- Email: [email protected]
Change of calcifications after arthroscopic subacromial decompression
Change of calcifications after arthroscopic subacromial decompression Bo M. Tillander,
MD, and Rolf 0.
Norlin,
MD,
PhD,
Fifty patients were reviewed after arthroscopic subacromial decompression. Twenty-five had calcific deposits in the rotafor cuff visible on x-ray evaluation. Each patient with calcification was matched with a patient without calcificafion who had a similar state of the rotator cuff, date of surgery, age, and sex. The calcific deposits were left untouched in all cases. No significant difference was found in the postoperative outcome between the patients in the two groups measured by the Constant score. Before surgery 7 (28%) patients had calcifications of <5 mm, and 18 (72%) pafienfs hod calcifkaf;ons that were 25 mm. At a 2.year follow-up (n = 24) these figures were 20 (83%) and 4 /77%), respectively Q < 0.00 1). Postoperative x-ray evaluations revealed a disappearance or decrease in size of the calcific deposits in J 9 (79%) of the patients. These results provide new information on the course of calcifying tendinitis, which may indicate that we can leave calcific deposits untouched within the rotator cuff when performing arthroscopic subacromial decompression. (1 Shoulder Elbow Surg 7998;7:2 J3-7.)
of calcium carbonate apaThe d eposition tite6z ’ 2, 22 within the rotator cuff is commonly found in both symptomatic and asymptomatic shoulders.*, 16, 37 Hedtmann and Fett17 noted calcific deposits on x-ray evaluations in 17% of 1266 patients with painful shoulders. In patients with no symptoms the figures vary between 2.7% and 2()yo,2,34>
37
The calcifications are usually categorized into two types. In type 1 the deposit exhibits a diffuse appearance with poorly defined borders, whereas in type 2 the calcification is homogenous, dense, and has a well-defined margin.4, 5, 23 Type 1 deposits are most common in patients with acute pain, and type 2 are most common in patients with chronic pain.5 From
the
Department
of Orthopaedics,
Reprint requests. Bo paedics, University
Tillander, Hospital,
MD, S-58
University
Hospital.
Department of 1 85 Linkoping,
OrthoSwe-
den. Copyright Board
0 1998 of Trustees.
1058-2746/98/$5.00
by Journal + 0
of Shoulder 32/l/84045
and
Elbow
Surgery
Linkoping,
Sweden
According to some authors calcifying tendinitis is a self-limiting disease with subsequent healing of the tendon.z4, *5, 35, 36 In the acute phase the deposits are resorbed within a few weeks,13 and the treatment of choice is a subacromial cortisone injection. 33 Some authors sugg est needling and lavage. 11, 15,20 In the chronic stage the patient either has no pain or describes slight or moderate pain.4, 35 The cause of the pain is not clear. Uhthoff and Sarkar35 suggested
that
it
originates
from
the
increased
intratendinous pressure in the vicinity of the calcific deposit, whereas DePalma4 proposed that a local bursitis causes the pain. The size of the calcification does not seem to play a major role for the severity of the pain.51 *,*A Treatment of the chronic phase of calcifying tendinitis includes physiotherapy and analgesics.35 Invasive treatment may include needling, lavage and subacromial cortisone injection,3’ and open25, 33 or arthroscopic7 removal of the calcification. In both open and arthroscopic surgery the removal of calcification may be combined with bursectomy,‘, 25, 32 bursectomy, division of the coracoacromial ligament,5, l4 partial resection of the coracoacromial ligament,4, 35 and acromioplasty.8-'Or
'8.
19, 26
Ellman and Kay9 reported a satisfactory outcome in each of 14 cases after arthroscopic subacromial decompression (ASD) combined with a removal of the calcific deposits. They did not, however, compare this method with a simple removal of the deposits or with ASD without a removal of the calcific deposits. The purpose of this study was to evaluate whether untouched calcific deposits play a role for the postoperative outcome after ASD. MATERIAL
AND
METHODS
Between February 1992 and July 1994, 194 patients underwent ASDz9 at our institution. Open surgery was never performed. The preoperative diagnosis in all cases was impingement syndrome: chronic pain for more than 1 year, which was exacerbated by activity,
213
2 14
Table surgery
Tillander
and Norlin
I Clinical outcome at 2 years and at 2year follow-up
after
ASD,
measured
by the Constant
score
and
Active Active
n Calcific group Noncalcific
25 25
Preoperative 141 139
Surg
J Shoulder Elbow May/June
flexion
Active
2-year follow-up 154 150
abduction 2-year follow-up
Preoperative 126 126
Preoperative
154 145
67 62
the active
range
outward rotation
of motion
I998
before
Constant score (points)
2-year follow-up 46 47
Median
value
(range) 78 79
(55-l (37-l
00) 00)
group
