Subacromial spacer implantation for massive rotator cuff tears: Clinical outcome of arthroscopically treated patients

The "Balloon Dip": Insights into a Post-operative Trend in Patients Undergoing Subacromial Balloon Procedure

Introduction

The subacromial balloon is a novel therapeutic device that is used in patients with massive irreparable rotator cuff tears (MIRCTs). The novelty of this device implies that there is still a lot to be known about its mechanism of action and rehabilitation trends. One rehabilitation trend that has been noticed is the "balloon dip", where a patient exhibits exacerbations in pain and function around 3 months following balloon implantation and after having experienced earlier symptomatic relief post-operative. We discuss the clinical, diagnostic, and therapeutic aspects of the patient's management while providing additional insight into this prognostic trend.

Case Report

In this report, we present the case of a 65-year-old male patient who underwent a subacromial balloon procedure for a MIRCT. During his recovery, the patient exhibited a classic "balloon dip" evident by an exacerbation of pain and function around the 3-month mark. After a notable deterioration in pain and function, the patient was examined, reassured, and educated on the importance of adhering to physical therapy. He was able to successfully recover and showed gradual improvement in pain and function along the course of the year.

Conclusion

The "balloon dip" is a rehabilitation pattern that occurs 3-6 months following subacromial balloon spacer implantation. In the majority of cases, careful clinical assessment, watchful monitoring, and education on the importance of following up with physical therapy are sufficient to overcome the dip.

Subacromial Balloon Spacer for Irreparable Rotator Cuff Tear Treatment Shows Improved Pain and Strength at 5-Year Follow-Up

PURPOSE

To report on minimum 5-year outcomes following subacromial balloon spacer implantation (SBSI), in terms of survivorship, pain reduction, functional outcomes, complications, and reoperations.

METHODS

Data were prospectively collected and retrospectively analyzed for consecutive patients undergoing SBSI between April 1, 2012, and June 30, 2016. Patients completed preoperative and postoperative follow-up for minimum 5 years on the following patient-reported outcomes (PROs): Constant-Murley Score (CMS), visual analog scale for pain (VAS), strength, and patient satisfaction. Reoperations and complications were recorded. Minimal detectable change (MDC) was calculated and the proportion of patients achieving MDC for CMS and VAS were calculated.

RESULTS

During the study period, SBSI was performed in 36 patients. Three patients were deceased within 5 years. Of the remaining 33 patients, follow-up was available on 29 patients (80.6%). Mean age at the time of operation was 72.7 ± 4.5 years, and 69% of the patients were males. Mean follow-up time was 72.5 months. Significant improvements from preoperative to last follow-up were demonstrated in CMS (36.08 vs. 63.88; P < .001), VAS (6.72 vs. 1.68; P < .001), and strength (3.8 vs 5.87 kg; P < .001). These improvements were demonstrated at 3 weeks, 6 months, 12 months, 24 months, and 60 months. Mean patient satisfaction at last follow-up was 8.72. The MDC for both CMS and VAS was achieved by 75.9% (22/29) of patients. Four patients underwent conversion to a reverse total shoulder arthroplasty (RTSA). Complications included one patient with balloon dislocation and one patient with a secondary infection due to urinary tract infection.

CONCLUSIONS

Pain reduction and functional improvements are sustained at minimum 5 years after SBSI in patients with irreparable rotator cuff tears. The 5-year conversion rate to an RTSA was 13.79%.

LEVEL OF EVIDENCE

Level IV, retrospective case-series.

Subacromial Balloon Spacer Implantation Is a Promising Alternative for Patients With Massive Irreparable Rotator Cuff Tears: A Systematic Review

PURPOSE

To provide an overview of the existing literature on subacromial balloon spacers for the treatment of massive irreparable rotator cuff tears, in an effort to inform surgeons of the procedure's clinical effectiveness.

METHODS

The PubMed, Scopus, and Ovid EMBASE databases were queried to identify studies evaluating the clinical, radiographic, and patient-reported outcomes of patients indicated for subacromial balloon spacer implantation. The following datapoints were extracted: study demographics, patient baseline characteristics, and postoperative outcomes of interest. Outcomes were evaluated at baseline and at the longest available follow-up period.

RESULTS

A total 766 patients were included among 22 included studies, with an average follow-up of 27.54 months. Improvements were seen for all clinical and patient-reported outcomes: forward elevation (ranging from 9.20 to 90.00° improvement), external rotation (ranging from 2.00 to 22.00°), abduction (ranging from 14.00 to 95.00°), Total Constant Score (ranging from 7.70 to 50.00), American Shoulder and Elbow Surgeons score (ranging from 24.60 to 59.84), Oxford Shoulder Score (ranging from 7.20 to 22.20), and pain score (ranging from 3.57 to 6.50). Minimal differences were seen in acromiohumeral interval (ranging from -2.00 to 1.27). Reoperation and complication rates ranged from 0% to 33% and 0% to 19.64%, respectively.

CONCLUSIONS

The short-term results of subacromial balloon spacers for management of massive rotator cuff tears demonstrate clinically relevant improvements in shoulder range of motion and substantial improvements in patient-reported outcome measures. Of note, minimal change in acromiohumeral interval was seen on postoperative radiography, and wide variations in complication and reoperation rates were reported across studies.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.

Evaluation of spin in reviews of biodegradable balloon spacers for massive irreparable rotator cuff tears

HYPOTHESIS

Clinical studies are often at risk of spin, a form of bias where beneficial claims are overstated while negative findings are minimized or dismissed. Spin is often more problematic in abstracts given their brevity and can result in the misrepresentation of a study's actual findings. The goal of this study is to aggregate primary and secondary studies reporting the clinical outcomes of the use of subacromial balloon spacers in the treatment of massive irreparable rotator cuff tears to identify the incidence of spin and find any significant association with study design parameters.

MATERIALS AND METHODS

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Independent searches were completed on 2 databases (PubMed and Embase) for primary studies, systematic and current concepts reviews, and meta-analyses and the results were compiled. Two authors independently screened the studies using a predetermined inclusion criteria and aggregated data including titles, publication journals and years, authors, study design, etc. Each study was independently assessed for the presence of 15 different types of spin. Statistical analysis was conducted to identify associations between study characteristics and spin.

RESULTS

Twenty-nine studies met the inclusion criteria for our analysis, of which 10 were reviews or meta-analyses and 19 were primary studies. Spin was identified in every study except for 2 (27/29, 93.1%). Type 3 spin, "Selective reporting of or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention" and type 9 spin, "Conclusion claims the beneficial effect of the experimental treatment despite reporting bias" were most frequently noted in our study, both observed in 12/29 studies (41.4%). Date of publication, and adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses or "The International Prospective Register of Systematic Reviews" were study characteristics associated with a higher rate of certain types of spin. There was a statistically significant association between disclosure of external study funding source and the presence of spin type 4, but none of the other forms of spin.

CONCLUSION

Spin is highly prevalent in the abstracts of primary studies, systematic reviews, and meta-analyses discussing the use of subacromial balloon spacer technology in the treatment of massive irreparable rotator cuff tears. Our findings revealed that spin in the abstract tended to favor the balloon spacer intervention. Further efforts are required in the future to mitigate spin within the abstracts of published manuscripts.

Subacromial Balloon Spacer: When to Use This?

The subacromial balloon spacer is a novel treatment option for the management of massive irreparable rotator cuff tears. This device is introduced into the glenohumeral joint and acts to alleviate the acromiohumeral impingement, caused by the massive irreparable rotator cuff tear. The device also redistributes the tension around the adjacent muscles in the joint, allowing them to compensate for the torn rotator cuff tendons. By doing so, the balloon can act as a "rehabilitation accelerator", ultimately resulting in improved shoulder pain and function. Adherence to balloon indications when selecting the appropriate patient is necessary, and these include an irreparable posterosuperior rotator cuff tear, with preserved subscapularis function, minimal to no osteoarthritis, and the ability to forward flex to 90 degrees. Clinical studies have demonstrated promising potential regarding the benefit of the balloon, with numerous studies demonstrating great outcomes after its implantation. Nevertheless, future research remains necessary to render the evidence behind its utility unequivocal.

Outcomes of subacromial balloon spacer implantation for irreparable rotator cuff tears: a systematic review and meta-analysis

BACKGROUND

The management of irreparable rotator cuff tears remains a topic of considerable debate among orthopedic surgeons. Currently, there is little consensus regarding the gold-standard treatment; however, an emerging option involves the use of a biodegradable subacromial spacer. The purpose of this study, therefore, was to systematically review and synthesize the current literature reporting on the clinical outcomes following implantation of a subacromial balloon spacer (SABS) for the treatment of patients with irreparable rotator cuff tears.

METHODS

A systematic review of the PubMed Central, MEDLINE, Embase, Scopus, and Cochrane Library databases from inception through December 2022 was performed. Clinical outcome studies reporting on functional and clinical outcomes, as well as postoperative complications, were included.

