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Calcified Tenditinitis of The Shoulder.pptx

  2. INTRODUCTION • classified as enthesopathy, is a self-limiting disease • deposition of calcium phosphate crystals in the rotator cuff tendons. • commonly occurs between the ages of 30 and 50 and is rare in those older than 70 years • twice as likely to occur in women as in men • more common in the right shoulder than in the left, and involves both shoulders in 10% of patients • Most common site of occurrence is 1.5–2 cm away from the supraspinatus tendon insertion site on the greater tuberosity
  3. INTRODUCTION • Location: • 63% of cases occur in the supraspinatus tendon • 20% in both the supraspinatus and subscapularis tendons • 7% in both the infraspinatus tendon and subacromial bursa • 3% in the subscapularis tendon • diabetes and gout are considered to be risk factors for calcific tendinitis • endocrine diseases, and conservative treatment is likely to fail in such cases • rotator cuff tear present in approximately 25% of patients – A/W small VS large calcific deposits
  4. THREE MAIN THEORIES A.Reactive calcification - involves an active cell-mediated process, usually followed by spontaneous resorption by phagocytosing multinucleated cells showing a typical osteoclast phenotype B.Calcium deposits are formed by a process resembling endochondral ossification. The mechanism involves regional hypoxia, which transforms tenocytes into chondrocytes C.Ectopic bone formation from metaplasia of mesenchymal stem cells normally present in tendon tissue into osteogenic cells. As no single theory is satisfactory to explain all cases, calcific tendinopathy is currently believed to be multifactorial.
  5. ETIO-PATHOLOGY Degenerative Posits accumulate with age Leading to ↓ blood vessels ↓ local oxygenation 🡪 hypoxia Thinning & early tearing of tendon 🡪 necrosis & calcification Reactive Precalcific – metaplasia of tenocytes into chondrocytes Formative – calcium deposits form & ↑ size Resting – calcific deposition stops Resorptive – Ca deposits absorbed by phagocytosis by Macrophages & Giant cells Postcalcific – remaining space replaced by granulation & remodels
  6. *Schematic representation of tendinopathy pathogenesis. various risk factors - mechanical overuse - intrinsic and extrinsic factors -trigger the development of tendinopathy in a continuous manner *the first step is that these risk factors impair proper tendon repair leading to early reactive tendinopathy - harbors the capacity for healing - accumulation and increase of risk factors lead to tendon disrepair - subsequently results in tendon degeneration * Poor function and load capacity of the tendon finally end up in the end-state of tendinopathy leads to tendon tearing or rupture. Based on Cook and Purdam and Shearn et al.
  7. CLASSIFICATIONS Time Acute (2 weeks) Subacute (3-8 weeks) Chronic >3 weeks Neer (Pain) Irritation Local pressure Impingement Chronic stiffness
  8. CLINICAL TYPES • Type I – Idiopathic (Responds to conservative mx) • Type II – Secondary - endocrine-related disorders of thyroid, oestrogen and glucose metabolism (usually requires surgical treatment)
  9. MORPHOLOGY Bosworth Small <0.5cm Medium 0.5-1cm Large >1cm DePlama & Kruper Type I – fluffy, ill defined margins , resorptive (acute pain) Type II – homogenous, well defined margins (No pain) Mole (French) A – dense homogenous, sharp B – dense, segmented, sharp C – soft contour, heterogenous D – dystrophic, calcification @ the insertion RC Gartner Type I: Well demarcated, dense Soft, dense Or Sharp transparent Soft, translucent & cloudy
  10. IMAGING CLASSIFICATION Farin hyperechoic focus with a well- defined shadow hyperechoic focus with a faint shadow hyperechoic focus with no shadow Chiou calcific plaques arc-shape (echogenic arc with clear shadowing) fragmented (at least two separated echogenic plaques punctuated (tiny calcific spots without shadowing), nodular (echogenic nodule without shadowing) cystic (bold echogenic wall with echo-free content Sansone granular, calcifications with partially defined margins and irregular echogenicity nodular, cystic appearance with a sediment-type content linear, slight thickening following the course of the collagen fascicle Loewet (CT Scan) A: compact & homogeneous one- part structure, clearly defined outline B: subdivided homogen eous structure, clearly d efined outline C: diffuse area of low signal intensity, no defin ed outline in the tendon
  11. ARTHROSCOPIC CLASSIFICATION The French society of arthroscopy divided the condition into four types: • Type A (20%) with homogenous deposits with well defined edges; • Type B (45%) with heterogeneous fragmented deposits with well defined edges; • Type C (30%) with heterogeneous deposits with ill defined edges • Type D which is not calcific tendinitis but degenerative dystrophic calcifications at the rotator cuff
  12. CLINICAL EVALUATION •Severe, acute pain is typically seen in the resorptive phase • 2.7%–20% are asymptomatic, 35%–45% are discovered inadvertently on radiograph developed symptoms • Patients will describe waking up with a sharp stabbing pain in the shoulder at night • There is absence of any inciting trauma or overuse •Acute pain due to rupture of calcific deposits into the subacromial bursa causing an inflammatory bursitis
