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

Arthroscopic additional biceps augmentation and biceps superior capsular reconstruction yield similar clinical and radiological outcomes for patients with medium to large rotator cuff tears

Purpose: To compare the outcomes of additional biceps augmentation (ABA) and biceps superior capsule reconstruction (BSCR) in arthroscopic medium to large rotator cuff tear (RCT) repair. Hypothesis: Both ABA and BSCR yielded comparable clinical and radiological outcomes and retear rates at the 2-year follow-up in patients with medium to large RCTs. Methods: Patients undergoing ABA or BSCR for RCT repairs were included retrospectively between January 2019 and May 2020. The preoperative and postoperative Constant-Murley score (CMS), American Shoulder and Elbow Surgeons (ASES) score, subjective shoulder value (SSV), visual analog scale (VAS), and range of motion (ROM) were recorded, as well as the radiographic evaluation. Results: 67 patients (41 with ABA, 26 with BSCR) were included. There were no significant differences regarding preoperative patient demographics between groups unless forward flexion. In the ABA group, CMS, ASES, SSV, and VAS improved significantly from 33.9 ± 6.0, 37.3 ± 8.7, 24.9 ± 12.3, and 5.1 ± 1.1 to 79.3 ± 8.4, 82.7 ± 8.4, 77.5 ± 10.9, and 2.4 ± 0.6, at 2-year follow-up (all p < .001). In the BSCR group, the CMS, ASES, SSV, and VAS significantly improved from 33.9 ± 5.5, 33.5 ± 11.6, 20.8 ± 9.8, and 5.3 ± 1.5 to 72.8 ± 12.9, 79.6 ± 12.1, 73.1 ± 10.2, and 2.7 ± 0.8, at follow-up (all p < .001). All ROM improved at follow-up in both groups (all p < .001). No significant differences were found between the two groups regarding the postoperative clinical and radiological results. All patients reached minimal clinically important differences for CMS, ASES, SSV, and VAS at the final follow-up. The retear rates in the ABA and BSCR groups were 0% and 7.7%, respectively (p = .001). Conclusions: Both ABA and BSCR provided similar clinical and radiological outcomes in patients with medium to large RCTs. The BSCR group had a higher retear rate than the ABA group. Level of Evidence: Level III, Retrospective comparative therapeutic trial. Clinical Relevance: Both ABA and BSCR provided comparable clinical and radiological outcomes in patients with medium to large RCTs.

Balloon Spacer Implant Is an "Intermediate Value" Innovation Relative to Partial Repair for Full-Thickness Massive Rotator Cuff Repairs: A Cost-Utility Analysis

PURPOSE

To evaluate the cost-utility of a balloon spacer implant relative to partial repair (PR) for the surgical treatment of full-thickness massive rotator cuff tears (MRCTs).

METHODS

A decision-analytic model comparing balloon spacer with PR was developed using data from a prospective, randomized, single-blinded, multicenter-controlled trial of 184 randomized patients. Our model was constructed on the basis of the various event pathways a patient could have after the procedure. The probability that each patient progressed to a given outcome and the quality-adjusted life years (QALY) associated with each outcome were derived from the clinical trial data. Incremental cost utility ratio (ICUR) and incremental net monetary benefit were calculated on the basis of a probabilistic sensitivity analysis using Monte Carlo simulations of 1,000 hypothetical patients progressing through the decision-analytic model. One-way sensitivity and threshold analyses were performed by varying cost, event probability, and QALY estimates.

RESULTS

The balloon spacer had an ICUR of $106,851 (95% confidence interval $96,317-$119,143) relative to PR for surgical treatment of MRCT. Across all patients, the balloon spacer was associated with greater 2-year QALY gain compared with PR (0.20 ± 0.02 for balloon spacer vs 0.18 ± 0.02 for PR), but with substantially greater total 2-year cost ($9,701 ± $939 for balloon spacer vs $6,315 ± $627 for PR). PR was associated with a positive incremental net monetary benefit of $1,802 (95% confidence interval $1,653-$1,951) over balloon spacer at the $50,000/QALY willingness-to-pay threshold.

