Applications in Musculoskeletal Disorders - part 7 docx

Tendon calcifications have been observed in 2.7–20 % of patients without pain in their shoulders; calcifying tendinitis has been observed in as many as 17 % of shoulders of patients with

of Chronic Calcifying Tendinitis of the Shoulder

Introduction

Calcific tendinitis as a source of shoulder pain

initially was described more than 100 years

ago as Maladie de Duplay The disease usually

is self-limiting and the natural history still is

contradictory (Rupp et al 2000,Uhthoff and

Loehr 1998)

Reports concerning the incidence of the

dis-ease are inconsistent Tendon calcifications

have been observed in 2.7–20 % of patients

without pain in their shoulders; calcifying

tendinitis has been observed in as many as

17 % of shoulders of patients with chronic

periarthritis (Bosworth 1941,Hedtmann and

Fett 1989,Rowe 1988) Bosworth (1941)

describes progressive vanishing of the

depos-its in 9.3 % of patients within 3 years after the

initial diagnosis Wagenhäuser (1972) reports

that deposits disappeared in 27.1 % of his

patients after 10 years

Treatment of patients with calcific tendon-itis typically is conservative (Farin et al 1996)

If the pain becomes chronic or intermittent after several months of conservative treat-ment,surgical removal has been recom-mended (Uhthoff and Loehr 1998) Success rates above 80 % have been reported (Loehr and Uhthoff 1996)

Recently,extracorporeal shock wave ther-apy (ESWT) has shown encouraging prelimi-nary results in the treatment of calcific depos-its (Loew et al 1995,1999,Rompe et al 1995, 1998b) The goal of the current study was to compare the efficiency of open surgery and extracorporeal shock wave application (ESWA) in patients with chronic,symptomatic calcifying tendinitis of the supraspinatus ten-don (Rompe et al 2001b)

Materials and Methods

Prospectively 79 consecutive patients with a

chronic calcifying tendinitis of the

supraspi-natus tendon were recruited between 1996

and 1998 All patients had been referred to the

author’s shoulder clinic for recalcitrant

shoul-der pain by local general practitioners or

orthopedic practitioners All patients had a

clinical examination and anteroposterior

(A-P) radiographs,acromial outlet

views,sonog-raphy,and/or magnetic resonance imaging

(MRI) (Wirth et al 1990) The patients were

informed about open surgical removal of the

deposit and about high-energy ESWT as a nonsurgical alternative All patients contacted their health insurance companies and asked for reimbursement of the shock wave therapy (SWT) In 29 cases reimbursement was denied and the patients had to undergo surgery The remaining 50 patients decided to receive SWT after reimbursement had been offered So the assignment of the patients to either group was carried out completely independent of our institution

Fig 7.1 a Anteroposterior (A-P) radiograph of a

Gaertner III calcium deposit b Axial radiograph of a Gaertner II calcium deposit c A-P radiograph showing

spontaneous disintegration within 9 weeks.

a

b

c

Table 7.1 Methods of treatment before referral to the

hospital 1

(n = 29)

Group II (n = 50)

Infiltration with local

anesthetic

1 Number of patients

Inclusion Criteria

Inclusion and exclusion criteria were

identi-cal All patients reported in this study fulfilled

the following criteria

Inclusion criteria were: calcareous deposit

on standardized A-P radiographs of a

diame-ter of at least 10 mm; the morphology of the

deposit had to be homogenous in appearance

and with well-defined borders

(correspond-ing to Type I in the Gaertner classification of

1993),or inhomogenous in structure with a

sharp outline or homogenous in structure

with no defined border (corresponding to

Type II in the Gaertner classification);

shoul-der pain for more than 12 months; clinical

signs of subacromial impingement (Hawkins

and Kennedy 1980,Neer 1972): unsuccessful

conservative therapy in the previous 6

months (Table 7.1); no evidence of

bone-related anatomical outlet impingement or

functional outlet impingement as seen on

radiographs or MRI scans

Exclusion Criteria

Exclusion criteria were: cloudy and

transpar-ent appearance of the deposit (Type III

according to Gaertner 1993); radiological

signs of spontaneous resorption (Fig 7.1);

evi-dence of a Type-III acromial morphological

feature according to Bigliani et al (1982) on

the outlet view of the acromion; evidence of

acute subacromial bursitis; evidence of an

acromial spur or acromioclavicular

osteophy-tes on the A-P radiographs; evidence of

rota-7 Extracorporeal Shock Wave Application in the Treatment of Chronic Calcifying Tendinitis

