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.
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: multiple procedures, poor initial response, longer onset of symptoms, smaller calcific deposit size
 
==Anatomy==
==Indications==
Rotator cuff calcific tendinitis
==Contraindications==
active skin infection, and coagulopathies and anticoagulation medication (relative)
==Pre-procedural Evaluation==
Review contraindications, review previous images and localise calcific deposits, informed consent.
If there is significant post-acoustic shadowing on ultrasound, this suggests that the calcification is very hard, and so barbotage may be less successful.
==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 anaesthetic e.g. 1% lidocaine, 0.5% bupivacaine
* corticosteroids: e.g. methylprednisolone
==Technique==
File:Rotator-cuff-barbotage-ultrasound-guided.jpg|Longitudinal
Rotator-cuff-barbotage-ultrasound-guided 2.jpg|Longitudinal
===Ultrasound Guided===
*sterile technique
*sonographic visualisation of the calcific deposit (typically on a lateral transverse view)
*infiltration of local anaesthetic (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 a 16-18 G needle attached to a 5 mL syringe containing 4 mL normal saline into the centre of the calcific deposit, ensuring a horizontal lie, and the calcification is flushed
*Pulse the syringe plunger to inject saline into the deposit with pressing the plunger down, and allowing backflow of calcium into the syringe when the pressure is released.
*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.
*Part of the process is breaking up the calcium with the needle. Often you aren't able to aspirate the calcium, but once broke up it can be absorbed by the body.
;Dual needle technique
The two needle technique allows greater fragmentation of the calcium due to two needles, and lower saline pressures because saline is removed at the same rate it is injected. There was no statistically significant difference in a trial comparing the single versus two needle technique.Orlandi D, Mauri G, Lacelli F, Corazza A, Messina C, Silvestri E, Serafini G, Sconfienza LM. Rotator Cuff Calcific Tendinopathy: Randomized Comparison of US-guided Percutaneous Treatments by Using One or Two Needles. Radiology. 2017 Nov;285(2):518-527. doi: 10.1148/radiol.2017162888. Epub 2017 Jun 14. PMID: 28613120.
*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 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 
==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. 
==Aftercare==
==Videos==
==See Also==
Shoulder
==External Links==
==References==
# Stefan Moosmayer, Ole Marius Ekeberg, Hanna Bjørnsson Hallgren, Ingar Heier, Synnøve Kvalheim, Jesper Blomquist, Are Hugo Pripp, Nils Gunnar Juel, Stein Harald Kjellevold, Jens Ivar Brox. KALK study: ultrasound guided needling and lavage (barbotage) with steroid injection versus sham barbotage with and without steroid injection - protocol for a randomized, double-blinded, controlled, multicenter study. (2017) BMC Musculoskeletal Disorders. 18 (1): 1. doi:10.1186/s12891-017-1501-9 - Pubmed
# Pieter Bas de Witte, Arjen Kolk, Ferdinand Overes, Rob G.H.H. Nelissen, Monique Reijnierse. Rotator Cuff Calcific Tendinitis: Ultrasound-Guided Needling and Lavage Versus Subacromial Corticosteroids: Five-Year Outcomes of a Randomized Controlled Trial:. (2017) The American Journal of Sports Medicine. 45 (14): 3305-3314. doi:10.1177/0363546517721686 - Pubmed
# Bart W. Oudelaar, Rianne Huis In ‘t Veld, Relinde Schepers-Bok, Edwin M. Ooms, Rob G. H. H. Nelissen, Anne J. H. Vochteloo. Prognostic factors for the outcome of needle aspiration of calcific deposits for rotator cuff calcific tendinitis. (2020) European Radiology. doi:10.1007/s00330-020-06669-0 - Pubmed
# Luca Maria Sconfienza, Sara Viganò, Chiara Martini, Alberto Aliprandi, Pietro Randelli, Giovanni Serafini, Francesco Sardanelli. Double-needle ultrasound-guided percutaneous treatment of rotator cuff calcific tendinitis: tips & tricks. (2013) Skeletal Radiology. 42 (1): 19. doi:10.1007/s00256-012-1462-x - Pubmed
# Alisara Arirachakaran, Manusuk Boonard, Sarunpong Yamaphai, Akom Prommahachai, Suraphol Kesprayura, Jatupon Kongtharvonskul. Extracorporeal shock wave therapy, ultrasound-guided percutaneous lavage, corticosteroid injection and combined treatment for the treatment of rotator cuff calcific tendinopathy: a network meta-analysis of RCTs. (2017) European Journal of Orthopaedic Surgery & Traumatology. 27 (3): 381. doi:10.1007/s00590-016-1839-y - Pubmed
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Category:Shoulder Procedures