Rotator cuff calcific tendinitis barbotage

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

• rotator cuff calcific tendinitis

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 ^1-4

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 ^1-3

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 ⁴

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 bursa³.  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 ⁴. 

Complications

Post-procedural complicates are rare ⁴ 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 ^1,3. An average pain improvement with barbotage of 55% has been reported ¹. Lessened improvement in pain scores post-procedure are associated with ³:

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