This study was conducted in the Department of Orthopedics at West China Hospital of Sichuan University, was approved by the Human and Ethics Committee for Medical Research at Sichuan University, and was performed in accordance with the Helsinki Declaration. All the patients provided informed consent prior to enrolment in the study.
Patients were included if they were symptomatic, had a poor response to conservative treatments lasting for more than 6 months prior to enrolment, had experienced night pain [8, 32, 33] with a severity of more than 60 mm on a 100-mm visual analogue pain scale (VAS; 0 mm representing no pain and 100 mm representing the worst imaginable pain) at night in the target shoulder joint, could not sleep well for more than 4 hours during the night, and had significant X-ray (Fig. 1) and magnetic resonance imaging (MRI) (Fig. 2) evidence of CT with a diameter of no less than 1 cm in the target shoulder [31, 34]. Patients with an unstable medical condition from a shoulder surgery, such as infection or abnormal vital signs, a secondary definite full rotator cuff tear, and a follow-up period of less than one year were excluded from the study.
At the time of screening, the medical history of each patient was recorded. A complete physical examination, particularly focused on the target shoulder, and laboratory assessments were performed. A radiograph of the target shoulder was also taken. Clinical diagnoses of CT of the rotator cuff were made based on the classic symptoms and radiographical evidence, and were finally confirmed by pathological diagnoses after the operation. The American Shoulder and Elbow Surgeons (ASES) scores [11], University of California at Los Angeles (UCLA) scores [2], and VAS scores were assessed preoperatively. All scores were reported by the patients themselves.
Between Jan 2015 and Apr 2018, a total of 49 patients received surgery in our department were screened. Eleven patients were excluded; 6 patients did not undergo conservative treatments for more than 6 months, 4 had definite full rotator cuff tears, and 1 had a concomitant immune disease. Finally, thirty-eight patients who underwent CT arthroscopic excision were evaluated retrospectively. The age of the patients we included ranged from 32 years to 76 years (average 55.08 years), and 78.9% were women (8 men and 30 women). The baseline main characteristics for all 38 patients are shown in Table 1. All operations were performed by the same group of surgeons. Among the 38 patients with affected shoulders, 1 patient had previously suffered from CT in the right shoulder and underwent arthroscopic excision, and CT developed in the left shoulder 2 years later. Among the 39 affected shoulders, 3 cases involved both the supraspinatus and infraspinatus, 28 involved the supraspinatus, 5 involved the infraspinatus, and 3 involved the subscapularis tendon. Among all the patients we enrolled, 13 patients suffered from partial rotator cuff tears (Elman grade lower than II), and 9 suffered from stiff shoulders before enrolment.
Table 1
Demographic and Clinical Patient Data (n = 38)
Item | | Data |
Age, (mean ± SD), y | | 55.08 ± 8.84 |
Sex, n | | |
| Male | 8 |
| Female | 30 |
Side#, n | | |
| Left | 10 |
| Right | 27 |
| Double | 1 |
The affected tendon#, n | Supraspinatus | 28 |
Infraspinatus | 5 |
Both two above | 3 |
Subscapularis | 3 |
Concomitant PRCT#, n | Elman grade I Elman grade II Elman grade II | 13 6 0 |
Concomitant stiff shoulder#, n | 9 |
Duration of symptoms#, (mean ± SD), m | 39.69 ± 47.95* |
Follow-up time#, (mean ± SD), m | 45.38 ± 16.37 |
PRCT, partial rotator cuff tear; SD, standard deviation; |
# 39 shoulders; |
* One patient suffered from right shoulder pain for 20 years. |
Surgical procedure
All surgical procedures were performed by the same surgeon team with the patient under general anaesthesia and in the lateral decubitus position. First, target shoulder arthroscopy with the routine posterior portal was used to evaluate the glenohumeral joint. Then, the routine anterior upper portal was established under arthroscopic guidance. Intra-articular pathologies were identified and managed, as required. Subsequently, the scope was moved to the bursa surface for further evaluation, and subacromial decompression was performed if evidence of impingement was observed. Then, under needle guidance, the routine lateral portal was made, and the scope was moved to this portal for an outlet view.
