Fluoroscopy-guided biodegradable spacer implantation using local anesthesia: safety and efficacy study in patients with massive rotator cuff tears

Subacromial balloon spacer massive rotator cuff tear treatment systematic review and meta-analysis: Patient selection and physical therapy may be keys to outcome success

PURPOSE

Subacromial balloon spacer implantation (SBSI) efficacy for massive rotator cuff tear treatment was evaluated based on perceived shoulder function, active shoulder mobility, pain, complications and research study methodological quality. The purpose was to better discern the efficacy of this device from both surgical and rehabilitative perspectives to improve patient outcomes.

METHODS

PubMed, EMBASE and Cochrane Library databases were searched (1 January 2010 to 1 June 2024) using 'balloon spacer', 'subacromial spacer', 'subacromial balloon spacer', 'shoulder spacer' and 'inspace' terms. Pre-surgery (baseline), 12-month (12-m) and 24-month (24-m) post-SBSI mean changes were compared using one-way ANOVA and Scheffe post hoc tests, and comparative study effect sizes were calculated (p ≤ 0.05).

RESULTS

This review consists of 27 studies with 894 patients (67.8 ± 5 years of age) and 29.4 ± 17-month follow-up. Modified Coleman Methodology Scores (MCMS) revealed fair overall quality (mean = 61.4 ± 11). Constant-Murley scores improved from 34.8 ± 6 (baseline), to 64.2 ± 9 (12-m) and 67.9 ± 8 (24-m) (12-m, 24-m > baseline, p < 0.001). ASES scores improved from 35.1 ± 14 (baseline), to 83.3 ± 7 (12-m) and 81.8 ± 5 (24-m)(12-m, 24-m > baseline, p < 0.001). VAS pain scores improved from 6.6 ± 1 (baseline), to 2.6 ± 1 (12-m) and 2.0 ± 1 (24-m) (12-m, 24-m < baseline, p < 0.001). Flexion increased from 108.5 ± 25° (baseline), to 128.5 ± 30° (12-m) and 151.2 ± 14° (24-m) (24-m > 12-m, baseline, p = 0.01). Abduction increased from 97.7 ± 24° (baseline) to 116.3 ± 23° (12-m) and 142.3 ± 15° (24-m) (24-m > 12-m, baseline, p = 0.02). External rotation (ER) in adduction changed from 33.1 ± 7° (baseline) to 32.5 ± 4° (12-m) and 53.9 ± 9° (24-m)(24-m > 12-m, baseline, p = 0.01). ER at 90° abduction increased from 56.3 ± 3° (baseline) to 83.5 ± 5° (12-m) and 77.1 ± 4° (24-m) (24-m, 12-m > baseline, p = 0.01). Comparison studies, however, displayed insignificant results with small effect sizes.

CONCLUSION

Despite overall fair MCMS scores, at 24-m post-SBSI, shoulder function improved and pain decreased. More rigorous comparative studies, however, revealed insignificant findings. Patients with the potential to re-establish the essential glenohumeral joint force couple that depresses the humeral head on the glenoid fossa and who comply with physical therapy may be more likely to achieve success following SBSI.

LEVEL OF EVIDENCE

Level IV.

Subacromial Balloon Placement Demonstrates No Advantage Over Debridement in the Treatment of Massive Irreparable Rotator Cuff Tears: A Dual-Armed Systematic Review and Meta-analysis of Over 1000 Patients

BACKGROUND

In recent years, the placement of a subacromial balloon (SAB) spacer has emerged as a treatment option for massive irreparable rotator cuff tears (MIRCTs); however, there is significant controversy regarding its utility in comparison with other surgical interventions.

PURPOSE

To compare outcomes after SAB spacer placement versus arthroscopic debridement for MIRCTs.

STUDY DESIGN

Dual-armed systematic review and meta-analysis (level IV evidence).

METHODS

A literature search of PubMed (MEDLINE), Scopus, and CINAHL Complete databases for articles published before May 7, 2022, was conducted to identify patients with MIRCTs undergoing the 2 procedures. For the SAB arm, 14 of 449 studies were considered eligible for inclusion, while 14 of 272 studies were considered eligible for inclusion in the debridement arm.

