Gluteus minimus/medius calcific tendinopathy barbotage (technique)

Gluteus minimus/medius calcific tendinopathy barbotage is a procedure performed under ultrasound guidance with the aim of reducing the bulk of tendon calcification, in a similar fashion to that performed for rotator cuff calcific tendinopathy. 

Indications

• gluteus minimus/medius tendon calcific tendinopathy

Contraindications

Absolute

• anaphylaxis to contrast/ injectates

• active local/systemic infection 

Relative

• bleeding diathesis

• recent injection with steroid in same/other body parts

• gluteus minimus and/or gluteus medius tendon tear

• ipsilateral hip arthroplasty in situ

• unable to remain still for the procedure

• young age

Procedure

The general principles of barbotage procedures are to:

• administer local anesthetic along the needle track and into the overlying bursa under image guidance

• cannulate the target area of calcification with a larger bore needle and perform pulsation lavage

• administer injectate, usually a corticosteroid and a small amount of longer-acting local anesthetic into the overlying bursae

Pre-procedural evaluation

Relevant imaging should be reviewed, and the details of the patient confirmed. The patient should have an opportunity to discuss the risks and benefits and consent obtained. Focused pre-procedure ultrasound is usually performed to assess the ‘rotator cuff of the hip’ ¹.

Risks include:

• infection

• bleeding

• allergy 

• focal fat necrosis/ skin discolouration at the injection site

• complete tendon tear

Equipment

• ultrasound machine, sterile probe cover, and a skin marker

• skin cleaning product

• sterile drape

• sterile field and tray for sharps

• syringe selection i.e. 10 mL, x2-3 5 mL and 3 mL

• larger bore drawing up needle

• needle to administer local anesthetic i.e. 25 G needle

• needle to cannulate the bursae i.e. 25 or 22 G 90 mm Quincke needle

• needle to cannulate the calcification i.e. 22 or 18 G 90 mm Quincke needle

• sterile gauze

• adhesive dressing

Syringe selection

A suggested syringe and injectate selection for an ultrasound-guided gluteus minimus/medius calcific tendinopathy barbotage procedure:

• 10 mL syringe: 10 mL of local anesthetic i.e. 1% lidocaine

• x2-3 5 mL syringes: half-filled syringes with pulsation lavage solution; which can be a mixture of local anesthetic and 0.9% saline

• 3 mL syringe: 40 mg triamcinolone acetonide (40 mg/1 mL) and 2 mL 0.5% ropivacaine

Needle selection

Smaller gauge needles can be less painful but are less stiff and can bend when trying to pass through the iliotibial band to reach the bursa. Pre-procedure planning should calculate the length required to reach the bursa, as larger patients will require longer needles ². Larger bore needles are required to cannulate the calcification, so the calcification can be aspirated. 

• greater trochanteric bursa: 25 or 22 G 90 mm Quincke needle

• barbotage: 22 or 18 G 90 mm Quincke needle

Technique

Ultrasound

• check for allergies and if on blood thinners

• consent

• optimize patient positioning by lying them on the side and facing away, with the ipsilateral hip facing upwards and exposing the lateral targeted proximal femur, aiming for a posterior access

• identify the greater trochanteric bursa in a transverse plane; perpendicular to the long axis, with dynamic maneuvers helping to identify a non-distended bursa ³

• optimize imaging and mark a posterior skin entry point

• clean skin and draw up appropriate medications

• give local anesthesia along the proposed needle path

• under ultrasound guidance using posterior to anterior approach, insert the needle in-plane with the probe to give deeper local anesthetic over the ITB and into the bursa (7-8 mL into the bursa)

• after waiting an appropriate time, using the same technique with a larger needle pass into the targeted area of calcification

• use pulsation lavage (small pumps of the syringe) to flush out the central calcification

• once complete, remove the larger needle and reuse the smaller needle to re-enter the bursa

• administer steroid containing injectate under direct visualization

• removed the needle and apply dressing/band-aid as required

• pain diary to be given

Complications

The most serious complication is infection. Steroid containing injections should be postponed if there are signs and/or symptoms of local and/ or systemic infection. Possible fat necrosis causing skin dimpling and skin discolouration can occur due to steroid leaking into the surrounding soft tissues ⁴. As larger needles are used, a complete full-thickness tear can occur.