50

Fig 7.2 a A-P radiograph of a Gaertner III deposit.

b A-P radiograph of a Gaertner III after needling and

lavage c Dissolved deposit.

c

tor cuff tears on MRI scans; evidence of

func-tional impingement of the rotator cuff on

sonographs or Arthro-MRI scans or both; tears

of the glenohumeral ligaments of the labrum;

hypertrophy of the supraspinatus muscle;

dysfunction in the neck

(spondylarthritis,cer-vical disc herniation) or thoracic region

(hyperkyphosis,spondylarthritis); prior

sur-gery to the shoulder; local degenerative

dis-ease of the shoulder; rheumatoid arthritis;

neurological abnormalities of the upper

extremity with calcifying tendonitis;

preg-nancy; infection; tumor

Group I

The patients in group I underwent surgery as described below Group I comprised 29 patients (20 women and 19 men),with a mean age of 53 years (range: 31–68 years), and a mean duration of pain of 36.1 ± 28.6 months (range: 12–60 months) There were 19 Type-I deposits and 10 Type-II deposits according to the Gaertner (1993) classifica-tion The right shoulder was affected in 54 % of the patients

The patient was in a beach chair position with a towel placed under the scapula With the patient under general anesthesia the rota-tor cuff was exposed through a 5–6 cm–long anterior incision as for an acromioplasty The deltoid was split parallel to its fibers for no more than 5 cm distal to its acromial attach-ment to prevent damage to the axillary nerve After partial subdeltoid bursectomy,the rota-tor cuff was exposed Following identification

of the calcium deposit in the supraspinatus tendon either macroscopically or by fluoros-copy,the tendon was incised longitudinally and the calcium was removed by curettage

(Fig 7.3) The defect was closed by means of

slowly resorbable sutures The anterior

acro-Fig 7.3 Open removal of the calcific deposit a Skin incision and division of the deltoid muscle ( X 5 cm) b Partial resection of the subdeltoid bursa c Longitudinal incision of the supraspinatus tendon d Extracted deposit.

a

c

b

d

mial edge was smoothed with a rasp and a

drain inserted Then the deltoid and its fascia

were reapproximated with a resorbable vicryl

suture,the subcutaneous tissues were closed,

and a subcuticular nonresorbable suture was

applied for the skin A sterile dressing was

applied After the operation,the arm was

sup-ported by a sling,and pendulum exercises

were started after removal of the drain the

day after surgery Passive assisted exercises

were performed on the following 3 days,then

assisted active motion was done for 4–6

weeks with no limitation on the range of

motion (ROM)

Group II

The patients in group II underwent ESWT Group II comprised 50 patients (28 women,

22 men),with a mean age of 49.6 ± 7.5 years (range: 31–63 years) and a mean duration of pain of 52.6 ± 54.4 months (range: 12–66 months) There were 28 Type-I deposits and

22 Type-II deposits according to the Gaertner classification The right shoulder was affected

in 56 % of the patients

7 Extracorporeal Shock Wave Application in the Treatment of Chronic Calcifying Tendinitis

52

Method of Treatment

High-energy ESWT was performed using an

experimental device (Siemens AG,Erlangen,

Germany),characterized by the integration of

an electromagnetic shock wave generator in a

mobile fluoroscopy unit Once the calcium

deposit was situated in the center of the

C-arm (Fig 7.4a),the shock wave unit was

docked to the shoulder by means of a

water-filled cylinder Standard ultrasound gel was

used as a contact medium between cylinder

and skin (Fig 4b) Three thousand impulses of

0.60 mJ/mm2 were administered under regi-nal anesthesia Only one therapy session was undertaken with each patient No cold ther-apy or nonsteroidal antiinflammatory drugs (NSAIDs) were allowed after the procedure Active exercises began as an outpatient treat-ment the day after SWT for 4–6 weeks

Fig 7.4 a Deposit in the reticule of the fluoroscopy unit of the shock wave device b High-energy SWA using a

fluoroscopy guided shock wave device in plexus anesthesia with the patient under permanent control of an anes-thesiologist.