RESULTS

In total, 528 patients were eligible for inclusion in the SAB arm and 479 patients in the debridement arm, and 69.9% of patients undergoing SAB placement also underwent concomitant debridement. Decreases in the visual analog scale (VAS) pain score and increases in the Constant score were found to be significantly larger after debridement (-0.7 points [P < .001] and +5.5 points [P < .001], respectively), although the Patient Acceptable Symptom State for the VAS was not achieved after either procedure. Both SAB placement and debridement significantly improved range of motion in forward flexion/forward elevation, internal and external rotation, and abduction (P < .001). Rates of general complication were higher after debridement versus SAB placement (5.2% ± 5.6% vs 3.5% ± 6.3%, respectively; P < .001); however, there were no significant differences between SAB placement and debridement in rates of persistent symptoms requiring a reintervention (3.3% ± 6.2% vs 3.8% ± 7.3%, respectively; P = .252) or reoperation rates (5.1% ± 7.6% vs 4.8% ± 8.4%, respectively; P = .552). The mean time to conversion to reverse total shoulder arthroplasty was 11.0 versus 25.4 months, respectively, for the SAB versus debridement arm.

CONCLUSION

While SAB placement was associated with acceptable postoperative outcomes in the treatment of MIRCTs, there was no clear benefit over debridement alone. Shorter operative times coupled with better postoperative outcomes and longer times to conversion to reverse total shoulder arthroplasty rendered debridement a more attractive option. While there may be a role for SAB placement in poor surgical candidates, there is burgeoning evidence to support debridement alone without SAB placement for the treatment of MIRCTs.

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 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.

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.

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 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.

Superior capsule reconstruction, partial cuff repair, graft interposition, arthroscopic debridement or balloon spacers for large and massive irreparable rotator cuff tears: a systematic review and meta-analysis

BACKGROUND

Multiple non-arthroplasty surgical techniques are described for the management of large and massive irreparable rotator cuff tears. There is currently no consensus on the best management strategy. Our aim was to compare clinical outcomes following arthroscopic debridement, arthroscopic partial cuff repair, superior capsule reconstruction, balloon spacers or graft interposition for the management of large and massive irreparable rotator cuff tears.

METHODS

A comprehensive search was performed of the following databases: Medline, Embase, CINAHL and Cochrane Database of Systematic Reviews. Data were extracted from relevant studies published since January 2000 according to the pre-specified inclusion criteria. The primary outcome was the post-operative improvement in shoulder scores. Meta-analysis of the primary outcome was performed. Secondary outcomes included retear rates and complications.

RESULTS

Eighty-two studies were included reporting the outcomes of 2790 shoulders. Fifty-one studies were included in the meta-analysis of the primary outcome. The definition of an irreparable tear varied. All procedures resulted in improved shoulder scores at early follow-up. Shoulder scores declined after 2 years following balloon spacers, arthroscopic debridement and partial cuff repair. High retear rates were seen with partial cuff repairs (45%), graft interposition (21%) and superior capsule reconstruction (21%).

CONCLUSIONS

Large initial improvements in shoulder scores were demonstrated for all techniques despite high retear rates for reconstructive procedures. Shoulder scores may decline at mid- to long-term follow-up.

Irreparable Massive Rotator Cuff Tears: Subacromial Balloon Surgical Technique

Massive irreparable rotator cuff tears pose a significant challenge for both the treating orthopedic surgeon and patient. Surgical treatment options for massive rotator cuff tears include arthroscopic debridement, biceps tenotomy or tenodesis, arthroscopic rotator cuff repair, partial rotator cuff repair, cuff augmentation, tendon transfers, superior capsular reconstruction, subacromial balloon spacer, and ultimately reverse shoulder arthroplasty. The present study will provide a brief overview of these treatment options along with a description of the surgical technique for subacromial balloon spacer placement.

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).

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.

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.

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.

Clinical outcomes at medium-term follow-up of sub-acromial balloon spacer insertion in the operative management of massive rotator cuff tears

INTRODUCTION

The management of massive rotator cuff tears (RCTs) remains a debated topic amongst orthopaedic surgeons, with a wide spectrum of treatment options available. In recent years, the use of sub-acromial balloon spacers has emerged as an option in the management of massive RCTs. The purpose of this study is to evaluate the clinical outcomes of patients with massive RCTs who underwent arthroscopic sub-acromial balloon spacer insertion at medium-term follow-up.

METHODS

All consecutive patients in our institution who had undergone sub-acromial balloon spacer insertion under the senior author from 2015 to 2020 were identified and followed up via telephone survey. Patient demographics, patient-reported outcomes, complications and subsequent surgeries were all analysed using the SPSS.

