Biocompatibility of the InSpace subacromial balloon spacer: an in vivo murine pouch model cytokine analysis

• Published in: Journal of shoulder and elbow surgery
• Main Authors: Chatterji, Rishi, Elagamy, Noah, Miller, Adam, Bou-Akl, Therese, Fry, Michael, Pawlitz, Paula, Markel, David C., Holcomb, Jason O.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 29.07.2025
• Subjects: biocompatibility; cytokine analysis; massive irreparable rotator cuff tears; murine pouch model; rotator cuff; Subacromial balloon spacer; In-vivo Animal Model; cytokine analysis; murine pouch model; Histology and Microbiology; biocompatibility; rotator cuff; Basic Science Study; Subacromial balloon spacer; massive irreparable rotator cuff tears
• ISSN: 1058-2746; 1532-6500; 1532-6500
• DOI: 10.1016/j.jse.2025.06.009

There are several methods of treating massive rotator cuff tears in patients without severe glenohumeral arthritis. Subacromial balloon spacers have emerged as one solution to this problem. Previous studies identified a lasting film in the subacromial space well after the balloon should have dissolved, and there is limited information regarding the biocompatibility and reactivity of the resorbable implant. This study sought to characterize the inflammatory response to the balloons histologically and via cytokine production using an established in vivo animal model. Forty-two BALB/c mice were randomized into 2 groups: control (no balloon device, n = 4/time point) and experimental (balloon device implanted, n = 10/time point). Time points were 1, 4, and 12 weeks creating 3 subgroups that contained 4 controls and 10 experimental mice. One subacromial balloon spacer (InSpace; Stryker) was sectioned into equally sized 3-mm-diameter sections. Subcutaneous mouse air pouches were created and one 3-mm-diameter sample was implanted into each mouse pouch. No implants were placed in control pouches. The mice were humanely killed at the noted time points. Bead array assay was used to measure cytokines transforming growth factor beta 1 (TGF-β1), interleukin (IL)-13, IL-1B, IL-4, IL-6, IL-10, and TNF-α. Histologic analysis was also performed for hematoxylin and eosin (H&E)–stained sections. Cytokine analysis: cytokine analysis curves correlated appropriately to the array standards. At 1 week and 4 weeks, all cytokines besides TGF-β1 remained within the standard curve and were therefore undetectable. At 12 weeks, all cytokines were undetectable. Histologic analysis: no differences were seen between the control and experimental groups histologically. When characterizing the pouch histology, at 1 week, pouch membranes were dense and infiltrated with inflammatory neutrophils and few macrophages. At 4 weeks, the membranes were less densely populated with cells, consisting of mostly fibroblasts, few neutrophils, and no macrophages or lymphocytes. At 12 weeks, the pouch membranes had few cell layers showing mostly fibroblasts. Although a thin film may remain after resorption of balloons, the inflammatory response appeared minimal. Further studies using human subjects and/or insufflated balloons may be helpful in better defining the biocompatibility profile of subacromial balloon spacers.