Method of Evaluation

Follow-up evaluations were done

indepen-dently of the treating orthopedic surgeon at 12

months and at 24 months The University of

Cal-ifornia at Los Angeles score for pain and function

of the shoulder (Kay and Amstutz 1988) was

used to grade each patient before treatment and

at each follow-up According to this protocol,

pain and function are each rated on a scale of

1–10 points,with 1 point being the worst and

10 points being the best score The range of

active forward flexion and strength in forward flexion were scored from 0–5 points; and the patient’s satisfaction was scored from 0–5 points The maximum score to be achieved was

35 points The outcome score was as follows: Excellent = G 33 points

Good = 29–33 points Poor = X 29 points

Table 7.2 Points 1 according to the University of California at Los Angeles Rating System

Follow-up

(months)

Total Gaertner

I

Gaertner II

Total Gaertner

I

Gaertner II

Total Gaertner

I

Gaertner II

0 17.8±4.0 18.0±3.4 17.4±4.7 19.0±3.3 18.7±3.2 19.2±4.8 – – –

12 30.3±3.2 29.3±3.8 31.7±4.5 28.3±6.9 26.7±3.6 30.6±4.3 – X 01 –

24 32.4±2.9 32.0±4.1 33.1±3.9 29.1±4.2 26.7±3.6 31.9±4.7 X 001 X 0001 –

1 Mean±standard deviation

Radiological Evaluation

An A-P view (Kilcoyne et al 1989) and an

out-let view of the acromion were obtained 1 day

before surgery or ESWT and at 12 months

after either treatment On the A-P views,

resorption was graded as none,partial,or

complete by the author’s colleagues from the

local Department of Radiology,who were

blinded as to the treatment status and

ante-cedent studies

Statistics

Statistical analysis was done by the local

Insti-tute of Medical Statistics and Documentation

Differences between the groups regarding

pain,function,flexion,strength,and total

out-come were tested by using the Wilcoxon test

for two independent samples The Fisher

exact test for 2 × 2 contingency tables was

used for the analysis of satisfaction and

out-come,and its extended version was used to

test the removal of the calcific deposits and the time until the patients returned to work The comparison of preoperative data with data from the 12-month and 24-month follow-up was done by means of the Wilcoxon signed rank test for pain,function,flexion, strength,and total outcome Differences in time concerning the patients’ satisfaction and the outcome were done by the McNemar test Dependencies between removal of the deposit,return to work,and outcome were tested with the Fisher exact test and its exten-sion Differences in total outcome scores according to different radiological outcome and removal of the deposits were shown with the Wilcoxon test The level of significance was set at 95 % for each test; therefore p-values X 0.05 were considered to be signifi-cant All tests were calculated two-sided; multiple adjustment was not done

Results

Rate of Follow-up

At 12 months,20 patients in group I and 45

patients in group II were examined At 24

months,20 patients in group I and 39 patients

in group II were examined The remaining

patients were lost to follow-up Regarding the

epidemiolgical data,the patients who were

lost to follow-up did not differ from the

patients included in the current study

Clinical Outcome in the University

of California Los Angeles Score

The total outcome in the University of

Califor-nia Los Angeles score is shown in Tables 7.2 and 7.3 The comparison of the two groups

regarding point values or regarding “Excel-lent” and “Good” outcomes showed no signifi-cant difference at 12 months At 24 months, point values were significantly higher in group I than in group II (32.4 and 29.1 points, respectively; p X 0.001),and there were

sig-7 Extracorporeal Shock Wave Application in the Treatment of Chronic Calcifying Tendinitis

54

Good Poor

Fig 7.5 a A-P radiograph showing a Gaertner I

cal-cium deposit (homogenous structure with

well-defined borders) b A-P radiograph showing complete

disintegration 12 months after SWA.

a

b

nificantly more “Excellent” and “Good” results

in group I than in group II (90 % and 64 %, respectively; p X 0.05)

Radiological Outcome

Table 7.4 shows the extent of calcium

elimina-tion in relaelimina-tion to its radiomorphological fea-tures

Group I: At 12 months,the calcium deposit had disappearded in 85 % of the patients; in

15 % of the patients only minor particles were observed

Table 7.4 Elimination rates of the calcific deposit

Elimination of

Gaertner I (n=12)

Gaertner II (n= 8)

Gaertner I (n=25)

Gaertner II (n=20)

1

12-month follow-up

Fig 7.6 a A-P radiograph showing a Gaertner II

deposit (inhomogenous structure with well-defined

border) b A-P radiograph showing complete

disinte-gration 12 months after SWA.