CONCLUSIONS

Compared with PR, the balloon spacer is an "intermediate-value" innovation for treatment of MRCT over a 2-year postoperative period with an ICUR value that falls within the $50,000 to $150,000 willingness-to-pay threshold.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

A Biological Spacer to Treat Irreparable Rotator Cuff Tears: A Biomechanical Study Utilizing a Secured Versus Unsecured Tensor Fascia Lata Graft

BACKGROUND

Designed to help treat pain and loss of function after rotator cuff repair, allograft spacer procedures utilize a graft to act as a spacer in the subacromial space, decreasing pain from impingement of the greater tuberosity on the acromion at the extremes of overhead motion.

PURPOSE

To evaluate the biomechanical characteristics of secured versus unsecured tensor fascia lata allografts used in an allograft spacer procedure.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 8 fresh-frozen cadaveric shoulder specimens were used. There were 4 conditions tested: (1) intact rotator cuff, (2) stage III rotator cuff tear (complete supraspinatus tendon and superior one-half of the infraspinatus tendon), (3) unsecured tensor fascia lata graft, and (4) secured tensor fascia lata graft. Both superior and posterior translation of the humeral head were calculated in each condition. A 4-cm × 5-cm × 6-mm tensor fascia lata graft was used in the subacromial space to act as a spacer. Grafts were secured at the lateral edge of the native rotator cuff footprint with 2 knotless anchors.

RESULTS

With unbalanced loading, both secured and unsecured grafts varied in their ability to limit superior and posterior translation at various rotation angles back to levels seen with intact rotator cuffs at 0° and 20° of abduction. During balanced loading, both unsecured and secured grafts limited superior and posterior translation more than those seen in the rotator cuff-deficient condition (P < .01) and similar to those seen in the intact condition (P > .05). The secured and unsecured grafts allowed similar amounts of translation at every position with both unbalanced and balanced loading (P > .05). Finally, total graft motion was <7 mm in all positions.

CONCLUSION

Unsecured tensor fascia lata grafts were biomechanically equivalent to secured grafts when used during allograft spacer procedures.

CLINICAL RELEVANCE

While both grafts were successful at limiting superior and posterior translation of the humeral head during early range of motion, the unsecured graft represents a cheaper, easier option to utilize during allograft spacer procedures.

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 the Massive Irreparable Cuff Tear

PURPOSE OF REVIEW

The purpose of the review is to provide an updated overview of a relatively novel but controversial surgical device (InSpace subacromial balloon, Stryker, Kalamazoo, MI) that can be readily incorporated into the armamentarium of the shoulder surgeon. The authors review the critical clinical and surgical decision-making aspects of InSpace. A recommended surgical technique and rehabilitation protocol are outlined. The authors present a nuanced view of the balloon spacer in the continuum of care of the irreparable rotator cuff tear.

RECENT FINDINGS

Within the last year, two Level I clinical trials have been published, and the data from these studies offer conflicting evidence regarding the utility of the subacromial balloon spacer. The current review contrasts these two recent studies and offers a framework by which the available evidence can be practically understood with respect to clinical decision-making. The literature currently supports a limited indication for use of InSpace: the elderly, low-demand patient with preserved active range of motion with an operatively irreparable, posterosuperior rotator cuff tear with an intact subscapularis. The InSpace subacromial balloon spacer is a simple device that can yield substantial improvements in clinical outcomes among a subset of patients with irreparable rotator cuff tears. InSpace is not a panacea for the complex, irreparable rotator cuff tear. Individualized decision-making is necessary in this diverse and challening patient population.

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.

High Rate of Clinically Meaningful Achievement in Outcomes After Subacromial Balloon Spacer Implantation for Massive Irreparable Rotator Cuff Tears: A Systematic Review and Meta-analysis

BACKGROUND

Subacromial balloon spacers have been introduced as a potential treatment option for patients with massive irreparable rotator cuff tears. However, it is important to comprehensively assess the clinical efficacy of this procedure in the context of an increasing amount of contemporary literature.