RESULTS

Overall, 45 patients (31 males) including 36 retired (80.0%) patients, with a mean age of 70.3 ± 7.0 (40-83) years, and mean follow-up of 37.1 ± 16.4 (12-62) months were included. At final follow-up, the mean ASES score was 73.4 ± 21.8 (25-100), the mean SSV was 76.4 ± 16.0 (45-100), baseline VAS score was 0.3 ± 1.1 (0.0-6.0) and functional VAS score was 2.6 ± 2.3 (0.0-8.0), with a total of 89.9% of patients (n = 40) being satisfied at final follow-up. This series reported no intra-operative complications (0.0%), with 4 patients (8.9%) required subsequent procedures to the ispilateral shoulder post-sub-acromial balloon insertion.

CONCLUSION

In selected patient cohorts, the use of sub-acromial balloon spacer insertion represents a minimally invasive, viable surgical option in the management of massive rotator cuff tears, with satisfactory patient-reported outcomes, high rates of satisfaction and a low complication rate reported at medium-term follow-up.

LEVEL OF EVIDENCE

III; Retrospective Cohort Study.

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.

Results after the application of biodegradable spacer balloons as a therapeutic option in non-repairable massive ruptures of the shoulder rotator cuff

INTRODUCTION

One of the most frequently treated pathologies in our department are tendon lesions that affect the rotator cuff of the shoulder. There are different types of treatment for massive or irreparable tears. For a few years, a low-invasive technique was introduced based on the placement of a biodegradable subacromial spacer. The objective of the work is to analyse the results of our experience with the use of this device (InSpace^TM).

MATERIAL AND METHOD

The study collects the results obtained in 25 patients with irreparable ruptures of rotator cuff defined by RM, in which they were implanted a balloon subacromial in our centre in the period from January 2015 - until December 2017. All patients were evaluated preoperatively and one year after surgery including the visual analogue scale (VAS), the Constant test (CS) and the QuickDASH (QD).

RESULTS

Of the 25 patients, 5 patients (20%) were operated by arthroscopy and 20 (80%) By open approach (mini-open). A total of 22 patients completed the follow-up year. At 12 months, 64% of the patients obtained an improvement of at least 10 points in the CS. Patients departed from an initial average CS of 32 points that improved to 54.9 points of average in the postoperative evaluation at 12 months (average improvement 22.9 points; Value-p < 0.05). In terms of pain assessment, in our study, 87% of patients obtained an improvement of at least 2 points in the EVA at 12 months of follow-up (P-value < 0.05). Patients departed from an initial average EVA of 8.7 that improved to 3.7 points average at 12 months. 73% of the patients responded to be satisfied with the intervention and would return to the surgery. CONCLUSIóN: The results obtained in our series to one year of follow-up speak in favour of the use of the Subacromial Balloon (InSpace^TM), as a therapeutic option available for patients with irreparable ruptures of the rotator cuff. It can be used as an interim procedure, delaying the need for more invasive surgery, or as a definitive procedure in patients medically non-candidates for reverse arthroplasty. It is important to have clear indications of this procedure in order not to make mistakes.

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.

A Historical Analysis of Randomized Controlled Trials in Rotator Cuff Tears

Background and objectives: Our research aimed to evaluate the quality of reporting of randomized controlled trials (RCTs) linked to rotator cuff (RC) tears. The present study analyzed factors connected to the quality of the RCTs and trends in the quality of reporting through time. Materials and Methods: The online databases used to search all RCTs on the topic of RC surgery completed until March 2020 were PubMed and Ovid (MEDLINE). The quality of reporting was evaluated using the modified Coleman methodology score (MCMS) and the consolidated standards of reporting trials (CONSORT). Results: The online search found 957 articles. Finally, 183 studies were included in the quantitative synthesis. A total of 97 (53%) of 183 studies had a level of evidence I and 86 (47%) of 183 studies had a level of evidence II, according to the Oxford Center of Evidence Based Medicine (EBM). A statistically significant difference in MCMS between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had, on average, the highest Coleman score. The average number of CONSORT checklist items for each article across all analyzed RCTs was 21.67. The 37 studies completed up to 2010 averaged a number of checklist items of 19.97 and the studies completed between 2011 and 2019 averaged a number of checklist items of 22.10. A statistically significant difference in the number of checklist items between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had on average more checklist items. However, low correlation (0.26) between the number of checklist items for each article and the respective Coleman score was found. On the other hand, articles with the CONSORT diagram had a significantly high Coleman score. Conclusions: An improvement in the quantity and quality of RCTs relating to RC surgery over the analyzed period was found.

