Arthroscopic Treatment of Subscapularis Calcific Tendonitis Logan K. Fields, M.D., Chad J. Muxlow, D.O., and Paul E. Caldwell III, M.D.
Abstract: Rotator cuff tendonitis is a very common diagnosis of the shoulder that usually responds to conservative management. However, calcific tendonitis occurs less frequently and often necessitates surgical intervention. The etiology and treatment options for this disorder remain controversial among orthopaedic shoulder specialists. Calcific tendonitis frequently presents within the supraspinatus tendon and rarely appears within the subscapularis tendon. We present a case and accompanying video technique of arthroscopic treatment of subscapularis calcific tendonitis.
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alcific tendonitis of the rotator cuff is a common disorder of the shoulder that often necessitates surgical management. Controversy exists as to the etiology and pathogenesis of this disabling ailment. One theory suggests that impingement leads to rotator cuff tendon degeneration followed by calcification of the diseased tendon. Another explanation attributes hypoxia as the inciting event, leading to eventual calcification of the tendon.1,2 Despite the cause, the clinical manifestation of the disease process is dependent on the stage of calcification. There are 3 phases associated with the disease process, and symptoms generally begin at the end of the formative phase and dissipate at the beginning of the resorptive phase. Nonoperative treatment consisting of cortisone injections, extracorporeal shockwave therapy, iontophoresis, and physical therapy remains successful in most patients. In chronic cases that fail to respond to nonoperative measures, arthroscopic treatment has shown favorable results.3,4 Calcific tendonitis of the rotator cuff is most commonly associated with the supraspinatus tendon.1,2 The subscapularis tendon is rarely affected, and only 2 prior cases have been reported.5,6 Both cases were treated with arthroscopic procedures with good clinical results. We present the case of a 60-year-old right From Orthopaedic Research of Virginia (L.K.F., C.J.M., P.E.C.); and Tuckahoe Orthopaedic Associates (P.E.C.), Richmond, Virginia, U.S.A. The authors report the following potential conflict of interest or source of funding: L.K.F., C.J.M., and P.E.C. receive support from Arthrex, Bon Secours, DJO, DePuy Mitek, Smith & Nephew. Received April 18, 2014; accepted June 11, 2014. Address correspondence to Paul E. Caldwell III, M.D., 1501 Maple Ave, Ste 200, Richmond, VA 23226, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/14322/$36.00 http://dx.doi.org/10.1016/j.eats.2014.06.005
handedominant female desk worker who had a yearlong history of nontraumatic right shoulder pain and mechanical symptoms. Despite conservative measures, her condition did not improve and she ultimately underwent shoulder arthroscopy with removal of the calcific deposit and repair of the defect with an excellent clinical outcome (Video 1).
Surgical Technique The arthroscopic technique is performed with the patient in the lateral decubitus position but is certainly amenable to the beach-chair position as well. A standard posterior portal (Fig 1) is created, and a diagnostic arthroscopy of the glenohumeral joint is performed. Additional intra-articular pathology may be addressed in the same setting. The articular aspect of the subscapularis tendon is inspected for undersurface tears, as well as any evidence of the calcific deposit. Once the remainder of the diagnostic arthroscopy is completed, attention is turned to the subacromial space and a bursectomy is performed. The bursal surface of the rotator cuff is inspected, and the calcific deposit is visualized. An 18-gauge spinal needle is used to confirm the location of the calcific deposit and establish an accessory anterior portal. A scalpel is percutaneously used to create a 1-cm incision parallel to the fibers of the subscapularis tendon in an effort to decompress the calcium. A probe and a shaver are further used to remove the remainder of the calcium. The defect is inspected to determine that the majority of the calcium is removed and the defect is not full thickness in nature. Attention is then turned to closing the defect in the tendon using a simple suture configuration. Suture-passing hooks (Spectrum suture hooks; ConMed Linvatec, Largo, FL) and a monofilament suture (PDS; Ethicon, Somerville, NJ) are passed and retrieved on both sides of the defect in a simple
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Fig 1. Anterior view of shoulder joint showing arthroscopic setup along with calcific deposit located within subscapularis tendon.
suture configuration. This process is repeated on the proximal and distal aspect of the defect. A high-strength polyethylene suture (Orthocord; DePuy Mitek, Raynham, MA) is then shuttled using standard arthroscopic shuttling techniques. The sutures are retrieved and tied using a sliding locking knot with 3 reversed half-hitches to close the defect and repair the tendon (Fig 2).
