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Editorial Commentary: Treating Irreparable Rotator Cuff Tears With a Patch or Balloon: Is It All a Bunch of Hot Air?
Editorial Commentary: Treating Irreparable Rotator Cuff Tears With a Patch or Balloon: Is It All a Bunch of Hot Air? Josef K. Eichinger, M.D., Editorial Board
Abstract: Both superior capsular reconstruction and a biodegradable balloon spacer function to limit proximal migration and restore glenohumeral joint forces similar to the intact rotator cuff in a cadaveric rotator cuffedeficient model. Although both the superior capsular reconstruction and biodegradable balloon spacer represent promising alternatives, additional clinical outcome data are needed to determine their role in the treatment of the massive, irreparable rotator cuff tear.
See related article on page 382
T
he optimal treatment option for the irreparable rotator cuff tear in the patients without arthritis is unknown. A plethora of options exists including 2 recently introduced novel options including the superior capsular reconstruction (SCR) as well as a biodegradable balloon spacer filled with saline. Although Mihata et al.1 have published both clinical results as well as a biomechanical assessment,2 only a small limited case series is available on the balloon spacer.3 In their article “The Subacromial Balloon Spacer Versus Superior Capsular Reconstruction in the Treatment of Irreparable Rotator Cuff Tears: A Biomechanical Assessment,” Singh, Reeves, Langohr, Johnson, and Athwal4 have provided the first high-quality biomechanical analysis of the balloon spacer and have taken the extra step to compare it with the SCR. This welldone study reveals at least in a time zero cadaveric model that both the SCR and balloon spacer effectively keep the humeral head reduced and stop proximal humeral escape in a very similar fashion to the intact rotator cuff state. An added bonus is the brilliantly written discussion section, which contains a valuable The author reports the following potential conflicts of interest or sources of funding: J.F.K. receives grant support from Johnson and Johnson Ethicon, is a consultant for Exactech, and receives nonfinancial support from Arthrex, Smith and Nephew, and Johnson and Johnson Depuy. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2019 by the Arthroscopy Association of North America 0749-8063/181363/$36.00 https://doi.org/10.1016/j.arthro.2018.11.030
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and thoughtful analysis of the biomechanical function of the deltoid and rotator cuff at different angles of abduction that any surgeon, at any stage of his or her career, would appreciate and learn from. I am not surprised that the balloon spacer was effective at keeping the humeral head reduced; after all, anyone who has ever performed a subacromial cortisone injection under ultrasound probably has noticed that even a few milliliters of fluid can depress the humeral head in the presence of an intact rotator cuff. Although clinical outcomes for a given approach and technique outweigh any evidence from a biomechanical study, it is far more reassuring to know that biomechanical rationale and evidence to support a particular technique actually exist. Singh et al. provide that evidence for us. Now we all wait for the results of a multicenter balloon spacer trial in the United States to see whether this balloon will rise and travel the Atlantic. If the balloon spacer ultimately delivers promising clinical results, perhaps it will find a home in the ever-changing paradigm of treatment options for the difficult to manage irreparable rotator cuff tear. Stay tuneddwe might all end up blowing up balloons.
References 1. Mihata T, Lee TQ, Watanabe C, et al. Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears. Arthroscopy 2013;29:459-470. 2. Mihata T, McGarry MH, Pirolo JM, Kinoshita M, Lee TQ. Superior capsule reconstruction to restore
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 35, No 2 (February), 2019: pp 390-391
EDITORIAL COMMENTARY superior stability in irreparable rotator cuff tears: A biomechanical cadaveric study. Am J Sports Med 2012;40:2248-2255. 3. Deranlot J, Herisson O, Nourissat G, et al. Arthroscopic subacromial spacer implantation in patients with massive irreparable rotator cuff tears: Clinical and radiographic
391
results of 39 retrospectives cases. Arthroscopy 2017;33: 1639-1644. 4. Singh S, Reeves J, Langohr DG, Johnson JA, Athwal GS. The subacromial balloon spacer versus superior capsular reconstruction in the treatment of irreparable rotator cuff tears: A biomechanical assessment. Arthroscopy 2019;35:382-389.
