Efficacy of Adjuvant Application of Platelet-Rich Plasma After Needle Aspiration of Calcific Deposits for the Treatment of Rotator Cuff Calcific Tendinitis: A Double-Blinded, Randomized Controlled Trial With 2-Year Follow-up.

BACKGROUND: Needle aspiration of calcific deposits (NACD) is a frequently used treatment for rotator cuff calcific tendinitis (RCCT). However, a substantial number of patients experience recurrent or persisting shoulder symptoms after NACD. PURPOSE: To compare the effects of adjuvant application of platelet-rich plasma (PRP) after NACD (NACP+PRP) with those of conventional NACD with corticosteroids (NACD+corticosteroids) on pain, shoulder function, and quality of life (QoL). STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: In a single-center, double-blinded, randomized controlled trial, 80 adults with symptomatic RCCT were randomly allocated to receive NACD+corticosteroids or NACD+PRP. Pain, shoulder function, and QoL were assessed at baseline; 6 weeks; and 3, 6, 12, and 24 months after treatment using a numeric rating scale for pain (NRS); the Constant-Murley score (CMS); the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH); the Oxford Shoulder Score (OSS); and the EuroQol 5-dimension scale (EQ-5D). Additionally, resorption of calcific deposits and the integrity of rotator cuff tendons were assessed by using standard radiographs and ultrasound examination, respectively. The results were analyzed using noninferiority analysis for NRS scores and a mixed model for repeated measures. RESULTS: Eighty patients were included (48 female; mean age, 49 ± 6 years; 41 patients in the NACD+PRP group). Both groups showed improvement of clinical scores at the 2-year follow-up (P < .001 for all clinical scores). NACD+PRP was found to be noninferior to NACD+corticosteroids with regard to the mean decrease of NRS scores (4.34 vs 3.56; P = .003). Mixed-model analysis showed a significant difference in favor of NACD+PRP (CMS, P < .001; DASH, P = .002; OSS, P = .010; EQ-5D, P < .001). However, clinically relevant differences in favor of NACD+PRP were only seen at the 6-month follow-up for NRS and CMS scores, whereas at the 6-week follow-up a clinically relevant difference in favor of NACD+corticosteroids was found for all clinical scores except for the NRS. Full resorption of calcific deposits was present in 84% of the NACD+PRP group compared with 66% in the NACD+corticosteroids group (P = .081). In the NACD+PRP group, 10 (24%) patients required a second NACD procedure compared with 19 (49%) patients in the NACD+corticosteroids group (P = .036). Six complications, of which 5 were frozen shoulders, occurred in the NACD+PRP group compared with 1 complication in the NACD+corticosteroids group (P = .11). CONCLUSION: NACD+PRP resulted in worse clinical scores at the 6-week follow-up but better clinical scores at the 6-month follow-up compared with NACD+corticosteroids. At the 1- and 2-year follow-ups, the results were comparable between groups. Furthermore, PRP seemed to reduce the need for additional treatments but was associated with more complications. In conclusion, NACD+corticosteroids had a favorable early effect on pain and function combined with low comorbidity. Thus, it remains the treatment of choice for patients with RCCT. REGISTRATION: NCT02173743 (ClinicalTrials.gov identifier).

Prognostic factors for the outcome of needle aspiration of calcific deposits for rotator cuff calcific tendinitis.

OBJECTIVE: To identify prognostic factors for the effectiveness of needle aspiration of calcific deposits (NACD) for rotator cuff calcific tendinitis (RCCT) METHODS: One hundred forty-nine patients with symptomatic RCCT were included in a prospective cohort study. Pain (VAS), shoulder function (SST and DASH), and quality of life (EQ-5D) were assessed at baseline and at 3, 6, and 12 months post-NACD. Univariate analyses (independent t tests or Mann-Whitney U tests depending on the distribution of data) were performed to build a multivariable linear regression model. Stepwise regression analysis through backward elimination was performed to evaluate the effect of predefined prognostic factors on the outcome. RESULTS: Patients who underwent multiple NACD procedures had less reduction of pain (p < 0.01). Furthermore, a larger reduction in VAS pain scores at 3 months post-NACD was associated with a larger reduction in VAS pain scores at 12 months (p < 0.01). More improvement of SST and DASH scores at 3 months was associated with better SST, DASH, and EQ-5D scores at 12 months (p < 0.01). Smaller-size calcific deposits were associated with less improvement of DASH (p = 0.03) and EQ-5D scores (p = 0.01). A longer duration of symptoms prior to NACD was associated with less improvement of EQ-5D scores (p = 0.01). CONCLUSIONS: A good initial response after NACD is associated with better outcomes at 12 months. Patients with a longer duration of symptoms prior to NACD and patients who require multiple procedures showed inferior outcomes in terms of pain reduction and improvement of quality of life. Smaller-size calcific deposits are associated with a less favorable outcome of shoulder function and quality of life scores and might therefore be less susceptible for NACD. KEY POINTS: • A good initial response to NACD is associated with a better outcome in the longer term. • A longer duration of symptoms and the need for multiple NACD procedures are associated with inferior outcomes. • Smaller-size calcific deposits seem less susceptible for NACD.

