Shoulder arthritis - arthroscopic management

Survivorship and Patient-Reported Outcomes After Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis Minimum 10-Year Follow-up

The "comprehensive arthroscopic management" (CAM) procedure for glenohumeral arthritis includes some or all of the following elements:

(1) debridement of degenerative labral tears, unstable chondral injuries, and synovitis

(2) microfracture for high grade chondral defects

(3) removal of loose bodies

(4) biceps tenodesis if the long head tendon was unstable or had pathology of the intra-articular portion (5) resection of inferior humeral osteophytes 

(6) release of the inferior glenohumeral capsule was released

(7) axillary neurolysis if the inferior humeral osteophyte appeared to affect the course of the axillary nerve on preoperative magnetic resonance imaging or intraoperatively or if patients’ symptoms were consistent with nerve compression

(8) anterior and posterior capsular release 

(9) rotator interval was released

(10) coracoplasty 

(11) acromioplasty

Fluoroscopic guidance is used to localize the osteophyte and to assure complete resection.

These authors call attention to the " technical complexity of the procedure, which requires an expert arthroscopist for osteophyte excision and axillary neurolysis"."No serious complications were noted in these patients; however, axillary nerve injury could lead to very poor outcomes if it occurred. "

They sought to determine outcomes, risk factors for failure, and survivorship for 38 patients (mean age 53 years) having the CAM procedure for glenohumeral arthritis at minimum 10-year follow-up.

Survivorship was 75.3% at 5 years and 63.2% at minimum 10 years.

Those who progressed to arthroplasty did so at a mean 4.7 years (range, 0.8-9.6 years). 

For those who did not undergo arthroplasty, American Shoulder and Elbow Surgeons scores significantly improved postoperatively at 5 years (63.3 to 89.6) and 10 years (63.3 to 80.6). 

CAM failure was associated with severe preoperative humeral head flattening and joint incongruity in 93.8% of failures as compared with 50.0% of patients who did not go on to arthroplasty.

The group of shoulders that were revised to arthroplasty after the CAM procedure also had a higher Kellgren-Lawrence grade, a higher percentage of B2 or C glenoid types, larger osteophytes, and narrower joint space as shown the the table below.

Comment: This experience by a surgeon highly experienced with the CAM procedure found a benefit for certain patients with mild glenohumeral arthritis. The procedure itself is technically complex, requiring, for example the use of fluoroscopic guidance (see this YouTube). Release of the inferior capsule takes the surgeon close to the potentially adherent axillary nerve. The performance of  an axillary neurolysis is daunting. The risk of complications in less experienced hands would seem to be substantial.

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Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          

Note that author has no financial relationships with any orthopaedic companies.

Is "comprehensive arthroscopic management of glenohumeral osteoarthritis" a conservative procedure?

Survivorship and Patient-Reported Outcomes After Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis Minimum 5-Year Follow-up

These authors reported their outcomes and survivorship for the comprehensive arthroscopic management (CAM) procedure for the treatment of glenohumeral osteoarthritis at a minimum of 5 years postoperatively in 46 patients (49 shoulders).

 The CAM procedure included glenohumeral chondroplasty, capsular release, synovectomy, humeral osteoplasty, axillary nerve neurolysis, subacromial decompression, loose body removal, microfracture, and biceps tenodesis. 

Two patients were excluded for refusing to participate before study initiation. 

The mean age at surgery was 52 years (range, 27-68 years) in 15 women and 29 men. 

Twelve shoulders (26%) progressed to total shoulder arthroplasty at a mean of 2.6 years (range, 0.5-8.2 years). For 45 of 47 (96%) shoulders, survivorship was 95.6% at 1 year, 86.7% at 3 years, and 76.9% at 5 years. 

2 additional patients required secondary arthroscopic surgery; one underwent capsular release for stiffness at 5.6 months, and another underwent a revision CAM procedure at 7.9 years.

Factors associated with failure and progression to TSA were a Walch type B2 or C glenoid shape and preoperative joint space narrowing defined as less than 2 mm of joint space remaining as seen on a Grashey or true  anterior-posterior radiograph of the glenohumeral joint.

Subjective outcome data were available for 28 shoulders at a mean of 5.7 years. 

Comment: 

As indicated by Table 2 of this paper, there is wide variability in what is actually done in this procedure, making it difficult to discern what elements contribute to the outcome. For example, is there evidence that an axillary nerve release is indicated in 1/3 of shoulders with arthritis? Do patients with osteoarthritis have synovitis requiring synovectomy? 

Five year followup was available only on 53% (28/49) of the cases.

It appears that the outcomes were better if the arthritis was milder (2 mm or more of preserved joint space, less severe Walch glenoid types). 

It would be of interest to know whether the 26% of the patients who required subsequent total shoulder arthroplasty realized the same quality results as patients having primary arthroplasty.

Further comparative studies will be needed to determine the place of this procedure among the other options in the management of arthritis for patients with a mean age of 52. 

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

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You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'