Thank you very much. So approaching this topic is one where I'll submit that I use all of these techniques that are in this session, but this is an interesting one where it's sort of disruptive technology that how do we make sense of this and where do we put this into our whole armamentarium of ways to address this? My disclosures are in the book and online. So Valenti first talked about this in 2018. This was a very nice algorithm that laid out their interpretation of where to put the balloon. You had younger patients on the left and older patients on the right. And here down on the lower right-hand side, you see debridement with biceps tenotomy plus or minus the balloon and or maybe a partial repair. And so this was the original approach of how to go about employing the balloon and where to use it and so on. The question comes up, well, what is the balloon? It's biodegradable. You place it in the subacromial space. It lasts for three months. It's gone in a year. And its real goal is to maintain the humeral head position so it gets the head down and into the glenoid and it creates a frictionless gliding surface within the shoulder. This was first described or shown in the arthroscopy technique in which you measure a centimeter medial to the glenoid and then in essence, you slide this balloon in and you go ahead and fill this with saline and you can physically see the head being depressed as you watch this video. It pushes the head down. You cycle the shoulder a little bit to get the right tension on the balloon itself. So you let some fluid back out and then you cap the balloon and you're done. So it's really quite simple. Deckel and company reported their initial results back in 2012. They had 20 patients that they followed for three years and they found that the outcomes were improved and that their strength actually continued to improve until 18 months and then was maintained at three years. They also followed this group up at five years and what they noticed was there was very low risk, minimal invasiveness in terms of the procedure itself and also that the outcome scores held over that time. In Germany, they published a report where there was 11 patients without the balloon, just a partial repair and then 12 patients with partial repair and the balloon and the balloon patients did better. Another study looked at 46 patients with just basically a prospective single arm study, only one year of follow up but basically 80% satisfied patients with outcomes and no complications. So again, the recurring theme here is it's very safe, very simple, very easy to do when used in the right way. Another article out of France, basically published in 2017, demonstrated that with Hamada changes under grade three and a follow up of 33 months, they had improved constant scores, improved forward elevation and extra rotation and it was again safe and reproducible. George Athwal and his group looked at this biomechanically and what they looked at, they compared the SCR, which is basically a tether, versus the balloon, which is a filler and they wanted to see if you could restore humeral head depression and found that that was exactly the case, albeit they accomplished this goal in very different ways. They were both very close to an intact cuff in terms of its values and there was no significant difference between the two. The genetic review also confirms that patients do quite well. Here's seven studies that are level three and level four evidence, 204 shoulders, mean age, 67 years old, 100% of patients had consistent improvement with ASES and constant score and a 3% complication rate. There's a North American trial that's just finishing up. This is a very rigorous trial, prospective single blinded multicenter randomized controlled study. I was part of this study and massive irreparable two tendon five centimeter tears, balloon spacer was done arthroscopically, 184 patients were enrolled. So 92 patients got the balloon, 92 didn't and the patients did not know what they had put in there. So it was a pretty fun study to be involved with because you didn't know what surgery you were doing until you literally did it. So that data is coming out and we're just collecting the last bit of it. So it'll be interesting to see what that shows. LaFosse however took this in a different direction. Two tendon or three tendon tears that were able to be fixed and put the balloon in over the top of the tendon because he felt that you could reduce the friction on the repair, you could diminish the stress on the cuff and potentially even flatten out minor dog ears. And so there was some protective sort of quality to this balloon. Biomechanically this was published in 2018 in which they took cadaveric specimens and they basically confirmed that you reduce the peak pressures and have wider load distribution when you put in a balloon over the top of a repaired cuff. So is there, maybe could we prevent retear rate and could we possibly diminish the wear on a repaired cuff that's already have some damage to it. I think in conclusion the balloon is a good option certainly for someone who's low demand. Maybe they're a high fall risk that you don't want to put an arthroplasty in that person. It may be a good soft tissue reverse in someone because there's some people that think that there's actually a residue that this balloon leaves that mimics a superior capsular type structure. It may actually be good for at risk repairable tendons as well. I think the North American trial will really be the next step in terms of dealing with how to understand the balloon, where its indications are, and how far can we go with it. All in all I think the evidence is really mounting and it's something that we have to sort of pay attention to in the future as we learn more about this. Thank you.

biodegradable balloon

shoulder injuries

subacromial space

humeral head

frictionless surface