Discussion Arthroscopic treatment of calcific tendonitis of the rotator cuff has proved to be an effective treatment option in chronic cases that fail to improve with conservative measures.3,4 Although the vast majority of cases occur within the supraspinatus and infraspinatus
Fig 2. Anterior view of shoulder joint showing passage of sutures in a simple configuration in preparation for closure of defect in subscapularis tendon along with inset of final repair.
tendons, treatment of the subscapularis has been reported successfully with similar arthroscopic techniques. Documented cases of subscapularis calcific tendonitis are rare, and we are unaware of published video techniques.5,6 The location of the calcific deposit may differ from other tendons, but as previously suggested, subcoracoid impingement may indeed lead to involvement of the subscapularis causing degeneration and subsequent calcification.5 Radiographic and magnetic resonance imaging evaluation certainly provides a guide for initial management, but ultimately, arthroscopic evaluation is the gold standard for localizing the calcific deposit and determining definitive treatment. Controversy exists as to treatment using simple debridement of the calcium opposed to repair of the tendon as well as repair techniques. Manaka et al.7 have recommended that defects greater than 10 mm after debridement of the deposit require repair because of the high likelihood of propagation. The decision to use a side-to-side simple suture repair versus anchor-based repair depends on the amount of bone exposed and size of the defect after debridement. Our preference is to use a side-to-side repair for smaller defects located within the more proximal aspect of the tendon and anchor-based repair for larger defects more distal in the tendon. Traditional open techniques certainly require less specialized training and less equipment and potentially are less expensive. Arthroscopic techniques do require additional training and more specialized equipment but offer the potential advantage of a minimally invasive approach with less postoperative pain and early mobilization. This technical note provides additional support
SUBSCAPULARIS CALCIFIC TENDONITIS Table 1. Advantages of Arthroscopic Treatment of Subscapularis Calcific Tendonitis Standard arthroscopic setup and portals No special instrumentation Standard arthroscopic suture shuttling and tying Tendon-splitting approach Potential for early mobilization Low-profile repair
for arthroscopic treatment of subscapularis calcific tendonitis (Table 1), as well as a video demonstration of this arthroscopic technique.
3.
4.
5.
References
6.
1. Seil R, Litzenburger H, Kohn D, Rupp S. Arthroscopic treatment of chronically painful calcifying tendinitis of the supraspinatus tendon. Arthroscopy 2006;22:521-527. 2. Bethune R, Bull AM, Dickinson RJ, Emery RJ. Removal of calcific deposits of the rotator cuff tendon using an intra-
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articular ultrasound probe. Knee Surg Sports Traumatol Arthrosc 2006;15:289-291. Porcellini G, Paladini P, Campi F, Paganelli M. Arthroscopic treatment of calcifying tendonitis of the shoulder: Clinical and ultrasonographic findings at two to five years. J Shoulder Elbow Surg 2004;13: 503-508. Ark JW, Flock TJ, Flatow EL, Bigliani LU. Arthroscopic treatment of calcific tendonitis of the shoulder. Arthroscopy 1992;8:183-188. Arrigoni P, Brady PC, Burkhart SS. Calcific tendonitis of the subscapularis tendon causing subcoracoid stenosis and coracoid impingement. Arthroscopy 2006;22:1139.e1-1139. e3. Available at www.arthroscopyjournal.org. Mitsui Y, Gotoh M, Tanesue R, et al. Calcific tendonitis of the rotator cuff: An unusual case. Case Rep Orthop 2012;2012:806769. Manaka T, Ito Y, Nakao Y, et al. [Clinical evaluation of arthroscopic calcification removal for calcifying tendinitis]. Katakansetsu 2007;31:641-644 [in Japanese].
