Calcifications in the cuff: take it or leave it?

Objectives

The aim of this study was to evaluate whether removing the calcifications in the rotator cuff tendons during surgical subacromial decompression improves outcome in patients with calcific tendonitis.

Methods

Two groups of 20 patients with a subacromial impingement syndrome and cuff calcifications were operated on. In group A, patients had an anterolateral acromioplasty according to Neer with excision of calcifications. In group B, the same procedure was performed without additional excision of calcifications. After a minimum follow‐up of 3 years the patients were assessed with the disabilities of arm, shoulder and hand score (DASH), the visual analogue scale (VAS) for pain, measurements of range of motion (ROM) in all planes, and satisfaction with treatment.

Results

The results for the DASH score, ROM, VAS and satisfaction with treatement showed no significant difference between the two groups.

Conclusion

The results of our study suggest that removal of calcific deposits with anterolateral acromioplasty does not influence patient outcome. Further prospective studies are needed to determine the optimal surgical treatment for calcific tendonitis.Calcific tendonitis of the shoulder is a common and painful disorder and is characterised by calcifications in the tendons of the rotator cuff (fig 1​1).). The incidence in the healthy population is 2.7%, rising to 6.8% in patients with shoulder pain.^1,2 The predominant age is 30–60 years and women are affected slightly more often than men. The calcifications are most often seen in the tendon of the supraspinatus muscle.¹ Risk factors for shoulder pain due to problems of the rotator cuff include overhead activities and sports.^3,4 The treatment of choice is primarily conservative. This includes rest, physiotherapy, non‐steroidal anti‐inflammatory drugs and at a later stage a subacromial infiltration with corticosteroids. When conservative treatment fails, surgery can be recommended. In most studies on surgical treatment of calcific tendonitis, removal of the calcifications in combination with a subacromial decompression is only recommended when there are signs of subacromial irritation.^{5,6,7,8,9,10,11} However, it has also been advocated that a subacromial decompression alone might be sufficient, stating that the calcifications will dissolve as a matter of natural course.¹² The aim of this study was to evaluate whether it is beneficial for patient outcome to remove the calcifications of the tendons of the rotator cuff when performing a subacromial decompression.Open in a separate windowFigure 1 Example of a calcification in the rotator cuff on an x ray of the shoulder.     

Is it epilepsy?

Detainees in police stations frequently claim to suffer from epilepsy. The diagnosis of epilepsy is not always straight forward and a misdiagnosis can be easily made, even by specialists. The case of a detained person claiming to suffer from epilepsy is described. The differential diagnosis and management is discussed with particular attention given to non epileptic attack disorder and the problems that this condition may cause for the examining forensic physician.     

Domestic violence: do forensic physicians have a role?

The role of the forensic physician in domestic violence incidents in South London was investigated over a 6-month period. The aim of the study was to identify the nature of domestic violence, to determine whether the individuals involved had previously been in contact with the primary health care team or other agencies and whether direct communication between the examining forensic physician and the patient's general practitioner was of assistance to the latter. We concluded that there is a definite role for the forensic physician in documenting injuries in victims and assailants (although most were minor injuries), providing appropriate medical treatment, supplying information regarding support agencies and passing the relevant information, with the patient's consent, to the primary health care team.     

Do forensic physicians have a future in the UK?

This article represents a personal view of the future of forensic physicians (police surgeons) in the UK.     

Proximal iliotibial band syndrome: what is it and where is it?

Objective  

To describe the clinical and MR imaging features of a unique strain at the iliac tubercle enthesis. While this strain appeared to correspond to the iliotibial band (IT band) enthesis, the literature regarding the IT band origin was discrepant. As such, our second goal was to prove that the IT band originated at the iliac tubercle, through cadaveric dissection.     

Parathyroid imaging: how good is it and how should it be done?

Hypersecretion of parathormone in primary hyperparathyroidism is common, occurring in approximately 1 in 500 women and 1 in 2,000 men per year in their fifth to seventh decades of life. This has been suggested from the literature to be primarily the result of a parathyroid adenoma (80-85% of cases), hyperplasia involving more than 1 gland, usually with all 4 glands being involved (10-15% of cases), or the result, albeit rarely, of parathyroid carcinoma (0.5-1% of cases). Surgical removal of the hypersecreting gland is the primary treatment; this procedure is best performed by a skilled surgeon who would normally find the abnormality in 95% of cases. Imaging, however, should be used to identify the site of abnormality, potentially reducing inpatient stay and improving the patient experience. Functional imaging of parathyroid tissue using thallium was introduced in the 1980s but has largely been superceded by the use of (99m)Tc-labeled isonitriles. The optimum techniques have used (99m)Tc-sestamibi with subtraction imaging or washout imaging. A recent systematic review reported the percentage sensitivity (95% confidence intervals) for sestamibi in the identification of solitary adenomas as 88.44 (87.48-89.40), multigland hyperplasia 44.46 (41.13-47.8), double adenomas 29.95 (-2.19 to 62.09), and carcinoma 33 (33). This review does not separate the washout and subtraction techniques. The subtraction technique using (99m)Tc-sestamibi and (123)I is the optimal technique enabling the site to be related to the thyroid tissue when the parathyroid gland is in the neck in a normal position. If there is an equivocal scan then confirmation with high resolution ultrasound should be used. With ectopic glands, the combined use of single-photon emission computed tomography may then provide anatomical information to enable localization of the functional abnormality. In patients who have had surgical exploration by an experienced parathyroid surgeon in a unit with an experienced nuclear medicine team and negative sestamibi imaging, it is reasonable to image the patient with (11)C methionine. It is debatable whether patients with a high likelihood of secondary hyperparathyroidism should be imaged. The only possible justification for this is to exclude an ectopic site. There is no substitute for an experienced surgeon and an experienced imaging unit to provide a parathyroid service.     

Should Canadian physicians have a mandatory duty to report woman abuse?

As in other countries, woman abuse is a leading public health issue in Canada. In recognition of its seriousness and the need to interrupt the cycle of violence, several jurisdictions outside of Canada have enacted mandatory reporting laws for woman abuse that require health care workers to report cases. This article reviews the major debates surrounding mandatory reporting of woman abuse with an emphasis on where knowledge is incomplete but would be of benefit when weighing the pros and cons of such laws. We conclude with comments and recommendations with respect to Canada and its health legislation.