Prior to the operation, the supraspinatus outlet view was thoroughly evaluated to locate the calcific lesion in the rotator cuff tendon. Usually, calcific materials are easily identified because calcific lesions are in a superficial location (Fig. 3a). In some cases, it was difficult to visualize any pathologies on the outer surfaces of the tendons, so exploration of the supraspinatus tendon was performed using a spinal needle to identify the calcific materials. A spinal needle was introduced into the supraspinatus tendon percutaneously to locate the calcific deposits. Once the calcific lesion was located, an additional lateral portal was normally established, and a small longitudinal incision (measuring no more than 1.5 cm) parallel to the rotator cuff tendon on the synovial side was made using a No. 11 sharp blade so that all of the calcific materials could be removed. For the three-calcific subscapularis, an additional anterolateral portal was established when we located the calcific lesion, and a small longitudinal incision (no more than 1.5 cm) parallel to the subscapularis tendon was made.
Those patients need acromioplasty underwent release of the coracoacromial ligament and flattening of the anterior-inferior surface of the acromion. This was performed with a combination of electrocautery and shaver use to remove bursal tissue and define the lateral border and under surface of the acromion. A motorized bur was then used to remove bone until the under surface of the acromion was flat when viewed from the lateral portal.
In all 38 patients with 39 affected shoulders, 14 lesions were identified directly under arthroscopy, and the other 25 were confirmed by spinal needles. All visible calcifications were removed by irrigation or debridement and were sent for further pathological assessments (Fig. 3b). After complete calcification removal and the debridement of serious degenerative changes in the surrounding tissue, a rotator cuff defect developed in most cases (Fig. 3c).
When the rotator cuff defect was considered to be a relatively large defect or the tendon was torn in full thickness, repair was performed using one or two suture anchors or side-to-side stitches, depending on defect size and shape (Fig. 3d). Suture anchor repair was performed when there were relatively large defects and partial thickness tears with an Elman grade higher than III after the removal of calcific materials, and one stitch of side-to-side repair was performed in partial tears with an Elman grade of II to prevent the progression of the rotator cuff tears. In cases with minimal damage (an Elman grade of I or lower) of the rotator cuff after the removal of the calcific deposits, only debridement was performed.
For concomitant shoulder stiffness, all patients underwent manipulation release prior to surgery and intra-articular debridement. A shaver and radiofrequency were used to remove all inflammatory synovium and release all adhesive capsules, including the capsule of the rotator cuff interval.
Postoperative management and assessment
All patients received an intramuscular injection of pethidine and/or oral NSAIDs to relieve pain after surgery. A standard protocol was designed for most of the patients included by our rehabilitation team, but an individualized rehabilitation plan was also provided as needed, depending on the outcomes and the patients’ compliance at each clinical follow-up. Normally, a shoulder abduction brace was used for 4 to 6 weeks after the surgery, and then, active range of motion and strengthening exercises were started gradually, depending on the defect size, shape and repair patterns of the rotator cuff after the removal of the calcific lesions. All patients were prescribed passive range of motion exercises and rehabilitation two weeks after surgery. For calcified tendinitis of the rotator cuff accompanying stiff shoulder, passive range of motion exercises and rehabilitation were started the first day after the operation [4, 8, 35].
All patients underwent clinical follow-ups at intervals of 2, 4, and 8 weeks and 3, 6, 12 and 24 months after the surgery and annually thereafter. All radiographic and clinical efficacy measures, including the ASES scores, UCLA scores, and VAS scores at night, were determined at the outpatient clinics. The achieving pain relief and functional scores after surgery were evaluated by the patients themselves then reviewed by two surgeons (LT and XY) at each clinical visit. The radiographic data were reviewed by two physicians from our hospital imaging centre. All complications were recorded and reviewed by two senior surgeons (TX and LJ).
Statistical analysis
Statistical analyses were performed by SPSS 22.0 software (SPSS Inc., Chicago, IL, USA). Continuous data are presented as the mean ± standard deviation (SD). Changes in the VAS, ULCA and ASES scores were analysed with repeated measures analysis of variance. A p value of less than 0.05 was considered significant.