Long Head Biceps Tendon Pathology

What is Balloon Arthroplasty?

Balloon arthroplasty, also known as subacromial balloon arthroplasty, is a minimally invasive surgical procedure designed to reset the biomechanical balance of the shoulder for individuals with massive irreparable rotator cuff tears (MIRCT). Tears are characterized as irreparable when a direct repair of the native tendon to its insertion site is not feasible, due to size, retraction, and muscle impairment.

In a normal shoulder, when the rotator cuff is intact, the head of the humerus (upper arm bone) remains centered on the socket (glenoid) of the shoulder blade (scapula). However, when the tendons are torn, what occurs is that the humeral head migrates up and then there is abnormal contact of the shoulder bones, resulting in restricted and painful motion of the shoulder. Balloon arthroplasty procedure basically involves the placement of an inflatable balloon (spacer) device into the subacromial space of the shoulder between the humeral head and the acromion (ceiling of the shoulder). The balloon implant occupies the space where the rotator cuff tendons are supposed to be and prevents the humeral head from contacting with the acromion, enabling smooth movement of the humeral head against the acromion. The subacromial space is the space between the acromion and the top surface of the humeral head. This space houses several soft tissue structures such as the rotator cuff, bicep tendon, and bursa, which are instrumental in the proper functioning of the shoulder.

Anatomy

The shoulder joint is a ball and socket joint with the head of the humerus (upper arm bone) forming the ball, and the cup-shaped depression on the shoulder blade (glenoid fossa) forming the socket. The rotator cuff is a group of four tendons that join the head of the humerus to the deeper shoulder muscles to provide stability and mobility to the shoulder joint. Major injury to these tendons may result in a condition called rotator cuff tear. The tear results in symptoms such as severe pain, swelling, stiffness, weakness of the arm, and loss of joint motion.

Indications for Balloon Arthroplasty

Your surgeon may recommend balloon arthroplasty to treat irreparable, massive rotator cuff tears in the shoulder caused by significant trauma.

In general, your surgeon may recommend a balloon spacer implant in the following scenarios:

For individuals who are not suitable candidates for standard tendon transfer treatment for rotator cuff repair
In patients who manifest proximal humeral migration secondary to massive full-thickness rotator cuff tears
In seniors suffering rotator cuff tendon degradation with mild to moderate glenohumeral osteoarthritis
In patients with multiple comorbidities and who are contraindicated to undergo general anesthesia or open surgery

Preparation for Balloon Arthroplasty

Preparation for balloon arthroplasty may involve the following steps:

A review of your medical history and a physical examination are performed by your doctor to check for any medical issues that need to be addressed prior to surgery.
Diagnostic tests such as blood work to help detect any abnormalities that could compromise the safety of the procedure and imaging such as a CT and MRI scans are also performed to assess the gravity of the rotator cuff tear, retraction of the tendons, and degenerative status of the rotator cuff.
You will be asked if you have allergies to medications, anesthesia, or latex.
You should disclose your current medications or supplements you are taking or any current illnesses or conditions you have such as heart or lung disease.
You may be asked to stop taking certain medications, such as blood thinners, anti-inflammatories, aspirin, or other supplements for a week or two.
You should refrain from alcohol and tobacco at least a few days prior to surgery and several weeks after, as it can hinder the healing process.
You should not consume any solids or liquids at least 8 hours prior to surgery.
You should arrange for someone to drive you home after surgery.
A signed informed consent form will be obtained from you after the pros and cons of the surgery have been explained.

Procedure for Balloon Arthroplasty

Balloon arthroplasty is usually performed using a minimally invasive arthroscopic technique under general or regional anesthesia. The procedure generally involves the following steps:

After cleaning the skin over the shoulder area, your surgeon makes a few small entry points known as keyhole incisions in your shoulder joint.
An arthroscope, a slender tubular device attached with a light and a small camera at the end is inserted through one of the incisions into your shoulder joint.
The camera transmits the image of the inside of your shoulder joint onto a monitor for your surgeon to view.
Your surgeon then guides miniature surgical instruments through the other tiny incisions to perform surgical debridement of the joint area (removal of damaged tissue). Care is taken to prevent damage to healthy tissue.
After adequate repair of all fixable portions of the rotator cuff tear, the area for balloon placement is measured and a suitable balloon spacer is implanted between the humeral head and the acromion and is inflated with a normal saline solution.
The inflated spacer decreases subacromial friction and creates more space between the humeral head and coracoacromial arch and helps heal the torn rotator cuff tendon following rotator cuff repair. The saline-filled balloon gradually dissolves in the body in about a year.

Post-Operative Care and Recovery

In general, postoperative care and recovery after balloon arthroplasty will involve the following steps:

You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anesthetic reactions and monitor your vital signs.
Following the surgery, your arm will be placed in a shoulder sling for 2 to 4 weeks to rest the shoulder and promote healing.
You may experience pain, swelling, and discomfort in the shoulder area. Pain and anti-inflammatory medications are provided as needed to address these.
Antibiotics are also prescribed to address the risk of surgery-related infection.
You may also apply ice packs on the shoulder area to help reduce swelling and pain.
You are encouraged to move around in bed and walk as frequently as possible to prevent the risk of blood clots.
Instructions on incision site care and bathing will be provided to keep the wound clean and dry.
An individualized physical therapy protocol will be designed to help strengthen your shoulder muscles and optimize shoulder function once you are off the sling.
You are advised not to engage in any strenuous activities such as push-up exercises, playing sports, or lifting heavy weights for at least 6 months. A gradual increase in activities is recommended with your physician’s guidance. However, you should be able to resume light activities of daily living after approximately 6 weeks. More strenuous housework should be avoided until 3 months after your operation.
Refrain from driving until you are fully fit and receive your doctor’s consent.
A periodic follow-up appointment will be scheduled to monitor your progress.

Risks and Complications

Balloon arthroplasty is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as:

Infection
Bleeding
Swelling
Postoperative pain
Damage to surrounding soft-tissue structures
Blood clots or deep vein thrombosis (DVT)
Implant migration