night pain, and a positive impingement test. Indications for surgery were shoulder pain and impairment of function for more than 1 year despite conservative treatment including physical therapy, nonsteroidal antiinflammatory medications, and steroid injections. A positive impingement test before surgery was found in all cases. No cases of instability were found. Patients with an acute exacerbation of calcifying tendinitis who had sudden severe pain caused by secondary inflammatory bursitis did not undergo surgery. Thirty-two (16%) of these patients had calcific deposits on preoperative x-ray evaluation. Roentgenograms of the affected shoulder were taken in four positions: anteroposterior views in internal and external rotation, a lateral view in the scapular plane, and an axillary view. The size and structure of each calcific deposit were recorded to compare preoperative and postoperative findings on roentgenograms. The preoperative x-ray evaluation showed calcific deposits of type 1 in 4 cases and of type 2 in 28 cases. The time between onset of symptoms and surgery was at an average 5.5 years (range 1 to 18 years). ASD was performed on all patients. The calcific deposits were left untouched. Five patients were excluded from the study: one patient with arthrosis of the glenohumeral joint, a second who previously had surgery with open biceps tenodesis, a third who could only be interviewed by telephone, and two patients with a rotator cuff rupture. Another two patients were not available for reexamination. The remaining 25 patients with calcific deposits on the preoperative x-ray evaluation were reexamined by an independent examiner. Each one of these patients was matched with another patient without calcification on x-ray evaluation with similar state of the rotator cuff, date of surgery, age, and sex. In 18 of the 25 cases the rotator cuff was described as normal at surgery, and in 7 cases a partial deep surface tear of the supraspinatus tendon was found. The date of surgery within each matched pair of patients was the same +3 months. The follow-up time after surgery was 2 years (range 9 to 39 months, median 24 months). The Constant score was
used.3 follow-up evaluation was blind regarding the presence or absence of calcific deposits on x-ray evaluation. Twenty-four patients with calcifications before surgery were reexamined by x-ray evaluation 12 to 42 months after surgery. One patient did not permit a postoperative x-ray evaluation to be performed. The same x-ray views were taken before surgery and at follow-up. The calcifications were classified according to their size in the greatest dimension. 2, 25 The chi-squared and paired t tests were used for statistical analysis of the data. RESULTS
The mean
age in the two matched groups was 40 to 53 years) for women and 53 years (range 41 to 67 years) for men. Seventyfour percent of the patients were women. Of the patients with calcifications in the rotator cuff, 60% had their right shoulder involved. In 68% the calcification was found on the patient’s dominant side. Postoperative active range of motion did not show any significant difference between the calcific (n = 25) and the noncalcific groups (n = 25) (Table I). The mean value of forward flexion among patients with calcific deposits on preoperative xray evaluation increased from 141’ to 154” (p < 0.1) and among patients without calcification from 139” to 150” (NS). Th e mean value of abduction increased from 126” to 154” in the calcific group (p < 0.05) and from 126” to 145” in the noncalcific group (p < 0.1). External rotation decreased in both groups from 67” to 46” in the calcific group (p < 0.05) and in th e noncalcific group from 62” to 47” (NS) (see Table I). The postoperative results with respect to pain, activities of daily living, range of motion, and power in the group of patients with calcifications were almost identical with the results in the group 47
years
(range
J Shoulder E/bow Volume 7, Number
Tillunder
Surg 3
Table II Change in size of the calcific and Constant score at 2year follow-up Number patients Calcification at follow-up Increased Unchanged Decreased Resorbed
of (with
ASD
Constant score (points; median, range)
We 1 calcifications) ’ (0) 4 (0) 61’) 13 (2)
deposit after (n = 24)
\ / \ /
75 78
(55 (62-l
100) 00)
of patients without calcifications on preoperative x-ray evaluation, measured by the Constant score.3 The median value in the first group (n = 25) was 78 points (range 55 to 100 points) and in the latter group (I-I = 25) 79 points (range 37 to 100 points) (see Table I). Seventy-two percent of the patients without calcific deposits on x-ray evaluation were satisfied with the postoperative result compared with 80% of the patients with calcification in the rotator cuff. This difference was not significant. In 13 (54%) of the 24 patients who were examined by x-ray evaluation after surgery (Table II), the calcific deposits had completely disappeared. Among these patients two had type 1 calcifications on preoperative x-ray evaluation, and 1 1 had type 2 calcifications. In another six (25%) patients the calcifications had decreased in size. One of these patients had a type 1 calcification on preoperative x-ray evaluation, and the other five patients had type 2 calcifications (see Table II). The calcifications were unchanged after surgery in four cases. No significant difference was seen in the postoperative result measured by the Constant score when the patients with increased or unchanged calcifications were compared with those with decreased or resorbed ones (see Table II). In one case more than 2 years after surgery, the calcific deposit on x-ray evaluation had increased compared with the preoperative findings. Despite that, the Constant score was 98 points. Before surgery 17 patients (n = 24) had calcifications of 5 mm or more (71%). Of these, three calcifications were greater than 15 mm, and seven (29%) had calcific deposits smaller than 5 mm. On x-ray evaluation at follow-up 20 (83%) of 24 patients had no or small (<5 mm) calcifications left F our (17%) patients had calcifica(p < 0.001). tions left that were 5 mm or greater (Table Ill).
