Caroline Parlier Cuau Marc Wybier and Jean Denis Laredo

Department of Bone and Joint Radiology, Lariboisière Hôpital, Assistance Publique-Hopîtaux de Paris, Paris, France

INTRODUCTION

Calcific tendinitis results from the deposition of calcium hydroxyapatite crystals in or around tendons mostly in periarticular locations. The shoulder is the most frequent location of calcific tendinitis. However, calcific tendinitis may be encountered in a large variety of anatomical locations such as the hip, wrist, foot, and cervical spine. Some patients have a single joint involved, whereas many others have bilateral involvement of the shoulders or involvement of multiple different joints (calcium hydroxyapatite deposition disease).

Apatite deposits may be symptomatic. In such cases, pain may be related to the inflammation process caused by the presence of the calcification (1). The aim of needle aspiration in calcified deposits (NACD) is to remove a significant part of the calcification to decrease the patient's pain. Partial removal of the calcification by the needle aspiration is usually followed by a spontaneous resorption of the remaining calcium (2). This is probably facilitated by the opening of the calcium-containing cavity at the time of needle aspiration (3-5). NACD is mostly indicated in calcified tendinitis of the shoulder; however, it may be occasionally performed in other anatomic locations.

INDICATIONS

The procedure has three goals: evacuation of a maximum of calcium, opening of the calcium-containing cavity, and fragmentation of the residual calcific deposits in order to facilitate resorption during the following weeks, with reduction of inflammation secondary to the presence and migration of residual calcific deposits by in situ injection of corticosteroids.

The most important clinical selection criterion for NACD is exacerbation of pain at night (6,7). Conversely, absence of pain at night, pain caused by a specific kind of motion within a given arc, and limitation of a specific motion suggest that pain is related to an impingement syndrome rather than to the calcific deposit. Prior studies have shown that, in most cases, no cuff tear is associated with calcified tendinitis (5,8,9). Prior to NACD, a careful radiologic evaluation is necessary. The structure of the calcific deposits and their relation to the rotator cuff tendons and subacromial bursa must be determined (1,7). Other features to evaluate are number, size, density, contours, and homogeneity of the calcific deposits and their tendency to evacuate into the subacromial bursa (4,5). The absence of changes on successive X-rays suggests an indication for needle aspiration. The calcification must be larger than 5 mm in diameter. The composition of the deposit will determine the success or failure of the aspiration. Faint milky calcifications with fuzzy contours are usually liquid and easily aspirated (Fig. 1), whereas very dense calcifications with clearly defined margins are often very hard and cannot be aspirated. Irregular striated calcifications are usually located within tendon fibers (Fig. 2). They usually correspond to degenerative tendinitis and cannot be aspirated.

TECHNIQUE

The technique described here is performed under fluoroscopic guidance and involves the shoulder, which is the most frequent site of tendinous calcific deposits. Recently, ultrasonography (US) has also been shown to detect and localize rotator cuff calcifications reliably (10). NACD under US guidance has also been reported by two different teams (3,10-12).

A direct anteroposterior approach under fluoroscopic guidance is used. The patient is placed in a supine position on the radiographic table. The X-ray beam is centered vertically to

FIGURE 1 (A) Supraspinatus calcific deposit with faint and milky appearances and fuzzy contours (usually liquid and easily aspirated). (B) After needle aspiration the plain radiograph shows hardly any residual deposit.

the shoulder or slightly tilted if this allows better separation of the calcium deposit from the underlying bone on the image intensifier screen. Arm position is chosen according to the location of the calcification within the rotator cuff. Aseptic conditions are mandatory. The skin and superficial planes are anesthetized with 1% lidocaine. A 19-gauge needle is vertically advanced under fluoroscopic guidance to the center of the calcification, following a direction parallel to the X-ray beam (Figs. 3 and 4A). During the entire approach, the needle appears on the image

Calcium Deposits Inside Arms Images
FIGURE 2 Calcific deposits with striated appearance. These calcifications are usually located within tendon fibers and cannot be significantly evacuated by needle aspiration.