PURPOSE

To perform a systematic review of the contemporary literature to understand the propensity for clinically meaningful improvements after subacromial balloon spacer implantation for massive irreparable rotator cuff tears.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

The PubMed, Ovid/MEDLINE, and Cochrane databases were queried in July 2022 for data pertaining to studies reporting clinically significant outcomes after subacromial balloon spacer implantation. Freeman-Tukey double arcsine transformation was used to quantify the pooled rate of clinically meaningful improvements in outcomes as evaluated using the minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and substantial clinical benefit (SCB). Qualitative analysis was performed when data were variably presented to avoid misleading reporting.

RESULTS

There were 10 studies included, all of which reported MCID achievement. The overall pooled rate of MCID achievement for the Constant-Murley score was 83% (95% CI, 71%-93%; range, 40%-98%), with 6 of 8 studies reporting rates equal to or exceeding 85%. One study reported a 98% rate of PASS achievement for the Constant-Murley score at 3-year follow-up. The rate of MCID achievement for the American Shoulder and Elbow Surgeons (ASES) score ranged between 83% and 87.5%. The rate of PASS achievement for the ASES score was 56% at 2-year follow-up, while the rate of SCB achievement for the ASES score was 83% and 82% at 1- and 2-year follow-up, respectively. At 1-year follow-up, 74% and 78% of patients achieved the MCID for the Numeric Rating Scale and Oxford Shoulder Score, respectively. At 3 years, 69% of patients achieved the MCID for the Numeric Rating Scale and 87% achieved it for the Oxford Shoulder Score.

CONCLUSION

Patients who underwent isolated subacromial balloon spacer implantation for massive irreparable rotator cuff tears demonstrated a high rate of clinically significant improvement in outcomes at short- to mid-term follow-up. A paucity of literature exists to appropriately define and evaluate the rates of achieving the PASS and SCB after subacromial balloon spacer implantation, necessitating further study.

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.

Guidelines for the Diagnosis and Treatment of Rotator Cuff Tear with Integrated Traditional Chinese and Western Medicine

Rotator cuff tear is a common injury among middle-aged and elderly people, and it has a great impact on patients' physical and mental health and quality of life. Integrative medicine based on Traditional Chinese Medicine (TCM) has certain advantages in the diagnosis and treatment of rotator cuff tears. TCM, which mainly involves the use of plant-based products, has relatively stable and reliable curative effects. It is of great significance to formulate a combined diagnosis and treatment plan for rotator cuff tear based on evidence-based medicine, which can help to standardize the clinical diagnosis and treatment techniques of TCM and Western medicine and achieve better therapeutic effects. This guideline standardizes the diagnosis and treatment process of rotator cuff tear from the aspects of range, terminology and definition, diagnosis, TCM syndrome differentiation, treatment, functional exercise, and prevention and care. It makes recommendations that cover the adoption of manual therapy, acupuncture, and other integrative medicine based on TCM. Users of these guidelines are most likely to include clinicians and health managers in healthcare settings.

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.

Early clinical and patient-reported outcomes for arthroscopic and mini-open superior capsular reconstruction are similar for irreparable rotator cuff tears

OBJECTIVES

The purpose of this study was to report and compare postoperative range of motion (ROM), patient-reported outcomes, and failure rates following superior capsular reconstruction (SCR) and to compare outcomes between arthroscopic and mini-open techniques.

METHODS

All SCR procedures utilising dermal allograft with a minimum of 6 months of follow-up at multiple institutions between November 2015 and October 2019 were retrospectively reviewed. Preoperative patient demographics, imaging measurements, surgical technique (arthroscopic versus mini-open), and outcomes including pain scores, conversion to reverse shoulder arthroplasty, subsequent surgery, and postoperative ROM were recorded. Outcomes for arthroscopic versus mini-open approaches were compared via t-test, Fisher's exact test, or chi square test, as appropriate, with differences of p ​< ​0.05 considered significant.

