Departments of 1Medical Imaging and 2Orthopaedics, Rotherham General Hospital NHS Trust, Moorgate Road,. RotherhamS60 2UD, UK. Abstract.
1995, The British Journal of Radiology, 68, 716-719
Ultrasound guided aspiration of symptomatic supraspinatus calcific deposits 1
M BRADLEY, MB, ChB, FRCR, 2 M S BHAMRA, ChM, FRCS and 2 M J ROBSON, FRCS
Departments of 1Medical Imaging and 2Orthopaedics, Rotherham General Hospital NHS Trust, Moorgate Road, RotherhamS60 2UD, UK Abstract
11 consecutive patients with shoulder pain were referred from the shoulder clinic for plain radiography. Supraspinatus calcific deposits were suspected after other causes of shoulder pain had been eliminated by clinical examination and local anaesthetic tests. Radiographs confirmed calcific deposits in all 11 shoulders and all deposits were shown by ultrasound to be lying in the supraspinatus tendon. Using a free-hand ultrasound guidance technique, a 19 G needle was passed percutaneously into all 11 shoulders in an attempt to aspirate the deposit. Six patients experienced immediate pain relief or relief on the same day, whilst four others were pain free at the 2 weeks follow-up clinic. One patient who was thought to have a co-existing supraspinatus tear diagnosed by the scan was symptomatically unchanged. Calcium hydroxyapatite deposits are laid down in many tendons and peri-articular sites, but there is disagreement as to terminology regarding such deposition, i.e. whether it is "tendonosis" or "tendonitis". The supraspinatus tendon is probably the most commonly affected [1, 2] and, whilst this may be an asymptomatic condition, it is a recognized cause of severe shoulder pain which can last many weeks, months or even years. The standard therapeutic approach is usually local anaesthetic (lignocaine) or steroid injection into the subacromial space, or attempted injection into the tendon. Needling of the deposits by hand and without radiological guidance has been advocated [3] but this has not been successful in our experience. Barbotage, needling of deposits under fiuoroscopic guidance, has the disadvantage of exposing the patient to considerable radiation dosages [4]. Persistent pain and debility may eventually require an open or arthroscopic decompression [5] of the tendon and the subacromial space. This study demonstrates our preliminary experience of ultrasound guided aspiration of these deposits (Figure 1) which obviates the need for fiuoroscopic control and has proven effective in relieving symptoms.
of calcific deposits and showed no other abnormality (Figure 2). Ultrasound examinations were then performed using a linear 7.5 MHz probe, with or without a stand-off medium to obtain the best images. Longitudinal and transverse scans were" obtained through the rotator cuff in order to locate accurately the deposits and to exclude any other coincident pathology. After identification of deposits, a simple attempt to
Patients and methods
11 consecutive patients were referred from the shoulder clinic to the Medical Imaging Department. The mean age of the patients was 63 years (range 54-82 years). The time for presentation was between 3 months and 3 years from onset of symptoms. All patients had limitation of movements particularly on 30°-40° of abduction. In all 11 cases, radiographs confirmed the presence Received 21 September 1994 and in final form 6 February 1995, accepted 23 February 1995. 716
Figure 1. Ultrasound in a normal left shoulder demonstrates the normal supraspinatus tendon in the longitudinal plane (d, deltoid; h, humeral head; a, acromium; s, supraspinatus; b, sub-deltoid bursa).
The British Journal of Radiology, July 1995
US guided aspiration of symptomatic supraspinatus calcific deposits
Figure 2. (a) AP radiograph showing a large calcific deposit in the region of the supraspinatus tendon, (b) The longitudinal scan confirms the deposit (arrows) within the tendon. This large deposit is demonstrating "acoustic shadowing", (c) Radiograph 2 weeks post-aspiration confirms full resolution of the deposit, (s, supraspinatus; h, humeral head; a, acromium).
aspirate the deposits was made; each case utilizing a freehand ultrasound guided technique in the longitudinal plane of the supraspinatus tendon. Aspiration was performed via a 20 ml syringe with a 19 G needle. The tip of the needle was guided into the centre of the deposit and suction applied (Figure 3). Local anaesthesia was
not used routinely but only according to patient preference. A positive result was achieved when a small quantity of milky fluid (< 1 ml) was aspirated or when solid gritty material was seen in the syringe. If neither of these features were noted, the needle was then passed repetitively into the deposit to cause its maximum disruption. All aspirated material was sent for analysis. Post-procedure scans and radiographs were performed and a further radiograph was obtained at the 2 week follow-up clinic. Results
Figure 3. Longitudinal scan through the supraspinatus tendon shows the needle tip in a calcific deposit (arrows) during the freehand aspiration technique (a, acromium; h, humeral head; s, supraspinatus; n, needle).