RESULTS

A total of 127 studies were initially identified, of which 28 were deemed eligible for inclusion in our review. Of these studies, 17 reported adequate preoperative and postoperative data (mean and a measure of variance) and thus were included in the meta-analysis. Among the included studies, a total of 894 shoulders (886 patients) were included; the mean age was 67.4 years (range, 61.7-76.2 years). The average follow-up period was 30.4 months (range, 12-56 months). All postoperative patient-reported outcomes improved significantly from baseline, including the Constant score (mean difference, 33.53; P < .001), American Shoulder and Elbow Surgeons score (mean difference, 40.38; P < .001), Oxford Shoulder Score (mean difference, 12.05; P = .004), and visual analog scale pain score or Numeric Pain Rating Scale score (mean difference, -3.79; P < .001). Forward elevation (mean difference, 24°; P < .001), abduction (mean difference, 52°; P = .02), and external rotation (mean difference, 15°; P < .001) improved. Device-related complications occurred at a rate of 3.6%, the most common of which were balloon migration (1.0%) and synovitis (0.6%). Ultimately, 5% of patients required salvage reverse shoulder arthroplasty.

CONCLUSION

Short-term outcomes suggest that SABS implantation can be a safe and effective treatment and appears to be associated with early improvements in postoperative pain and function. Clinical heterogeneity, use of concomitant procedures, and variations in patient selection limit our ability to conclusively interpret the available evidence. We do not yet know the potential therapeutic value of SABS implantation relative to other currently accepted treatment strategies, the length of symptomatic improvement that can be expected, or the long-term implications of SABS use on the outcomes of further salvage procedures.

InSpace Balloon for the Management of Massive Irreparable Rotator Cuff Tears: A Systematic Review and Meta-Analysis

Background

The best course of action for massive irreparable rotator cuff tears (MIRCTs) is not universally agreed upon. Numerous surgical techniques have been discussed. The implantation of a biodegradable spacer into the subacromial area has been documented since 2012 by several authors. The implantation method is touted as being simpler, repeatable, and less invasive than other solutions that are now available. The purpose of this systematic review and meta-analysis, being the first of its kind, was to evaluate the literature to see the efficacy of InSpace balloon (ISB) implantation in the management of MIRCTs.

Methods

Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, and with 2 researchers assessing and analyzing each study separately, an extensive electronic search of the literature was conducted in the PubMed database from 1961 until July 27, 2022.

Results

Fourteen studies were included in this systematic review and three in the meta-analysis. Eleven out of fourteen studies favored ISB use for MIRCTs, while only three were against its use. All spacers were arthroscopically implanted in the subacromial space. Three studies were included in the meta-analysis. The differences in the compared outcomes were statistically insignificant.

Conclusions

A controversy about the use of ISB remains in patients with MIRCTs. Both good and bad outcomes were reported. However, the majority of patients had good clinical outcomes across several grading scales, radiographic evidence of improved impingement, and self-report that they would redo the procedure in hindsight. To draw more solid conclusions and have statistically significant results in the meta-analysis, more randomized controlled trials and comparative studies comparing this device to other treatments are needed.

Subacromial balloon spacers for the treatment of irreparable rotator cuff tears: a review

Massive irreparable rotator cuff tears (RCTs) are a commonly encountered orthopedic condition that can be difficult to treat. Several techniques have been described to manage these tears, with the implantable subacromial balloon spacer being one of the most recent. The device, which has only been approved for clinical use in the United States since 2021, functions by resisting the superior humeral head migration seen in the setting of massive RCTs and restoring normal shoulder biomechanics, as corroborated by cadaveric studies. However, results regarding clinical outcomes have been mixed to date, and further high-quality studies are needed to define the optimal use of the subacromial balloon spacer in the treatment of massive irreparable RCTs.

Subacromial Balloon Implantation for the Treatment of Irreparable Posterosuperior Rotator Cuff Tears

Despite the development of various therapeutic options, surgical management of irreparable rotator cuff tears (IRCTs) remains controversial. Recently, implantation of a biodegradable subacromial balloon spacer (InSpace, Stryker Corporation; Kalamazoo, MI) has gained considerable interest for the treatment of certain IRCTs. The reported outcome of balloon implantation has not been consistent, likely due to differing indications and technical approaches. The purpose of this article is to present a reproducible arthroscopic technique for implantation of a subacromial balloon and to review the literature published to date, regarding the efficacy and outcomes of this procedure.

Massive and Irreparable Rotator Cuff Tears: A Review of Current Definitions and Concepts

Background

While massive and irreparable rotator cuff tears (MIRCTs) have been abundantly studied, inconsistent definitions in the literature and theories about pain and dysfunction related to them can be difficult to navigate when considering an individual patient.

Purpose

To review the current literature for definitions and critical concepts that drive decision-making for MIRCTs.

Study Design

Narrative review.

Methods

A search of the PubMed database was performed to conduct a comprehensive literature review on MIRCTs. A total of 97 studies were included.

Results

Recent literature reflects added attention to clarifying the definitions of "massive, "irreparable," and "pseudoparalysis." In addition, numerous recent studies have added to the understanding of what generates pain and dysfunction from this condition and have reported on new techniques for addressing them.

Conclusion

The current literature provides a nuanced set of definitions and conceptual foundations on MIRCTs. These can be used to better define these complex conditions in patients when comparing current surgical techniques to address MIRCTs, as well as when interpreting the results of new techniques. While the number of effective treatment options has increased, high-quality and comparative evidence on treatments for MIRCTs is lacking.

Better functional outcomes and a lower infection rate can be expected after superior capsular reconstruction in comparison with latissimus dorsi tendon transfer for massive, irreparable posterosuperior rotator cuff tears: a systematic review

BACKGROUND

Massive, irreparable rotator cuff tears, if left untreated, may result in cuff tear arthropathy, which causes shoulder disability and pain. The primary outcome of this systematic review was to evaluate differences in functional outcomes between the arthroscopic superior capsular reconstruction (SCR) and latissimus dorsi tendon transfer (LDTT) for the treatment of massive, irreparable posterosuperior rotator cuff tears without arthritis. The secondary outcome was to compare complication and reoperation rates between the 2 surgical procedures.

METHODS

The PubMed, MEDLINE, Scopus, and Cochrane Central databases were searched using keywords, and 20 studies were included in this review. Data extracted for quantitative analysis included the American Shoulder and Elbow Surgeons score, the Constant-Murley score, the subjective shoulder value, the range of motion, the visual analog scale for pain, numbers and types of complications, and reoperation rate. The preoperative fatty degeneration of the muscles and the preoperative and follow-up acromiohumeral distance and glenohumeral osteoarthritis according to the Hamada grading system were also reported.

RESULTS

A total of 1112 patients were identified, among whom 407 and 399 underwent SCR and LDTT, respectively. The SCR group showed a higher mean age at the time of operation (64.5 ± 7.8 vs. 62.1 ± 8.9 years; P < .001). The SCR group showed a lower rate of previous surgical procedures on the shoulder (35 out of 407 vs. 111 out of 399; P < .001) and a shorter mean follow-up (30.4 ± 7.5 vs. 36.3 ± 10.3 months; P < .001). Patients who underwent SCR reported significantly better functionality and residual pain as measured by the Constant-Murley score (75.5 ± 11.2 vs. 65.6 ± 22.8, P < .001), the American Shoulder and Elbow Surgeons score (84.3 ± 13 vs. 67.7 ± 23, P < .001), the subjective shoulder value (79.4 ± 13 vs. 64.4 ± 23, P < .001), and the visual analog scale (1.4 ± 2 vs. 2.8 ± 3, P < .001) than patients who underwent LDTT. A greater acromiohumeral distance (5.8 ± 2.5 vs. 7.6 ± 2.7, P < .001) was found in the SCR group. The SCR group showed a significantly lower infection rate (0.2% vs. 2.8%., P = .003) and a higher graft failure rate (12.3% vs. 6.8%, P = .012). No differences in terms of reoperation for graft failure (1% vs. 2.3% for SCR and LDTT, respectively; P = .172) or for conversion to reverse total shoulder arthroplasty (1.7% vs. 2% for SCR and LDTT, respectively; P = .800) were found.

CONCLUSION

Patients undergoing SCR report better functional outcomes and greater acromiohumeral distance than those undergoing LDTT. The LDTT group shows a significantly higher infection rate, while the SCR group shows a significantly higher graft failure rate, but there are no differences in terms of reoperation between the 2 surgical procedures.

Management of Irreparable Posterosuperior Rotator Cuff Tears-A Current Concepts Review and Proposed Treatment Algorithm by the AGA Shoulder Committee

Posterosuperior rotator cuff tears range among the most common causes of shoulder complaints. While non-operative treatment is typically reserved for the elderly patient with low functional demands, surgical treatment is considered the gold standard for active patients. More precisely, an anatomic rotator cuff repair (RCR) is considered the most desirable treatment option and should be generally attempted during surgery. If an anatomic RCR is impossible, the adequate choice of treatment for irreparable rotator cuff tears remains a matter of debate among shoulder surgeons. Following a critical review of the contemporary literature, the authors suggest the following evidence- and experience-based treatment recommendation. In the non-functional, osteoarthritic shoulder, treatment strategies in the management of irreparable posterosuperior RCT include debridement-based procedures and reverse total shoulder arthroplasty as the treatment of choice. Joint-preserving procedures aimed at restoring glenohumeral biomechanics and function should be reserved for the non-osteoarthritic shoulder. Prior to these procedures, however, patients should be counseled about deteriorating results over time. Recent innovations such as the superior capsule reconstruction and the implantation of a subacromial spacer show promising short-term results, yet future studies with long-term follow-up are required to derive stronger recommendations.