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 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.

Treatment of large, massive irreparable rotator cuff tears

The rotator cuff is a complex anatomical and biomechanical structure which allows stabilization of the shoulder joint in the correct position and movements in it. The rotator cuff tears remain the most frequent injury as compared to those of other anatomical structures of the shoulder joint and reach the incidence of 21%, according to a number of authors. Such injuries are prone to inducing a fat replacement of muscle tissues in elderly patients against the background of degenerative changes in the structure of the rotator cuff. These injuries are hard-to-heal, and the incidence of relapses after the surgical treatment reaches 2090%, according to several authors. Based on the investigation of the postoperative treatment failures, alternative methods for the replacement, transfer or surgical repair of damaged tendons are adopted, but there is still no single approach and method in the treatment of this pathology. In this literature review, we have analyzed the data on the anatomical structure and biomechanics of the rotator cuff, the role of the rotator cuff damage in the dysfunction of the shoulder joint and possible methods for its recovery.

The role of Superior Capsule Reconstruction in the irreparable rotator cuff tear - A systematic review

BACKGROUND

Irreparable rotator cuff tears in active patients provide a significant challenge and a consensus on the gold standard treatment is currently lacking. Superior capsule reconstruction (SCR) has recently been advocated and functions by providing a passive biological constraint to superior humeral head migration. The aim of this study is to systematically review the literature to evaluate the role of SCR in terms of functional outcome scores and failure rates.

PATIENTS AND METHODS

A review of the online databases Medline and EMBASE was conducted in accordance with the PRISMA guidelines on the 28th January 2019. Clinical studies reporting SCR using any type of graft or surgical technique were included if reporting either functional outcome scores or rate of secondary surgery. The studies were appraised using the Methodological index for non-randomised studies tool.

RESULTS

The search strategy identified nine studies eligible for inclusion; five reported on fascia lata autografts and four studies reported on dermal allografts. All nine studies reported significant improvement in functional scores after SCR. Rates of secondary surgery were only provided in the dermal allograft studies at short-term follow-up (mean 10.9 to 32.4months) and ranged from 0 to 18.6%. Radiological assessment revealed graft failure in 5.5 to 55% of dermal allografts and 4.2 to 36.1% of fascia lata autografts.

CONCLUSION

This review demonstrates that SCR is a useful treatment modality for patients with irreparable rotator cuff tears. SCR was associated with significantly improved functional outcome scores in all studies. All studies reported a preserved or increased mean AHD. The radiological graft failure rate ranged from 4.2 to 55% and the short duration of follow-up in most studies means that this remains an important concern that requires longer-term evaluation.

LEVEL OF EVIDENCE

IV, systematic review.

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.

The effect of the subacromial balloon spacer on humeral head translation in the treatment of massive, irreparable rotator cuff tears: a biomechanical assessment

BACKGROUND

The current management of massive, irreparable rotator cuff tears is challenging, and no individual surgical technique has demonstrated clinical superiority. This study evaluated the role of a subacromial balloon spacer and its ability to depress the humeral head in the setting of a massive, irreparable rotator cuff tear.

METHODS

Eight cadaveric shoulders were tested. The specimens were mounted onto a shoulder simulator that applied muscle loading. Five shoulder states were tested: intact; irreparable rotator cuff tear; and inflation of the subacromial balloon spacer with 10, 25, and 40 mL of saline solution on the irreparable rotator cuff tear. Humeral head migration was measured at 0°, 30°, 60°, and 90° of shoulder abduction.

RESULTS

After creation of a massive, irreparable rotator cuff tear, in 0° of abduction, the humeral head migrated superiorly by a mean of 3.5 ± 0.7 mm compared with the intact shoulder state (P = .002). The subacromial balloon spacer inflated to 25 mL translated the humeral head inferiorly relative to the torn state by an average of 3.2 ± 0.6 mm (P = .001) for all abduction angles. The balloon inflated to 10 mL was ineffective at restoring humeral head position as it was still significantly superior than intact (P = .017). The balloon inflated to 40 mL was successful in depressing the humeral head; however, it over-translated the humeral head anteroinferiorly, such that it was significantly different from the intact condition (P < .001). Overall, the 25-mL balloon best restored the humeral head position.