a

b

Group II: At 12 months,complete resorption

was observed in 47 % of the patients (Figs 7.5,

7.6) and partial resorption of the calcium

deposit was observed in 33 % of the patients

In 20 % of the patients there was no change in

the radiomorphological features at all

The calcium deposit was no longer

detect-able radiologically in significantly more

patients in group I than in group II

(p X 0.0001) Complete disintegration of the

calcium was found significantly more often in

Gaertner Type-II deposits than in Gaertner

Type-I deposits after SWT (70 % and 28 %,

respectively; p X 0.0001)

Radiomorphological Features and Clinical

Outcome

In group I Gaertner Type-I patients achieved

29.3 points at 1 year and 32.0 points at 2

years; Gaertner Type-II patients had 31.7

points at 1 year and 33.1 points at 2 years

In group II Gaertner Type-I patients

achieved 26.7 points at 1 year and at 2 years

Gaertner Type-II patients had 30.6 points at 1

year and 31.9 points at 2 years

Gaertner Type-I patients showed

signifi-cantly better point values in the University of

California at Los Angeles score in group I than

in group II at both follow-ups (all p X 0.0001)

There was no significant difference between

Gaertner Type-II patients in group I and group

II (Table 7.2).

In group I patients with a Gaertner Type-I

deposit had “Excellent/Good” outcomes in

75 % of cases at 1 year and in 92 % at 2 years

Patients with a Gaertner Type-II deposit

showed “Excellent/Good” results in 75 % of

cases at 1 year and in 88 % at 2 years

In group II 48 % of the patients with a Gaert-ner Type-I deposit had “Excellent/Good” out-comes at 1 year, and in 53 % of cases at 2 years

7 Extracorporeal Shock Wave Application in the Treatment of Chronic Calcifying Tendinitis

56

Fig 7.7 Hematoma after high-energy ESWTin the contact area of shock wave device and skin.

Patients with a Gaertner Type-II deposit

achieved “Excellent/Good” outcomes in 75 %

of cases at 1 year,and in 84 % at 2 years

At both follow-ups there were significantly

more “Excellent/Good” outcomes in Gaertner

Type-I patients in group I than in group II (12

months: p X 0.01; 24 months: p X 0.0001)

There was no significant difference

concern-ing Gaertner Type-II patients between group I

and group II (Table 7.3).

Hospital Stay

Patients in group I remained in hospital for an

average of 12 ± 4.5 days; patients in group II

for 3.1 ± 0.65 days So the period of

hospital-ization was significantly shorter in group II

(p X 0.0001), resulting in an average cost

advantage in group II of US$ 2970 per patient

Absence from Work

After dismissal from the hospital it took

patients in group I an average of 9.1 ± 11.6

weeks to return to work, and patients in group

II 2.5 ± 3.0 weeks Absence from work was

sig-nificantly shorter in group II (p X

0.01),result-ing in an average cost advantage of US$ 9240

per patient

Complications

Although one deep wound infection was

observed in a patient from group I,no side

effects except for transient subcutaneous

hematomas were observed in patients from

group II (Fig 7.7) Lesions in the rotator cuff

were ruled out after SWT by MRI or through ultrasonography

Subjective Rating

At 24 months 55 % of the patients in group I reported a complete relief from pain and 29 %

a significant reduction in pain Five percent and 11 % of the patients observed only slight

or no improvement,respectively

In group II there 43 % of patients were with-out pain and 24 % with a significant reduction

in pain Four percent and 29 % of the patients had a slight relief or no reduction in pain, respectively With the numbers available we could not detect a significant difference between group I and group II

Discussion

The usual conservative treatment of the

chronic or subacute phase of calcifying

tendi-nitis comprises physical therapy,infiltration

with local anesthetics or corticosteroids,or

both,and needling and lavage Success rates

reported vary between 30 % and 85 % (De

Palma and Kruper 1961,Gaertner

1993,Har-mon 1958,Lapidus 1943,Pfister and Gerber

1994,Reichelt 1996,Wainner and Hasz 1998)

In a series of 100 patients treated

conserva-tively,Litchman et al 1968 report only one

patient who had to undergo surgery The effect of ultrasonic energy is questionable (Griffin and Karselis 1982) Radiation therapy

is not an acceptable mode of treatment according to studies by Chapman (1942), Young (1946),and Plenk (1952)

Open surgery is regarded as a dependable and quick method to relieve the deposit Vebostad (1975) report excellent and good results in 34 out of 43 patients (79 %),and Gschwend et al (1981) report excellent and

good results in 25 out of 28 patients (89 %).