Management of Massive Rotator Cuff Tears Without Arthropathy

Arthroplasty is not an optimal treatment for massive rotator cuff tears in patients who are active and without glenohumeral arthritis. Several surgical techniques have been developed for these patients, including arthroscopic rotator cuff repair with single-/double-row repair (with or without interval slides, margin convergence, graft augmentation), graft bridging, superior capsular reconstruction, tuberoplasty, and tendon transfers. Complete, tension-free, anatomic repair is ideal; however, tendon atrophy and retraction associated with massive tears often complicate repairs. All surgical treatments significantly increase patient-reported functional outcomes 1 year after intervention, with many treatments demonstrating improved mid-term and long-term outcomes. [Orthopedics. 2023;46(1):e1-e12.].

Poor Results After Arthroscopic Treatment of Irreparable Rotator Cuff Tears Using a Subacromial Balloon Spacer

INTRODUCTION

Arthroscopic balloon spacer arthroplasty (BSA) is a relatively recent procedure for patients with irreparable rotator cuff tears, conceived to prevent degenerative joint changes and relieve subacromial pain.

METHODS

This is a retrospective case series of 16 consecutive patients treated with BSA and followed up for a minimum 12 months. Besides BSA, partial tendon repair was done whenever possible. Radiographical parameters such as acromiohumeral distance and Hamada stage were measured preoperatively and postoperatively. Range of motion, functional results (Constant score; Simple Shoulder Test; American Shoulder and Elbow Surgeons score; and Disabilities of the Arm, Shoulder, and Hand score), health-related quality of life results with the EuroQol Five Dimensions tool, complications, and patient satisfaction were also analyzed.

RESULTS

The mean age was 64 ± 10.3 years, and the male/female ratio was 6/10. Partial repair was achieved in five patients (31.2%) and did not influence functional or health-related quality of life results ( P = 0.11). The mean acromiohumeral distance and Hamada stage worsened from preoperative measures (3.7 ± 2.0 mm and 2.3 ± 1.1) to final follow-up measures (3.1 ± 2.4 mm and 3.1 ± 1.3). Shoulder abduction increased by 7.8° ± 26.8° and forward flexion decreased by 25.5° ± 32.4° after surgery. The functional results at the final follow-up were Constant 49.5 ± 18.0; American Shoulder and Elbow Surgeons 60.2 ± 27.2; Simple Shoulder Test 8.5 ± 4.6; and Disabilities of the Arm, Shoulder, and Hand 32.7 ± 12.1. The mean index value for the EuroQol Five Dimensions was 0.79, and perceived quality of life was 85.6 ± 15.4 of 100 points. 62.5% of the patients (10) were satisfied with surgery. The complication rate was 13% (2), accounting for one deep infection and one balloon migration.

CONCLUSION

Theoretical benefits of BSA for delaying superior humeral head translation and arthropathic changes could not be demonstrated in our series. Its functional results and satisfaction rates are low, but self-reported quality of life after surgery does not seem impaired. Complications do not occur frequently but require reintervention and endanger joint viability.

LEVEL OF EVIDENCE

Level IV (case series).

Advances toward transformative therapies for tendon diseases

Approved therapies for tendon diseases have not yet changed the clinical practice of symptomatic pain treatment and physiotherapy. This review article summarizes advances in the development of novel drugs, biologic products, and biomaterial therapies for tendon diseases with perspectives for translation of integrated therapies. Shifting from targeting symptom relief toward disease modification and prevention of disease progression may open new avenues for therapies. Deep evidence-based clinical, cellular, and molecular characterization of the underlying pathology of tendon diseases, as well as therapeutic delivery optimization and establishment of multidiscipline interorganizational collaboration platforms, may accelerate the discovery and translation of transformative therapies for tendon diseases.

The role of biodegradable spacer implantation under local anesthesia for patients with massive rotator cuff tears and significant medical comorbidities

Background

Massive rotator cuff tears are common, and the incidence increases with age. They are a challenging problem to deal with as many are irreparable. While there are a host of surgical options available, these can be prolonged procedures requiring general anesthesia and thus not suitable for elderly patients or those with significant medical comorbidities. In this study, we evaluate the role of a biodegradable balloon inserted under local anesthetic for a series of patients with massive cuff tears and significant medical comorbidities.

Methods

A prospective pilot study was performed on a series of patients between June 2018 and April 2019. Demographic data, as well as preoperative and postoperative clinical data including Subjective Shoulder Value and Oxford Shoulder Scores, were obtained.

Results

Four patients with magnetic resonance imaging-proven massive rotator cuff tears involving the supraspinatus were treated with an InSpace balloon under local anesthesia. All were of American Society of Anesthesiologists grade 4 and had exhausted nonoperative treatment. The mean Oxford Shoulder Score improved from a preoperative baseline of 17.25 (range 6-25) to a peak of 25.75 (range 15-34) at the 6-week postoperative mark before declining to 13.67 (range 6-23) at the final follow-up of 6 months. Subjective Shoulder Values also improved initially from a mean of 31.25 (range of 20-40) to a peak of 58.75 (range of 50-70) before reducing to 36.67 (range of 30-50) at the final follow-up of 6 months.

Conclusion

We have described the safety and early benefit from the use of a biodegradable balloon spacer inserted under local anesthetic as a management option for patients with massive rotator cuff tears, who may be unfit for other extensive reconstruction options, particularly for short-term pain relief as significant long-term gains were not demonstrated.

InSpace Implant Compared with Partial Repair for the Treatment of Full-Thickness Massive Rotator Cuff Tears: A Multicenter, Single-Blinded, Randomized Controlled Trial

BACKGROUND

The purpose of this study was to prospectively evaluate the efficacy and safety of a subacromial balloon spacer (InSpace implant; Stryker) compared with arthroscopic partial repair in patients with irreparable, posterosuperior massive rotator cuff tears.

METHODS

Patients ≥40 years of age with symptomatic, irreparable, posterosuperior, massive rotator cuff tears and an intact subscapularis who underwent failed nonoperative management were included in this randomized controlled trial comparing the InSpace implant with partial repair. Clinical outcome data were collected at baseline through a 24-month follow-up. The primary outcome was improvement in the American Shoulder and Elbow Surgeons (ASES) scores. The secondary outcomes included change from baseline in the Western Ontario Rotator Cuff (WORC) score, the visual analog scale (VAS) pain score, the Constant-Murley shoulder score, the EuroQol-5 Dimensions-5-Level (EQ-5D-5L) score, active range of motion, and operative time. Complications and reoperations for each group were also recorded.

RESULTS

Twenty sites randomized 184 patients: 93 in the InSpace group and 91 in the partial repair group. Significant and clinically relevant improvements in the ASES score from baseline were noted in both groups at Month 12 and were maintained at Month 24. Overall, 83% of patients in the InSpace group and 81% of patients in the partial repair group achieved the ASES minimally clinically important difference threshold, and 82% of patients in the InSpace group and 79% of patients in the partial repair group achieved the substantial clinical benefit threshold. Forward elevation was significantly greater in the InSpace group compared with the partial repair group at Day 10 (p = 0.04), Week 6 (p = 0.0001), Month 12 (p = 0.005), and Month 24 (p = 0.003). The operative time was significantly shorter in the InSpace group (p < 0.0001). No device-related surgical complications were noted, and 4 reoperations after InSpace implantation and 3 reoperations after partial repair were required.

CONCLUSIONS

The InSpace implant is an appropriate alternative to partial repair in patients with irreparable posterosuperior massive rotator cuff tears and an intact subscapularis. Notable benefits include early functional recovery and pain relief combined with a shorter operative time.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

The subacromial spacer system for irreparable posterosuperior rotator cuff tears: A retrospective study of 47 patients with a two-year follow-up

BACKGROUND

Numerous surgical options are available for the management of massive irreparable rotator cuff tears, but there are no current definitive guidelines concerning the optimal treatment modality. The purpose of this study was to evaluate the efficacy and safety of a biodegradable subacromial spacer (InSpace) implantation in patients with irreparable rotator cuff tears.

METHODS

A retrospective study was conducted involving 47 patients treated with the InSpace balloon between 2016 and 2018. Shoulder function was assessed using Constant Score. Pain was scored using a visual analogue scale, with scores ranging from 0 to 10.

RESULTS

At an average follow-up of 24.6 months (range 12-38), the Constant Score had improved from 39.4 to 71.5 points (p < 0.0001). The range of motion, a main component of Constant Score, was improved after two years, from 27.6 to 42.2 points (p < .001). The visual analogue scale score decreased from 6.32 at baseline to a mean score of 2.7 points (p < 0.0001).

DISCUSSION

Arthroscopic deployment of the InSpace device was found to be a safe, reliable treatment option in patients with painful irreparable rotator cuff tears, with meaningful improvement in shoulder function without serious complications.

Effect of Active and Passive Function of the Posterosuperior Rotator Cuff on Compensatory Muscle Loads in the Shoulder

Background:

Irreparable posterosuperior rotator cuff (PSRC) tears have been shown to result in shoulder pain and loss of function.