Table before
III Number of patients surgery and at 2year
Size of calcification (mm)
0 1-4 5-15 >15
and
Norlin
2 15
with different size calcification follow-up (n = 24)
No. patients
of (with
We 1 calcifications)
0 PI 7 (0) 14 (21 3 (11
No. of patients at at 2-year follow-up 13 7 3 1
DISCUSSION
In 1907 Painter30 demonstrated calcifications on x-ray evaluation for the first time. Bosworth* suggested that “large deposits should be excised regardless of symptoms” but “medium and tiny deposits should, in general, be treated conservatively.” Later the need for surgery was considered by Mctaughlinz5 to be “almost never absolutely necessary” or according to Uhtoff and Sarka.rs5 “the exception.” The fact that the calcific deposits disappear spontaneously supports this strategy of treatment.24, 25, 35 Furthermore a great number of patients show visible calcifications on x-ray evaluation but do not have any or only minor symptoms.*, 34, 37 These findings may raise the question that if a calcification is present, is it always the cause of pain in the patient with chronic shoulder pain?’ In the acute phase of calcifying tendinitis the calcifications are resorbed within a few weeks,13, *O and neither open nor arthroscopic surgery is indicated. 33 The cause of the pain is presumed to be the bursitis.20, 25 In the chronic phase both diagnosis and choice of correct treatment may be more difficult. It is difficult to know whether the calcification is the source of the pain or just an insignificant finding on x-ray evaluation. The clinical picture resembles impingement syndrome2s in terms of pain at rest, at night, and when lifting the arm. The impingement test is positive in both calcifying tendinitis and in other types of impingement syndrome. Several authors have reported good results after surgical excision of calcifications, but in most of these reports removal of calcification is combined with bursectomy, 1’ 25, 32 bursectomy and division of the coracoacromial ligament,5, l4 partial resection of the coracoacromial ligament,4, 35 and/or acromioplasty.8-‘0, 15, 19, 26 Harmon15 and Litch-
216
Tillander
and Norlin
man et al?’ reported good results after removal of calcific deposits without any of the previously mentioned measures but had a great number of patients with acute symptoms. In this study the postoperative result at a 2-year follow-up measured by the Constant score was as good for the patients who had calcific deposits on preoperative x-ray evaluation as it was for patients without. If the calcification itself had a negative influence on the postoperative outcome, one would expect a lower value of the Constant score in the patients with calcification on preoperative x-ray evaluation. This result was not found in this study. Even the patients’ active range of motion before surgery compared with the postoperative results did not differ between the patients with and without calcifications. As many as 54% of the patients had no calcification on x-ray evaluation at follow-up, although the calcifications had not been removed during surgery, whereas in 25% of the patients the calcific deposits had decreased in size. The number of patients with calcifications smaller than 5 mm had increased significantly from 29% to 83% (p <
J Shoulder Elbow May/June
evaluation do not need surgical treatment. Among those with persisting pain over years, we still do not always know the cause of the pain. Many authors describe a removal of calcific deposits combined with bursectomy, division or removal of the coracoacromial ligament, or acromioplasty. We perform ASD on patients with chronic pain and a positive impingement sign, because we believe that these patients have a subacromial problem. The results of this study indicate that the calcifications may not be the cause of the pain but a finding that we may regard as an insignificant observation on x-ray evaluation with regard to the indication for treatment. The tance.
thank
Mrs.
lnger
Eriksson
for
her
assis-
1.
Ark JW, Flock TJ, Flatow Et, Bigltani LU. Arthroscopic treatment of calcific tendinitis of the shoulder. Arthroscopy 1992;8: 183-8.
2.
Bosworth subacromtal
3.
Constant functional 1987;2
4.
DePalma AF. Calcareous tendinitis. In: DePalma AF, editor. Surgery of the shoulder. Philadelphia: Lippincott; 1983. p. 257-85. DePalma AF, Kruper JS. tong-term study of shoulder joints afflicted with and treated for calcific tendinitrs. Clin Orthop 1961;20:61-72.
5.
BM.
Culcium deposits bursitis JAMA 1941;
CR, Murfey assessment 14: 160-4.
AHG. of the
in the shoulder 1 16:2477-82.
A clinical shoulder.
and
method of Clin Orthop
6.
Dieppe tissues.
P. Crystal Clin Rheum
7.
Ellman Orthop
H. Arthroscopic Trans 1989;
8.
Ellman H, Bigliani LU, Flatow E, et al. Arthroscopic treatment of calcifying tendinitis: the American Experience. Fifth International Shoulder Conference, Paris, July 1992:1-15.
9.
Eilman H, Kay SP. Arthroscopic pression for chronic impingement. 1991;73B:395-8.
10
11 CONCLUSION
Calcification on x-ray evaluation is a condition that is found in both painful and painfree shoulders. The calcifications are resorbed spontaneously, and the tendon heals. Most patients with painful shoulders and calcific deposits on x-ray
authors
REFERENCES
0.001).
Bosworth2 found among 202 shoulders a disappearance of the calcific deposits in only 6.4% of the shoulders. This result may indicate that the calcifications disappear more rapidly after ASD, possibly after a reduction in pressure in the subacromial space. The Constant score did not differ significantly between those patients with unchanged or even increased calcifications and those with decreased or even resorbed calcifications. One patient had an increase of the calcific deposit on postoperative x-ray evaluation but nevertheless an excellent Constant score of 98 points. The change in size of the calcific deposit at a 2-year follow-up does not seem to be important for the postoperative outcome. In many cases the calcific deposits are small and difficult to find on arthroscopy. This study indicates that the postoperative outcome might be as satisfying if we ignore calcifications when performing ASD.
Surg I998
deposition disease Dis 1979;5:807-22. treatment 13:240-l
and
the
of calcific
soft
tendinitis.
subacromial J Bone Joint
decomSurg Br
Esch JC. Calcific tendinitis. In: Whipple TL, Esch JC, Baker JRCL, editors. Arthroscopic surgery. The shoulder and elbow. Philadelphia: tippincott; 1993. p. 195200. Farin PU, Jaroma H, Soimakallio S. Rotator cuff calcifications: treatment with US-guided technique. Radiology 1995;195:841-3.
12
Faui-e G, Daculsi G. Calcified Ann Rheum Dis 1983;42(Suppl):49-53.
13
Gartner J, Heyer A. Tendinosis Orthoptide 1995,24:284-302.
