Subacromial Balloon Arthroplasty Offered for Massive Irreparable Rotator Cuff Tears

Subacromial balloon arthroplasty is a minimally invasive procedure designed to reset the biomechanical balance of the shoulder for patients with massive irreparable rotator cuff tears (MIRCT). Approved last summer by the FDA, the biodegradable balloon implant has been shown to decrease pain and improve shoulder motion and function, with far less surgery and a reduced recovery time.

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“The rotator cuff balloon procedure is a new treatment option in the United States, though it has been available for more than a decade in Europe,” says Gregory Gilot, MD, an orthopaedic surgeon with Cleveland Clinic Weston Hospital who specializes in shoulder arthroscopy and replacement and rotator cuff disorders.

This novel treatment is now offered by Cleveland Clinic physicians in Ohio and across the Florida region, including Cleveland Clinic Weston Hospital, Cleveland Clinic Martin Health, and Cleveland Clinic Indian River Hospital.

The role of the rotator cuff

The function of the rotator cuff is to push the humeral head down into position within the glenoid cavity of the shoulder blade, allowing the deltoid and other muscles to move the arm. When the head rises out of position as a result of a tear, the muscles become ineffective and movement is painful.

“A properly functioning shoulder is a balancing act between the rotator cuff and the deltoid muscle,” describes Peter J. Evans, MD, PhD, Chair of the Orthopaedic and Rheumatologic Institute for Cleveland Clinic Florida. Based at Cleveland Clinic Martin Health, about 20% of his practice are patients with rotator cuff issues.

The posterosuperior rotator cuff is the most common site for MIRCTs. It is composed of the supraspinatus and infraspinatus tendons, two of the four tendons that make up the rotator cuff. Tears are defined as irreparable when a direct repair of the native tendon to its insertion site is not possible, due to size, retraction, and muscle impairment.

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“Massive irreparable tears can be the most challenging to treat and historically have a high treatment failure rate,” notes Dr. Evans.

The continuum of care for rotator cuff tears range from nonoperative care to surgical treatment and finally to complex reconstruction or shoulder replacement. Management depends on several factor, including the tear size, the quality of the tendon tissue and bone, as well as patient symptoms, age and comorbidities, among others.

A minimally invasive approach

Developed for the treatment of MIRCTs, the balloon procedure is performed arthroscopically through a lateral portal. Intraoperative measurements are used to select one of three balloon implant sizes. It is then inserted between the acromion and the humeral head, where it is inflated with a saline solution.

“There are no activity limitations after the procedure, and patients are encouraged to begin physical therapy right away,” says Dr. Gilot, noting the spacer will deflate over several weeks and completely degrade in about a year. “It’s a good option for patients because of the low morbidity and the much shorter rehabilitation process.”

According to Dr. Evans, the implant lowers the head of the humerus thus reducing subacromial friction during movement and allowing the deltoid to elevate the arm. “It is believed that by restoring the subacromial space, patients will experience less pain and physical therapy will be more effective. There is also some indication that scar tissue helps to stabilize the position of the humeral head,” he says.

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The ideal patient

More than two million Americans experience some type of rotator cuff problem every year. Rotator cuff tears can result from acute trauma or develop slowly as a result of intrinsic changes to the tendon.

“The ideal patient for subacromial balloon arthroplasty is 65 or older with an intact subscapularis muscle, which is the largest muscle in the rotator cuff, there is little to no osteoarthritis in the joint, and a massive and irreparable posterosuperior tendon tear exists,” explains Dr. Gilot. “It is also best suited for low-demand patients.”

“This is a no harm, no foul procedure that offers a simple recovery and can provide significant pain relief while either eliminating or postponing the need for much more complicated reconstructive procedures or a shoulder replacement,” adds Dr. Evans.