Purpose/Hypothesis:

The purpose of this study was to determine the effect of the loss of active or passive function of the PSRC on compensatory muscle loads in the deltoid and the remaining rotator cuff. It was hypothesized that both deactivation and resection of the PSRC would result in load increases in the remaining muscles and that resection of the PSRC would result in even higher required compensatory forces than would mere deactivation.

Study Design:

Controlled laboratory study.

Methods:

A total of 7 cadaveric shoulders were tested using a biomechanical shoulder simulator with 10 independently controlled actuators for various muscles (anterior, middle, and posterior deltoid; inferior and superior subscapularis; latissimus dorsi; pectoralis major; teres minor; supraspinatus; and infraspinatus) and 3-dimensional motion tracking. The muscle loads representing the latissimus dorsi and pectoralis major were each held constant, and the remaining muscle actuator forces required to abduct the arm in the scapular plane were determined. The actuator forces corresponding with arm elevation from 20° to 65° were compared at 5° increments for 3 testing conditions: (1) intact, active PSRC; (2) intact, deactivated PSRC; and (3) resected PSRC and shoulder capsule.

Results:

In both the deactivated and resected states, the teres minor showed a significant increase in required muscle forces through nearly the entire tested range of arm elevation compared to the active state. This was also the case for the subscapularis but only at higher elevation angles. The deltoid demonstrated increased muscle forces of at least 1 of its subunits between 25° and 55° of elevation when comparing the deactivated state or resected state to the active state. However, through nearly the entire range of elevation, no statistically significant differences were found between the deactivated and resected states for any of the actuator loads representing muscle forces.

Conclusion:

The loss of active function of the PSRC led to compensatory loads on the remaining rotator cuff and deltoid, regardless of the passive presence of the PSRC as a supposed subacromial spacer.

Clinical Relevance:

The findings encourage the exploration of treatment procedures that mimic the active function of the PSRC when the rotator cuff itself is irreparable.

Biodegradable balloon spacer for massive irreparable rotator cuff tears is associated with improved functional outcomes, low revisions, and complications rate at minimum one year follow-up

PURPOSE

This study was designed to investigate the efficacy of the InSpace balloon spacer with a specific focus on clinical and patient-related parameters, functional scores InSpace durability, and satisfaction in patients with massive irreparable rotator cuff tears (IRCT) at minimum one year follow-up.

METHODS

Between 2010 and 2018, patients with symptomatic IRCTs were treated with InSpace balloon implantation. Demographic characteristics, concomitant procedures, and patient's reported outcomes (PROMs) were obtained as well as satisfaction rate and willingness to undergo the procedure again. Need for subsequent surgery and conversion to reverse total shoulder arthroplasty (RTSA) and time to conversion were also evaluated.

RESULTS

Seventy-eight patients (mean age of 70 years, range 46-86) who underwent an InSpace (OrthoSpace, Inc., Caesarea, Israel) balloon implantation were included. Mean follow-up was 56 months (median = 49.6, range 16-129 months). Sixteen out of our 29 pseudoparalytic patients (55.2%) exceed 90° of forward flexion post-surgery with mean improvement of 73° (20-150). Patients older than 65 years of age displayed a statistically significant improved ASES score (60.6 to 46.4, P < 0.05). Patients who underwent a subscapularis (SSC) repair demonstrated a superior ASES score (63.4 compared to 50.4, P = 0.06).

CONCLUSIONS

Based on the current study, spacer implantation is a low-risk, clinically effective treatment for the patients with IRCTs. Patient-specific parameters such as age, BMI, and gender should be considered during patient selection process. SSC tendon tears should be repaired if needed. Improvement in function and symptoms from this procedure may negate or delay the need for RTSA even for some of the pseudoparalytic patients.

Classification system of graft tears following superior capsule reconstruction

OBJECTIVE

Superior capsule reconstruction (SCR) is a treatment option for irreparable massive rotator cuff tears (MRCT). The purpose of this study is to describe a classification system for graft integrity and tear location.

METHODS

Patients who underwent SCR at a single institution were included. Pre-operative age, gender, prior surgery, Hamada grade, and Goutallier stage were recorded. An MRI was performed postoperatively to assess graft integrity and tear location.

RESULTS

53 patients met inclusion criteria. Mean age was 60.1 ± 7.9 years. A post-operative MRI was performed in 42 (80%) patients at a mean of 14 ± 7 months (range, 6-40 months). MRIs demonstrated an intact graft in 16 (38%) shoulders. Of the 26 graft tears, 14 (54%) were from the glenoid, 5 (19%) mid-substance, 6 (23%) from the tuberosity, and 1 (3.8%) had complete graft absence.

CONCLUSION

Graft tears are common following SCR. We describe four different graft tear locations and submit a classification system that can be used in future studies to better compare outcomes based on graft integrity and tear location. Clinical correlation with graft integrity and graft tear location needs to be further investigated.

Treatment Options for Massive Irreparable Rotator Cuff Tears

PURPOSE OF REVIEW

Massive irreparable rotator cuff tears present a significant challenge to the orthopedic surgeon. No single treatment, particularly among joint-preserving options, has been shown to be superior. The purpose of this review is to discuss recent advances in the treatment of massive irreparable rotator cuff tears, including partial repair with and without graft augmentation, interposition grafts, superior capsule reconstruction, subacromial balloon spacers, tendon transfer, and reverse total shoulder arthroplasty. We will also offer guidance on surgical indications based on our clinical experience.

RECENT FINDINGS

Partial repair may offer reasonable clinical improvement for patients with lower preoperative function despite high re-tear rates. Additionally, several types of interposition grafts have shown promising short-term results and may outperform repair alone. Subacromial balloon spacers may lead to clinical improvement, especially in patients without glenohumeral osteoarthritis or pseudoparalysis, and recently received FDA approval for use in the USA. Superior capsule reconstruction is a technically demanding procedure that appears to produce excellent short-term results particularly when performed at high volume, but long-term studies in heterogeneous study groups are needed. Tendon transfers improve function by restoring force coupling in the shoulder, offering a promising option for younger patients. Reverse total shoulder arthroplasty (RTSA) is a reliable option for treatment of irreparable cuff tears in elderly patients with lower functional demands. Irreparable cuff tears remain a difficult condition to treat. Recommended treatment for younger patients without glenohumeral osteoarthritis is particularly controversial. For older patients with low-demand lifestyles and glenohumeral osteoarthritis, RTSA is an effective treatment option. For all discussed procedures, patient selection appears to play a critical role in clinical outcomes.

Subacromial spacer implantation: an alternative to arthroscopic superior capsular reconstruction. A systematic review

INTRODUCTION

This systematic review evaluated and compared the use of a subacromial spacer implantation (SSI) with arthroscopic superior capsular repair (ASCR) in the management of massive irreparable rotator cuff tears (MIRCTs) with an assessment of clinical and imaging outcomes.

SOURCES OF DATA

This systematic review was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched in PubMed, Medline and Embase database literature using the keywords 'subacromial spacer', 'subacromial balloon', 'subacromial device', 'arthroscopy', 'superior capsular reconstruction', 'irreparable rotator cuff tears', 'satisfaction' and 'quality of life'.

AREAS OF AGREEMENT

We included a total of 29 articles (14 about SSI and 15 about ASCR) dealing with outcomes, satisfaction and patients' quality of life.

AREAS OF CONTROVERSY

The use of a subacromial spacer showed similar results in terms of patients' satisfaction and quality of life when compared with ASCR.

GROWING POINTS

SSI can be implanted quickly and has a low complication rate. It can therefore be considered a good alternative for the management of MIRCTs.

AREAS TIMELY FOR DEVELOPING RESEARCH

The subacromial spacer is a biodegradable implant easily implanted at arthroscopy. It can lead good clinical and imaging outcomes in MIRCTs. Similarly, ASCR can be performed with either an autograft or synthetic allograft transplantation, with satisfactory results. Long-term prospective studies are needed to compare SSI and ASCR to verify their effectiveness.

Fluoroscopically Guided Subacromial Spacer Implantation for Massive Rotator Cuff Tears: Two Years of Prospective Follow-up

Background

Massive rotator cuff tears (MRCTs) are common and have been estimated to account for nearly 40% of all rotator cuff tears. An evolving strategy for management of MRCTs has been the implantation of a degradable subacromial spacer balloon that attempts to restore normal shoulder biomechanics.

Purpose

To assess the safety and efficacy of fluoroscopically guided balloon spacer implantation under local anesthesia in a cohort of patients with 2 years of postoperative follow-up.

Study Design

Case series; Level of evidence, 4.

Methods

The safety and efficacy of using fluoroscopically guided subacromial spacer implantation was assessed in 46 patients. Follow-up visits were scheduled according to routine clinical practice. Shoulder function was evaluated using Constant and American Shoulder and Elbow Society (ASES) scores.

Results

Overall, 87.5% (35/40) of patients saw clinically significant improvement in the total Constant and ASES scores from 6 weeks postoperatively, with improvement maintained up to 24 months postoperatively.

Conclusion

The data suggest that fluoroscopically guided subacromial spacer implantation under local anesthesia is a low-risk, clinically effective option, especially for the elderly population and those patients who have multiple comorbidities or a contraindication to general anesthesia. Patients undergoing subacromial spacer implantation for the treatment of MRCTs had satisfactory outcomes at 2-year follow-up, with a low rate of complications.

Subacromial balloon spacer - Where are we now?

