31 patients (20F,
11M,
mean age 44±8) affected by symptomatic calcific tendinopathy were treated with a percutaneous US-guided approach,
for a total amount of 31 tendons ( Fig. 5 Fig. 6 Fig. 7 ):
• 18 gluteus medius;
• 2 gluteus maximus;
• 1 extensor carpi radialis longus;
• 2 common extensor digitorum;
• 2 rectus femoris;
• 1 ilio-tibial band;
• 1 peroneus longus;
• 4 patellar.
Clinical outcome was measured by means of a Visual Analogue Scale (VAS) ( Fig. 16 ) at baseline and at 1 and 3 months.
1) Patient positioning
According to calcification location,
the patient lies in the most confortable position (supine,
prone or on one side) to reduce movements and vagal reactions.
2) Sterile setting
Sterile field is made with the use of a two-steps disinfection first made using a iodine-based solution (e.g.,
7.5% polivinilpirrolidone) and then with a color-free solution (e.g.
0,25% benzalkonium chloride + 70% ethylic alcool).
The probe is covered with a sterile cover,
and sterile US gel is applied at the cutaneous site of examination ( Fig. 8 ).
3) Local anesthesia
An effective local anesthesia can be achieved by injecting the drug under ultrasound guidance along the path of the needles and in the pericalcific tissues,
avoiding vascular or nervous structures according to local anatomic topography ( Fig. 11 ).
Up to 10 mL of lidocaine chloridrate (2%) can be used.
4) Needle positioning
1 or 2 needles are used with different dimensions and lenghts according to the procedure location and calcific deposit size ( Fig. 9 ).
With a free-hand US-guided in-plane technique,
the needle tips are inserted within the calcification with a path as parallel as possible to US probe (that means as perpendicular as possible to the US beam),
keeping about 15° between the 2 needles,
with both bevels facing each other.
The deeper needle is inserted first to avoid artifacts.
5) Calcification lavage
Once a correct positioning of the needles is achieved,
warm saline solution (42°C) is repeatedly injected by a needle and drained by the other,
alternating needles until the washing fluid is free from visible calcium ( Fig. 10 Fig. 12 Fig. 13 Fig. 14 Fig. 3 ).
6) Post-procedural care
Corticosteroid “slow release” (1ml Depo-Medrol) is accurately injected in soft tissue around the tendon or in gluteus bursa for gluteus tendons,
avoiding the tendon ( Fig. 15 ).
A plaster is then applied on the cutaneous puncture site and an ice bag is maintained for about two hours.