Rotator cuff calcific tendinitis barbotage

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Rotator cuff calcific tendonitis can be treated with various techniques including ultrasound-guided barbotage, which is also known as ultrasound-guided needling and lavage. It is often performed in conjunction with a subacromial bursal injection. Alternative treatments include extracorporeal shock wave therapy (ECSW) or shoulder arthroscopy.

Indications

Contraindications

  • active skin infection
  • coagulopathies and anticoagulation medication (relative)

Procedure

Preprocedural evaluation
  • review contraindications
  • review previous images and localize calcific deposits
  • informed consent
Equipment
  • sterile dressing pack, probe cover, ultrasound gel
  • sterile gloves 
  • skin disinfectant
  • 16 to 22 G long needles (user preference)
  • syringes (volume depending on technique)
  • normal saline
  • local anesthetic e.g. 1% lidocaine, 0.5% bupivacaine
  • corticosteroids: e.g. methylprednisolone
Technique
  • sterile technique
  • sonographic visualization of the calcific deposit (typically on a lateral transverse view)
  • infiltration of local anesthetic (e.g. 10 mL 1% lidocaine) using a 25 G needle along the expected needle track and into the subacromial bursa +/- adjacent to or within the calcific deposit
Single needle technique
  • insertion of an 18 G needle attached to a 5 mL syringe containing 4 mL normal saline into the center of the calcific deposit, ensuring a horizontal lie, and the calcification is flushed
  • if calcific material flows back into the syringe, lavage the calcific deposit with calcific debris layering dependently in the syringe to avoid re-injection
  • exchange syringes when the saline has become cloudy and continue lavage until backflow is clear
Dual needle technique
  • 2 x 16 G needles are inserted into the calcific deposit as parallel as possible to the ultrasound transducer so that both can be seen simultaneously
    • the deeper needle should be inserted first with the bevel rotated upwards
    • the superficial needle should have its bevel rotated downwards
    • needle tip distance should be very close (2-3 mm)
  • normal saline is injected using a 20 mL syringe into one needle with free drainage of saline and calcium from the other needle

N.B. Corticosteroid (e.g. 40 mg methylprednisolone) is usually injected into the subacromial subdeltoid bursa after lavage as the patient can experience a chemical bursitis from leak of calcification into the bursa.  A new or different needle from the 'barbotage' needle, should be used to inject the bursa with corticosteroid.

N.B. Warmed saline may facilitate removal of calcification over room temperature saline .

Complications

Post-procedural complicates are rare but could potentially include infection.  There is an associated risk of tendon rupture, which should be included in the pre-procedure consent.

Outcomes

Barbotage has been shown to be an effective short-to-medium term treatment for rotator cuff calcific tendonitis and is superior to subacromial bursal injection alone . An average pain improvement with barbotage of 55% has been reported . Lessened improvement in pain scores post-procedure are associated with :

  • multiple procedures
  • poor initial response
  • longer onset of symptoms
  • smaller calcific deposit size