INTRODUCTION

Rotator cuff tears are a common cause of disability and pain. The ideal treatment for truly irreparable rotator cuffs is still debated, and one recent surgical advance is the development of the subacromial balloon spacer. This review aims to clarify the current evidence and indications for this device.

METHODS

A comprehensive literature search was undertaken using the MeSH search terms combining "balloon spacer" and "irreparable cuff tear". A total of 20 studies using the balloon spacer as a treatment modality in more than two patients, were analysed.

RESULTS

A total of 513 patients were analysed, representing 83% of those initially identified as meeting the inclusion criteria. The majority of studies recommended the device, with only four suggesting it was not recommended based on their results. Notable bias was present in the studies analysed, and there were no papers providing greater than level III evidence.

CONCLUSION

The subacromial balloon spacer is one possible treatment option for older, low-demand patients with a full thickness rotator cuff tear involving only the supraspinatus tendon, who also have no arthritis and have preserved active elevation beyond 90°. However, the results of two large randomised prospective trials are awaited to provide satisfactory evidence regarding the use of the balloon spacer.

Consider Long Head of Biceps Tendon for Reconstruction of Massive, Irreparable Rotator Cuff Tear

Despite the different treatment options for irreparable and massive rotator cuff tears (RCTs), there is no optimal treatment. Thirty percent of total RCTs can be classified as irreparable because of the massive tear size and severe muscle atrophy. The reported treatment failure rate is approximately 40% for massive RCTs. RCTs may be treated conservatively or surgically depending on pain, disability, and functional demands. The surgical treatment options are many, but decision making is a challenge; the real challenge is to apply the correct procedure for the correct indication in each patient. The long head of the biceps tendon (LHBT) was used for augmentation to bridge the gap in immobile, massive RCTs. An arthroscopic biceps-incorporating technique was used for repair of large and massive RCTs, avoiding undue tension on the rotator cuff (RC). Recently, the LHBT was used for superior capsular reconstruction. This article describes the use of the LHBT for reconstruction of massive and irreparable RCTs through the following steps: (1) open exposure of the RCT, (2) debridement and subacromial decompression, (3) biceps tenotomy at the LHBT's origin on the glenoid, (4) LHBT and RC cuff mobilization, (5) passage of the LHBT through the mobilized RC and reflection onto itself, (6) tuberoplasty, and (7) fixation of the RC complex at the RC footprint.

[Irreparable rotator cuff tear-reverse shoulder arthroplasty and alternative procedures]

Irreparable rotator cuff tears represent a significant everyday clinical challenge. A high degree of tendon retraction and muscle degeneration means that a direct reconstruction is impossible. Patients often suffer from pain and pseudoparalysis. In older patients this can reliably be resolved by the implantation of a semiconstrained inverse shoulder prosthesis; however, for younger patients joint-preserving techniques should be employed. Furthermore, for frail older patients who may not be suitable for a joint replacement operation, alternative treatment strategies are required. Management options include physiotherapy and pain relieving or reconstructive operations. Minimally invasive arthroscopic treatment approaches can lead to pain relief and slight functional improvements in selected patients; however, to restore the active movement of the joint a partial cuff repair, augmentation with a graft or replacement with muscle transfer is necessary. This article presents the various treatment options and the results reported in the literature. Through this a treatment algorithm is suggested in order to facilitate management decisions.

Editorial Commentary: Balloons for Rotator Cuff Tears: A Viable Treatment or Just a Bunch of Hot Air?

Rotator cuff tears are very common. They can be either traumatic or degenerative in nature. Many tears can be successfully treated nonoperatively with physical therapy or home exercises. For patients in whom conservative measures fail, there are a variety of ways to repair the rotator cuff. Despite our advances in knowledge about rotator cuff tears, improved technology, and advanced repair techniques, failure rates after surgery are still high. Large tears that are deemed irreparable can be treated with partial repair, debridement, tendon transfers such as a latissimus dorsi transfer or lower trapezius transfer, biceps tenotomy or tenodesis, superior capsular reconstruction, bridge grafting, or even arthroplasty options such as a hemiarthroplasty or reverse total shoulder arthroplasty. No technique has proved vastly superior to another, and there are many advantages and disadvantages of each surgical procedure. Add balloon spacer implantation to that list. A surgeon can now place a subacromial balloon spacer to help improve functional outcomes and reduce pain in patients with irreparable rotator cuff tears. Studies have shown promising results, with improvements in strength and range of motion, as well as reductions in pain. Outcomes have only been studied in the short term, so much is still unknown about the full effects of this treatment. More studies are needed to find out whether the results persist into the long term and to confirm that complications do not arise that may complicate future procedures such as a reverse total shoulder arthroplasty.

Subacromial Balloon Spacer for Massive, Irreparable Rotator Cuff Tears Is Associated With Improved Shoulder Function and High Patient Satisfaction

PURPOSE

To investigate associations between clinical and demographic parameters and Constant-Murley (CM) scores after subacromial balloon placement for massive, irreparable rotator cuff tears and to evaluate implant survival, shoulder function, and patient satisfaction.

METHODS

We prospectively analyzed patients with rotator cuff tears deemed irreparable on preoperative magnetic resonance imaging for whom nonoperative therapy was unsuccessful and who underwent balloon placement from 2014 to 2017 with minimum 1-year follow-up. Shoulder function was assessed using the CM score and the 12-Item Short Form Health Survey.

RESULTS

The study included 51 patients (22 women and 29 men) with a mean age at surgery of 63 years (range, 50-78 years). The mean follow-up period was 36 months (range, 24-56 months). The postoperative acromiohumeral interval and total preoperative CM score predicted the postoperative CM score at final follow-up. The implant survival rates were 92% at 6 and 12 months, 90% at 2 years, and 87% at 3 and 4 years. Five patients underwent reverse total shoulder arthroplasty, and 1 underwent latissimus dorsi tendon transfer. Postoperatively, mean CM scores (± standard deviation) improved for range of motion (from 11 ± 5.4 to 34 ± 6.8) and strength (from 13 ± 5.4 to 28 ± 12) (P < .01 for both). The total CM score improved from 27 ± 7.4 preoperatively to 77 ± 15 postoperatively (P < .01). The physical and mental component summary scores on the 12-Item Short Form Health Survey improved from 27 ± 5.0 to 51 ± 6.5 (P = .02) and from 44 ± 15 to 56 ± 8.0, respectively (P < .01). Thirty-eight patients reported excellent satisfaction, 8 were satisfied, and 5 were dissatisfied. Of the patients, 50 (98%) exceeded the minimal clinically important difference (≥10.4) and patient acceptable symptom state (≥44).

CONCLUSIONS

At mean 3-year follow-up, subacromial balloon spacer placement for massive, irreparable rotator cuff tears was associated with a significant improvement in shoulder function, limited need for revision surgery, and high patient satisfaction. A greater postoperative acromiohumeral interval and lower preoperative CM score predicted a lower postoperative CM score at final follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study and treatment study.

Subacromial balloon spacer implantation for patients with massive irreparable rotator cuff tears achieves satisfactory clinical outcomes in the short and middle of follow-up period: a meta-analysis

PURPOSE

This meta-analysis was performed systematically to evaluate the efficacy of subacromial balloon spacers for patients with massive, irreparable rotator cuff tears.

METHODS

Electronic databases, including Medline/PubMed, Embase and Cochrane Library, were systematically searched to identify studies evaluating the efficacy of subacromial spacers for patients with irreparable or massive rotator cuff tears. Meta-analyses were performed to pool the outcome estimates of interest, such as the total constant score (TCS) and its sub-score (pain, activities of daily living [ADL], range of motion [ROM], and strength), Oxford shoulder score (OSS), American Shoulder and Elbow Society scores (ASES) and numeric rating scale (NRS), as well as different outcomes at different time points in the follow-up period.

RESULTS

Ten studies with a total of 261 patients involving 270 shoulders were deemed viable for inclusion in the meta-analysis. The combined results demonstrated significant improvements in the TCS at the final follow-up (pooled mean difference = 26.4, 95% confidence intervals [CIs] 23.3 to 29.5). A sensitivity analysis and subgroup analysis, which were implemented based on two factors, different follow-up points and sub-scores (pain, ADL, ROM, and strength), revealed a consistent trend. The combined shoulder motion results demonstrated significant improvements in the forward flexion and external rotation (0° abduction) variables rather than in the abduction and external rotation (90° abduction) variables. Additionally, significant improvements in the OSS and ASES and a decrease in the NRS were observed in the middle of the follow-up period.

CONCLUSION

This meta-analysis indicated that subacromial balloon spacer implantation for patients with massive irreparable rotator cuff tears may achieve satisfactory outcomes between 3 months and 3 years of follow-ups. Although the short- and middle- term effect is significant, the long-term effect needs to be confirmed by large-sample randomized controlled trial.

LEVEL OF EVIDENCE

IV.

Implantable Subacromial Balloon Spacers in Patients With Massive Irreparable Rotator Cuff Tears: A Systematic Review of Clinical, Biomechanical, and Financial Implications

Purpose

To determine the clinical, biomechanical, and financial impact of the use of subacromial balloon spacers in the surgical management of massive, irreparable rotator cuff tears (RCTs).