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Ultrasound guided aspiration was the initial therapeutic procedure in eight patients, while in the other three patients hydrocortisone injection into the subacromial space had been performed. These latter three patients had not responded to the injections after 6 weeks and were therefore referred for ultrasound guided aspiration. 10 of the patients had no other identifiable pathology on ultrasound examination, while one patient was seen to have a tear of the supraspinatus tendon in addition to the calcific deposit. 111
M Bradley, M S Bhamra and M J Robson
Six patients experienced immediate pain relief at the end of the ultrasound aspiration with complete resolution of all shoulder symptoms at 1 week. Four other patients had complete pain resolution when reviewed in the shoulder clinic at 2 weeks. The remaining patient had limited pain relief, and was the patient who had a rotator cuff tear demonstrated on ultrasound. In five shoulders there was residual calcification on the post-aspiration radiograph (Figure 4) but the followup films performed at 2 weeks confirmed complete resolution of the calcific deposit in all 11 cases (Figure 2c). The post-procedure ultrasound scans were difficult to interpret due to artefacts in the area of interest, presumably due to local bleeding. At aspiration only four of the 11 patients' deposits were fluid in nature—less than 1 ml of milky fluid being obtained in each case. In the remaining seven shoulders, the aspirated material was solid and gritty. Birefringent crystals were confirmed on microscopy, and staining with Alizarin Red S suggested the presence of hydroxyapatite crystals in all the fluid and solid specimens. Patients were followed up for 6 months post-procedure with only one patient with persistent symptoms being treated for 14 months. Patients were asked to contact
the shoulder clinic if there was any recurrence of pain. There were no further communications up to 14 months post-procedure. Discussion
"Calcific tendonitis" is characterized by deposition of calcium phosphate crystals, predominantly hydroxyapatite, in tendons. The most frequent site is around the shoulder in the supraspinatus and long head of biceps brachii tendons [6], although any of the rotator cuff tendons can be involved. This may be either a primary or idiopathic condition or a secondary phenomenon associated with other disease processes which include end stage renal disease, collagen vascular disease, Vitamin D intoxification and tumoral calcinosis [7]. There have been many theories of the pathogenesis of peri-articular calcium deposits and the debate remains open. Consequently, terms such as "tendonosis" and "tendonitis" are used interchangeably by authors. In the supraspinatus tendon there is a relatively hypovascular section approximately 1 cm from its insertion. Hypoxia in this "critical area" may lead to fibrocartilagenous metaplasia and this has a propensity to calcify [2, 8].
Figure 4. (a) AP radiograph immediately post-aspiration revealing a small remaining fragment of the calcific deposit, (b) The scan confirmed this deposit in the supraspinatus tendon post-procedure (arrow), (c) The 2 week follow-up AP radiograph shows full resolution of the calcific deposit (a, acromium; s, supraspinatus; h, humeral head).