14
Gschwend
N,
Scherer
M,
tendinitis: calcarea
tohr
J. Die
a review. der
Schulter.
Tendinitis
cal-
I Shoulder E/bow Volume 7, Number
Tillander
Surg 3
carea des Schultergelenkes 10: 196205.
(T.c.).
Orthoptide
198
15
Harmon 2,580 44.
16
Hazleman B. Clinical conundrum: natus tendon such a common J Rheumatol 1990;29:373.
17
Hedtmann A, Fett H. Die sogenannte periarthropathia humeroscapularis-Klassifizierung und analyse hand von 1266 FGIlen. Z Orthop 1989; 125:643-9.
1;
PH. Methods and results in the treatment painful shoulders. Am J Surg 1958;95:525-
ooeraPraxis
19
Johannsen VJ, Holmark NA, Sojbjerg JO,Sneppen Arthroscopic treatment of calcifying tendinitis. Orthop Stand 1996;67(Suppl 267):25.
0. Acta
20
Lippmann RK. Observations cuff deposit. Clin Orthop
21
Litchman HM, Silver surgical management der. An analysis of 1968;50:474-9.
22
McCarty associated tis Rheum
23
McKendry RJR, Uhthoff HK, Sarkar K, St George Hyslop P. Calcifying tendinitis of the shoulder: prognostic value of clinical. histoloaic. and radioloaic features In 57 surgically treated”c&es. J Rheum& 1982;9:75-80.
25
concerning 1961;20:49-59.
the
CM, Simon SD, Eshl-agi A. The of calcific tendinitis of the shoul100 consecutive cases. Int Surg
McLaughlin HI. lesions of the musculotendinous the shoulder. Observations on the pathology, and treatment of calcific deposits. Ann Surg 124:354-62.
cuff of course 1946;
HL. The selection of calcium deposits the technique and results of operation. Am 1963;43: 1501-4.
BOUND Bound
volumes
subscribers and
of the
(only)
$82.00 contains
shipped
within
from
issues
days
after
author
with
the Journal
name,
must
accompany
all
Westline
Industrial
Subscriptions regular
Journal
29.
Norlin versus 321-3.
R. Arthroscopic subacromial decompression open acromioplasty. Arthroscopy 1989;5:
30.
Painter 1907;
CF. Subdeltoid 156:345-9.
31.
Pfister J, Gerber humeroscapularis lung: retrospektive 1994; 132:300-5.
32.
Reichelt A. Beitrag zur operativen Therapie nosis calcarea der Schulter. Z Orthop 21-4.
33.
Rowe CR. Calcific tendinitis. In: Rowe CR, shoulder. New York: Churchill iivingstone; 122-9.
34.
Ruttimann G. Uber die Haufigkeit rontgenologischer Verbnderungen bei Patienten mit typischer Periarthritis humeroscapularis und bei Schultergesunden. Inaugural-Diss. Zurich: Juris-Verlag; 1959.
3.5
Uhthoff HK, Sarkar K. Calcifying tendinitis. In: Rockwood CR Jr, Matsen FA Ill/ editors. The shoulder. Vol 2. Philadelphia: WB Saunders; 1990. p. 774-90.
36.
Uhthoff Orthop
37.
Welfing J, Kahn M-F, Desroy Seze S. Les calcifications de des calcifications tendineuses 1965;32:325-34.
St.
Louis,
and
for domestic,
7, shipping
and
number, Contact
MO
bursitis.
Boston
Behandlung der calcarea mittels Fragebogenanalyse.
all and
Mosby,
Elbow
Surgery
charges
in the volume.
The
year
stamped
Inc.,
Subscription
USA,
or
in gold call
Copies
to
the
Services, (800)
bound are
is durable on
453-4351
spine. 1 1830 or
1 must
be in force
subscription.
to qualify.
Bound
volumes
are
not
available
editor. 1988.
The p.
Beitr
M, Paoioggi J-B, De 18paule. II. la maladie multiples. Rev Rheum
Each
binding
J
der Tendi198 1; 1 19:
calcificans.
available
is removed.
Surg
Periarthropathia SchulterkatkspuZ Orthop
for Canadian,
included.
advertising
63146-3318,
are
$87.74
and operaClin North
Med
TO SUBSCRIBERS
of the last issue
volume
H.
of nonoperative deposits. Surg
HK, Sarkar K. Tendopathia Traumat 198 1 ;28:269-77.
of $76.00
for Vol.
orders.
The results of calcified 15056.
of Shoulder
indexes,
publication
buckram,
Dr.,
at a cost
subscribers, and
Payment (3 14)453-435
Neer CS. Cuff tears, biceps lesions and impingement. In: Charles S, Neer II, editors. Shoulder reconstruction. Philadelphia: WB Saunders; 1990. p. 41-l 42.
AVAILABLE
of Journal
the Publisher,
subject 60
28.
for Surg
VOLUMES
1998
for international
volume
Moseley HF. tive treatment Am 1963;43:
calcific
DJ, Gaiter RA. Recurrent acute inflammation with focal apatite crystal deposition. Arthri1966;9:804-19.
McLaughlin operation: Clin North
27.
an-
calcarea die Orthop
24
Mol& D. The arthroscopic treatment of calcifying tendinitis. Results of the multicentric European Study. Fifth International Conference on Shoulder Surgery, Paris, July 1992.
why is the supraspisite for calcification?
Huber HM. 1st bei der Tendinitis tive Kalkentfernung gerechtfertigt. 1992;3:179-83.