Methods

All studies assessing the use of implantable subacromial balloon spacers for management of massive, irreparable RCTs were systematically searched. Risk of bias was assessed using Methodological Index for Non-Randomized Studies criteria. Data extraction and analysis was performed for pain and function scores, shoulder range of motion (ROM), glenohumeral contact pressure and vertical migration of humeral head, and cost. Subjective synthesis was performed with forest plots when outcomes were reported in 3 or more studies.

Results

In total, 19 studies met inclusion criteria for analysis; 337 patients (mean age 68 years) had 343 subacromial balloon spacer implantations. Throughout a mean follow-up of 33 months, there was significant improvement in the Total Constant Score (preoperative: 22.5-41.8; postoperative: 51.4-72.3), Oxford Shoulder Score (preoperative: 21.3-26; postoperative: 34.39-48.2), American Shoulder and Elbow Surgeons score (preoperative: 24.5-59.1; postoperative: 72.5-85.7), and shoulder ROM parameters. Subacromial balloon spacer placement resisted superior humeral head migration (range of preoperative to postoperative difference: 2.8-6.2 mm) and decreased peak subacromial pressure during shoulder ROM.

Conclusions

Existing literature of subacromial balloon spacers has a high risk of bias, lack of appropriate control, and low levels of evidence. A qualitative synthesis indicates that subacromial balloon spacer implantation in patients with massive irreparable RCTs is cost-effective and leads to improved function (Total Constant Score and Oxford Shoulder Score) and ROM. In cadaveric studies, subacromial balloon spacers resist superior humeral head migration and reduce subacromial pressure. The theoretical risk of biodegradation of the balloon spacer has not been substantiated in study of up to 5-years follow-up, and the risk of complications from this procedure appears to be minimal.

Level of Evidence

IV; Systematic review of level III-IV studies.

The subacromial balloon spacer for massive irreparable rotator cuff tears: approximately 3 years of prospective follow-up

BACKGROUND

Irreparable rotator cuff tears (RCT) are still a challenging problem. RCT can result in disability and severe pain. The optimal treatment for this disabling and painful diagnosis remains controversial. The arthroscopic implantation of a biodegradable subacromial balloon spacer is a possible treatment option. In this prospective study, we evaluate the clinical outcome of this balloon spacer after approximately 3 years.

METHODS

Between March 2014 and December 2015, the biodegradable balloon spacer was implanted into the subacromial space of 46 shoulders of 44 patients with massive irreparable RCT. Pain was evaluated using a numeric rating scale (NRS), and functional outcome was evaluated using the Oxford shoulder score (OSS). Patients were followed prospectively for approximately 3 years. This present study focuses on the comparison between the early and the midterm results up to approximately 3 years.

RESULTS

All patients were treated by surgical implantation of the subacromial balloon spacer. The comparison between the outcomes of the NRS and the OSS after one and 3 years was made and showed no mutual significant differences, respectively, p = 0.61 and p = 0.08. Significant pain reduction and functional improvement was noticed postoperatively and maintained after approximately 3 years. At last follow-up (mean: 34 months), pain was reduced to a NRS of 3.09 points (95% CI: 2.17-4.01). Functional outcome based on the OSS improved significantly from 21.32 preoperatively to 34.39 (95% CI: 29.17-36.70) at the last follow-up. Correction for estimated confounders did not show significant differences. 82% of the patients were satisfied with the outcome after implantation of the subacromial balloon spacer. No surgical or postoperative medical complications due to implantation of the balloon spacer were reported.

CONCLUSIONS

Arthroscopic implantation of the biodegradable balloon spacer in the subacromial space is a safe and minimally invasive intervention. It leads to significant reduction in pain and significant improvement of functional daily activities in patients with irreparable RCT during 3 years of follow-up starting postoperative and maintain over time beyond device degradation. A high percentage of patients are satisfied postoperatively. Despite of these positive results after 3 years of follow-up, the specific contribution of the balloon needs further investigation.

Subacromial Balloon Spacer Implantation

PURPOSE OF REVIEW

Massive irreparable rotator cuff tears present a treatment challenge for the orthopedic surgeon. There is no gold standard among numerous treatment options including nonoperative management, partial repair, debridement, superior capsular reconstruction, and reverse shoulder arthroplasty. In recent years, yet another option, an implantable biodegradable subacromial balloon spacer has become available with promising early results.

RECENT FINDINGS

Biomechanical studies have demonstrated that the balloon spacer effectively restores the normal humeral head position and glenohumeral joint mechanics. This device has been used in Europe since 2012 with promising clinical results. Most of the studies on this implantable balloon represent single surgeon uncontrolled case series with small numbers of patients, but they report improvements in pain and function following spacer placement, with the longest term studies reporting maintenance of improvements for up to 5 years. Certain studies have shown a benefit when the procedure is done in isolation as well as in combination with other arthroscopic procedures, such as partial rotator cuff repair. The balloon subacromial spacer is a promising new device that can be used in the treatment of patients with massive, irreparable rotator cuff tears. In our experience, patients without arthritis who have active forward elevation over 90 degrees and an intact subscapularis have the best chance of a good outcome. We recommend performing the procedure arthroscopically along with any other indicated procedures including debridement, partial repair, and biceps tenotomy or tenodesis. High-quality long-term studies are needed to better define the indications and outcomes of the implantable balloon spacer in the management of irreparable cuff tears.

Arthroscopic Superior Capsular Reconstruction of the Shoulder Using Dermal Allograft

Irreparable massive cuff tears in young patients pose a difficult problem for shoulder surgeons. Arthroscopic superior capsular reconstruction has shown promise in recent years in the treatment of this challenging patient population. The majority of the literature is limited to surgical techniques. The authors present the 2-year clinical outcomes of 25 patients undergoing arthroscopic superior capsular reconstruction with dermal allograft from a single center. The Oxford Shoulder Score and range of motion were assessed preoperatively and then at 3 to 6 months, 1 year, and 2 years following surgery. Patient satisfaction was recorded at final follow-up. Magnetic resonance imaging was performed at 3 months postoperatively to assess graft integrity. All patients were available at 1-year follow-up, and 23 were available at 2 years. The mean Oxford Shoulder Score improved by a minimum of 10 points at all time points compared with preoperatively. The mean forward flexion and abduction improved by 20° and external rotation by 7°. Revision to reverse shoulder arthroplasty was seen in 3 patients (12%). Graft failure was seen in 4 patients (16%). Overall, 20 patients had successful outcomes at 1 year (80%) and 18 patients had successful outcomes at 2 years (72%). Superior capsular reconstruction offers a safe and effective short-term bridging option for young patients with irreparable supraspinatus tears in the absence of glenohumeral arthritis. However, long-term outcome studies are required to evaluate the true clinical effectiveness and failure rates. [Orthopedics. 2020;43(4):215-220.].

Protocol for a randomised controlled trial of Subacromial spacer for Tears Affecting Rotator cuff Tendons: a Randomised, Efficient, Adaptive Clinical Trial in Surgery (START:REACTS)

INTRODUCTION

Shoulder pain due to irreparable rotator cuff tears can cause substantial disability, but treatment options are limited. A balloon spacer is a relatively simple addition to a standard arthroscopic debridement procedure, but it is costly and there is no current randomised trial evidence to support its use. This trial will evaluate the clinical and cost-effectiveness of a subacromial balloon spacer for individuals undergoing arthroscopic debridement for irreparable rotator cuff tears.New surgical procedures can provide substantial benefit to patients. Good quality randomised controlled trials (RCTs) are needed, but trials in surgery are typically long and expensive, exposing patients to risk and the healthcare system to substantial costs. One way to improve the efficiency of trials is with an adaptive sample size. Such methods are well established in drug trials but have rarely, if ever, been used in surgical trials.

METHODS AND ANALYSIS

Subacromial spacer for Tears Affecting Rotator cuff Tendons: a Randomised, Efficient, Adaptive Clinical Trial in Surgery (START:REACTS) is a participant and assessor blinded, adaptive, multicentre RCT comparing arthroscopic debridement with the InSpace balloon (Stryker, USA) to arthroscopic debridement alone for people with a symptomatic irreparable rotator cuff tear. It uses a group sequential adaptive design where interim analyses are performed using all of the 3, 6 and 12-month data that are available at each time point. A maximum of 221 participants will be randomised (1:1 ratio), this will provide 90% power (at the 5% level) for a 6 point difference in the primary outcome; the Oxford Shoulder Score at 12 months. A substudy will use deltoid-active MRI scans in 56 participants to assess the function of the balloon. Analysis will be on an intention-to-treat basis and reported according to principles established in the Consolidated Standards of Reporting Trials statement.

ETHICS AND DISSEMINATION

NRES number 18/WM/0025. The results will be disseminated via peer-reviewed publications, presentations at conferences, lay summaries and social media.

TRIAL REGISTRATION NUMBER

ISRCTN17825590.

Arthroscopic partial repair with versus without biodegradable subacromial spacer for patients with massive rotator cuff tears: a case-control study

BACKGROUND

To investigate whether arthroscopic partial repair with the additional use of a biodegradable subacromial spacer would be proven better treatment for irreparable massive rotator cuff tears (MRCT) compared to single arthroscopic partial repair.

