What used to be a long and arduous treatment and rehabilitation for massive and irreparable rotator cuff tears has been cut in half with a procedure now being performed at UAB. Amit Momaya, MD, UAB Chief of Sports Medicine, completed the first subacromial balloon spacer technique in Alabama in January.
Most massive and irreparable rotator cuff tears occur in older adults over 55. "Not to say we couldn't do this in someone under 55, you're just not likely to see this condition in the young because they don't have this muscle atrophy and wasting," Momaya says.
Typically, this severe condition occurs as an aging disfunction where blood supply to the rotator cuff wanes allowing for tears that worsen over time. "Some people may not even know they have a tear, until it's affecting their function," Momaya says. "If it goes untreated, the rotator cuff tears more and more and can get scarred and become not repairable."
When the tendons and muscles of the rotator cuff that surround the shoulder joint tear, it allows the humeral head--the top of the upper arm bone--that normally fits into the shoulder joint to float upwards and out of the socket well. That leaves the humeral head free to rub against the bony tip of the outer edge of the shoulder blade, the acromion, causing pain and limiting the arm's ability to roll and lift.
The subacromial balloon spacer greatly relieves that pain by placing a temporary pillow of saline between the two bones. "It pushes the humeral head down where it belongs, and that allows the shoulder to function better and the body to retrain the remaining musculature and use it more efficiently," Momaya says.
The arthroscopic procedure begins by inserting a camera inside the shoulder joint to ensure an accurate diagnosis by first cleaning out any scarring and bone spurs. Making standard portal site incisions of about one to two fingernails long, the surgeon then inserts a sheath that pushes in the empty polymer balloon. Next, a saline-filled syringe is inserted to inject into the balloon a set measurement.
"That's about it," Momaya says. "It feels like a waterbed inside the shoulder once it's deployed. The temporary spacer requires no means of attachment. It doesn't migrate around. After several months, it starts to deflate slowly, and within a year it disintegrates. The biggest surprise about this procedure is how quickly it can be done and how quickly and aggressively you can rehab the shoulder afterwards."
Momaya and assistant professors Aaron Casp, MD, and Will Brabston, MD, published the first composite study covering 204 shoulders over three years with a mean age of 67.6 years and mean follow up of 19 months. Only three percent had complications.
"Pain is decreased significantly," Momaya says. "The pain scores we see in studies was at least a 50 to 75 percent improvement in most patients."
Because the balloon spacer allows for so much more movement and alleviates so much pain, rehab can begin more quickly and be more aggressive than after other rotator cuff treatments, such as injections and partial repairs. Following the standard rotator cuff repair surgery, rehab can last six to 12 months. With the balloon spacer, rehab for massive and irreparable rotator cuff tears takes only about three months. The need for a sling lasts a week or two versus the four to six weeks of immobility after the standard repair surgery.
"Even if you could work through the pain and try rehab without this procedure, you couldn't achieve the results," Momaya says. With the humeral bone not resting properly in the socket, the muscles would be adapting to wrongly placed bones and unable to attain the right motions.
Momaya sees additional ways to utilize the balloon spacers beyond just these extreme irreparable rotator cuff cases. "We could augment what we already do," he says. "The standard rotator cuff repair still has rate of failure much higher than we would like. So we could augment that with a balloon procedure and make our current procedures better."
That's likely in the future. "The interest in this procedure is growing exponentially," Momaya says. "I expect UAB to do 10 to 20 subacromial balloon spacer techniques in this first year, and double that in the near future. But if we start using them on current procedures we already do, for example on top of a rotator cuff repair, that opens up the market dramatically to put in many more."