217
26.
of
18
and Norlin
in place
of a
MD, and Rolf 0.
Norlin,
MD,
PhD,
Fifty patients were reviewed after arthroscopic subacromial decompression. Twenty-five had calcific deposits in the rotafor cuff visible on x-ray evaluation. Each patient with calcification was matched with a patient without calcificafion who had a similar state of the rotator cuff, date of surgery, age, and sex. The calcific deposits were left untouched in all cases. No significant difference was found in the postoperative outcome between the patients in the two groups measured by the Constant score. Before surgery 7 (28%) patients had calcifications of <5 mm, and 18 (72%) pafienfs hod calcifkaf;ons that were 25 mm. At a 2.year follow-up (n = 24) these figures were 20 (83%) and 4 /77%), respectively Q < 0.00 1). Postoperative x-ray evaluations revealed a disappearance or decrease in size of the calcific deposits in J 9 (79%) of the patients. These results provide new information on the course of calcifying tendinitis, which may indicate that we can leave calcific deposits untouched within the rotator cuff when performing arthroscopic subacromial decompression. (1 Shoulder Elbow Surg 7998;7:2 J3-7.)
of calcium carbonate apaThe d eposition tite6z ’ 2, 22 within the rotator cuff is commonly found in both symptomatic and asymptomatic shoulders.*, 16, 37 Hedtmann and Fett17 noted calcific deposits on x-ray evaluations in 17% of 1266 patients with painful shoulders. In patients with no symptoms the figures vary between 2.7% and 2()yo,2,34>
37
The calcifications are usually categorized into two types. In type 1 the deposit exhibits a diffuse appearance with poorly defined borders, whereas in type 2 the calcification is homogenous, dense, and has a well-defined margin.4, 5, 23 Type 1 deposits are most common in patients with acute pain, and type 2 are most common in patients with chronic pain.5 From
the
Department
of Orthopaedics,
Reprint requests. Bo paedics, University
Tillander, Hospital,
MD, S-58
University
Hospital.
Department of 1 85 Linkoping,
OrthoSwe-
den. Copyright Board
0 1998 of Trustees.
1058-2746/98/$5.00
by Journal + 0
of Shoulder 32/l/84045
and
Elbow
Surgery
Linkoping,
Sweden
According to some authors calcifying tendinitis is a self-limiting disease with subsequent healing of the tendon.z4, *5, 35, 36 In the acute phase the deposits are resorbed within a few weeks,13 and the treatment of choice is a subacromial cortisone injection. 33 Some authors sugg est needling and lavage. 11, 15,20 In the chronic stage the patient either has no pain or describes slight or moderate pain.4, 35 The cause of the pain is not clear. Uhthoff and Sarkar35 suggested
that
it
originates
from
the
increased
intratendinous pressure in the vicinity of the calcific deposit, whereas DePalma4 proposed that a local bursitis causes the pain. The size of the calcification does not seem to play a major role for the severity of the pain.51 *,*A Treatment of the chronic phase of calcifying tendinitis includes physiotherapy and analgesics.35 Invasive treatment may include needling, lavage and subacromial cortisone injection,3’ and open25, 33 or arthroscopic7 removal of the calcification. In both open and arthroscopic surgery the removal of calcification may be combined with bursectomy,‘, 25, 32 bursectomy, division of the coracoacromial ligament,5, l4 partial resection of the coracoacromial ligament,4, 35 and acromioplasty.8-'Or
'8.
19, 26
Ellman and Kay9 reported a satisfactory outcome in each of 14 cases after arthroscopic subacromial decompression (ASD) combined with a removal of the calcific deposits. They did not, however, compare this method with a simple removal of the deposits or with ASD without a removal of the calcific deposits. The purpose of this study was to evaluate whether untouched calcific deposits play a role for the postoperative outcome after ASD. MATERIAL
AND
METHODS
Between February 1992 and July 1994, 194 patients underwent ASDz9 at our institution. Open surgery was never performed. The preoperative diagnosis in all cases was impingement syndrome: chronic pain for more than 1 year, which was exacerbated by activity,
213
2 14
Table surgery
Tillander
and Norlin
I Clinical outcome at 2 years and at 2year follow-up
after
ASD,
measured
by the Constant
score
and
Active Active
n Calcific group Noncalcific
25 25
Preoperative 141 139
Surg
J Shoulder Elbow May/June
flexion
Active
2-year follow-up 154 150
abduction 2-year follow-up
Preoperative 126 126
Preoperative
154 145
67 62
the active
range
outward rotation
of motion
I998
before
Constant score (points)
2-year follow-up 46 47
Median
value
(range) 78 79
(55-l (37-l
00) 00)
group
