Percutaneous Ultrasonic Barbotage: A Novel Approach for Persistent Rotator Cuff Calcific Tendinopathy Following Surgery

Introduction Calcific tendinopathy (CT) of the rotator cuff (RC) is a prevalent cause of chronic shoulder pain, affecting approximately 2.5% to 7.5% of healthy adults, with females accounting for nearly 70% of the cases (1). Despite the availability of both conservative and invasive treatment modalities, there is a scarcity of evidence supporting the use of percutaneous ultrasonic barbotage (PUB) in the management of CT. To date, there are no documented cases in the literature that specifically address the utilization of PUB for CT of the RC that has returned following prior surgical intervention. This case report presents the first documented application of PUB in the management of CT in patients who have previously undergone surgical treatment. By such, the report aims to contribute valuable insights into the potential effectiveness of PUB for managing CT of the RC when symptoms return after surgical management. Case Report A 36-year-old female presented with persistent left shoulder pain and was diagnosed with calcific tendinopathy of the left supraspinatus (SS) tendon via diagnostic ultrasound (U/S) and MRI. The patient underwent a comprehensive treatment regimen, including multiple rounds of physical therapy, ultrasound-guided (USG) subacromial corticosteroid injections (CSI), USG needle barbotage to the SS, and CSI in the biceps tendon sheath. However, these interventions provided minimal pain relief. One year after her initial diagnosis, she underwent surgical intervention consisting of calcific excision and debridement of the SS tendon with biceps tenodesis. Postoperatively, the patient showed improvement with physical therapy for 4 months, but her shoulder pain recurred, leading to the recommendation of continued nonoperative treatment. During subsequent visits, repeat USG subacromial CSI, barbotage, and dextrose prolotherapy injections were administered into the SS tendon, resulting in minimal improvement in symptoms. A repeat left shoulder MRI revealed calcific tendinopathy of the superior RC (see Figure). Physical examination demonstrated full passive range of motion (ROM) in all planes, but active ROM was limited by pain at 160 degrees of abduction, accompanied by a positive empty can test, with pain localizing to the SS footprint during resisted abduction without weakness.Figure: MRI image of left shoulder: left supraspinatus calcific tendinopathy.To confirm the diagnosis, a USG lidocaine injection was administered in the left SS calcific tendon, resulting in immediate pain resolution and increased active ROM. After careful consideration of the risks and benefits, the patient underwent PUB of the calcified aspect of the left SS tendon under ultrasound guidance. The Tenex TX2 device was utilized to target the CT under ultrasound guidance. The patient was positioned in the lateral decubitus position during the sterile procedure. Given the potential risk of tendon rupture following surgical debridement of the RC, the TENEX device use was limited to a total cutting time of 1 min 30 s at the medium cut and aspiration strengths. The calcification was challenging to remove, requiring multiple passes of the device. The patient tolerated the procedure well, and approximately 90% of the calcification was successfully removed as estimated by ultrasound. Postprocedure, the patient was given a shoulder sling to wear for up to 3 d for comfort and to minimize loading of the RC. Rehabilitation followed the Ohio State University’s PUB clinical practice guideline, which was augmented by the patient’s physical therapist (2). Subsequent follow-ups at 2 wk and 2 months revealed sustained 100% improvement of their pain and ROM, allowing her to resume regular physical activity. She is now 1 year pain free and performing weight training and all activities of daily living. Discussion CT, typically caused by small calcium deposits in the tendon resulting from microtrauma or idiopathic factors, often requires intervention due to persistent pain or disability. Symptoms from CT may be caused by impingement or inflammation associated with the calcific deposits. Severity of pain as well as duration of symptoms varies considerably between cases. Surgical intervention through arthroscopy or open surgical debridement is considered the definitive treatment when conservative measures fail (3). PUB is a minimally invasive procedure that uses ultrasonic energy to break down debris, eliminate calcium deposits, and potentially promote healing. However, there is limited data on its application for RC CT. Erickson and Jagim conducted a case series involving eight patients with CT of the SS who were unresponsive to conservative therapy (4). The study demonstrated significant pain improvement and complete restoration of daily activities within 6 weeks post-PUB. It highlighted the value of PUB for patients who are not suitable candidates for surgery due to anticoagulant use or comorbidities. Berrigan et al. conducted a retrospective chart review of 75 patients with refractory CT of the RC (5). The patients were divided into two groups: traditional barbotage (n = 23) and PUB (n = 52). Both groups showed significant pain improvement during follow-up (>6 months after the procedure), with no statistically significant difference between them. However, the traditional barbotage group had a higher treatment failure rate and required repeat procedures or surgery compared to the PUB group. Previously, the clinical outcomes of PUB following surgical intervention were unclear. However, this case report highlights the potential benefits of PUB in this setting. There is a lack of reported cases in the literature regarding PUB following surgical debridement or viable alternatives for managing persistent CT that has failed surgical intervention. Consequently, considering PUB as a treatment option may be appropriate for patients with CT who have not experienced success with surgical intervention or who elect not to have surgery. Conclusions While conservative management can resolve many cases of CT, surgical intervention is often necessary for definitive treatment. PUB is a minimally invasive procedure that shows promise in the treatment of RC CT. However, there is limited literature available on PUB following postsurgical debridement. Further studies are needed to establish the efficacy and safety of PUB in this context. Nevertheless, this case report provides valuable evidence supporting the effectiveness of PUB as a treatment option for both pre- and postoperative CT of the RC. However, further research is needed to determine when in the treatment pathway PUB should be pursued. PUB holds the potential for delivering significant clinical benefits and should be considered in the management of patients with persistent CT.