RESULTS

180 total patients were included, including 98 who underwent arthroscopic SCR and 82 who underwent mini-open SCR. Final follow-up was at a mean of 32 months (standard deviation = 11 months). SCR improved pain (visual analog scale ​= ​4.4 pre-operatively vs. 1.4 post-operatively, p ​< ​0.0001) and ROMin active forward flexion (136° pre-operatively vs. 150° post-operatively, p ​= ​0.0012). No difference in post-operative pain visual analog scores was found between mini-open and arthroscopic cohorts (1.3 vs. 1.6, p ​= ​0.3432) at a mean of 14 months post-operatively. At a mean of 32 months post-operatively, there were no differences in ASES, QuickDASH, SST, WORC, or SANE scores between open and arthroscopic cohorts. There was no difference in rates of failure between mini-open and arthroscopic cohorts (15.9% vs. 17.3%, p ​= ​0.789).

CONCLUSIONS

This study confirmed that SCR improves pain and ROM in the short term. Mini-open SCR appears to provide similar improvements in pain and ROM compared with arthroscopic SCR, as well as patient-reported outcomes at 3 years. No difference in failure rates was detected between the 2 procedures.

LEVEL OF EVIDENCE

Level 3 evidence.

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.

Ultrasound-Guided Deflation and Arthroscopic Removal of a Migrated Subacromial Balloon Spacer

Full-thickness massive irreparable rotator cuff tears present a demanding challenge for the surgeon. The subacromial balloon spacer is a novel biodegradable implant used to treat massive, irreparable rotator cuff tears. There have, however, been several isolated reports of balloon migration. This Technical Note describes ultrasound-assisted balloon deflation followed by arthroscopic removal of a symptomatic dislodged balloon.

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 Spacer Versus Partial Rotator Cuff Repair in the Treatment of Massive Irreparable Rotator Cuff Tears: Facility Personnel Allocation and Procedural Cost Analysis

Background The subacromial balloon is a novel technology that has shown promise in managing a select patient population with massive irreparable rotator cuff tears. The purpose of this study was to quantify the true facility cost difference between subacromial balloon placement (SBP) and partial rotator cuff repair (PCR). Methodology A prospective cohort of patients with massive irreparable rotator cuff tears randomized to SBP versus PCR between 2015 and 2018 was retrospectively reviewed. Demographic variables, medical comorbidities, and range-of-motion (ROM) outcomes for all patients were recorded. True facility costs with respect to personnel were calculated using a time-driven activity based-costing (TDABC) algorithm and were classified into personnel costs and supply costs. Results Seven patients were treated with PCR compared to nine treated with SBP. No significant differences were observed with respect to demographic characteristics. Postoperative mean external rotation was 37° in SBP patients significantly higher than that of PCR patients at 8° (P = 0.023). Personnel time and cost differences while in the operating room (OR) were significantly less for the SBP ($605.58) compared to PCR ($1362.76) (P < 0.001). Implant costs were higher for SBP when compared to PCR, whereas disposable equipment costs were higher for PCR when compared to SBP. The total mean true facility cost was $7658.00 for SBP, significantly higher than that of PCR at $3429.00 (P < 0.001). Conclusions Despite the substantial reduction in personnel costs seen with SBP, the true facility cost of SBP was significantly higher than that of PCR. As this novel technology is used more ubiquitously and its price is negotiated down, the cost savings seen in personnel and OR time will become more significant. Future prospective cost analyses should follow up on the changes in implant costs and account for potential anesthesia cost savings.

