1. Focal Extracorporeal Shockwaves for the Treatment of Rotator Cuff Calcific Tendinopathies: Is it worth it? Daniel Moya, Osvaldo Patiño, Leonardo Guiloff, Manuel Brañes, Carlos Leal Buenos Aires, Argentina

4. Mechanotransduction Augmented perfussion Tissue healing
Biological approach
Shoulder rotator cuff responses to ESWT: morphological and immunohistochemical analysis
Brañes et al, Shoulder & Elbow 2012
Application of extracorporeal shockwaves induce through mechanotransduction an improvement in tissue healing associated with augmented perfusion. In the case of rotator cuff calcific tendinopathies this gives us the chance to change the course of the natural history of the disease in a biological way.

5. Study Prospective series of cases.
Aim: to evaluate the results of focal ESWT in patients with symptomatic rotator cuff calcifications.
The aim of our study was to prospectively evaluate the results of focal shock wave therapy in patients with symptomatic rotator cuff calcifications in a consecutive series of cases.

6. Inclusion criteria Symptomatic calcifications in rotator cuff tendons.
Failed conservative treatment (> 6 months).
Gärtner types 1 or 2.
Concomitant shoulder pathologies were ruled out.
We included symptomatic patients in which conservative or surgical treatment failed and were eligible for an invasive procedure.
Type 3 radiological Gärtner stage and other soulder pathologies were excluded.

7. Material 44 cases (prior surgery in 7). Average age: 48.6 years old.
Average evolution: 40 months.
We finally got 44 cases with an age average of 48 years old and an average evolution of 40 months.

8. Location Supraspinatus: 93% Infraspinatus: 4.5% Teres minor: 2.5%
Most of the calcifications were located in the supraspinatus.

9. Methods Electro hydraulic device. 3 sessions. 2000 pulses.
0.35 mJ/mm2.
Shockwaves were generated by an electrohydraulic device. Patients received 2000 pulses of high energy level in three sessions every two weeks.

10. Results 6 months follow-up Clinical examination X-rays
Student Test for related samples (SSPS17.0)
We evaluated the patients and analyzed the radiological findings at 6 months.

11. Radiological findings
25%
25%
45.5%
In 45.5 % of the cases we found a complete disappearance of the calcification on the X rays, in 29.5 there was partial resorption and we did not find radiological changes in 25% of the cases.
29.5%

12. A case of partial resorption with an excellent clinical outcome

13. Another case in advance process of resorption at 6 months

14. Complete disappereance of a Gärtner type 1 calcification

16. We found better results in the cases where the calcification disappeared but even a partial resorption lead to good results in 76% of these cases.

17. A big calcification that disapeared after a painful acute resorption.

18. The preoperative X ray of a patient who underwent an arthroscopic surgery

19. 8 monhs after surgey the size of the calcification was even bigger and the patient was suffering an intensive pain
Post-op

20. The result after 3 shockwave sessions
The result after 3 shockwave sessions. 5 of 7 patients refered to us after a prior failed surgery had god or excellent results.
Post ESWT

21. Pain VAS
5.5
Pain decreased according VAS from a mean baseline of 5.5…..

22. Pain VAS ( p <0000.1)
1.4
to 1.4 at 6 months

23. ASES Score (p <0000.1) 84.6 48 Pre ESWT 6 months FU
The Self ASES evaluation scored 84.6 as compared to the initial value of 48
Pre ESWT
6 months FU

24. UCLA Score ( p <0000.1) 29.3 11 Pre ESWT 6 months FU
UCLA score was in average 11 in the beginning and 29.3 at the 6 months evaluation 11
Pre ESWT
6 months FU

25. Patient satisfaction Not satisfied 22,8% Satisfied 77,2%
77 % of the patients were satisfied at the follow up. No important complications were reported. 10 of 44 cases had poor results, 5 of which were finally operated..

26. Discusion
Shock wave therapy versus conventional surgery in the treatment of calcifying tendinitis of the shoulder
Rompe, Clin Orthop Relat Res. 2001
Arthroscopy surgery versus shock wave therapy for chronic calcifying tendinitis of the shoulder
Rebuzzi, J Orthop Traumatol. 2008
Influence of deposit stage and failed ESWT on the surgical results of arthroscopic treatment of calcifying tendonitis of the shoulder
Lorbach, Knee Surg Sports Traumatol Arthrosc. 2008
Several papers have found similar outcomes comparing sugery and shockwave therapy. Lorbach have shown that the preoperative treatment of the shoulder with ESWT did not have any significant impact on the postoperative results.

27. ESWT is a valid biological alternative to invasive techniques
Clinical relevance
ESWT is a valid biological alternative to invasive techniques
According to the literature and our own results we think that ESWT gives us the chance to change the course of the natural history of the disease in a biological way and it is a is a valid alternative to invasive techniques when conservative treatment or even prior surgery have failed.