  13. CLINICAL EVALUATION • Formative phase – asymptomatic, found by chance, chronic intermittent pai, discovered occasionally • Resorptive phase – severe acute pain, worsen @ night, difficult lying on affected side, limited ROM, characterised by internal rotation to relieve pain & ED visit • The resorptive phase causes local edema and cyto-proliferation leads to increase pressure within the tendon substance, directly triggering pain • May accompanied by local heat, redness & oppressive pain (DDx: Septic Arthritis)
  14. INVESTIGATIONS • radiographic images • shoulder anteroposterior view • internal and external rotation views • supraspinatus outlet views • axillary views • should be acquired to determine the location of calcific deposits and predict the possibility of collision symptoms. • follow-up images are acquired, changes in the disease stage can be assessed • the size of the calcific deposits does not change significantly over time, although a previous study reported that 18% of patients experienced an increase in the size of calcific deposits after follow- up for an average of 16 months
  15. INVESTIGATIONS • ultrasonography - used to assess calcific deposits. • shows hyperechoic areas and an obvious posterior acoustic shadow in the formative or resting phase • resorptive phase, on the other hand, hyperechoic areas are relatively reduced, and the posterior acoustic shadow is also reduced or not observed • MRI is not a routine evaluation - helpful in identifying lesions in the shoulder joint, including the location of calcific deposits and the condition of the rotator cuff. • T1-weighted images, calcific deposits show a low signal intensity, whereas • T2-weighted images, the edema pattern surrounding the calcific deposits can show a high signal intensity
  16. TREATMENTS – PRIMARY Non–Operative Management • Rest • Physiotherapy • NSAIDs • Corticosteroid injection • When there are signs of collision or the patient is in the resorptive phase, subacromial steroid injections are effective in alleviating pain • Extracorporeal shock wave therapy (ESWT) • Ultrasound guided needle lavage (barbotage technique) • PRP INJECTION 30 -80 % success rate
  17. AjR,2007
  18. NEEDLE THERAPY • Needling and lavage has been reported to augment the relief of acute pain • Multiple perforations of the lesion can decrease pressure within the tendon substance • A two-needle technique which facilitates lavage and deposit outflow can be performed • During the procedure, lidocaine can be injected, followed by administration of a corticosteroid
  19. SURGICAL TREATMENT • Surgery is indicated in patients with severe symptoms persisting for more than 6 months • Surgery 🡪 conservative treatment failure ~ 10% of patients, best effects in patients with chronic calcific tendinitis - symptoms was > a year prior to surgery • Chronic calcific tendinitis often requires surgical treatment, which can take the form of open surgery or arthroscopic surgery. • Arthroscopic surgery has the advantages of a short rehabilitation period and cosmetic superiority, and it is a less invasive method 🡪 protect surrounding tissues and can be used to treat comorbidities such as frozen shoulder and rotator cuff tears
  20. SURGICAL DILEMMAS • No significant differences in the clinical outcomes after complete and incomplete removal of calcific deposits • patients whose radiographic findings after surgery indicated a removal or reduction of calcific deposits showed better prognoses than those whose calcific deposits remained unchanged • Whether rotator cuff repair after the removal of calcific deposits affects clinical outcomes remains controversial • Several authors have suggested that rotator cuff repair can facilitate rehabilitation treatment in patients with a combined full-thickness rotator cuff tear
  21. SURGICAL TECHNIQUES - GLENOHUMERAL JOINT posterior portal 🡪 2 cm inferior and 1 cm medial to the posterolateral corner of the acromion anterior portal 🡪 lateral to the coracoid process and anterior to the acromioclavicular joint Assess for capsular adhesion, expansion, swelling or fibrillation of articulation side of SST Polydioxanone (PDS)
  22. SURGICAL TECHNIQUES - SUBACROMIAL JOINT • After adequate glenohumeral joint exploration, arthroscope moves into the subacromial space. • Arthroscopic treatment of calcific tendinitis is mostly performed in the subacromial space. • In general, moderate inflammatory changes, as well as hyperproliferation and thickening of the bursa, can be observed. • Afterward, a lateral working portal is made at the anterolateral area of the acromion
  23. SURGICAL TECHNIQUES – BURSECTOMY AND DECOMPRESSION • Decompression is conducted by thoroughly removing the bursa using a shaver with a suction opening through the lateral working portal. • If no lesion is visible in the articular joint or if calcific deposits are located on the bursal side, comprehensive bursectomy is performed first.