night pain, and a positive impingement test. Indications for surgery were shoulder pain and impairment of function for more than 1 year despite conservative treatment including physical therapy, nonsteroidal antiinflammatory medications, and steroid injections. A positive impingement test before surgery was found in all cases. No cases of instability were found. Patients with an acute exacerbation of calcifying tendinitis who had sudden severe pain caused by secondary inflammatory bursitis did not undergo surgery. Thirty-two (16%) of these patients had calcific deposits on preoperative x-ray evaluation. Roentgenograms of the affected shoulder were taken in four positions: anteroposterior views in internal and external rotation, a lateral view in the scapular plane, and an axillary view. The size and structure of each calcific deposit were recorded to compare preoperative and postoperative findings on roentgenograms. The preoperative x-ray evaluation showed calcific deposits of type 1 in 4 cases and of type 2 in 28 cases. The time between onset of symptoms and surgery was at an average 5.5 years (range 1 to 18 years). ASD was performed on all patients. The calcific deposits were left untouched. Five patients were excluded from the study: one patient with arthrosis of the glenohumeral joint, a second who previously had surgery with open biceps tenodesis, a third who could only be interviewed by telephone, and two patients with a rotator cuff rupture. Another two patients were not available for reexamination. The remaining 25 patients with calcific deposits on the preoperative x-ray evaluation were reexamined by an independent examiner. Each one of these patients was matched with another patient without calcification on x-ray evaluation with similar state of the rotator cuff, date of surgery, age, and sex. In 18 of the 25 cases the rotator cuff was described as normal at surgery, and in 7 cases a partial deep surface tear of the supraspinatus tendon was found. The date of surgery within each matched pair of patients was the same +3 months. The follow-up time after surgery was 2 years (range 9 to 39 months, median 24 months). The Constant score was
used.3 follow-up evaluation was blind regarding the presence or absence of calcific deposits on x-ray evaluation. Twenty-four patients with calcifications before surgery were reexamined by x-ray evaluation 12 to 42 months after surgery. One patient did not permit a postoperative x-ray evaluation to be performed. The same x-ray views were taken before surgery and at follow-up. The calcifications were classified according to their size in the greatest dimension. 2, 25 The chi-squared and paired t tests were used for statistical analysis of the data. RESULTS
The mean
age in the two matched groups was 40 to 53 years) for women and 53 years (range 41 to 67 years) for men. Seventyfour percent of the patients were women. Of the patients with calcifications in the rotator cuff, 60% had their right shoulder involved. In 68% the calcification was found on the patient’s dominant side. Postoperative active range of motion did not show any significant difference between the calcific (n = 25) and the noncalcific groups (n = 25) (Table I). The mean value of forward flexion among patients with calcific deposits on preoperative xray evaluation increased from 141’ to 154” (p < 0.1) and among patients without calcification from 139” to 150” (NS). Th e mean value of abduction increased from 126” to 154” in the calcific group (p < 0.05) and from 126” to 145” in the noncalcific group (p < 0.1). External rotation decreased in both groups from 67” to 46” in the calcific group (p < 0.05) and in th e noncalcific group from 62” to 47” (NS) (see Table I). The postoperative results with respect to pain, activities of daily living, range of motion, and power in the group of patients with calcifications were almost identical with the results in the group 47
years
(range
J Shoulder E/bow Volume 7, Number
Tillunder
Surg 3
Table II Change in size of the calcific and Constant score at 2year follow-up Number patients Calcification at follow-up Increased Unchanged Decreased Resorbed
of (with
ASD
Constant score (points; median, range)
We 1 calcifications) ’ (0) 4 (0) 61’) 13 (2)
deposit after (n = 24)
\ / \ /
75 78
(55 (62-l
100) 00)
of patients without calcifications on preoperative x-ray evaluation, measured by the Constant score.3 The median value in the first group (n = 25) was 78 points (range 55 to 100 points) and in the latter group (I-I = 25) 79 points (range 37 to 100 points) (see Table I). Seventy-two percent of the patients without calcific deposits on x-ray evaluation were satisfied with the postoperative result compared with 80% of the patients with calcification in the rotator cuff. This difference was not significant. In 13 (54%) of the 24 patients who were examined by x-ray evaluation after surgery (Table II), the calcific deposits had completely disappeared. Among these patients two had type 1 calcifications on preoperative x-ray evaluation, and 1 1 had type 2 calcifications. In another six (25%) patients the calcifications had decreased in size. One of these patients had a type 1 calcification on preoperative x-ray evaluation, and the other five patients had type 2 calcifications (see Table II). The calcifications were unchanged after surgery in four cases. No significant difference was seen in the postoperative result measured by the Constant score when the patients with increased or unchanged calcifications were compared with those with decreased or resorbed ones (see Table II). In one case more than 2 years after surgery, the calcific deposit on x-ray evaluation had increased compared with the preoperative findings. Despite that, the Constant score was 98 points. Before surgery 17 patients (n = 24) had calcifications of 5 mm or more (71%). Of these, three calcifications were greater than 15 mm, and seven (29%) had calcific deposits smaller than 5 mm. On x-ray evaluation at follow-up 20 (83%) of 24 patients had no or small (<5 mm) calcifications left F our (17%) patients had calcifica(p < 0.001). tions left that were 5 mm or greater (Table Ill).
