Percutaneous treatment of calcific tendonitis (Barbotage Technique)

There are different percutaneous techniques for the treatment of calcific tendonitis, all based on puncture of the calcification to fragment it and aspirate its calcium content. Previously, fluoroscopy-guided needle aspiration was considered an elective technique. Several authors have proposed ultrasound guidance as an effective modality to avoid radiation exposure from fluoroscopy, while allowing us to pinpoint the specific location of the calcification. Therefore, a prior ultrasound examination is necessary to locate it. If multiple calcifications are present, the procedure will focus on the largest ones or those most clearly related to the patient's clinical symptoms. Spontaneous resolution of intrabursal calcium deposits means that these deposits do not require treatment.

The procedure can be performed with the patient sitting or supine; the latter position is preferable for calcifications in the subscapularis tendon or in patients with a history of vagal syncope.

Local anesthetic is administered intrabursally and along the serosal surface of the affected tendon. Next, using the same anesthetic needle, we puncture the calcification and check the needle positioning in long and short axis views. Once in long axis view, we exchange the syringe for another one filled with saline (preferably a Luer-lock) and begin a sequence of short pressures and releases with the syringe plunger.

During this procedure, the extraction of calcium fragments is observed, creating turbidity in the saline solution and precipitating in the syringe itself. Simultaneously, a hypoechoic cavity appears in the calcification, which expands upon compression and shrinks when the pressure is released. Lavage should be discontinued when calcium extraction ceases. Occasionally, the needle may become blocked during the procedure, especially during the first punctures of the calcification. Several syringe changes with clean saline solution are usually necessary to monitor continued calcium extraction. At the end of the final lavage, we will infiltrate the subacromiodeltoid bursa with local anesthetic plus a corticosteroid to control pain in the first few days after the procedure, which will cause the calcium to leak into the bursa.

We must warn the patient about pain during the post-procedure and for six weeks afterward. The barbotage procedure may be repeated or injections may be performed at the level of the subacromiosubdeltoid bursa.

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