METHODS

A matched-pairs case-control study of 32 patients suffering from irreparable MRCT who underwent an arthroscopic partial repair with (Group B: 16 patients) or without (Group A: 16 patients) InSpace Balloon (ISB^®; Orthospace, Caesarea, Israel) implantation was conducted. For the clinical and functional assessment of the patients, the visual analog scale, Constant score, American Shoulder and Elbow Surgeons Shoulder Score (ASES), Range of Motion (RoM), and patients' satisfaction were obtained.

RESULTS

The two groups were matched in all baseline demographic and clinical characteristics (n.s.). All mean final quantitative postoperative clinical and functional scores of group A (partial repair and ISB) and group B (single partial repair), as well as active RoM, were significantly improved (t test) in comparison with the mean preoperative values (p < 0.05). No significant differences were observed between the two groups in relation to the two success rate criteria (ASES minimal clinically important difference or MCID > 17, Constant score MCID > 10.4), as well as pain relief and RoM 12 months after surgery.

CONCLUSION

Arthroscopic partial repair, either with or without ISB implantation, resulted in significantly improved clinical and functional short-term outcomes for the treatment of MRCT. Patients who were treated with combined partial repair and ISB implantation had a potential propensity toward better functional outcomes and higher patient satisfaction compared to the single-partial-repair-treated group. However, given that these differences were not significant, we feel that further studies are required to clarify the potential therapeutic value of ISB implantation in the treatment of irreparable MRCT.

LEVEL OF EVIDENCE

Level III.

CLINICAL TRIALS' REGISTRY

German Clinical Trials Register (WHO International Clinical Trials Registry Platform). ID number: DRKS00014725. Date of registration: 07/05/2018.

Satisfactory mid-term outcome of subacromial balloon spacer for the treatment of irreparable rotator cuff tears

PURPOSE

To answer the question whether arthroscopic subacromial balloon spacer (InSpace Balloon-ISB) implantation results in improved outcomes in patients suffering by irreparable massive rotator cuff tears (MRCT). Secondarily, we aimed to compare the outcomes of a combined ISB and arthroscopic partial repair procedure with those of a single ISB implantation without any repair.

METHODS

A retrospective single-centre case series, based on prospectively collected data of patients who were suffering by irreparable MRCT, was conducted. An ISB implantation along with an arthroscopic non-anatomic repair or debridement was carried out in all patients included in this study. Patients were functionally evaluated with the use of the American Shoulder and Elbow Surgeons Shoulder Score and the Constant score. Individual's pain was pre- and postoperatively measured with the Visual Analogue Scale (0-100/100). Patients' satisfaction and postoperative complications were also documented. As for the active range of motion (RoM), shoulder's forward flexion, external rotation at 0° and of 90° of abduction, and internal rotation were also pre- and postoperatively assessed.

RESULTS

Thirty-one patients [mean age: 65.2 years, standard deviation (SD): 8.5, and range: 50-80 years] with a mean follow-up of 22.1 months (SD: 9.8; range: 6-31 months) were reviewed. All final postoperative clinical and functional scores were significantly improved in comparison with the preoperative values (p < 0.05). The vast majority of the patients declared fully or almost fully satisfied with their treatment (80.6%), while most patients were free of pain at their last follow-up (83.9%). We identified 18 patients (group A), who were treated with a combined ISB implantation and arthroscopic non-anatomic repair and 13 patients (group B) who received an ISB implant without any repair. The long head of biceps, where existed, was tenotomized in both groups. No significant difference was found between the baseline demographic and clinical characteristics of the two groups. As for the mean final postoperative scores and RoM, the differences between the two groups were insignificant (p > 0.05).

CONCLUSIONS

The use of ISB implantation for patients suffering by MRCT leads to significantly improved mid-term outcomes and high patents' satisfaction. The additional use of arthroscopic partial repair with ISB was not proven superior to the single ISB implantation.

LEVEL OF EVIDENCE

IV; therapeutic case series.

Outcomes of Subacromial Balloon Spacer Implantation for Massive and Irreparable Rotator Cuff Tears: A Systematic Review

Background

Selection of optimal treatment for massive to irreparable rotator cuff tears (RCTs) entails a challenging decision-making process in which surgeons must consider several factors, including duration of symptoms, tear pattern, tear size, and muscle quality, as well as patient characteristics such as age, comorbidities, shoulder dominance, and activity level. Unfortunately, no clear consensus has been reached regarding optimal management.

Purpose

To systematically review the published literature assessing outcomes after subacromial balloon spacer implantation for treatment of massive and irreparable RCTs.

Study Design

Systematic review; Level of evidence, 4.

Methods

A comprehensive literature search was performed in September 2018 through use of MEDLINE and the Cochrane Library electronic databases. Studies were assessed for multiple outcomes of interest including Constant score, Oxford Shoulder Score (OSS), University of California Los Angeles (UCLA) Shoulder Score, complications, and patient satisfaction.

Results

After applying the selection criteria, 12 clinical studies were included for data extraction and analysis. In total, 291 shoulders (in 284 patients) treated with subacromial balloon spacer implantation were pooled for evaluation, with a mean follow-up of 22.9 ± 14.9 months (range, 6-60 months). Constant scores were used as an outcome metric for 267 shoulders (91.7%; 11 studies), with improvements in mean Constant score ranging from 18.5 to 49.6 points. Patient satisfaction was assessed in 105 patients (37.0%; 5 studies), with rates of patients indicating they were satisfied or very satisfied with their treatment outcome ranging from 45.8% to 100%. A total of 6 patients (2.1%) experienced complications related to balloon spacer implantation, including transient neurapraxia of the lateral antebrachial cutaneous nerve, superficial wound infection, deep wound infection, and balloon migration. Of these, 3 patients (2 balloon migration, 1 deep wound infection) required subsequent surgeries for balloon removal.

Conclusion

Placement of the subacromial balloon spacer is a minimally invasive, technically simple procedure with favorable patient-reported outcomes at limited short-term follow-up. However, inherent methodological limitations and patient heterogeneity between studies may impair our ability to fully characterize the longer term efficacy, particularly relative to other potential surgical options. Further prospective randomized or comparative studies are warranted to ascertain clinical outcomes of subacromial balloon spacer in the management of massive and irreparable RCTs.

Comparing Clinical Outcomes After Subacromial Spacer Insertion Versus Other Reconstruction Methods in the Treatment of Irreparable Massive Rotator Cuff Tears

Background:

Previous studies on subacromial spacer (SAS) insertion have been limited to case series that did not compare the effectiveness of this technique with other techniques.

Hypothesis:

Outcomes after SAS insertion for the treatment of irreparable massive rotator cuff tears (IMRCTs) will be similar to those of other techniques.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This retrospective study was based on data collected from patients who underwent correction of IMRCTs between January 2010 and October 2017. Group 1 patients (n = 17) received SAS insertion with or without partial repair; group 2 patients (n = 36) were treated with other techniques (isolated partial repairs or bridging grafts). Preoperative tear size and global fatty degeneration index values were evaluated. Range of motion, visual analog scale for pain, American Shoulder and Elbow Surgeons (ASES) score, Constant score, Simple Shoulder Test (SST), Disabilities of the Arm, Shoulder and Hand score, and acromiohumeral distance (AHD) were assessed preoperatively and at final follow-up at least 2 years after the surgery (range, 24-60 months). In both groups, ultrasonographic examination was performed at 3 and 6 months postoperatively, and magnetic resonance imaging (MRI) was performed at 1 year.

Results:

Tear size and preoperative global fatty degeneration index were not significantly different between the groups (all P > .05). There were no differences in functional scores between the groups at final follow-up (all P > .05). AHD was maintained at final follow-up in group 1 (mean ± SD: 6.2 ± 2.1 mm [postoperatively] vs 6.7 ± 2.3 mm [final follow-up]; P = .678), and there was no difference compared with group 2 (7.2 ± 3.2 mm; P = .244). Patients with retears in group 2 (23 of 36, 63.9%) had lower ASES (P = .041) and SST (P = .027) scores at final follow-up when compared with patients in group 1. Six patients (35.3%) in group 1 had partial repairs; these patients had better external rotation at 90° (P = .047), better SST scores (P = .036), and higher AHDs at final follow-up (P = .046) than those in group 1 who had no repair. Three patients (50%) showed retears of partially repaired tendons on MRI. Of 13 patients (76.5%) in group 1 with postoperative MRI, 12 (92.3%) showed fibrotic tissue in the subacromial space not seen preoperatively.

Conclusion:

There was no difference in outcomes between SAS and the other reconstruction methods for treating IMRCTs. However, given the high retear rate associated with other techniques and poor functional outcomes after retear, SAS insertion could be a viable option for treating IMRCTs.

Irreparable rotator cuff tears: Current treatment options

Rotator cuff disease is one of the most common causes of shoulder pain, yet controversy still exists regarding treatment of "irreparable" tears. Nonoperative management, including physical therapy and steroid injections, should be reserved for those without significant pain or functional impairment. Debridement may be used for low-demand patients, and should be performed with partial cuff repair, subacromial decompression, and/or acromioplasty to maximize outcomes. Biceps tenotomy and/or tenodesis have been shown to reduce postoperative pain and improve satisfaction when performed in conjunction with rotator cuff repairs, with no difference in functional outcome comparatively. Tendon transfers have been advocated with the potential benefit to improve function and decrease pain. More recently, extracellular matrix and human-derived dermal allografts have been used off-label as patch grafts in irreparable tears. Superior capsular reconstructive techniques and subacromial balloon spacers serve a similar function by acting to depress the humeral head in a cuff-deficient shoulder, however long-term data is needed before widespread adoption of these procedures. Finally, reverse shoulder arthroplasty serves as a salvage option for low demand elderly patients.