CONCLUSION

The results of this study demonstrate that the subacromial balloon spacer is most effective in depressing the humeral head and restoring the glenohumeral joint position when inflated to 25 mL.

Biodegradable implantable balloons: Mechanical stability under physiological conditions

Rotator cuff tendons injuries occurs as a result of trauma, e.g. due to falling, mechanical injuries and frequent overhead activity and as natural degenerative tears in elderly people. Biodegradable balloon shaped spacer of Poly-(L-lactide-co-ε-caprolactone) (PLCL) are applied in the treatment of these injuries. This type of treatment involves insertion of inflated biodegradable implant into the tissues of the damaged region in the shoulder to avoid shoulder impingement and reduce friction between the acromion and the humeral head and propagation of inflammation. The implant must maintain integrity under significant mechanical loading in order to remain effective. However, with time, the implant is exposed to the risk of failure due to the high pressure caused by the muscular motion and the friction with the bones. We report in this study the limits of the mechanical stability of the PLCL balloon shape spacer (implant) under prolonged cyclic loading, so as to be able to predict their physical stability in vivo. We have demonstrated in an in vitro settings that the implant withstands fatigue cycles for significantly longer than 8 weeks, which provides sufficient time window for patients to perform substantial rehabilitation and recover from an injury. The data presented herein is expected to assist medical practitioners in safety and efficacy measurements and assessment following spacer implantation.

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.

Subacromial Balloon Interpositional Arthroplasty for the Management of Irreparable Rotator Cuff Tears: Five-year Results

Background:

Management of massive irreparable rotator cuff tears can be a source of significant dilemma for the treating surgeon. This is especially true when dealing with patients with poor physiological reserves where options of tendon transfer, superior capsular repair or arthroplasty might be unsuitable. We report the five-year outcomes of 26 patients who underwent balloon interpositional arthoplasty for the management of massive irreparable rotator cuff tears.

Methods:

Fifty-four consecutive patients underwent balloon interpositional arthroplasty in our institution. Of these, 26 patients completed at least two postoperative functional outcome measures over a five-year period, which included the Visual Analogue Score (VAS), Oxford Shoulder Score (OSS) and the SF12 score. Outcome scores were obtained prospectively.

Results:

The average age at implantation was 67 years old. Our result shows statistically significant improvement in pain up to five years post-implantation of the device (p = 0.012). Function measured by the OSS and SF12 (PCS) score showed improvement up to two years post-implantation (p = 0.006). Three of the 54 patients in our cohort went on to have arthroplasty surgery for their rotator cuff tears. None of the patients in our cohort suffered from any adverse reactions following implantation.

Discussion/Conclusion:

Results from our study identify the spacer device as an option in the management of irreparable rotator cuff tears with statistical improvement in pain and function. It may also delay the need for arthoplasty surgery.

Ultrasound-guided biodegradable subacromial spacer implantation in a patient with massive irreparable rotator cuff tears

The aim of this manuscript is to present a modification of the current arthroscopic implantation technique of a biodegradable subacromial spacer. This modified ultrasound-guided technique was intended to maximally reduce the invasiveness of the procedure. The ultrasound technique was used to measure the subacromial space for an optimal fit and to verify subacromial spacer placement in the sagittal and frontal planes. This finding is of particular importance for patients with contraindications to general or regional anesthesia. The follow-up (5 months) of subacromial spacer implantation using ultrasound in a patient with an irreparable rotator cuff tear showed correct spacer placement.

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.

The absorbable subacromial spacer for irreparable posterosuperior cuff tears has inconsistent results

PURPOSE

To evaluate the 2-year results of an absorbable subacromial spacer in patients with irreparable posterosuperior rotator cuff tears.

METHODS

Prospective longitudinal study of a consecutive case series of 16 subjects with irreparable tears of the posterosuperior rotator cuff in which the InSpace^® subacromial spacer was arthroscopically implanted. A full clinical evaluation that included the Constant test, Simple Shoulder Test (SST) and the QuickDash questionnaire was performed preoperatively and at 12 and 24 months follow-up. The primary outcome for assessing the success of the procedure was a variable composed of a clinically relevant variation of the Constant (established in an improvement greater than 10 points) and the absence of surgical reintervention.

