MSK Ultrasound Procedures


Calcific Tendinosis Aspiration and Lavage




Equipment and Medications

  • Probe: 14Mhz or 9Mhz Linear
  • 25g 1.5" needle
  • 18 or 20g 3.5" needle
  • 2 x 10cc syringe 1% lidocaine
  • 2 x 10cc syringe Normal Saline
  • 2cc injectable steroid (kenalog 40mg/cc) + 3cc ropivacaine 0.5% in 5 cc syringe
  • Procedure tray
  • Equipment

    Medications



    Procedure Instructions:
    Instructions
    1. Standard pre procedure workup (consent, indications, contraindications, allergies). Warn patient that he or she may be in more pain after the procedure due to release of hydroxyapatite.  
    2.Position patient supine.
    3.Scan patient looking for calcific tendinosis deposition typically in the supraspinatus tendon. Measure size of largest deposits.
    • descriptiondescription
    Long axis view of supraspinatus tendon with calcific deposit
    • descriptiondescription
    Short axis view of supraspinatus tendon with calcific deposit
    4. Mark probe location and probable injection site.  
    5.  Prep patient; betadine or chlorhexidine x 3. Clear wide area.  
    6. Place sterile drape and probe cover.  
    7. Place sterile ultrasound probe on skin and find site of injection again and inject 1% lidocaine superficially with 1.5" 25g needle.  
    8. Exchange for 18g 3.5” needle.
    9.Advance needle under ultrasound guidance to the level of a calcium deposit.
    • descriptiondescription
    Short axis view of supraspinatus tendon with calcific deposit
    10. Attach 10cc 1% lidocaine syringe. Administer a few cc’s of lidocaine into surrounding area.
    11. Advance needle to be within a calcium deposit. The pseudocapsule around the deposit will often expand. Intermittently place small amounts of lidocaine into the deposit watching the deposit expand and then aspirate and watch the pseudocapsule collapse. Be careful not to rupture the pseudocapsule. The aspirate often is milky.
    12. Exchange the 10cc lidocaine syringe with a 10cc syringe containing normal saline. Repeat the intermittent small injection and aspiration and look for milky aspirate. \
    13.Repeat once more with another 10cc syringe containing normal saline.
    • descriptiondescription
    Post procedure scan demonstrating decreased size and decreased central echogenicity of calcific deposit and injectate surrounding it.
    14.While keeping 18g needle in place, remove 10cc syringe and redirect needle to the subacromial/subdeltoid bursa. These patients often have subacromial/subdelotid bursitis.
     
    15. Test inject with 1% lidocaine. If no resistance and see distention of the bursa, exchange for 5cc syringe with injectable steroid and ropivacaine mixture. If resistance, spin needle or reposition until there is no resistance.
     
    16. Pull needle out and place bandage on skin.
     

     


    References

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