Epiq lly4-6. In case of failure of conservative management 7 ultrasound equipment were used to visualize the and, as a last resort, arthroscopy should be used. calcification and guide the procedure (Figure 1c). The present study aims to describe the technique Next, the calcification is punctured on the anesthetized of percutaneous lavage and aspiration of calcifications path, under ultrasound guidance, with a 14G trocar under ultrasound in our center and evaluate its short- and a second 19 or 21G needle is inserted in parallel term results (two months). (Figure 1d). Two 25 cc syringes are used, one that will aspirate through the thicker needle and the other Material and methods will introduce physiological saline creating a system In this study, approved by the ethics and research of lavage and aspiration. In case of more extensive or committee of our institution, we retrospectively co- multiple calcifications, the lavage can be carried out llected information on all patients diagnosed with in more than one sector. In the case of Gartner and symptomatic calcific tendinitis of one or more rotator Heyer type I calcifications, these can be fragmented cuff tendons and who underwent lavage and aspira- with the needle of greater diameter. The procedure tion of the shoulder under ultrasound between 2011 is repeated until the calcification has been lavaged and 2015 at the Clínica Alemana in Santiago. The or the physiological saline is seen to be clear. Finally, data included age at the time of diagnosis, evolution intrabursal are administered (Cidoten time of symptoms, previous treatments carried out, rapilento® or Depo-medrol® 40 or 80 mg according to involved tendons, affected side, and uni or bilaterality the preference of the attending physician) (Figure 2). of the condition. If there is more than one calcification, the previous 110 Revista Chilena de Radiología. Vol. 23 Nº 3, año 2017; 109-115. ARTÍCULO ORIGINAL - MUSCULOESQUELÉTICO technique can be repeated for each of them. The months, where it was checked whether there was treatment lasts on average 20 min. Immediately after improvement of symptoms, specifically assessing the the procedure is finished, an is prescribed to pain and range of mobility of the affected shoulder, be used if necessary in the first days after lavage. All classifying it later as complete improvement in cases procedures were performed by a radiologist with more of absence of symptoms, partial in cases where there than 15 years of experience in shoulder ultrasound was improvement of the symptoms but incomplete, or and guided interventions under ultrasound. finally without improvement in the cases in which the All the patients included in the study had at symptomatology remained without significant changes. least one follow-up consultation post-lavage with The electronic clinical record was reviewed, and a traumatologist, with control at approximately two all the data was collected and registered on a form

Figure 1. Puncture and lavage procedure under ultrasound guidance. A and B. Demonstrate the start of the procedure under antiseptic technique. C. The anesthetic injection is made in the access path. D. The technique is demonstrated using two 25 cc syringes to perform the lavage. 111 Revista Chilena de Radiología. Vol. 23 Nº 3, año 2017; 109-115.

Figure 2. 58-year-old woman with left shoulder pain of 12 months evolution. A. Shows dense, clearly definable calcification (type I) of approximately 20 mm on its major axis in the supraspinatus tendon insertion area (arrow). B. Ultrasound focused on the insertion of the supraspinatus muscle where a thick calcification is identified, with posterior acoustic shadow. C. Demonstrates the use of two needles for the calcification lavage. D. Distension of the bursa after injection of corticosteroids (double arrow). specially designed for this study, using the RedCap performed without guidance by a traumatologist. Most 6.6.0 platform (Vanderbilt University, Nashville, TN). patients presented symptoms in the right shoulder The univariate statistical analyzes were performed (70.4%). For this study, 63.4% were evaluated with using measures of central tendency and dispersion shoulder ultrasound and the remaining 32.6% with for continuous variables. The bivariate analyzes were shoulder radiography. The majority of the patients performed using X2 test for dichotomous variables. (74.7%) had calcifications in a single tendon, 18.3% We considered 95% confidence intervals and values in two tendons and 7.0% in three tendons, the most of statistical significance p< 0.05 and all the statistical affected tendon being the supraspinatus in 90.1% of analyzes were performed using Stata Statistical Soft- the cases (Figure 4). The calcifications correspon- ware version 12 (StataCorp, 2011, College Station, TX). ded mainly to type II according to the classification of Gartner and Heyer (73.3%), with a median size Results of 14 mm on its major axis (IQR: 10-18 mm) (Figure We identified 94 patients, of which 23 were excluded 5). As for the improvement of symptoms, 29 patients due to incomplete data. The remaining 71 patients (40.8%) had complete improvement of symptoms and were included in the present review. The median age 32 patients (45.1%) had partial improvement at two of the patients was 49.8 years (IQR: 41.8-56.8 years) months follow-up. Only 10 patients (14.1%) did not (Figure 3) and 32 were women (45.1%). Patients were show improvement of symptoms with the procedure. treated after an average of 5 months with symptoms 42.3% of patients received adjuvant treatment with non- (IQR: 2-24 months), 47.8% had attended sessions steroidal anti-inflammatory drugs and 53.4% attended of kinesiotherapy before and prior to the procedure, kinesiotherapy. Only 11 patients (15.5%) required a 22.5% had another bursal infiltration with corticosteroids new lavage and aspiration of microcalcifications and

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six (8.5%) ended up with shoulder arthroscopy for the management of this pathology. When analyzing the final improvement regarding the variables that could have affected the result, there was no statistically significant association with the Gartner and Heyer type (p= 0.3), size (p= 0.16), being calculated both as continuous or categorical variable, affected side (p= 0.5), or the evolution time symptoms (p= 0.7) (Figure 6).

