So, my task this morning is to discuss the subacomeal balloon spacer and specifically the technique for insertion of the spacer itself. And I promise that we're going to get there, but if I just show you the technique, this is going to be a really short lecture. And number two is we're going to miss the most important part of this, which is how to identify and indicate patients appropriately. My disclosures are available through the Academy's online disclosure program. So I think we're all familiar with the controversies that come with managing patients with massive rotator cuff tears. And we talk about some of these complex concepts, such as humoral head depression, reeducation of the deltoid to provide elevation. But at the end of the day, what our patients will want is pain relief. And if we can do this with an accelerated rehabilitation program that shortens their recovery time, that's a huge bonus. In terms of considerations, I think this is true of all of the soft tissue procedures that you're going to hear about today. We need to think about patients that are primary or revision surgery without arthritis. They should have generally a maintenance of pre-op elevation, avoidance of pseudoparalysis. They should prioritize pain over function. They should have an intact subscapularis. And we always need to think about age, cost, complications. And what do we do next if this fails? So for me, the sweet spot here is the Hamada 1 and 2 classifications. Why use the balloon? It's a simplified surgical technique. It provides for accelerated rehabilitation with early clinical improvement and improved patient satisfaction and the ability to get them back to their regular life on a quicker basis. The million-dollar question is how does this work? And the answer is we don't know completely. What we do know from the laboratory setting is that it decreases peak pressure in the subocomial space, that it helps to provide humoral head depression. But in reality, at least my opinion is that this provides pain relief that allows for a pain-free or pain-reduced interval that facilitates rehabilitation to bring them back to a compensated state. So our patient today is a 71-year-old female, chronic worsening of left shoulder pain. She's actually had a rotator cuff tear on the opposite side that failed. So she knows what that's like. These are her radiographs. You can see pretty clearly a Hamada 1 classification with well-maintained joint spaces, but a large retracted rotator cuff tear with poor tissue quality and early fatty infiltration of the superinfraspinatus, but maintenance of the subscapularis. She's undergone the appropriate conservative care, cortisone injections with temporary response. She has preserved range of motion, but her main complaint is pain, and we're concerned about the ability to achieve a stable repair given the poor tissue quality. This is what her exam looks like in the preoperative setting. You can see that there's maintenance of forward elevation, maintenance of abduction, maybe slight limitation secondary to pain, and she does have some loss of external rotation at the side, but a negative hornblower sign. My preference is to do this in the beach tear position. It just allows me to set up for the subacomial surgery. We evaluate all sources of pain in the shoulder. So as you can see here, a pretty pathologic biceps with tenosynovitis and partial tearing, and so I prefer a biceps tenotomy versus tenodesis in this situation simply because we can accelerate the rehabilitation, and so we start by transecting the bicep stump. A release of the interval and also a synovectomy is performed, and then we closely evaluate the subscapularis to determine that it's intact and also evaluate the glenohumeral joint. As you can see here, very little arthritis present in this patient, a large retracted rotator cuff tear involving the suprainfraspinatus. We do a limited bursectomy trying to avoid an excessive bursectomy, particularly in the anterior and lateral gutters that may cause an increased risk of balloon displacement. I do do a debridement as I think that's an important part of the procedure. There's some controversy as to whether a formal acromioplasty or not is indicated. I think that a subacomial smoothing as well as a tuberoplasty is important because it helps to smooth the interface between the balloon and the bone, and later, once the balloon is gone, between the greater tuberosity and the humeral head. So it's a gentle smoothing procedure on both sides to achieve a stable articulation as you see here. We can see that she's got a massive rotator cuff tear, fairly atrophic tissue. One could make the argument that this is mechanically repairable. I would make the argument that this is biomechanically irreparable. And so we indicate this patient for a balloon procedure. The balloon implant is fairly simple. It's the device, a syringe, and then a probe for measurement. We're viewing from the posterior portal here, working from the lateral portal. We take two measurements. We measure from the skin to about a centimeter medial to the glenoid over the top of the rotator cuff. We take that measurement. We then take a second measurement that goes from the skin to the inner margin of the deltoid, and we subtract those two measurements, and that gives us the distance within the subacomial space. And then we can size the balloon to small, medial, or large. You do need to expand the lateral portal using a hemostat to dilate, just to allow you to place the introducer within the subacomial space. There's a protective sheath over the balloon itself. That goes in first. We need to place that medial to the glenoid margin over the top of the remnant rotator cuff stump. And there's a demarcation line on the protection sleeve that helps you to make sure that the entirety of the balloon is placed within the subacomial space. There's a little red protection guide that helps you from avoiding pre-deployment of the balloon before you're ready, so you remove that. We're then going to slide back the protection sleeve, as you see here. This allows us to see the balloon within the subacomial space. And then we simply inflate the balloon to the pre-determined volume based on the size of the balloon itself. Once the balloon is deployed, we then confirm that it's adequately positioned within the subacomial space and stable, and that's really the end of the procedure. Where does this fit in? I think it's important for pain relief, older patients, lower demand, maintenance of function, minimal arthritis. Some remaining questions, what do we do with subscapularis tears? Can they be fixed and then use a balloon? Can we reverse pseudoparalysis? In my opinion, no. Is this durable over time? Our results are now up to five years, and the answer to that is yes. What are the implications with reverse shoulder arthroplasty in the future, and should we be thinking about using this to supplement rotator cuff repair? Thanks very much.

subacimal balloon spacer

pain relief

rehabilitation

patient satisfaction

rotator cuff tear