FIGURE 3 Fluoroscopic procedure to check that the needle tip is within the calcific deposits. (a) When the X-ray beam is directed along the needle axis, the needle appears as a dot in the center of the calcification. (b, c) The X-ray beam is then successively tilted in maximal cephalad and caudad directions. If correctly placed, the needle tip will remain within the calcification. Source: From Ref. 13.

FIGURE 3 Fluoroscopic procedure to check that the needle tip is within the calcific deposits. (a) When the X-ray beam is directed along the needle axis, the needle appears as a dot in the center of the calcification. (b, c) The X-ray beam is then successively tilted in maximal cephalad and caudad directions. If correctly placed, the needle tip will remain within the calcification. Source: From Ref. 13.

Caroline Parlier

FIGURE 4 Anteroposterior radiograghs of the shoulder. (A) Supraspinatus calcific deposits. The needle is advanced parallel to the X-ray beam and appears on the screen as a single point in the center of the calcification. (B, C) The X-ray beam is successively tilted in maximal cephalad and caudad directions. The needle tip has to always be within the calcification.

FIGURE 4 Anteroposterior radiograghs of the shoulder. (A) Supraspinatus calcific deposits. The needle is advanced parallel to the X-ray beam and appears on the screen as a single point in the center of the calcification. (B, C) The X-ray beam is successively tilted in maximal cephalad and caudad directions. The needle tip has to always be within the calcification.

intensifier screen as a single point in the center of the calcification (Figs. 3 and 4A). At any time of the procedure, the X-ray beam can be successively tilted cranially and caudally to confirm on the screen that the needle is actually within the calcification (Figs. 3B, C and 4B, C). A firm sensation is obtained when the calcification is reached. Calcium aspiration is then performed using a syringe containing first lidocaine and then sterile water or saline solution (1-2 mm), doing a succession of propulsions and suctions with the syringe piston. Aspirated calcium appears in the syringe as a white, cloudy return (Fig. 5). This procedure is repeated until maximal aspiration of calcium has been obtained (Figs. 1 and 6). In large and lobulated calcific deposits, insertion of two needles may be necessary (Fig. 7). The amount of calcium aspirated at the end of the procedure is variable and always incomplete (10-80%) (Figs. 1 and 6). In some cases, the calcification has a hard consistency and no calcium can be aspirated. However, grinding of the calcific deposit with the needle may in itself accelerate the process of spontaneous resorption (2,4,5,14) and is as important as aspiration. Once the maximum of calcium has been aspirated, 2 to 3-mL of prednisolone acetate (50-75 mg) is injected in situ (14). Radiographs are obtained at the end of the procedure to document evacuation of the deposits. In the great majority of cases, the procedure is well tolerated and painless.

Keeping the shoulder at rest for five or six days is recommended. One-third of patients have a painful reaction rarely lasting more than two to four days. This is managed with intermittent application of ice and prescription of pain medication and nonsteroid anti-inflammatory agents (14). This painful crisis is usually accompanied by an almost complete resorption of the remaining calcification.

Caroline Parlier
FIGURE 5 Aspirated calcium appears in the syringe as a white, cloudy return.

RESULTS AND DISCUSSION

Although aspiration of calcific deposits is conventionally done under fluoroscopy, they can also be performed quickly and efficiently with US. Usually, rotator cuff calcifications appear under US as bright echogenic images with posterior acoustic shadowing (3,11). In this case, it is easy to localize the calcific depots; then US offers a nonionizing imaging technique and a valuable tool for guiding aspiration. Its realtime capabilities permit continuous monitoring of the needle position relative to the target and to surrounding structures. In few cases, calcifications appear

FIGURE 7 Large and lobulated calcific deposit of the supraspinatus. Two needles have been necessary to obtain a maximal aspiration of calcium.

without posterior acoustic shadowing (3), and US guidance could be more difficult than fluoro-scopic guidance. Anyway US and fluoroscopic guidance both could be used, but they both mandate a proper training.