Figure 3. Histogram of age distribution of patients at the time of the procedure. Figure 5. Characterization of the calcifications by radiological type according to Gartner & Heyer and by size according to Bosworth, which showed a majority frequency of calcifications “Clearly dense and circumscribed”, as well as those classified as mediums.

Figure 6. Distribution of patients according to their degree Figure 4. Frequency distribution of the tendons involved in of clinical improvement, highlighting that the vast majority the sample of patients analyzed in our study, demonstrating had total or partial improvement of their symptoms, whereas that the vast majority of patients presented involvement of only 14.1% of them did not experience any improvement the supraspinatus tendon. with the treatment.

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Discussion We believe that pre- is not necessary in an During the last decades, multiple treatments have extended or routine way for these patients, since the been proposed for the conservative management of poor tolerance to the procedure is only anecdotal. In shoulder calcific tendinitis. Iontophoresis with acetic our study there were no complications or pain during acid and ultrasound therapy have not proven to be the procedure without pre-medication or during the more effective than physiotherapy or placebo9,10. The month of follow-up. shock waves have demonstrated their effectiveness Among our patients, there was clinical improve- proving that, in the short term, this technique resol- ment in the short-term follow-up, both in pain and ves calcifications in 57-60% of cases and achieves range of motion, completely or partially in 85.9% of a substantial or complete clinical improvement in cases. These results are similar to the most promi- 53-71%. In the long term, calcifications resolve in 47 sing results published for shock wave therapy and to 93%, and substantial or complete clinical improve- are not worse compared to arthroscopy, but unlike ment is achieved in 66-91%. However, it is a painful these, lavage and aspiration under ultrasonographic procedure and requires special equipment, needing vision is minimally invasive, of shorter duration, not at least three sessions for its application separated very painful and of lower cost. by 2-4 weeks11-13. Arthroscopic is considered Regarding the negative predictive factors des- a second-line alternative in case of failure of medical cribed in the literature, that is to say they increase treatment, being even more effective than long-term the probability of a poor clinical outcome as they shock waves, achieving a substantial or complete cli- are, for example, bilaterality, localized calcification nical improvement in 80-100% of patients. However, it in relation to the anterior portion of the acromion, always requires hospitalization, rehabilitation and is not subacromial extension and calcium deposition with free from complications13,14. Percutaneous treatment of a volume greater than> 4500 m3(20), did not have in calcific tendinitis is not a new method; it is performed our study a statistically significant association with the under fluoroscopic support since 1978, however, its different variables studied, such as the evolution time disadvantage is the use of ionizing radiation and the of symptoms, history of previous treatments, location potential difficulty of locating the calcium deposit15. of the calcification(s), type according to Gartner and The lavage and aspiration of calcifications under Heyer7 classification and size categories according to ultrasonography was first described in 1996 by Farin Bosworth8 that determine a worse clinical evolution, et al16. Several variants in the technique have been at least in the short term. described among the authors who have proposed Our study has some limitations that must be taken the use of this procedure, the main difference being into account: It is a retrospective longitudinal work, the use of one needle6,17,18 versus two needles16,19. We with a relatively limited follow-up time. It could be chose to use two needles, one of 19-21G to introduce useful to develop a prospective controlled trial with the saline solution and another thick one of 14G to a larger number of patients to identify the variables aspirate the calcium. We believe, in our experience, that determine the success of the procedure in the that when using smaller diameter needles they tend medium and long term. The calcifications were not to become blocked during aspiration, while the use of monitored with images in the follow-up of the patients a larger diameter one increases the risk of damaging to check whether the improvement of the symptoms the compromised tendon. was actually related to the decrease in their size. In our institution, the procedure is performed with the patient in the supine position, since we believe Conclusions that, compared to the sitting or semi-sitting position, Patients with rotator cuff calcific tendinitis who it is more comfortable for both the patient and the undergo lavage and aspirate under ultrasound have, in operator. Some authors17,18 describe that calcium the majority, a significant or total resolution of symptoms aspiration must be performed after the needle has at two months of follow-up, requiring arthroscopy in fragmented the calcification. In our experience and a smaller percentage. It was not possible to identify according to the results reported by other studies5,6, predictors of poor evolution for this procedure, so it this technique frequently causes the needle to beco- can be proposed as a valid alternative for the symp- me blocked, so we always recommend injecting the tomatic management of any patient afflicted by this saline solution initially. condition, and without response to conventional medical Possible reported complications derived from the treatment. More studies are required to determine its minimally invasive procedure are rare. Some of them advantages over conventional medical treatment and are the presence of vagal reactions, hemorrhage or the long-term impact of this treatment on the quality local hematoma, infection and very rarely syncope4-6. of life and job recovery for our patients. Del Cura et al6 pre-medicated more than half of the patients in their study with a quick-acting anxiolytic to References prevent loss of consciousness and/or vagal reactions. 1. Speed CA, Hazleman BL. Calcific tendinitis of the