Abstract: Rotator cuff tendonitis is a very common diagnosis of the shoulder that usually responds to conservative management. However, calcific tendonitis occurs less frequently and often necessitates surgical intervention. The etiology and treatment options for this disorder remain controversial among orthopaedic shoulder specialists. Calcific tendonitis frequently presents within the supraspinatus tendon and rarely appears within the subscapularis tendon. We present a case and accompanying video technique of arthroscopic treatment of subscapularis calcific tendonitis.
C
alcific tendonitis of the rotator cuff is a common disorder of the shoulder that often necessitates surgical management. Controversy exists as to the etiology and pathogenesis of this disabling ailment. One theory suggests that impingement leads to rotator cuff tendon degeneration followed by calcification of the diseased tendon. Another explanation attributes hypoxia as the inciting event, leading to eventual calcification of the tendon.1,2 Despite the cause, the clinical manifestation of the disease process is dependent on the stage of calcification. There are 3 phases associated with the disease process, and symptoms generally begin at the end of the formative phase and dissipate at the beginning of the resorptive phase. Nonoperative treatment consisting of cortisone injections, extracorporeal shockwave therapy, iontophoresis, and physical therapy remains successful in most patients. In chronic cases that fail to respond to nonoperative measures, arthroscopic treatment has shown favorable results.3,4 Calcific tendonitis of the rotator cuff is most commonly associated with the supraspinatus tendon.1,2 The subscapularis tendon is rarely affected, and only 2 prior cases have been reported.5,6 Both cases were treated with arthroscopic procedures with good clinical results. We present the case of a 60-year-old right From Orthopaedic Research of Virginia (L.K.F., C.J.M., P.E.C.); and Tuckahoe Orthopaedic Associates (P.E.C.), Richmond, Virginia, U.S.A. The authors report the following potential conflict of interest or source of funding: L.K.F., C.J.M., and P.E.C. receive support from Arthrex, Bon Secours, DJO, DePuy Mitek, Smith & Nephew. Received April 18, 2014; accepted June 11, 2014. Address correspondence to Paul E. Caldwell III, M.D., 1501 Maple Ave, Ste 200, Richmond, VA 23226, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/14322/$36.00 http://dx.doi.org/10.1016/j.eats.2014.06.005
handedominant female desk worker who had a yearlong history of nontraumatic right shoulder pain and mechanical symptoms. Despite conservative measures, her condition did not improve and she ultimately underwent shoulder arthroscopy with removal of the calcific deposit and repair of the defect with an excellent clinical outcome (Video 1).
Surgical Technique The arthroscopic technique is performed with the patient in the lateral decubitus position but is certainly amenable to the beach-chair position as well. A standard posterior portal (Fig 1) is created, and a diagnostic arthroscopy of the glenohumeral joint is performed. Additional intra-articular pathology may be addressed in the same setting. The articular aspect of the subscapularis tendon is inspected for undersurface tears, as well as any evidence of the calcific deposit. Once the remainder of the diagnostic arthroscopy is completed, attention is turned to the subacromial space and a bursectomy is performed. The bursal surface of the rotator cuff is inspected, and the calcific deposit is visualized. An 18-gauge spinal needle is used to confirm the location of the calcific deposit and establish an accessory anterior portal. A scalpel is percutaneously used to create a 1-cm incision parallel to the fibers of the subscapularis tendon in an effort to decompress the calcium. A probe and a shaver are further used to remove the remainder of the calcium. The defect is inspected to determine that the majority of the calcium is removed and the defect is not full thickness in nature. Attention is then turned to closing the defect in the tendon using a simple suture configuration. Suture-passing hooks (Spectrum suture hooks; ConMed Linvatec, Largo, FL) and a monofilament suture (PDS; Ethicon, Somerville, NJ) are passed and retrieved on both sides of the defect in a simple
Arthroscopy Techniques, Vol 3, No 5 (October), 2014: pp e571-e573
e571
e572
L. K. FIELDS ET AL.
Fig 1. Anterior view of shoulder joint showing arthroscopic setup along with calcific deposit located within subscapularis tendon.
suture configuration. This process is repeated on the proximal and distal aspect of the defect. A high-strength polyethylene suture (Orthocord; DePuy Mitek, Raynham, MA) is then shuttled using standard arthroscopic shuttling techniques. The sutures are retrieved and tied using a sliding locking knot with 3 reversed half-hitches to close the defect and repair the tendon (Fig 2).