Table before
III Number of patients surgery and at 2year
Size of calcification (mm)
0 1-4 5-15 >15
and
Norlin
2 15
with different size calcification follow-up (n = 24)
No. patients
of (with
We 1 calcifications)
0 PI 7 (0) 14 (21 3 (11
No. of patients at at 2-year follow-up 13 7 3 1
DISCUSSION
In 1907 Painter30 demonstrated calcifications on x-ray evaluation for the first time. Bosworth* suggested that “large deposits should be excised regardless of symptoms” but “medium and tiny deposits should, in general, be treated conservatively.” Later the need for surgery was considered by Mctaughlinz5 to be “almost never absolutely necessary” or according to Uhtoff and Sarka.rs5 “the exception.” The fact that the calcific deposits disappear spontaneously supports this strategy of treatment.24, 25, 35 Furthermore a great number of patients show visible calcifications on x-ray evaluation but do not have any or only minor symptoms.*, 34, 37 These findings may raise the question that if a calcification is present, is it always the cause of pain in the patient with chronic shoulder pain?’ In the acute phase of calcifying tendinitis the calcifications are resorbed within a few weeks,13, *O and neither open nor arthroscopic surgery is indicated. 33 The cause of the pain is presumed to be the bursitis.20, 25 In the chronic phase both diagnosis and choice of correct treatment may be more difficult. It is difficult to know whether the calcification is the source of the pain or just an insignificant finding on x-ray evaluation. The clinical picture resembles impingement syndrome2s in terms of pain at rest, at night, and when lifting the arm. The impingement test is positive in both calcifying tendinitis and in other types of impingement syndrome. Several authors have reported good results after surgical excision of calcifications, but in most of these reports removal of calcification is combined with bursectomy, 1’ 25, 32 bursectomy and division of the coracoacromial ligament,5, l4 partial resection of the coracoacromial ligament,4, 35 and/or acromioplasty.8-‘0, 15, 19, 26 Harmon15 and Litch-
216
Tillander
and Norlin
man et al?’ reported good results after removal of calcific deposits without any of the previously mentioned measures but had a great number of patients with acute symptoms. In this study the postoperative result at a 2-year follow-up measured by the Constant score was as good for the patients who had calcific deposits on preoperative x-ray evaluation as it was for patients without. If the calcification itself had a negative influence on the postoperative outcome, one would expect a lower value of the Constant score in the patients with calcification on preoperative x-ray evaluation. This result was not found in this study. Even the patients’ active range of motion before surgery compared with the postoperative results did not differ between the patients with and without calcifications. As many as 54% of the patients had no calcification on x-ray evaluation at follow-up, although the calcifications had not been removed during surgery, whereas in 25% of the patients the calcific deposits had decreased in size. The number of patients with calcifications smaller than 5 mm had increased significantly from 29% to 83% (p <
J Shoulder Elbow May/June
evaluation do not need surgical treatment. Among those with persisting pain over years, we still do not always know the cause of the pain. Many authors describe a removal of calcific deposits combined with bursectomy, division or removal of the coracoacromial ligament, or acromioplasty. We perform ASD on patients with chronic pain and a positive impingement sign, because we believe that these patients have a subacromial problem. The results of this study indicate that the calcifications may not be the cause of the pain but a finding that we may regard as an insignificant observation on x-ray evaluation with regard to the indication for treatment. The tance.
thank
Mrs.
lnger
Eriksson
for
her
assis-
1.
Ark JW, Flock TJ, Flatow Et, Bigltani LU. Arthroscopic treatment of calcific tendinitis of the shoulder. Arthroscopy 1992;8: 183-8.
2.
Bosworth subacromtal
3.
Constant functional 1987;2
4.
DePalma AF. Calcareous tendinitis. In: DePalma AF, editor. Surgery of the shoulder. Philadelphia: Lippincott; 1983. p. 257-85. DePalma AF, Kruper JS. tong-term study of shoulder joints afflicted with and treated for calcific tendinitrs. Clin Orthop 1961;20:61-72.
5.
BM.
Culcium deposits bursitis JAMA 1941;
CR, Murfey assessment 14: 160-4.
AHG. of the
in the shoulder 1 16:2477-82.
A clinical shoulder.
and
method of Clin Orthop
6.
Dieppe tissues.
P. Crystal Clin Rheum
7.
Ellman Orthop
H. Arthroscopic Trans 1989;
8.
Ellman H, Bigliani LU, Flatow E, et al. Arthroscopic treatment of calcifying tendinitis: the American Experience. Fifth International Shoulder Conference, Paris, July 1992:1-15.
9.
Eilman H, Kay SP. Arthroscopic pression for chronic impingement. 1991;73B:395-8.
10
11 CONCLUSION
Calcification on x-ray evaluation is a condition that is found in both painful and painfree shoulders. The calcifications are resorbed spontaneously, and the tendon heals. Most patients with painful shoulders and calcific deposits on x-ray
authors
REFERENCES
0.001).
Bosworth2 found among 202 shoulders a disappearance of the calcific deposits in only 6.4% of the shoulders. This result may indicate that the calcifications disappear more rapidly after ASD, possibly after a reduction in pressure in the subacromial space. The Constant score did not differ significantly between those patients with unchanged or even increased calcifications and those with decreased or even resorbed calcifications. One patient had an increase of the calcific deposit on postoperative x-ray evaluation but nevertheless an excellent Constant score of 98 points. The change in size of the calcific deposit at a 2-year follow-up does not seem to be important for the postoperative outcome. In many cases the calcific deposits are small and difficult to find on arthroscopy. This study indicates that the postoperative outcome might be as satisfying if we ignore calcifications when performing ASD.
Surg I998
deposition disease Dis 1979;5:807-22. treatment 13:240-l
and
the
of calcific
soft
tendinitis.
subacromial J Bone Joint
decomSurg Br
Esch JC. Calcific tendinitis. In: Whipple TL, Esch JC, Baker JRCL, editors. Arthroscopic surgery. The shoulder and elbow. Philadelphia: tippincott; 1993. p. 195200. Farin PU, Jaroma H, Soimakallio S. Rotator cuff calcifications: treatment with US-guided technique. Radiology 1995;195:841-3.
12
Faui-e G, Daculsi G. Calcified Ann Rheum Dis 1983;42(Suppl):49-53.
13
Gartner J, Heyer A. Tendinosis Orthoptide 1995,24:284-302.