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shoulder. N Engl J Med 1999; 340: 1582-1584. 2580. 2. Hurt G., Baker C. Calcific tendinitis of the shoulder. 12. Hsu CJ., Wang DY., Tseng KF., Fong YC., Hsu HC., Orthop Clin N Am 2003; 34: 567-563. Jim YF. Extracorporeal shock wave therapy for cal- 3. Kachewar SG., Kulkarni DS. Calcific tendinitis of the cifying tendinitis of the shoulder. J Shoulder Elbow rotator cuff: A review. J Clin Diagn Res 2013; 7: 1482- Surg 2008; 17(1): 55-59. 1485. 13. Rompe JD., Zoellner J., Nafe B. Shockwave therapy 4. Vignesh K., McDowall A., Simunovic N., Bhandari M., versus conventional surgery in the treatment of cal- Choudur H. Efficacy of Ultrasound-Guided Percuta- cifying tendinitis of the shoulder. Clin Orthop Relat neous Needle Treatment of Calficific Tendinitis. AJR Res 2001; 387: 72-82. 2015; 204: 148-152. 14. Wittenberg RH., Rubenthaler F., Wolk Ludwig J., 5. Serafini G., Sconfienza L., Lacelli F., Silvestri E., Ali- Willburger RE., Steffen R. Surgical or conservative prandi A., Sardanelli F. Rotator Cuff Calcific Tendonitis: treatment for chronic rotator cuff calcifying tendinitis: Short-term and 10-year Outcomes after Two-Needle A matched-pair analysis of 100 patients. Arch Orthop US-guided Percutaneous Treatment- Nonrandomized Trauma Surg 2001; 121(1-2): 56-59. Controlled Trial. Radiology 2009; 252: 157-164. 15. Comfort TH., Arafiles RP. Barbotage of the shoulder 6. Del Cura J., Torre I., Zabala R., Legórburu A. Sono- with image-intensified fluoroscopic control of needle graphically Guided Percutaneous Needle Lavage in placement for calcific tendinitis. Clin Orthop Relat Calcific Tendinitis of the Shoulder: Short- and Long- Res 1978; 135: 171-178. Term Results. AJR 2007; 189: 128-134. 16. Farin PU., Jaroma H., Soimakallio S. Rotator cuff 7. Gartner J., Heyer A. Calcific tendinitis of the shoulder. calcifications: Treatment with US-guided technique. Orthopade 1995; 24(3): 284-302. Radiology 1995; 195(3): 841-843. 8. Bosworth BM. Calcium deposits in the shoulder and 17. Aina R., Cardinal E., Bureau NJ., Aubin B., Brassard subacromiali : A survey of 12,122 shoulder. P. Calcific shoulder tendinitis: Treatment with modified JAMA 1941; 116: 2477-2482. US-guided fine-needle technique. Radiology 2001; 9. Ebenbichler G., Erdogmus CB., Resch KL., et al. Ul- 221: 455-461. trasound therapy for calcific tendinitis of the shoulder. 18. Bradley M., Bhamra MS., Robson MJ. Ultrasound- N Engl J Med 1999; 340: 1533-1538. guided aspiration of symptomatic supraspinatus 10. Leduc BE., Caya J., Tremblay S., Bureau NJ. Treatment calcific deposits. Br J Radiol 1995; 68: 716-719. of calcific tendinitis of the shoulder by acetic acid 19. Galletti S., Magnani M., Rotini R., et al. The echo- iontophoresis: A double-blind randomized controlled guided treatment of calcific tendinitis of the shoulder. trial. Arch Phys Med Rehabil 2003; 84: 1523-1527. Chir Organi Mov 2004; 89(4): 319-323. 11. Gerdesmeyer L., Wagenpfeil S., Haake M., et al. 20. Ogon P., Suedkamp NP., Jaeger M., Izadpanah K., Extracorporeal shockwave therapy for the treatment Koestler W., Maier D. Prognostic factors in non operative of chronic calcifying tendinitis of the rotator cuff: A therapy for chronic symptomatic calcific tendinitis of randomized controlled trial. JAMA 2003; 290: 2573- the shoulder. Arthritis Rheum 2009; 60: 2978-2984.

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