RESULTS

Fifteen subjects (11 women/4 men, median age = 69.4 years [interquartile range 7.50], range 60-80 years) completed the 2-year of follow-up. According to the main evaluation criteria, only 6 patients (40%) had a successful outcome. Five subjects required reconversion to a reverse shoulder arthroplasty (at a median of 9.8 months postoperatively) due to absence of clinical improvement or worsening of symptoms. Of the ten remaining subjects, only 6 had improvements greater than 10 points in the Constant score. Despite of this, these 10 subjects had, on average, some improvement in the Constant test (preoperative Constant: median 35.0 [27.0-52.5] vs Constant at 24 months: 53.5 [55.0-84.0], significant differences p = 0.02), in the SST (3.0 [2.0-4.0] vs 6.0 [3.25-7.75], p = 0.039) and in the QuickDASH test (37.0 [33.25-40.0] vs 27.5 [20.5-32.75], p = 0.012).

CONCLUSIONS

The outcomes of the implantation of the subacromial biodegradable spacer at 2-year follow-up are not satisfactory. In this small case series only 40% of patients seem to clearly benefit from surgery. One in three required revision to a reverse shoulder arthroplasty. The described technique does not seem a reasonable alternative for the management of the majority of patients with irreparable ruptures of the rotator cuff. The indications of this device should be more clearly defined.

LEVEL OF EVIDENCE

IV.

Arthroscopic-assisted latissimus dorsi transfer for massive rotator cuff tear: a systematic review

INTRODUCTION

This systematic review provides a comprehensive description of different surgical techniques for massive rotator cuff tears (MRCTs) using arthroscopic-assisted latissimus dorsi transfer (A-LDT), reporting clinical outcomes and complications.

SOURCES OF DATA

We searched the literature on Medline (PubMed), Web of Science and Scopus databases using the combined keywords 'latissimus dorsi', 'tendon', 'transfer', 'rotator cuff tears', 'shoulder' and 'arthroscopy' to identify articles published in English, Spanish, French and Italian. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed for the manuscript selection.

AREAS OF AGREEMENT

Ten studies (five retrospective and five prospective investigations), all published between 2014 and 2018, fulfilled our inclusion criteria, dealing with 348 (55.7% male) patients, with a mean age of 61.6 years (range 31-83).

AREAS OF CONTROVERSY

A-LDT is a technical demanding procedure. When compared with the open technique, it does not seem to provide significant subjective and objective clinical outcome improvements.

GROWING POINTS

A-LDT seems to yield lesser surgical complications and post-operative stiffness. Sparing the deltoid muscle belly could result in a more effective shoulder post-surgery function.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further comparative randomized controlled trials with longer follow-up are needed to clarify the potentially promising superiority of A-LDT.

Nonarthroplasty Surgical Treatment Options for Massive, Irreparable Rotator Cuff Tears

Massive, irreparable rotator cuff tears (MIRCTs) provide a significant dilemma for orthopaedic surgeons. One treatment option for MIRCTs is reverse total shoulder arthroplasty. However, other methods of treating these massive tears have been developed. A search of the current literature on nonoperative management, arthroscopic debridement, partial repair, superior capsular reconstruction (SCR), graft interposition, balloon spacer arthroplasty, trapezius transfer, and latissimus dorsi transfer for MIRCTs was performed. Studies that described each surgical technique and reported on clinical outcomes were included in this review. Arthroscopic debridement may provide pain relief by removing damaged rotator cuff tissue, but no functional repair is performed. Partial repair has been suggested as a technique to restore shoulder functionality by repairing as much of the rotator cuff tendon as possible. This technique has demonstrated improved clinical outcomes but also fails at a significantly high rate. SCR has recently gained interest as a method to prohibit superior humeral head translation and has been met with encouraging early clinical outcomes. Graft interposition bridges the gap between the retracted tendon and humerus. Balloon spacer arthroplasty has also been recently proposed and acts to prohibit humeral head migration by placing a biodegradable saline-filled spacer between the humeral head and acromion; it has been shown to provide good clinical outcomes. Both trapezius and latissimus dorsi transfer techniques involve transferring the tendon of these respective muscles to the greater tuberosity of the humerus; these 2 techniques have shown promising restoration in shoulder function, especially in a younger, active population. Arthroscopic debridement, partial repair, SCR, graft interposition, balloon spacer arthroplasty, trapezius transfer, and latissimus dorsi transfer have all been shown to improve clinical outcomes for patients presenting with MIRCTs. Randomized controlled trials are necessary for confirming the efficacy of these procedures and to determine when each is indicated based on specific patient and anatomic factors.