14
Gschwend
N,
Scherer
M,
tendinitis: calcarea
tohr
J. Die
a review. der
Schulter.
Tendinitis
cal-
I Shoulder E/bow Volume 7, Number
Tillander
Surg 3
carea des Schultergelenkes 10: 196205.
(T.c.).
Orthoptide
198
15
Harmon 2,580 44.
16
Hazleman B. Clinical conundrum: natus tendon such a common J Rheumatol 1990;29:373.
17
Hedtmann A, Fett H. Die sogenannte periarthropathia humeroscapularis-Klassifizierung und analyse hand von 1266 FGIlen. Z Orthop 1989; 125:643-9.
1;
PH. Methods and results in the treatment painful shoulders. Am J Surg 1958;95:525-
ooeraPraxis
19
Johannsen VJ, Holmark NA, Sojbjerg JO,Sneppen Arthroscopic treatment of calcifying tendinitis. Orthop Stand 1996;67(Suppl 267):25.
0. Acta
20
Lippmann RK. Observations cuff deposit. Clin Orthop
21
Litchman HM, Silver surgical management der. An analysis of 1968;50:474-9.
22
McCarty associated tis Rheum
23
McKendry RJR, Uhthoff HK, Sarkar K, St George Hyslop P. Calcifying tendinitis of the shoulder: prognostic value of clinical. histoloaic. and radioloaic features In 57 surgically treated”c&es. J Rheum& 1982;9:75-80.
25
concerning 1961;20:49-59.
the
CM, Simon SD, Eshl-agi A. The of calcific tendinitis of the shoul100 consecutive cases. Int Surg
McLaughlin HI. lesions of the musculotendinous the shoulder. Observations on the pathology, and treatment of calcific deposits. Ann Surg 124:354-62.
cuff of course 1946;
HL. The selection of calcium deposits the technique and results of operation. Am 1963;43: 1501-4.
BOUND Bound
volumes
subscribers and
of the
(only)
$82.00 contains
shipped
within
from
issues
days
after
author
with
the Journal
name,
must
accompany
all
Westline
Industrial
Subscriptions regular
Journal
29.
Norlin versus 321-3.
R. Arthroscopic subacromial decompression open acromioplasty. Arthroscopy 1989;5:
30.
Painter 1907;
CF. Subdeltoid 156:345-9.
31.
Pfister J, Gerber humeroscapularis lung: retrospektive 1994; 132:300-5.
32.
Reichelt A. Beitrag zur operativen Therapie nosis calcarea der Schulter. Z Orthop 21-4.
33.
Rowe CR. Calcific tendinitis. In: Rowe CR, shoulder. New York: Churchill iivingstone; 122-9.
34.
Ruttimann G. Uber die Haufigkeit rontgenologischer Verbnderungen bei Patienten mit typischer Periarthritis humeroscapularis und bei Schultergesunden. Inaugural-Diss. Zurich: Juris-Verlag; 1959.
3.5
Uhthoff HK, Sarkar K. Calcifying tendinitis. In: Rockwood CR Jr, Matsen FA Ill/ editors. The shoulder. Vol 2. Philadelphia: WB Saunders; 1990. p. 774-90.
36.
Uhthoff Orthop
37.
Welfing J, Kahn M-F, Desroy Seze S. Les calcifications de des calcifications tendineuses 1965;32:325-34.
St.
Louis,
and
for domestic,
7, shipping
and
number, Contact
MO
bursitis.
Boston
Behandlung der calcarea mittels Fragebogenanalyse.
all and
Mosby,
Elbow
Surgery
charges
in the volume.
The
year
stamped
Inc.,
Subscription
USA,
or
in gold call
Copies
to
the
Services, (800)
bound are
is durable on
453-4351
spine. 1 1830 or
1 must
be in force
subscription.
to qualify.
Bound
volumes
are
not
available
editor. 1988.
The p.
Beitr
M, Paoioggi J-B, De 18paule. II. la maladie multiples. Rev Rheum
Each
binding
J
der Tendi198 1; 1 19:
calcificans.
available
is removed.
Surg
Periarthropathia SchulterkatkspuZ Orthop
for Canadian,
included.
advertising
63146-3318,
are
$87.74
and operaClin North
Med
TO SUBSCRIBERS
of the last issue
volume
H.
of nonoperative deposits. Surg
HK, Sarkar K. Tendopathia Traumat 198 1 ;28:269-77.
of $76.00
for Vol.
orders.
The results of calcified 15056.
of Shoulder
indexes,
publication
buckram,
Dr.,
at a cost
subscribers, and
Payment (3 14)453-435
Neer CS. Cuff tears, biceps lesions and impingement. In: Charles S, Neer II, editors. Shoulder reconstruction. Philadelphia: WB Saunders; 1990. p. 41-l 42.
AVAILABLE
of Journal
the Publisher,
subject 60
28.
for Surg
VOLUMES
1998
for international
volume
Moseley HF. tive treatment Am 1963;43:
calcific
DJ, Gaiter RA. Recurrent acute inflammation with focal apatite crystal deposition. Arthri1966;9:804-19.
McLaughlin operation: Clin North
27.
an-
calcarea die Orthop
24
Mol& D. The arthroscopic treatment of calcifying tendinitis. Results of the multicentric European Study. Fifth International Conference on Shoulder Surgery, Paris, July 1992.
why is the supraspisite for calcification?
Huber HM. 1st bei der Tendinitis tive Kalkentfernung gerechtfertigt. 1992;3:179-83.
217
26.
of
18
and Norlin
in place
of a