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

Which treatment strategy for irreparable rotator cuff tears is most cost-effective? A Markov model-based cost-utility analysis comparing superior capsular reconstruction, lower trapezius tendon transfer, subacromial balloon spacer implantation and reverse shoulder arthroplasty

Purpose

Treatment options for irreparable rotator cuff tears (IRCTs) remain controversial and include superior capsular reconstruction (SCR), lower trapezius tendon transfer (LTTT), subacromial balloon spacer (SABS), and reverse shoulder arthroplasty (RSA). Despite reports of positive treatment responses with all approaches, the relative clinical benefit in the context of associated cost has not been well delineated. The purpose of this study was to determine the most cost-effective treatment strategy among SCR, LTTT, SABS, and RSA for patients with massive IRCTs.

Methods

A Markov Chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1000 simulated patients undergoing either SCR, LTTT, SABS, or RSA for massive IRCTs. Upfront costs, health utility values, and reoperation rates including revisions and conversion to RSA were derived from the published literature. Outcome measures included costs, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER).

Results

Mean total costs of SCR, RSA, LTTT, and SABS were $30,540 ± 5,770, $26,896 ± 5,622, $25,819 ± 4,325, and $16,412 ± 2,583, respectively. On average, total QALYs from SCR, RSA, LTTT, and SABS were 6.17 ± 0.53, 3.78 ± 0.38, 5.33 ± 0.49, and 5.59 ± 0.48. Overall, SCR was determined the preferred, most cost-effective strategy in 60% of patients included in the microsimulation model, with SABS the optimal strategy in 31% of cases and LTTT the optimal strategy in 9% of cases.

Conclusion

SCR was found to be the most cost-effective treatment option for IRCTs based on the current microsimulation and probabilistic sensitivity analyses, although LTTT and SABS were also found to be cost-effective in select patients. Given that this statistical model does not consider the unique experiences of individual patients, shared decision-making remains an important component in determining the optimal treatment strategy for IRCTs.

Level of Evidence

Level III, economic decision model.

Improving shoulder function and pain in a paraplegic patient with massive irreparable rotator cuff tear using a subacromial balloon spacer

The subacromial balloon spacer is a promising treatment option for alleviating symptoms in patients with massive irreparable rotator cuff tears (MIRCTs). The balloon provides faster pain relief and easier rehabilitation than other options (such as arthroscopic partial rotator cuff repair). For a paraplegic MIRCT patient, the need for speedy recovery and rehabilitation is crucial, as these patients rely on their upper limbs for daily life activities and independence. In this report, we present a 60-year-old male paraplegic patient who presented to the clinic with an MIRCT of the right shoulder. After a holistic investigation and assessment of the patient, a subacromial balloon spacer with an upper border subscapularis repair was chosen as the treatment of choice. The patient had an uneventful recovery, and at the 1-year mark, had forward elevation of 170°, an American Shoulder and Elbow Surgeons score of 95, and a visual analog scale pain score of 0.

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.