Abstract: Both superior capsular reconstruction and a biodegradable balloon spacer function to limit proximal migration and restore glenohumeral joint forces similar to the intact rotator cuff in a cadaveric rotator cuffedeficient model. Although both the superior capsular reconstruction and biodegradable balloon spacer represent promising alternatives, additional clinical outcome data are needed to determine their role in the treatment of the massive, irreparable rotator cuff tear.
See related article on page 382
T
he optimal treatment option for the irreparable rotator cuff tear in the patients without arthritis is unknown. A plethora of options exists including 2 recently introduced novel options including the superior capsular reconstruction (SCR) as well as a biodegradable balloon spacer filled with saline. Although Mihata et al.1 have published both clinical results as well as a biomechanical assessment,2 only a small limited case series is available on the balloon spacer.3 In their article “The Subacromial Balloon Spacer Versus Superior Capsular Reconstruction in the Treatment of Irreparable Rotator Cuff Tears: A Biomechanical Assessment,” Singh, Reeves, Langohr, Johnson, and Athwal4 have provided the first high-quality biomechanical analysis of the balloon spacer and have taken the extra step to compare it with the SCR. This welldone study reveals at least in a time zero cadaveric model that both the SCR and balloon spacer effectively keep the humeral head reduced and stop proximal humeral escape in a very similar fashion to the intact rotator cuff state. An added bonus is the brilliantly written discussion section, which contains a valuable The author reports the following potential conflicts of interest or sources of funding: J.F.K. receives grant support from Johnson and Johnson Ethicon, is a consultant for Exactech, and receives nonfinancial support from Arthrex, Smith and Nephew, and Johnson and Johnson Depuy. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2019 by the Arthroscopy Association of North America 0749-8063/181363/$36.00 https://doi.org/10.1016/j.arthro.2018.11.030
390
and thoughtful analysis of the biomechanical function of the deltoid and rotator cuff at different angles of abduction that any surgeon, at any stage of his or her career, would appreciate and learn from. I am not surprised that the balloon spacer was effective at keeping the humeral head reduced; after all, anyone who has ever performed a subacromial cortisone injection under ultrasound probably has noticed that even a few milliliters of fluid can depress the humeral head in the presence of an intact rotator cuff. Although clinical outcomes for a given approach and technique outweigh any evidence from a biomechanical study, it is far more reassuring to know that biomechanical rationale and evidence to support a particular technique actually exist. Singh et al. provide that evidence for us. Now we all wait for the results of a multicenter balloon spacer trial in the United States to see whether this balloon will rise and travel the Atlantic. If the balloon spacer ultimately delivers promising clinical results, perhaps it will find a home in the ever-changing paradigm of treatment options for the difficult to manage irreparable rotator cuff tear. Stay tuneddwe might all end up blowing up balloons.
References 1. Mihata T, Lee TQ, Watanabe C, et al. Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears. Arthroscopy 2013;29:459-470. 2. Mihata T, McGarry MH, Pirolo JM, Kinoshita M, Lee TQ. Superior capsule reconstruction to restore
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 35, No 2 (February), 2019: pp 390-391
EDITORIAL COMMENTARY superior stability in irreparable rotator cuff tears: A biomechanical cadaveric study. Am J Sports Med 2012;40:2248-2255. 3. Deranlot J, Herisson O, Nourissat G, et al. Arthroscopic subacromial spacer implantation in patients with massive irreparable rotator cuff tears: Clinical and radiographic
391
results of 39 retrospectives cases. Arthroscopy 2017;33: 1639-1644. 4. Singh S, Reeves J, Langohr DG, Johnson JA, Athwal GS. The subacromial balloon spacer versus superior capsular reconstruction in the treatment of irreparable rotator cuff tears: A biomechanical assessment. Arthroscopy 2019;35:382-389.