Factors Associated With Clinical Improvement and the Disappearance of Calcifications After Ultrasound-Guided Percutaneous Lavage of Rotator Cuff Calcific Tendinopathy: A Post Hoc Analysis of a Randomized Controlled Trial

Abstract

Background: Calcific tendinitis of the rotator cuff is a frequent cause of shoulder pain. Ultrasound-guided percutaneous lavage (UGPL) is an effective treatment, but factors associated with good clinical and radiological outcomes still need to be identified. Purpose: To study the clinical, procedural, and radiological characteristics associated with improved shoulder function and the disappearance of calcification on radiograph after UGPL. Study Design: Case-control study; Level of evidence, 3. Methods: This is a post hoc analysis of the CALCECHO trial, a double-blinded randomized controlled trial conducted on 132 patients. The trial assessed the effect of corticosteroid injections after UGPL, and patients were randomly assigned to receive either corticosteroid or saline solution in the subacromial bursa. We analyzed all patients included in the randomized controlled trial as 1 cohort. We collected the patients’ clinical, procedural, and radiological characteristics at baseline and during follow-up (3, 6, and 12 months). Univariable analysis, followed by multivariable stepwise regression through forward elimination, was performed to identify the factors associated with clinical success (Disabilities of the Arm, Shoulder and Hand [DASH] score <15) or the disappearance of calcification. Results: Good clinical outcomes at 3 months were associated with steroid injections after the procedure (odd ratio [OR], 3.143; 95% CI, 1.105-8.94). At 6 months, good clinical evolution was associated with a lower DASH score at 3 months (OR, 0.92; 95% CI, 0.890-0.956) and calcium extraction (OR, 10.7; 95% CI, 1.791-63.927). A lower DASH at 6 months was also associated with a long-term favorable outcome at 12 months (OR, 0.939; 95% CI, 0.912-0.966). Disappearance of calcification at 3 and 12 months occurred more frequently in patients in whom communication was created between the calcification and the subacromial bursa during the procedure (OR, 2.728 [95% CI, 1.194-6.234] at 3 months; OR, 9.835 [95% CI, 1.977-48.931] at 12 months). Importantly, an association between calcification resorption and good clinical outcome was found at each time point. Conclusion: Assessing patients at 3 months seems to be an essential part of their management strategy. Calcium extraction and creating a communication between the calcific deposits and subacromial bursa are procedural characteristics associated with good clinical and radiological evolution.

Calcific Tendinitis: Limited Role of Surgery

“…Finally, steroid injections may be recommended when the calcification has become poorly defined on imaging and it is no longer possible to puncture it. The disappearance of the calcification between 3 and 12 months is also observed in one-third of patients, without any additional treatment [38].…”

Systematic literature review to inform the EULAR recommendations for the use of imaging in crystal-induced arthropathies in clinical practice

“…CR was assessed in nine studies,153 157 175–180 183 US in five179–183 and MRI in a single study 178. Study design included one SLR without meta-analysis, whose references were reviewed,176 two RCTs153 179 and eight cohort studies 157 175 177 178 180–183. Treatment included injections, aspiration, needling, lavage, extracorporeal shockwave therapy and radiotherapy.…”

“…The results across studies were variable, with some suggesting that the morphology and size of the calcifications on CR and US could predict response to treatment,157 177 180–182 184 while others yielded negative results 153 175 178 179 183. One study on US and one on MRI investigating inflammatory changes suggested a predictive role,178 181 while two US studies did not 179 182. A single study reported a predictive role of acromial shape on CR 175…”

Intraosseous calcific tendinitis of the rotator cuff yields similar outcomes to those of intratendinous lesions despite worse preoperative scores

“…The necessity of removing the intraosseous deposit in the surgical treatment of calcific tendinitis is still under debate [12, 13, 22, 23, 27]. Although the results in the previous series were generally successful, they show a range of satisfaction rates.…”