Subacromial Balloon Spacer for Massive Irreparable Rotator Cuff Tears

Massive irreparable rotator cuff tears (MIRCTs) represent 10% to 40% of cases of rotator cuff abnormality and are challenging to treat. When MIRCTs are unresponsive to nonoperative treatment, surgery may be considered. An arthroscopically inserted biodegradable subacromial balloon spacer (InSpace; Stryker) has grown in popularity in recent years for treatment of patients with MIRCTs. The balloon spacer is made of a copolymer of poly-L-lactide-eco-ε-caprolactone and is expected to fully resorb within 12 months after implantation. Research has suggested the balloon spacer becomes progressively compressed and is slowly replaced with fibrous tissue between the humeral head and the acromion, which may support a prolonged benefit following resorption. Clinical benefits may be achieved through reduced acromiohumeral abutment and subacromial friction during shoulder movement by lowering the humeral head and facilitating humeral gliding. The primary population indicated for use of the implant are patients older than 40 years with persistent shoulder pain and functional disability due to MIRCTs. Contraindications include irreparable subscapularis tears, moderate to severe arthritis, axillary nerve palsy, and known allergy to the implant material. There are not clear indications for use of the implant for treatment of partial-thickness tears or repairable complete rotator cuff tears. Familiari et al. reported that treatment with the balloon spacer was associated with a significant improvement in shoulder function, limited need for revision surgery, and high satisfaction at mean 3-year follow-up. More recently, a prospective multicenter randomized controlled trial was conducted to evaluate the efficacy and safety of the balloon spacer in 93 patients compared to 91 patients undergoing arthroscopic partial repair. Significant and clinically relevant improvements in the American Shoulder and Elbow Surgeons score from baseline were noted in both groups up to the 2-year follow-up.

Early Treatment of Shoulder Pathology Is Necessary but Not Enough Is Being Performed

Delayed treatment of shoulder instability results in bone loss requiring more-complicated surgery, in turn resulting in less-optimal outcomes. Similarly, delayed treatment of repairable rotator cuff tears results in irreparable tears requiring more-complicated surgery and resulting in less-optimal outcomes. Delayed treatment of shoulder pathology is a problem. Solutions include education and research investigation.

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).

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.

Rotator cuff repair protected with subacromial balloon spacer shows a low rate of non-healing

PURPOSE

The purpose of this study was to evaluate clinical outcomes and tendon integrity on magnetic resonance imaging (MRI) of chronic posterosuperior rotator cuff tears treated with single-row tensionless repair and subacromial balloon spacer as protection with a minimum follow-up of 2 years. The hypothesis of this study was that this procedure would have acceptable clinical outcomes and tendon-healing rate without increased complications.

METHODS

This is a retrospective study of patients with chronic posterosuperior rotator cuff tears repaired with a single-row technique protected with a subacromial balloon device. Patients were followed up for a minimum of 2 years. Clinical outcomes were evaluated with American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and Numerical Rating Scale (NRS) for pain. MRI study was obtained likewise after at least 2 years to assess tendon-healing rate. Statistical comparison was performed between pre-operative and at least 2-year clinical and imaging follow-up.

RESULTS

Thirty-two patients were included in the study with a mean follow-up of 27 ± 7 (range 24-48). The mean age of this cohort was 58 ± 6 (range 41-66) including 15 males and 17 females. The tear size was on average 2.3 cm (range 2-4) and a mean of 2.1 triple-loaded anchors were used (range 2-3). The ASES score significantly increased from a mean of 39 ± 12 points to a mean of 89 ± 12 at the final follow-up (P < 0.001). Similarly, pain significantly reduced from a mean pre-operative NRS of 6.8 ± 1.4 to 0.8 ± 1.5 at the final follow-up (P < 0.001). MRI scans showed that repair occurred in 26 patients (81.3%). Significant higher ASES score was reached at final follow-up in patients with a "healed" (Sugaya I-III) tendon when compared to patients with an evidence of tendon discontinuity on MRI study (Sugaya IV-V), 93 ± 9 and 74 ± 13, respectively (P < 0.001).

CONCLUSIONS

Arthroscopic repair of chronic posterosuperior rotator cuff tears using a single-row tensionless repair and subacromial spacer as protection resulted in an 81.3% of tendon integrity at a mean follow-up of 27 months. Clinical outcomes and pain scores significantly improved without severe complications reported after a minimum follow-up of 2 years.

LEVEL OF EVIDENCE

III.

Superior Capsular Reconstruction Using the Biceps Tendon in the Treatment of Irreparable Massive Rotator Cuff Tears Improves Patient-Reported Outcome Scores: A Systematic Review

Purpose

To systematically evaluate the clinical outcomes of superior capsular reconstruction (SCR) using the long head of the biceps tendon for irreparable massive rotator cuff tears.