Needle aspiration of calcific deposits (NACD) for calcific tendinitis is safe and effective: Six months follow-up of clinical results and complications in a series of 431 patients.

BACKGROUND: Although needle aspiration of calcific deposits (NACD) has proven to be an effective treatment for calcific tendinitis of the rotator cuff (CTRC) in patients who are resistant to conservative treatment, little is known about the effectiveness of NACD in terms of complete relief of symptoms and the effectiveness of repeated NACD procedures. Furthermore, analyses of complications of the procedure in large series are scarce. METHODS: 431 consecutive patients with symptomatic CTRC treated by NACD were included in this retrospective cohort study. Short-term effects were assessed at two weeks post-treatment by using an 11-point numeric rating scale (NRS). The six months outcome was determined on a dichotomous symptom scale (symptom free or persistence of symptoms). NACD procedures performed within six months of a previous NACD procedure were considered repeated procedures. All complications that occurred within six months of the NACD procedure were registered. RESULTS: At two weeks post-treatment, a significant improvement of pain scores was noted (mean reduction of NRS: 4.4 points; p<0.001). 74% of patients had complete relief of symptoms at six months post-treatment. 143 (33.2%) patients required multiple treatments. These repeated procedures were equally effective as the primary procedure. Complications of the NACD procedure were seen in 31 (7.2%) patients: 21 patients (4.9%) developed a subacromial bursitis, seven patients (1.6%) a frozen shoulder and three patients (0.7%) developed a septic bursitis. CONCLUSION: Needle aspiration of calcific deposits (NACD) is an effective treatment for calcific tendinitis of the rotator cuff in the majority of patients. Approximately one third of the patients will require multiple treatments, which were equally effective as the primary procedure. Based on this, patients should not be withheld a second or even a third treatment in case of persistent symptoms. Furthermore, NACD has a low complication rate, the risk of infection should, however, always be accounted for. LEVEL OF EVIDENCE: Retrospective study, level IV.

Smoking and morphology of calcific deposits affect the outcome of needle aspiration of calcific deposits (NACD) for calcific tendinitis of the rotator cuff.

INTRODUCTION: Although NACD has proven to be an effective minimal invasive treatment for calcific tendinitis of the rotator cuff, little is known about the factors associated with treatment failure or the need for multiple procedures. METHODS: Patients with symptomatic calcific tendinitis who were treated by NACD were evaluated in a retrospective cohort study. Demographic details, medical history, sonographic and radiographic findings were collected from patient files. Failure of NACD was defined as the persistence of symptoms after a follow-up of at least six months. NACD procedures performed within six months after a previous NACD procedure were considered repeated procedures. Multivariate logistic regression analysis was used to determine factors associated with treatment failure and multiple procedures. RESULTS: 431 patients (277 female; mean age 51.4±9.9 years) were included. Smoking (adjusted odds ratio (AOR): 1.7, 95% CI 1.0-2.7, p=0.04) was significantly associated with failure of NACD. Patients with Gärtner and Heyer (GH) type I calcific deposits were more likely to need multiple NACD procedures (AOR: 3.4, 95% CI 1.6-7.5, p<0.01) compared to patients with type III calcific deposits. Partial thickness rotator cuff tears were of no influence on the outcome of NACD or the number of treatments necessary. CONCLUSION: Smoking almost doubled the chance of failure of NACD and the presence of GH type I calcific deposits significantly increased the chance of multiple procedures. Partial thickness rotator cuff tears did not seem to affect the outcome of NACD. Based on the findings in this study, the importance of quitting smoking should be emphasized prior to NACD and partial thickness rotator cuff tears should not be a reason to withhold patients NACD.

Medial branch blocks and fresh vertebral compression fractures.

Article: Bogduk Nikolai, MacVicar J, Borowczyk J. The pain of vertebral compression fractures can arise in the posterior elements. Pain Med 2010;11:1666-73.