  24. SURGICAL TECHNIQUES – CALCIFIC DEPOSIT REMOVAL • In acute or resorptive phases 🡪 calcific deposits have a toothpaste-like appearance. In the chronic or formative phases, they have a chalk-like appearance - calcific deposits can be observed as creamy or snowy. • Larger deposits or if there are difficulties removing them, a small incision can be made in the long axis of the tendon using a scalpel
  25. ROTATOR CUFF TENDON REPAIR AND ACROMIOPLASTY • Controversial 🡪 if tear is 2 cm or larger and involves more than 70% of the thickness of the tendon, tendon repair is performed • Tear near the SST repaired with anchor sutures • Musculotendinous junction tear side-to-side 🡪 suture lasso • Acromioplasty is not required
  26. AUTHORS’ PREFERRED TREATMENTS • Sometimes difficult to identify the location of calcific deposits even after bursa removal • Calcific deposits 🡪 located by gently needling the rotator cuff tendon at suspicious areas with a 16- gauge spinal needle • After removing calcific deposits, large partial or small full-thickness rotator cuff tears are not repaired • Rotator cuff repair is performed only for medium or large full-thickness rotator cuff tears.
  27. POST OP REHAB •Immediate passive ROM of shoulder •Arm sling for 3/52 for those undergone decompression •Passive & active ROM 6-12 weeks post op •Light duty office work & moderate labour after 6-12 weeks •Shoulder abduction brace for post rotator cuff repair 🡪 4/52 • Passive ROM post op • Muscle strengthening after 6-12 weeks depending on the size of tear
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Notas do Editor

  1. This theory cannot explain why calcific tendinitis has a peak incidence in patients aged 50 years or why it is a self-limiting disease
  2. Calcific tendinitis eventually progresses to bursitis and inflammatory synovitis caused by chemical irritation due to the calcific deposits. Chemical furuncles are formed by swelling and increased local pressure in the tissue. Thickening of the bursa causes collisions in the subacromial space. All of these processes produce various forms of shoulder pain.
  3. Percutaneous needle aspiration and lavage is effective in the short term and in the long term in calcific tendinitis of the shoulder, with results similar to or better than those published for other techniques, and it is only slightly invasive and painful. Progress after treatment may include a transitory period of recurrence of the pain. Read More:
  4. ABSTRACT The most common indication for acromion– clavicular joint injection is degenerative osteoarthritis, with ultrasound representing a useful tool in localizing the joint space and properly injecting various types of drugs (steroids, lidocaine or hyaluronic acid). Suprascapular nerve block is an approved treatment for chronic shoulder pain non-responsive to conventional treatments as well as candidate patients for shoulder arthroscopy. This review provides an overview of these different ultrasonography-guided procedures that can be performed around the shoulder.
  5. Figure 2. Percutaneous treatment of calcific tendinopathy of the supraspinatus using double-needle technique. Scheme ultrasound image of a hard calcification (asterisks) with acoustic back shadow. Scheme ultrasound image of needle (arrows) insertion into the subacromial–subdeltoid bursa (circles) to inject anaesthesia. The calcification (asterisks) is visible under the reverberation artefact of the needle. Scheme ultrasound image of first needle (arrows) insertion in the calcification (asterisks). Note that the bevel is open upward. Scheme ultrasound image of the second needle (arrowheads) insertion in the calcification (asterisks) on the same coronal plane of the first needle (arrows). Note that the bevel of the second needle is open downward and that the back shadow of the more superficial needle partially covers the image of the deeper needle. Scheme ultrasound image at the end of the procedure. The calcification is completely empty Saline used to wash a calcification with a double-needle procedure collected in a bowl. Note the whitish fragment of calcium dispersed in the solution (arrows). H, humerus; S, supraspinatus tendon.
  6. Galletti et  ,  in  a  series  of  patients  followed  up for  around  two  years,  reported  resolution  of  the symptoms  after  percutaneous  needling  in  nearly  90%, and  complete  radiographic  resolution  of  the  calcific tendinopathy  in  54%. reported  complete  resolution  of  calcific  tendinopathy  in Joints 78.1%  of  shoulders  at  one  year  after aspiration  and  lavage.
  7. A  44-year-old  woman with calcific tendinitis of  the  shoulder  treated  with  platelet-rich  plasma injection.  Prior  to  this,  she  had  no  improvement of  the  symptoms  after  6  weeks  of  ultrasound treatment,  Codman  exercises,  and  anti-inflammatory treatment.  Platelet-rich  plasma  was  injected  into  the subacromial area  3  times  at  2-week  intervals.  She had  progressive  improvement  of  pain  after  2  weeks, and  was  asymptomatic  at  week  6. The  patient  then underwent  the  previous  protocol  of  rehabilitation. At  the  one-year follow-up,  the  patient  was  pain-free and  had  complete  resolution  of  calcific  tendinitis.
  8. ESWT Low and medium energy is effective Less than 0.28mj/mm2 local neoangiogenesis associated with an increase in antiinflammatory cytokines and growth factors after shock wave administration, followed  by cell  proliferation  and  increased metabolism lead to a cell-mediated reabsorption of calcification Daecke et al. published long-term follow-up of patients managed with ESWT