Arthroscopic Treatment of Calcific Tendonitis
Calcific tendonitis in the rotator cuff is a cause of shoulder pain that has been previously addressed by other authors. This condition infrequently requires surgery. It usually responds to local steroid injections into the bursa (or into the calcification) with spontaneous resolution of symptoms. Arthroscopic excision of the calcium is indicated if the patient has persistent pain or impingement symptoms from a large calcification within the rotator cuff. Rarely is arthroscopic subacromial decompression necessary. If necessary, the surgeon should rely on image intensification to locate the calcium. Fluoroscopy, at the end of the procedure, assures the surgeon that all of the calcium has been removed. Patients with small calcifications may have day and night pain. Individuals with large calcifications may have a painful impingement arc from 90 to 120 degrees of elevation. Beware of the large dumbbell-shaped calcification in the supraspinatus tendon. Removing this calcification leaves a large defect in the tendon that requires repair. Calcifications may also occur in the tendons of the subscapularis, infraspinatus, and biceps.
Role of Subacromial Decompression
The relationship between calcific tendonitis and subacromial impingement is not clear. A subacromial decompression is not necessary unless there is significant fraying of the acromial attachment of the coracoacromial ligament, or a type III acromion. Some surgeons have suggested subacromial decompression if the calcium is unable to be identified.
1. Calcification in the supraspinatus tendon is the most common indication.
2. Failure of nonoperative treatment with steroid injections.
Stiffness associated with a “frozen shoulder” is a relative contraindication. Treatment should be directed at the underlying stiffness. Steroid injections are placed in both the subacromial bursa and the glenohumeral joint.
1. Examine the patient for a full range of motion. Be sure to rule out any stiffness.
2. Tenderness may be present over the greater tuberosity in the presence of a supraspinatus calcification.
3. A painful “impingement” range from 90 to 120 degrees of elevation may be present with larger calcifications.
4. Pain, especially at night, may be the only finding in not only supraspinatus calcifications but also calcifications of other tendons.
The supraspinatus tendon is the most common area of calcification. Usually this is a 1 cm area of calcification that may appear dense or soft and fluffy on X-ray. Beware of the supraspinatus calcification that extends 1 inch medially and includes extensive intratendinous changes. Usually this is a dumbbell calcification involving a significant amount of the rotator cuff. Repair of the rotator cuff after excision is necessary.
1. Image intensifier
21. Rotator cuff repair instrumentation
1. General anesthesia
2. Scalene block (alternate)
Patient and Equipment Position
1. Lateral decubitus position with the arm suspended
2. Beach chair (alternate)
1. The patient is taken to the operating room and positioned in the lateral position with the arm suspended.
2. The image intensification machine is brought over the superior aspect of the shoulder to localize the calcification preoperatively (Fig. 35–1). This is an important step to determine the position that will be used for assuring the complete removal of the calcium. A needle may be placed into the tendon and into the calcification under image intensification for localization.
3. The image intensification is then moved off the surgical field, and sterile prepping and draping are carried out.
4. The initial surgery is done with the arthroscope in the posterior glenohumeral portal. An anterior portal is placed using the Wissinger rod technique. The joint is then examined in a systematic fashion.
5. Often, small calcifications can be noted within the supraspinatus tendon adjacent to the rotator cuff footprint. Calcification may also be found within the supraspinatus tendon by reducing the intensity of the light source for the arthroscope.
6. If this is seen, an 18-gauge needle is used to localize this region so that it may be found on the bursal side.
7. At this point, the subacromial space is inspected from the posterior portal. A lateral working portal is placed for the shaver and a bursectomy is performed. There may be fluffy calcification within the bursa. Attention should be directed to the acromial attachment of the coracoacromial ligament to see if there is any area of impingement.
8. Through the lateral portal, or a portal adjacent to the acromion, needle sticks are placed within the tendon until the calcium is localized. If there is difficulty doing this, the image intensifier should be used at this time.
9. Once the calcification is identified, the rotator cuff is opened in line with its fibers down to the deposit. The calcium is then extruded from the tissue. It may be necessary to use shaver blades or even a burr to remove the entire calcium deposit.
10. The surgeon should now evaluate the rotator cuff defect to see if a side-to-side repair can be performed.
11. At this point, a side-to-side rotator cuff repair is done in a routine fashion.
Surgical Tips (Other Calcifications)
1. A calcium deposit may be present within the infraspinatus tendon. In this case a lateral portal should be used for the arthroscope. A shaver in the posterior portal is used to remove the posterior aspect of the bursa for localization of this deposit. The calcium is removed in a routine fashion.
2. A focal area of calcification may be present within the biceps tendon at the superior labral insertion. If this is identified it should be removed. Debridement of this region creates a superior labral injury similar to a type II superior labrum anterior and posterior lesion. An appropriate repair of this lesion is necessary.
3. Extensive tendon calcification may be present diffusely within the rotator cuff. After removal of the calcium, there may be a large defect in the rotator cuff that will require repair.
Pitfalls and Technique Errors
1. The main complication is failure to remove all the calcification. This can be prevented by the use of image intensification. The persistent presence of intratendinous calcification postoperatively may account for continued symptoms and should be avoided.
2. The other major complication is a removal of an extensive amount of calcification leading to a defect in the rotator cuff that is not repaired.
Postoperative Care and Rehabilitation
1. Circumduction exercises are begun immediately. Supine overhead stretches with a bar and door pulley exercises are begun at the end of the first week. Muscle strengthening exercises can be initiated when the pain subsides, which is by 2 to 4 weeks after surgery.
2. If a cuff repair is performed, then delay active exercises for 6 weeks.