Efficacy of ultrasound-guided percutaneous treatment of the rotator cuff calcific tendinopathy with double needle technique

1. Introduction

The literature concerning the epidemiology of calcific tendinopathy (often hydroxyapatite)¹ or rotator cuff calcific tendinopathy (RCCT) of the shoulder is well known and one of the leading causes of chronic shoulder pain2.

The frequency according to the studies is variable (from 3 to 20%), with a female predominance, with a range of 30–50 years, while is bilateral in 13–24% of cases.3, 4, 5

The frequency is higher among manual workers and diabetics, or in the case of renal insufficiency.^6,7

The most frequent localization is in the supraspinatus muscle (up to 82%), then in the infraspinatus muscle (15%) and finally in the subscapularis muscle (5%).^3,4

In the presence of pain, calcification is responsible in about 20% of cases between 30 and 40 years.^2,8

The aim of this study was to evaluate the efficacy of the ultrasound-guided percutaneous technique with double needle in the irrigation of shoulder calcification in the acute pain.

2. Materials and methods

Data were prospectively analyzed from 10 patients (6 M and 4 F, range 26–54 years) treated by ultrasound-guided percutaneus irrigation with a double-needle technique, performed in the period from January 2019 to September 2019.

Only patients with calcification at least 5 mm in size with and with acute pain and functional limitation were selected.

All patients had a shoulder radiograph to compare it with post-treatment.

The patient was placed supine and disinfected profusely.

Then percutaneous local anesthesia (Lidocaine 10 mg/mL) was performed using 25 Gauge (G) needle, along the path chosen for the treatment and for both needles.

Then two 18 G needles were introduced into the calcification, with the first needle that must be inserted in a deep position (Fig. 1, Fig. 2).

Fig. 1.

The image shows the two needles introduced with ultrasound-guided percutaneous technique into the painful calcification.

Fig. 2.

The ultrasound image shows the two needles (arrows) introduced one on the other inside the calcification (first the depth one to avoid artifacts), in a parallel position.

With a 20 ml syringe pre-filled with saline and lidocaine (the irrigation of the calcification could be painful), pressure was applied to one of the two needles.

We can insert a 20 G needle into each needle to remove calcium that may obstruct needle tips.

During the procedure the needle can also be moved to other areas to be treated, depending on the size and shape of the calcification.

The duration of the treatment depending on the size and the hardness of the calcification.

After the destruction of the calcification, the fragments pushed by the physiological solution are able to exit by from de other needle positioned inside the calcification creating a washing circuit.

Finally infiltration into the subacromial-subdeltoid bursa (SASD) with cortisone (Betamethasone dipropionate 1 mL) is performed.

All the necessary material is summarized in Fig. 3.

Fig. 3.

The image summarizes the material used by our team during the procedure.

Ten days later a check radiograph is performed and compared to the previous one (Fig. 4a and b).

Fig. 4.

a–b: Comparison between the radiography carried out before (Fig. 4a) and after (Fig. 4b) the treatment of the ultrasound-guided percutaneous technique with double needle.

We asked the patient ten days later to evaluate the disappearance of pain from one to five (1 no change and 5 complete resolution) and the recovery of functional capacity (1 no change and 5 complete recovery of function).

3. Results

Ten calcific tendinopathy were treated, 6 of the supraspinatus muscle, 3 in the infraspinatus muscle and 1 in the subscapularis.

For all ten cases a double-needle (18 G) technique was performed; in all cases the calcification was destroyed with a leakage and aspiration of white materia.

There were no complications during and immediately after the procedure.

Two patients reported night pain on the day of the procedure.

At the ten-day radio-graphical check, the calcification appear either markedly reduced in size, or fragmented.

The results regarding the recovery of functionality are the following:

• -Pain score: 5 seven patients, 4 two patients and 3 one patient;
• -Recovery of functionality score: 5 six patients, 4 three patients and 3 one patient.

4. Discussion

The ultrasound-guided percutaneous irrigation of shoulder calcification with double needle is a reliable and reproducible technique, as long as you have a discreet manual skills and experience.

The main aim of this procedure is to treat patients with functional disorders and reduce pain, rather than complete destruction of the calcification.

The use of the guided infiltration within the SASD allows a further better result.

Conservative management of the calcific tendinopathy usually involves rest, physical therapy, and oral nonsteroidal anti-inflammatory drugs administration.9, 10, 11

Physiotherapy with range of motion exercises could be able to avoid gleno-humeral stiffness and frozen shoulder, but there is no evidence that the calcific tendinopathy is linked with gleno-humeral capsular impairment.^9,11

An intra-SASD injection of corticosteroids may be used to relieve patient's symptoms due to subacromial impingement and bursitis,¹⁰ but it has been demonstrated that US-guided percutaneous aspiration of calcific tendinopathy is superior to SASD bursa injections in this setting.¹¹

Serafini et al. on the other hand claims that treated patients had better outcomes than did non treated patients at 1 year. However, 5 and 10 years after the procedure, the non-treated group reported outcomes similar to those of the treated group.¹² Probably the fact can be linked to the maturation of the calcification; the goal remains however the treatment of acute pain.

Based on our experience we believe that the technique with double needle is more effectively because it allows a washing circuit between the two needles.

The effectiveness is maximally if the needles are positioned with careful ultrasound guidance. Both must be inserted in the same coronal plane for greater effectiveness.¹³

Thus, the effect with two needle is enhanced compared to the technique with a single needle, which allows only the destruction and trituration of the calcification.

Some authors have tried further to increase the technical quality, as for example that warm physiological saline is better than room temperature physiological saline for irrigation.¹⁴

Few studies have reported on complications of UGPL, such as vagus nerve stimulation and Pain^15,16, or a case of suppurative synovitis.¹⁷

Among the advantages of this semi-invasive technique we point out the fact that the patient after the therapeutic procedure does not need immobilization. Treatment not require the hospitalization or day hospital.

The control after ten days is important first for checking the radiological correctness of the procedure, but especially the outcome of the patient.

The limitation of the study has been the scarcity of patients and the lack of a multicenter study; finally the quality score is relatively low.

5. Conclusion

The ultrasound-guided percutaneous irrigation of shoulder calcification with double needle is a reliable and reproducible technique for treatment the RCCT and their clinical symptoms, when conservative treatments is insufficient.

Informed consent was obtained for experimentation with human subjects.

The authors ensure that the work described has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans.

Declaration of competing interest

There are no conflicts of interest.