Surgical Management of Comminuted, Displaced Greater Tuberosity Fractures: A New Technique of Subacromial Spacer on Top of Double-Row Suture Anchor Fixation

Arthroscopic treatment of greater tuberosity (GT) fractures has been previously described. Arthroscopy allows identifying and addressing coexisting injuries, such as rotator cuff tears, labrum, or superior labrum anterior and posterior lesions, which are often present. Fracture comminution precludes the use of rigid fracture fixation with screws and arthroscopic rotator cuff repair is performed instead. Recent articles have depicted the role of the balloon-shaped subacromial spacer in massive and irreparable rotator cuff tears. The purpose of this technical report is to outline another use of the spacer in patients with a GT fracture. The concept is to leverage the advantage of the compression effect of the subacromial spacer to prevent displacement of the GT fracture and allow early active shoulder rehabilitation, especially in comminuted or eggshell fractures when rigid fixation is not feasible.

Comparative cost-effectiveness analysis of the subacromial spacer for irreparable and massive rotator cuff tears

Purpose

There is ongoing debate regarding the optimal surgical treatment of irreparable rotator cuff tears (IRCT). This study aimed to assess within the Italian health care system the cost-effectiveness of subacromial spacer as a treatment modality for patients with IRCT.

Methods

An expected-value decision analysis was created comparing costs and outcomes of patients undergoing arthroscopic subacromial spacer implantation, rotator cuff repair (RCR), total shoulder arthroplasty, and conservative treatment for IRCTs. A broad literature search provided input data to extrapolate and inform treatment success and failure rates, costs, and health utility states for these outcomes. The primary outcome assessed was an incremental cost-effectiveness ratio (ICER) of subacromial spacer implantation versus shoulder arthroplasty, RCR, and conservative treatment.

Results

Subacromial spacer is favorable over both arthroscopic partial repair and shoulder arthroplasty since it costs less than both options and increases effectiveness by 0.06 and 0.10 quality-adjusted life years (QALYs), respectively. While conservative treatment is the least costly management strategy, subacromial spacer results in a gain of 0.05 QALYs for the additional cost of 522 €, resulting in an ICER of 10,440 €/QALY gain, which is below the standard willingness to pay ratio of $50,000 USD. Strategies with an ICER of less than 50,000 USD are considered to be cost-effective.

Conclusions

Based on the available evidence and reasonably conservative assumptions, subacromial spacer is likely to provide a safe, effective, and cost-effective option for patients with massive IRCTs. Furthermore, this cost-effectiveness analysis may ultimately serve as a guide for development of health care system and insurer policy as well as clinical practice.

Early promising outcome following arthroscopic implantation of the subacromial balloon spacer for treating massive rotator cuff tear

BACKGROUND

Massive rotator cuff tear (RCT) can result in disability and severe pain. When conservative treatment fails, surgical treatment should be considered, as various surgical options can provide relatively satisfactory results. However, choosing an optimal treatment remains controversial. A relatively new treatment for irreparable RCT is the arthroscopic implantation of a biodegradable balloon spacer into the subacromial space. Here, we examined whether placement of this balloon spacer reduces pain and improves functional outcome in patients with an irreparable RCT. Patients were followed for 1 year following implantation.

METHODS

In this prospective single-arm study, a biodegradable balloon spacer was implanted into the subacromial space of patients with a massive RCT. Pain was evaluated using a numeric rating scale (NRS), and functional outcome was evaluated using the Oxford shoulder score (OSS) and the Constant-Murley shoulder score (CMS). Five follow-up visits were performed during the first postoperative year.

RESULTS

Forty-six shoulders in 44 patients with massive RCT were treated by surgical implantation of the subacromial balloon spacer. The mean reduction in NRS score was 3.5 points (95% CI 2.5-4.4), and 74% of patients achieved the minimal clinically important difference of 2 points by the 1-year follow-up visit. Functional outcome improved significantly based on OSS and CMS scores, and 80% of patients reported that they were satisfied with their outcome. No surgical or postoperative medical complications due to implantation of the balloon spacer were reported.

CONCLUSIONS

Our results suggest that arthroscopic implantation of a biodegradable balloon spacer in the subacromial space significantly reduces pain and improves activities of daily living in patients with massive RCT during 1 year of follow-up. The specific contribution of the balloon with respect to improved clinical outcome needs further study, ideally in a randomized controlled trial.