Methods

Multiple electronic databases were searched for studies treating massive and/or irreparable rotator cuff tears with SCR using the biceps tendon while retaining its proximal attachment to the superior glenoid. A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) flowchart was created. All the included studies were assessed for quality with the Modified Coleman Methodology Score. Multiple variables including patient demographic characteristics, functional scores, visual analog scale (VAS) scores, and complications were extracted and analyzed.

Results

Seven studies were included in this review, with a total of 133 patients. The age range of patients was 39 to 82 years, and the duration of follow-up ranged from 6 to 40.7 months. Various validated scoring systems were used for functional outcome evaluation in all studies; all of them showed postoperative improvement greater than the minimal clinically important difference. The VAS score improvement ranged from 3.8 to 7.1. Five studies reported improvement in shoulder forward elevation, with a range of 22° to 95°. Three studies reported retear rates of 21%, 37%, and 66% on postoperative magnetic resonance imaging scans. Two studies reported complications, with the first study reporting revision surgery in 4 of 35 patients and the second study reporting 1 infection and 1 case of deltoid detachment (open procedure) among 17 patients.

Conclusions

SCR using the long head of the biceps tendon is a safe and effective procedure. VAS and patient-reported outcome scores showed significant improvement with minimal short-term complications.

Level of Evidence

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

Subacromial balloon spacer for irreparable rotator cuff tears of the shoulder (START:REACTS): a group-sequential, double-blind, multicentre randomised controlled trial

BACKGROUND

New surgical procedures can expose patients to harm and should be carefully evaluated before widespread use. The InSpace balloon (Stryker, USA) is an innovative surgical device used to treat people with rotator cuff tears that cannot be repaired. We aimed to determine the effectiveness of the InSpace balloon for people with irreparable rotator cuff tears.

METHODS

We conducted a double-blind, group-sequential, adaptive randomised controlled trial in 24 hospitals in the UK, comparing arthroscopic debridement of the subacromial space with biceps tenotomy (debridement only group) with the same procedure but including insertion of the InSpace balloon (debridement with device group). Participants had an irreparable rotator cuff tear, which had not resolved with conservative treatment, and they had symptoms warranting surgery. Eligibility was confirmed intraoperatively before randomly assigning (1:1) participants to a treatment group using a remote computer system. Participants and assessors were masked to group assignment. Masking was achieved by using identical incisions for both procedures, blinding the operation note, and a consistent rehabilitation programme was offered regardless of group allocation. The primary outcome was the Oxford Shoulder Score at 12 months. Pre-trial simulations using data from early and late timepoints informed stopping boundaries for two interim analyses. The primary analysis was on a modified intention-to-treat basis, adjusted for the planned interim analysis. The trial was registered with ISRCTN, ISRCTN17825590.

FINDINGS

Between June 1, 2018, and July 30, 2020, we assessed 385 people for eligibility, of which 317 were eligible. 249 (79%) people consented for inclusion in the study. 117 participants were randomly allocated to a treatment group, 61 participants to the debridement only group and 56 to the debridement with device group. A predefined stopping boundary was met at the first interim analysis and recruitment stopped with 117 participants randomised. 43% of participants were female, 57% were male. We obtained primary outcome data for 114 (97%) participants. The mean Oxford Shoulder Score at 12 months was 34·3 (SD 11·1) in the debridement only group and 30·3 (10·9) in the debridement with device group (mean difference adjusted for adaptive design -4·2 [95% CI -8·2 to -0·26];p=0·037) favouring control. There was no difference in adverse events between the two groups.

INTERPRETATION

In an efficient, adaptive trial design, our results favoured the debridement only group. We do not recommend the InSpace balloon for the treatment of irreparable rotator cuff tears.

FUNDING

Efficacy and Mechanism Evaluation Programme, a Medical Research Council and National Institute for Health and Care Research partnership.

[Arthroscopic augmentation techniques for superior capsule reconstruction]

OBJECTIVES

Reconstruction of the superior capsule for treatment of irreparable supraspinatus tendon tears.

INDICATIONS

Irreparable supraspinatus tendon tear; centered humeral head; largely intact cartilage; largely intact transversal "force-couple".