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The British Journal of Radiology, July 1995
US guided aspiration of symptomatic supraspinatus calcific deposits
Calcific tendonitis affects middle-aged women slightly more commonly than men. The condition may present with chronic or recurrent pain and disability, or as an acute severe shoulder pain with tenderness. Bosworth [9] found it to be an asymptomatic condition in onethird of cases. Moseley [10] described the natural history of this condition in three phases. During the "silent phase", the calcium deposit is contained within the tendon and appears radiographically as a sharply defined circumscribed deposit. When removed, this appears as a cheesy material. These patients have minimal symptoms. The deposit may then enlarge in the "mechanical phase", which is accompanied by impingement symptoms. The deposit liquefies, leading to bursitis, and the radiograph now shows a less well defined deposit. This is associated with an acutely painful shoulder. These "fluid" deposits are particularly amenable to complete aspiration by our procedure, as seen in four of our patients. The calcium may disperse at this stage into the subacromial or subdeltoid bursa. The disappearance of the deposit does not always correlate with the clinical course. In the late stages of "adhesive periarthritis", the patient is greatly debilitated by pain and limited shoulder movement. The calcium deposits are associated with an adhesive bursitis. Neer [3] discusses four types of pain in the aetiology of calcification. Firstly, pain due to the ability of the calcium to cause chemical irritation of the tissue. Secondly, pain due to swelling of the calcium deposit as a result of a hydrophilic reaction, leading to a semiliquid state in the deposit and an unrelenting pain due to raised pressure. Thirdly, the chemical irritation leads to bursal thickening, which can result in pain when the tendons are squeezed against the acromion. Finally, there may be stiffness of the shoulder due to chronic calcium deposition. Moseley's [9] final group and Neer's [3] third and fourth groups may derive most benefit from a surgical procedure where the deposit may be removed by curettage and any adhesive capsulitis is decompressed [11]. The large chalk-like deposits are likely to have been present for a long time prior to the onset of the acute episode. The results in the small group of patients in this study suggest that aspiration of these chronic deposits may lead to adequate relief, even though they may only be partially aspirated. Presumably the needle must decrease intratendinous pressure and cause sufficient disruption and localized bleeding for the remainder of the material
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to be absorbed or dispersed into the subacromial space. Ark et al [5] also noticed that even though arthroscopy did not fully aspirate the calcium deposits, significant pain relief was maintained. The arthroscopist can accomplish calcium deposit removal as well as bursectomy, coraco-acromial ligament release and acromial resection. It was shown that all our successful cases had calcium deposition as the only cause of their symptoms. This study relied on clinical examination and ultrasound to exclude other pathology to explain shoulder pain, but other clinicians may have individual preferences. The plain radiograph was extremely useful in enhancing diagnostic confidence, as it was felt that the ultrasound scan alone may underestimate small deposits or be misinterpreted for other pathology. In the authors' opinion, the advantage of ultrasound over fluoroscopy for needle guidance was easier positioning of the needle in relation to the calcium deposit without the need for ionizing radiation. References 1. PAINTER, C F, Subdeltoid bursitis Boston Med. Surg. J. 156, 345-349(1907). 2. KESSEL, L and BAYLEY, J I L, Clinical Disorders of the Shoulder (2nd edn) (Churchill Livingstone, London), pp. 68-71(1986). 3. NEER, C S II, Shoulder Reconstruction (W B Saunders Company, Philadelphia, USA), pp. 427-433 (1990). 4. COMFORT, T H and ARAFILES, R P, Barbotage of the shoulder with image intensified fluoroscopic control of needle placement for calcific tendonitis, Clin. Orthop., 135, 171(1978). 5. ARK, J W, FLOCK, T J, FLATOW, E L and BIGLIANI, L U, Arthroscopic treatment of calcific tendonitis of the shoulder, Arthroscopy, 8, 183-188 (1992). 6. GOLDMAN, A B, Calcific tendonitis of the long head of biceps brachii distal to the gleno-humeral joint: plain film radiographic findings, AJR, 153, 1011-1016 (1989). 7. HAYES, C W and CONWAY, W F, Calcium hydroxyapatite deposition disease, Radiographics, 10,1031-1048 (1990). 8. UTHOFF, H, SARKAR, K and MAYNARD, J, Calcifying tendonitis: a new concept of its pathogenesis, Clin. Orthop., 175,164-168(1976). 9. BOSWORTH, B M, Calcium deposits in the shoulder and subacromial bursitis: a survey of 122 shoulders, JAMA, 116, 2477-2482(1941). 10. MOSELEY, H F, Shoulder Lesions (3rd edn). (Williams and Wilkins, (Baltimore), pp. 99-118 (1969). 11. LITCHMANN, H M, SILVER, C M, SIMON, D D and ESHRAGI, A, The surgical management of calcific tendonitis of the shoulder, Int. Surg., 50, 475-479 (1968).
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