Rubenthaler and Wittenberg (1997) observed

88 % excellent and good results Rochwerger et

al.

(1999),also using the open procedure,

report an increase of the Constant score

val-ues from 52 to 89 points after a follow-up of

23 months

The endeavor to avoid damage to the

del-toid muscle led to the development of

mini-mally invasive techniques,guided by

arthros-copy (Ellman 1987,Ellman and Kay 1991,Esch

et al 1988,Gartsman et al 1988) This

techni-cally demanding procedure has proved to be

successful in prospective studies (Altchek et

al 1990,Ark et al 1992,Ellman and Kay 1991,

Habermeyer et al 1998,Sachs et al 1994) Ark

et al (1992) observed 50 % excellent results

Mol ´e et al.

(1993) report 82 % of their patients

to be satisfied with the postoperative

out-come Similar to Jerosch et al (1998) and Re

and Karzel (1993),the authors show an

improvement in results with an associated

acromioplasty All authors,with the exception

of Tillander and Norlin (1998),stress the

importance of complete removal of the

cal-cicfic deposit; subacromial decompression

was thought to be of minor importance

In a preliminary study,Loew et al (1995)

discuss the potential disintegrating capability

of extracorporeal shock waves regarding

cal-cific deposits of the rotator cuff They

pro-posed that increasing pressure within the

therapeutic focus caused fragmentation and

cavitation effects inside the amorphic

calcifi-cations and led to disorganization and

disinte-gration of the deposits A breakthrough of the

calcific masses into the adjacent subacromial

bursa or local resorptive reaction of the

sur-rounding tissue induced by extracorporeal

shock waves possibly led to the disappearance

of the deposits The exact working mechanism

remains unclear In an in vitro study,Perlick et

al (1999b) put artificial concrements in the

rotator cuff of a pig and reported that it took

at least 2000–3000 impulses of an energy flux

density of 0.42 mJ/mm2 to achieve a

disinte-gration of the deposit

Clinically,Loew et al (1995) report

signifi-cant improvement of symptoms in 14 out of

20 patients (70 %) after two applications of

2000 shock waves of an energy flux density of 0.3 mJ/mm2

Radiologically,there were seven cases of complete resorption and five cases of partial disintegration However,the follow-up was at only 12 weeks Radiologically,these results are much better than the data reported

in the author’s first preliminary series (Rompe

et al 1995) in which complete elimination of the deposit was observed in only 15 % of 40 patients who were treated once with 1500 impulses of an energy flux density of 0.28 mJ/

mm2 Daecke et al (1997) showed an influ-ence of two applications versus one applica-tion of 2000 shock wave impulses of an energy flux density of 0.3 mJ/mm2

in 115 patients Complete elimination of the deposit was seen on radiographs in 54 % of patients (two treatments) and in 33 % of patients (one treatment),and partial disintegration was seen in 23 % of patients (one treatment) and

14 % of patients (two treatments) The differ-ences in the radiological findings were signifi-cant in favor of two applications Clinically,

54 % of patients versus 45 % of patients did not have pain after 6 months,and 75 % of patients versus 65 % of patients attained at least 75 % of the age- and gender-dependent values of the score of Constant and Murley (1987) How-ever,the differences between the two treat-ment groups were not statistically significant Krischek et al (1997) observed 50 patients for

1 year after one application of 3000 shock waves of an energy flux density of 0.28 mJ/

mm2 Thirty-four percent of the patients were satisfied and 18 % of patients were moderately satisfied Radiologically,deposits had been eliminated completely in eight patients, whereas 21 patients had a partial disintegra-tion According to the Gaertner classification, they observed changes of the radiomorpho-logical features in 88 % of Type-II deposits,but

in only 44 % in Type-I deposits Clinically,the Constant and Murley score values improved from 60 to 76 points Therefore,by doubling the number of applied shock waves compared with previous studies,neither an increase in the elimination rate nor an improvement in the clinical outcome was achieved Eighteen

7 Extracorporeal Shock Wave Application in the Treatment of Chronic Calcifying Tendinitis

58