Discussion Arthroscopic treatment of calcific tendonitis of the rotator cuff has proved to be an effective treatment option in chronic cases that fail to improve with conservative measures.3,4 Although the vast majority of cases occur within the supraspinatus and infraspinatus
Fig 2. Anterior view of shoulder joint showing passage of sutures in a simple configuration in preparation for closure of defect in subscapularis tendon along with inset of final repair.
tendons, treatment of the subscapularis has been reported successfully with similar arthroscopic techniques. Documented cases of subscapularis calcific tendonitis are rare, and we are unaware of published video techniques.5,6 The location of the calcific deposit may differ from other tendons, but as previously suggested, subcoracoid impingement may indeed lead to involvement of the subscapularis causing degeneration and subsequent calcification.5 Radiographic and magnetic resonance imaging evaluation certainly provides a guide for initial management, but ultimately, arthroscopic evaluation is the gold standard for localizing the calcific deposit and determining definitive treatment. Controversy exists as to treatment using simple debridement of the calcium opposed to repair of the tendon as well as repair techniques. Manaka et al.7 have recommended that defects greater than 10 mm after debridement of the deposit require repair because of the high likelihood of propagation. The decision to use a side-to-side simple suture repair versus anchor-based repair depends on the amount of bone exposed and size of the defect after debridement. Our preference is to use a side-to-side repair for smaller defects located within the more proximal aspect of the tendon and anchor-based repair for larger defects more distal in the tendon. Traditional open techniques certainly require less specialized training and less equipment and potentially are less expensive. Arthroscopic techniques do require additional training and more specialized equipment but offer the potential advantage of a minimally invasive approach with less postoperative pain and early mobilization. This technical note provides additional support
SUBSCAPULARIS CALCIFIC TENDONITIS Table 1. Advantages of Arthroscopic Treatment of Subscapularis Calcific Tendonitis Standard arthroscopic setup and portals No special instrumentation Standard arthroscopic suture shuttling and tying Tendon-splitting approach Potential for early mobilization Low-profile repair
for arthroscopic treatment of subscapularis calcific tendonitis (Table 1), as well as a video demonstration of this arthroscopic technique.
3.
4.
5.
References
6.
1. Seil R, Litzenburger H, Kohn D, Rupp S. Arthroscopic treatment of chronically painful calcifying tendinitis of the supraspinatus tendon. Arthroscopy 2006;22:521-527. 2. Bethune R, Bull AM, Dickinson RJ, Emery RJ. Removal of calcific deposits of the rotator cuff tendon using an intra-
7.
e573
articular ultrasound probe. Knee Surg Sports Traumatol Arthrosc 2006;15:289-291. Porcellini G, Paladini P, Campi F, Paganelli M. Arthroscopic treatment of calcifying tendonitis of the shoulder: Clinical and ultrasonographic findings at two to five years. J Shoulder Elbow Surg 2004;13: 503-508. Ark JW, Flock TJ, Flatow EL, Bigliani LU. Arthroscopic treatment of calcific tendonitis of the shoulder. Arthroscopy 1992;8:183-188. Arrigoni P, Brady PC, Burkhart SS. Calcific tendonitis of the subscapularis tendon causing subcoracoid stenosis and coracoid impingement. Arthroscopy 2006;22:1139.e1-1139. e3. Available at www.arthroscopyjournal.org. Mitsui Y, Gotoh M, Tanesue R, et al. Calcific tendonitis of the rotator cuff: An unusual case. Case Rep Orthop 2012;2012:806769. Manaka T, Ito Y, Nakao Y, et al. [Clinical evaluation of arthroscopic calcification removal for calcifying tendinitis]. Katakansetsu 2007;31:641-644 [in Japanese].