Irreparable Rotator Cuff Tears: A Biomechanical Comparison of Superior Capsuloligamentous Complex Reconstruction Techniques and an Interpositional Graft Technique

Background:

Irreparable rotator cuff tears lead to superior translation of the humeral head. Numerous surgical management options are available to treat the condition.

Purpose:

To compare superior capsule stability among different types of patch grafting in irreparable rotator cuff tears.

Methods:

Six cadaveric shoulders were tested in a custom-designed shoulder testing system. Superior translation of the humerus and subacromial contact pressure were quantified in an intact condition (condition 1), after cutting the supraspinatus tendon (condition 2), and after additionally cutting the superior capsuloligamentous complex (condition 3). The results were compared among 3 types of patch grafting, in which capsule reconstruction was achieved by glenoidal 3-point (condition 4) or 2-point (condition 5) fixation or by affixing a graft below the acromion (condition 6).

Results:

No significant difference in subacromial pressure was measured by reconstruction with 2 or 3 anchors compared with conditions 1 and 2 (P > .05). However, with 3-point fixation, lower levels of pressure were measured than with 2-point fixation. Moreover, superior translation values were lower with 3-point fixation; the same applied for values of the preserved capsule as compared with the torn capsule. In condition 6, a significant increase in pressure in the neutral position was documented (P < .05).

Conclusion:

The superior capsuloligamentous complex plays an important role in stabilizing the glenohumeral joint. The results suggest that with additional medial anchoring at the coracoid base, the depressing and centering effect of the superior complex can probably be regained in a more physiological way compared with a reconstructed capsule with 2 glenoid attachments or with an interpositional graft below the acromion.

Failed Dermal Allograft Procedures for Irreparable Rotator Cuff Tears Can Still Improve Pain and Function: The "Biologic Tuberoplasty Effect"

Background:

Acellular dermal matrices (ADMs) have been used in the treatment of shoulders with massive rotator cuff tears (MRCTs). Despite clinical improvement, correlation of clinical findings with ADM integrity on imaging has not been investigated.

Hypothesis:

The pain in shoulders with MRCTs is partially due to bone-to-bone contact between the tuberosity and acromion. Coverage of the tuberosity with an intact graft or a graft that is torn in a way that the tuberosity remains covered will act as an interpositional tissue, preventing bone-to-bone contact and leading to clinical improvement.

Study Design:

Case series; Level of evidence, 4.

Methods:

Between 2006 and 2016, a total of 25 shoulders with MRCTs underwent a procedure with an ADM. Pre- and postoperative visual analog scale (VAS) results, American Shoulder and Elbow Surgeons (ASES) score, Hamada grade, and Goutallier classification were reviewed. A postoperative magnetic resonance imaging (MRI) was obtained in 22 (88%) shoulders. The status of the graft was divided into the following categories: type I, intact graft; type II, graft tear with tuberosity covered; and type III, graft tear with tuberosity uncovered (bare).

Results:

The mean patient age was 61 years (range, 49-73 years), and the mean follow-up was 25.6 months (range, 10-80 months). Mean length from surgery to postoperative MRI was 13.9 months (range, 6-80 months). The graft was torn in 59% (13/22 shoulders). Significant improvements were found in VAS and ASES scores (7 vs 0.7 and 32.6 vs 91.2, respectively; P < .01) for type I grafts and in VAS and ASES scores (8.1 vs 1.3 and 26.3 vs 84.6, respectively; P < .01) for type II grafts. No difference was found in postoperative VAS and ASES (0.7 vs 1.3 and 91.2 vs 84.6, respectively; P = .8) between type I and type II grafts. No improvement was seen in VAS (7.3 vs 5.7; P = .2) or ASES (30.6 vs 37.2; P = .5) for type III grafts.

Conclusion:

MRI appearance of the graft has a significant impact on functional outcomes. Patients with an intact graft or a graft tear leaving the tuberosity covered have lower pain and higher functional scores than those in whom the torn graft leaves the tuberosity uncovered.

Biomechanics of Biodegradable Subacromial Balloon Spacer for Irreparable Superior Rotator Cuff Tears: Study of a Cadaveric Model

BACKGROUND

A subacromial balloon spacer is an option to treat irreparable rotator cuff tears. We hypothesized that the balloon would restore glenohumeral contact pressure, the acromion-humeral interval, and deltoid load to intact values after a simulated irreparable supraspinatus tear in a cadaveric model.

METHODS

Fourteen cadaveric shoulders (mean age at the time of death, 67.9 years) were tested using a custom test frame. In this frame, glenohumeral contact pressure, the acromion-humeral interval, and deltoid load were measured using a digital sensor, a MicroScribe, and a spring scale, respectively. Test conditions included the intact shoulder, a small supraspinatus tear, supraspinatus repair, repair plus balloon, an irreparable supraspinatus tear (rotator cable-insufficient), and an irreparable tear plus balloon. Load was applied in a simulated neutral arm position (balanced) and active shoulder abduction (unbalanced).

RESULTS

When the balloon was inflated over the irreparable supraspinatus tear in the balanced condition, glenohumeral contact pressure increased by 122% (p = 0.006) compared with that for the irreparable tear at 0° of abduction and by 94% (p = 0.046) at 60°. In the unbalanced condition, pressure decreased in the irreparable tear condition after the balloon was inflated, restoring pressure to close to that in the intact state. The balloon did not restore glenohumeral contact area to that in the intact shoulder in either the balanced or the unbalanced condition. The irreparable tear displaced the humeral head superiorly in the unbalanced condition, decreasing the acromion-humeral interval. The balloon moved the head inferiorly by a mean (and standard error of the mean) of 6.2 ± 1.3 mm (p < 0.001) at 0° of abduction, 4.4 ± 1.3 mm (p < 0.001) at 30°, and 3.0 ± 0.8 mm (p < 0.001) at 60°. The balloon increased the deltoid load after an irreparable tear by 8.2% (p = 0.022) at 0°, 12.6% (p = 0.002) at 30°, and 11.1% (p = 0.008) at 60°.

CONCLUSIONS

In a cadaveric model of an irreparable supraspinatus tear, a balloon spacer restored intact-state glenohumeral contact pressures at most abduction angles, lowered the humeral head, and increased deltoid load at postoperative time 0.

CLINICAL RELEVANCE

This study supports further investigation of the balloon spacer in comparative clinical studies of surgical options for irreparable rotator cuff tears, with clinically relevant evaluation measures and observation periods.

Editorial Commentary: Yet Another Arrow in the Quiver for Surgical Treatment of the Rotator Cuff-Deficient Shoulder: Will It Fly Fast and Far or Fall Short Like Other Options Have?

Rotator cuff tears are common. When indicated, surgical repair is a highly successful procedure. There are circumstances when there is not enough tendon to perform an anatomic repair because of tear size, retraction, and/or atrophy. This clinical scenario, massive irreparable rotator cuff tear, has no perfect solution. Many options exist in treating massive irreparable rotator cuff tears: partial tendon repairs, debridement, tuberoplasty, intercalary allograft repairs, tendon transfers, superior capsular reconstruction, hemiarthroplasty, arthrodesis, and reverse total shoulder arthroplasty. No superior technique has been described. Another treatment has been added to this list: inserting a biodegradable balloon within the subacromial space to reduce the articulation of the humeral head on the acromion and aid in recentering the humeral head to restore balance to the remaining rotator cuff and improve deltoid function.

Subacromial Spacer Implantation for the Treatment of Massive Irreparable Rotator Cuff Tears: A Systematic Review

PURPOSE

To synthesize and report the early clinical and radiographic outcomes associated with subacromial spacer use in patients with massive irreparable rotator cuff tears.

METHODS

A systematic search on MEDLINE, Embase, and Cochrane Library databases was performed during February 2018. Included studies were evaluated regarding the level of evidence and quality using the methodological index for nonrandomized studies. Patient demographics, intraoperative findings, clinical and radiographic outcomes, and complications were recorded for each of the included studies.

RESULTS

Seven eligible studies including 204 shoulders from 200 patients with subacromial spacer implantation were identified (6 Level IV studies and 1 Level III study). The mean methodological index for nonrandomized studies score for noncomparative studies was 11, whereas that of comparative studies was 15. The mean age of patients was 67.6 years, and the mean reported follow-up time was 19.4 months. All patients had Goutallier stage 3 and 4 fatty infiltration on magnetic resonance imaging. All studies reported consistent improvement in the total Constant score or American Shoulder and Elbow Surgeons score over the duration of follow-up. A total of 6 (3%) complications were reported in the included studies. Two studies detailed radiographic outcomes, with discrepant changes in the acromiohumeral interval.

CONCLUSIONS

Patients undergoing subacromial spacer implantation for the treatment of massive irreparable rotator cuff tears have satisfactory outcomes at the 2- to 3-year follow-up with a low rate of complications.

LEVEL OF EVIDENCE

Level IV, systematic review of 1 Level III and 6 Level IV studies.