CONTRAINDICATIONS

Decentered humeral head; osteoarthritis of the glenohumeral joint/cuff tear arthropathy; irreparable anterosuperior and posterosuperior cuff tears.

SURGICAL TECHNIQUE

Arthroscopic superior capsule reconstruction (SCR) is performed in beach-chair position. At first the bone bed of the glenoid and the insertion of the supraspinatus tendon are prepared using a bone burr. Now, depending on the integrity of the long biceps tendon, two options are possible. Option 1: In the case of an existing long biceps tendon, a biceps tendon tenodesis to the greater tubercle is performed. Therefore, the long head of the biceps is fixed central to the former insertion of the supraspinatus tendon, using a suture anchor. Option 2: In the case of a nonexisting or degeneratively modified long biceps tendon, a PushLock® anchor (Arthrex, Inc. Naples, FL, USA) loaded with a FiberTape® (Arthrex, Inc. Naples, FL, USA) is placed centrally onto the glenoid. Now, the actual superior capsule reconstruction is completed. Two suture anchors are placed at the glenoid and two SwiveLock® anchors, each loaded with a FiberTape®, (Arthrex, Inc. Naples, FL, USA) are placed at the footprint of the supraspinatus tendon at the greater tubercle. The tapes are shuttled extra-articularly and the graft size is evaluated by measuring the distance between the anchors. The graft is customized to that size and armed with the tapes. Using the tapes of the glenoidal anchors, as tension ropes, the graft is placed intra-articularly. Medially the sutures are tied and laterally the graft is fixed in a knotless lateral row manner. The tails of the tape, of the glenoidal PushLock® (Arthrex, Inc. Naples, FL, USA) anchor are fixed within the lateral row and are tensioned above the graft. Afterwards side-to-side sutures to the infraspinatus and a subacromial decompression are completed.

POSTOPERATIVE MANAGEMENT

The arm is placed in a sling for 6 weeks, afterwards active physiotherapy begins. Passive-assisted physiotherapy is started on postoperative day 1.

RESULTS

Between 2017 and 2019, 11 patients were treated with SCR. As the combined procedure is our new treatment algorithm, case studies will be presented. For this study, 9 patients treated with singular SCR, with a mean follow-up of 18 months, were recruited. A statistically significant reduction of pain (VAS 6.3 → VAS 2), a good postoperative forward flexion (mean 138°; 56 standard deviation [SD]), and external rotation (mean 37°; 21 SD) were measured. A mean ASES of 76.5 (18 SD) a mean DASH of 17.8 (14 SD) and a mean Constant score of 64.6 (25 SD) were achieved.

Rotator Cuff Repair and Reconstruction

Rotator cuff pathology is the most common shoulder condition for which patients seek treatment. Schmidt et al covered the relevant anatomy, natural history, nonsurgical and surgical treatment, biological augmentation, and postoperative rehabilitation in their comprehensive review published in 2015. This current review builds upon the last update, discussing the most recent evidence-based medicine regarding rotator cuff repair: primary repair, revision repair, and reconstructive techniques for superior capsular reconstruction, subacromial balloon spacers, tendon transfer options (pectoralis major, latissimus dorsi, and lower trapezius), and reverse total shoulder arthroplasty.

Editorial Commentary: Mechanics Versus Biology: Both Are Relevant Principles in Understanding Superior Capsular Reconstruction

The topic of superior capsular reconstruction remains controversial. Whereas identifying the best time-zero graft configuration for this procedure remains important, the success or failure of the procedure will be dependent on the biology, not just the bench performance. Any conforming object placed in the subacromial space at time zero could center the humeral head and decrease superior translation compared with a massive rotator cuff tear but may not restore translation to normal. It does appear that a thicker graft is better in this regard, but how much thicker is better is unclear. Most of all, whether the mechanical benefits of a thicker graft will be offset by a thicker and potentially less biologically compatible construct is also unclear. In most orthopaedic settings, autografts remain consistently superior to allografts. The contrast in results may be better explained by biology, and the excellent superior capsular reconstruction results reported with autograft have not been replicated universally with dermal allograft.

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.