Needling and Lavage in Rotator Cuff Calcific Tendinitis: Ultrasound-Guided Technique.

Abstract

Background: Rotator cuff calcific tendinitis (RCCT) is a commonly occurring disease, with a prevalence of up to 42.5% in patients with shoulder pain^1,2. RCCT is characterized by hydroxyapatite deposits in the tendons of the rotator cuff and is considered a self-limiting disease that can be treated nonoperatively³. However, in a substantial group of patients, RCCT can have a very disabling and long-lasting course^1,4, requiring additional treatment. Ultrasound-guided percutaneous needling and lavage (i.e., barbotage) is a safe and effective treatment option for RCCT⁵. In the present article, we focus on the 1-needle barbotage technique utilized in combination with an injection of corticosteroids in the subacromial bursa.

Description: It must be emphasized that symptomatic RCCT should be confirmed before barbotage is performed. Therefore, we recommend a diagnostic ultrasound and/or physical examination prior to the barbotage. Barbotage is performed under ultrasound guidance with the patient in the supine position. After sterile preparation and localization of the calcified deposit(s), local anesthesia in the soft tissue (10 mL lidocaine 1%) is administered. Next, the subacromial bursa is injected with 4 mL bupivacaine (5 mg/mL) and 1 mL methylprednisolone (40 mg/mL) with use of a 21G needle. The deposit(s) are then punctured with use of an 18G needle. When the tip of the needle is in the center of the deposit(s), they are flushed with a 0.9% saline solution and the dissolved calcium re-enters the syringe passively. This process is repeated several times until no more calcium enters the syringe. In the case of solid deposits, it may not be possible to aspirate calcium; if so, an attempt to fragment the deposits by repeated perforations, and thus promote resorption, can be made. Postoperatively, patients are instructed to take analgesics and to cool the shoulder.

Alternatives: RCTT can initially be treated nonoperatively with rest, nonsteroidal anti-inflammatory drugs, and/or physiotherapy³. If the initial nonoperative treatment fails, extracorporeal shockwave therapy (ESWT), corticosteroid injections, and/or barbotage can be considered⁸. In severe chronic recalcitrant cases, arthroscopic debridement and/or removal can be performed as a last resort.

Rationale: Both barbotage and ESWT result in a reduction of calcific deposits, as well as significant pain reduction and improvement of function⁸. No standard of care has been established until now; however, several prior meta-analyses concluded that barbotage is the most effective treatment option, with superior clinical outcomes after 1 to 2 years of follow-up^9-11. No difference in complication rates has been reported between the various minimally invasive techniques. The purpose of barbotage is to stimulate the resorption process, which is promoted by the perforation of the deposits. Clinical outcomes are not associated with the success of the aspiration^7,12. Patients with ≥1 larger deposit show greater improvement following barbotage than patients with small deposits¹², in contrast with ESWT, in which larger deposits have been associated with worse outcomes. The inferior outcome of barbotage in patients with small deposits remains the subject of debate, but outcomes may be confounded by the fact that patients with smaller deposits might be less symptomatic at baseline and are therefore less likely to demonstrate improvement⁴.

Expected outcomes: In the first weeks after barbotage, there is generally a substantial reduction in symptoms. Symptoms can recur at around 3 months, presumably because the effect of the corticosteroids is temporary⁵. After 6 months and 1 year, patients show substantial improvement in pain, shoulder function, and quality of life, with results superior to those shown for subacromial injections and ESWT^9,10,13,14. At 5 years postoperatively, there are no significant differences in outcomes between barbotage and subacromial injections¹⁵. This may demonstrate a self-limiting course in the long term.

Important tips: Good candidates for barbotage are those with RCCT who have ≥1 large calcific deposit.If a patient has a solid deposit, the physician can gently rotate and repeatedly puncture the deposit to promote disaggregation and fragmentation.Barbotage generally results in adequate pain relief and functional improvement even in patients in whom calcium deposits cannot be aspirated¹².

Acronyms and abbreviations: SAI = injection in the subacromial bursaNSAIDs = nonsteroidal anti-inflammatory drugs.