- Introduction
Calcific tendinitis is a disease that causes pain as apatite form in a tendon. It has a well-known natural course from fibrocartilageous metaplasia to spontaneous phagocytic resorption, during this process the resorptive phase frequently requires medical interventions due to severe pain. It is frequently observed in rotator cuff tendons around the shoulder joint and often causes extreme pain that interfere with daily life. Here, we report calcific tendinitis in the posterolateral area of the proximal femur that had been missed and its successful clinical and radiographic remission after ultrasound-guided barbotage.
- Case report
A 58-year-old male patient without a history of trauma was referred at the musculoskeletal clinic for right buttock pain. He noted little resting pain and before activity there was no complaint of pain associated with trunk or hip joint motion, and there was no lateral hip pain or tenderness on the physical exam. But he rated his post-activity pain as 10 on a numeric rating scale (NRS) of 0-10.
Plain radiographs showed no specific findings in the soft tissue areas in the hip AP and frog-leg lateral views(Fig. 1A, B). However, at the level of the lesser trochanter in the posterior area of the femur, a calcific deposit split in two was identified on additional lateral femur radiographs (Fig. 1-C).
Longitudinal ultrasound scan of upper femur shaft showed a hyper-echoic mass with none or faint posterior acoustic shadow, and as moving the probe slightly medial, a mass with a more pronounced shade on the caudal part in gluteus maximus were visualized (Fig 2-A,B). So we performed ultrasound-guided barbotage as treatment for the calcific deposits(Fig. 3)Plain radiographs taken after the procedure showed a decrease in the size of the calcium deposits(Fig. 1-E). At the 6-month follow-up visit, the patient was able to live a daily life without pain and fading of most of the calcium deposits was observed on follow-up plain radiographs(Fig. 1-F).
From additional retrospective review of the patients records, pelvic computerized tomography showed calcific deposits at the posterior side from the gluteal tuberosity(Fig.2-a,b). Specifically, the calcific deposit was observed in the origin area of the vastus lateralis at the level where the lesser trochanter was most prominent, and the other deposit was observed in the insertion area of the gluteus maximus tendon(Fig. 2-a).
-Discussion
A calcific deposit at the gluteal tuberosity or linea aspera could be in various relative positions with proximal femur due to its externally rotated orientation in various degrees. Therefore, screening the calcific tendinitis require proper radiograph series according to each body parts in consideration of the normal anatomical variance and the overlap with the bony structure. And ultrasonography guided barbotage could be easily and safely tried to treat the calcific tendinitis around the hip joint.
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Fig 1. Simple radiographs series at first visit (A-D), and immediate after barbotage (E) and six-month follow-up (F) of the proximal femur. The pelvis antero-posterior (A), and Frog-leg lateral (B) radiographs do not show definite soft tissue lesion, but the femur lateral radiograph (C, D) show a 17 x 10 mm-sized calcific deposit split in two (arrow) behind the femur at the lesser trochanter (asterisk) level. And, it was almost faded at six months follow up (F), but because the shadow of scrotum (white dotted line, D) was slightly overlapped, it is difficult to judge the complete remission.
Fig 2. Ultrasonographic (A, B) and computerized tomographic (a, b) images and schematic demonstrations (C) of posterior femur shaft were presented. When transducer was placed longitudinally and moved from lateral (A) to medial (B), A 15 mm-length calcific deposit (black arrow) was observed at the vastus lateralis with faint posterior acoustic shadow (A), and another fragment of calcific deposits which more caudally prominent was observed (B). Cross-sectional computerized tomography revealed that more proximal part (a) of calcific deposits are within the vastus medialis origin and adjustment to lateral intermuscular septum (white arrow) at the level where the lesser trochanter (asterisk) is most prominent, and distal fragments were more likely within the gluteus maximus tendon insertion area (b). (VL, Vastus lateralis; GM, Gluteus maxiums; AM; QF, Quadriceps femoris; AM, Abductor muscle.)
Figure 3. Needle at the calcification located at the vastus lateralis The calcific deposit on the vastus lateralis was punctured with an 18G spinal needle (arrow).
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