According to several studies, good and excellent results are achieved in 61% (5) to 74% (11) of cases. Comfort and Arafiles, in 1978, first described this technique and reported nine cases followed for an average of nine years (2). Good-to-excellent results were obtained by needle irrigation and aspiration, and follow-up on plain radiographs showed no residual deposits. In 1989, Normandin et al. reported 69 cases of calcific tendinitis treated by needle aspiration (5). The clinical results were good in 60.9% of cases at 11 to 45 months (mean, 24) of follow-up. Aspiration of large amounts of calcium and secondary resorption of residual deposits on plain radiographs in the following weeks were significantly associated with good results. By contrast, in cases of hard stone-like consistency of the calcification or in cases of calcification encrusted within the tendon fibers, no significant calcium was usually aspirated, and the result of the procedure was poor. In 1994, Pfister and Gerber reported on 212 patients with calcific tendinitis of the shoulder treated with needle aspiration (15,16). At five years of follow-up, 60% of the patients were free of pain, 34% had a marked pain relief, and 6% were unchanged. These results, however, were not compared to the spontaneous outcome of shoulder calcific tendinitis, which is often favorable. In 1996, Farin et al. reported 61 patients with rotator cuff calcifications treated by needle aspiration and lavage under US guidance (11). Clinical results were good in 74% of cases and moderate or poor in 26%. Clinical results were compared to the changes in the calcification on plain radiographs at one-year follow-up. In cases with a good result, the calcification decreased in size in 86% of cases, whereas no change was seen in 14% of cases. In cases with a moderate or poor result, the calcification decreased in size in 37% of cases, whereas no change was seen in 63% of cases (11).

Surgical excision of calcifications of the rotator cuff gives prompt, complete, and permanent relief of symptoms (17). At present, surgical excision of calcifications is mostly performed through arthroscopy (18,19). There are, however, many objections to the use of surgery as the primary procedure in rotator cuff calcifications mainly owing to a prolonged period of disability and potential complications of surgery, especially the risk of secondary reflex sympathetic dystrophy. Therefore, NACD should always be attempted first because it is a minimally invasive technique providing good results in at least two-thirds of cases (2,5,11,15). In our experience, there are no technical failures resulting from difficulty in locating the calcification with the needle, under fluoroscopic guidance. As in arthroscopic treatment of calcific tendinitis (18), it seems not essential with NACD to remove the deposit completely. If the size of calcification is unchanged after the procedure, however, it is important to obtain a decreased density of the calcification. The good results in such cases can be explained by the opening of the calcium-containing cavity and creation of a communication between the cavity and surrounding vascu-larized tissues (Fig. 8). This may cause local inflammation and hyperhemia, which in turn accelerates the process of resorption.

Eswt Infraspinatus
FIGURE 8 (A) Infraspinatus calcific deposits. (B) Most of the calcification cannot be aspirated, but creation of a communication between the cavity and surrounding vascularized tissues may cause local inflammation and hyperhemia, which accelerates the process of resorption.

Extracorporal shock-wave therapy (ESWT) in the treatment of shoulder calcific tendinitis has been recently described (20-25). It may offer a new and safer additional nonoperative treatment of chronic calcific tendinitis of the shoulder. Good and excellent results were obtained in 55% (24) to 64% (21,22) of cases. Charrin and Noel reported a series of 32 patients treated with ESWT (24). Improvement in pain was noted in 55.1% of the patients after 24 weeks. Sixty-two percent of the patients were at significantly improved at 12-week-follow-up in another series of 21 patients (23). In a series of 50 patients treated with ESWT, Rompe et al. had 60% good and excellent results after one year and 64% good and excellent results after two years. The results have been significantly improved by the use of exact focusing of ESWT (20,24) and high-energy shock waves (21-23). All these reports, however, are noncontrolled studies and have an open format. Ebenbichler et al. have conducted a randomized, double-blind study in patients with symptomatic calcific tendonitis (26). Results showed that ESWT helps resolve calcifications and is associated with short-term (six weeks) clinical improvement. But at nine months, the difference between the two groups was no longer significant.

CONCLUSION

In cases of calcific tendinitis, needle aspiration of tendinous calcific deposits is a well-tolerated conservative procedure that should be attempted after failure of medical treatment in chronically painful shoulders associated with rotator cuff deposits. Excellent and good results vary from 61% to 74% of patients. In these patients, dramatic and durable improvement is obtained without surgery. Therefore surgery should be reserved to failures of NACD. ESWT for calcific tendonitis appears to be an effective therapy in 55% to 64% of the cases, but additional controlled studies are necessary to confirm the value of this technique.

REFERENCES

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