Glenohumeral Arthritis: Comprehensive Arthroscopic Management

Marco-Christopher Rupp

Annabel R. Geissbuhler

Joan C. Rutledge

Jared A. Hanson

Rony-Orijit Dey Hazra

Peter J. Millett

INTRODUCTION

Glenohumeral osteoarthritis (GHOA) is a common etiology of shoulder pain, weakness, and range-of-motion (ROM) deficits. Initial management of GHOA is nonoperative management and includes physical therapy, nonsteroidal anti-inflammatory medications, and corticosteroid injections.¹^,² However, patients often progress and require surgical intervention. The standard of care for end-stage osteoarthritis in the elderly patient is total shoulder arthroplasty (anatomic and reverse), which leads to predictable and improved patient outcomes with the contemporary implant models.³ However, total shoulder arthroplasty (TSA) is commonly avoided in younger or more active patients due to concerns regarding implant longevity, inadequate shoulder function, and the need for future revision procedures.⁴^, ⁵ ^and ⁶ Implant survivorship has been reported to be 80% at 20-year follow-up,⁷ leading to the potential for younger and more active patients to require one or multiple revision procedures during their lifetime. This has led to the use of nonarthroplasty procedures in younger and more active patients to delay or in some cases prevent the need for arthroplasty.⁸^, ⁹^, ¹⁰ ^and ¹¹ Millett et al¹² first introduced the concept of Comprehensive Arthroscopic Management (CAM) in 2011. The CAM procedure combines numerous arthroscopic techniques and is aimed at comprehensively addressing all the surgically treatable, common glenohumeral pain generators. At the same time, the CAM procedure protects the architecture of the joint so as not to obviate the possibility or compromise the result of a subsequent shoulder prosthetic arthroplasty.

The CAM procedure includes debridement of the glenohumeral joint, chondroplasty, synovectomy, loose body removal, inferior humeral head osteoplasty, axillary nerve neurolysis, capsular releases, biceps tenodesis, and decompression of the subacromial/subcoracoid spaces. The decision to employ each individual technique should be based on patient-specific factors determined on physical examination, advanced imaging, and during diagnostic arthroscopy. The CAM procedure prevents the need for arthroplasty in 85% of patients at 2 years,¹³ 77% of patients at 5 years,¹⁴ and 63% of patients at 10 years, without compromising future TSA outcomes.¹⁵^, ¹⁶ ^and ¹⁷

PREOPERATIVE PREPARATION

Assessment of the patient prior to CAM for glenohumeral arthritis consists of a physical examination, careful history taking, and imaging.¹⁸ History and physical examination findings consistent with glenohumeral arthritis include a gradual onset of pain with decreased ROM,¹⁹ weakness, and subjective feelings of grinding and/or instability.²⁰ For imaging, plain radiographs are typically collected first, including a true anteroposterior, scapular lateral, and axillary lateral view²¹ (Figure 44-1). Radiographic findings consistent with glenohumeral arthritis (GHOA) are then graded utilizing the Kellgren-Lawrence classification system.²² Stage I changes indicate a normal radiograph, stage II changes indicate joint concentricity with minimal loss of joint space, stage III changes indicate early inferior osteophyte formation with moderate joint space narrowing, and stage IV changes indicate a loss of joint concentricity with severe joint space narrowing and osteophyte formation.¹⁸ In our practice, patients often also receive either computed tomography or magnetic resonance imaging (MRI) to further assess eligibility for the CAM procedure.²³

FIGURE 44-1 Radiograph of a right shoulder prior to undergoing the CAM procedure.

Various signs of moderate glenohumeral osteoarthritis can be appreciated, including a moderately sized inferior humeral osteophyte, a mild inferior glenoid osteophyte, loose bodies, mild joint space narrowing, and subchondral sclerosis.

After diagnosis of symptomatic glenohumeral arthritis, patients are typically treated with nonsurgical modalities including occupational and lifestyle modifications, physical therapy, nonsteroidal anti-inflammatory pain medications, and intra-articular corticosteroid injections.²³ In patients with persistent symptoms after nonsurgical management, surgical intervention in the form of anatomic total shoulder arthroplasty, reverse shoulder arthroplasty, hemiarthroplasty, or comprehensive arthroscopic management is recommended, depending on the decision-making process detailed later.

INDICATIONS

The CAM procedure is typically indicated over other surgical treatments in young patients with moderate to advanced glenohumeral arthritis who live active lifestyles and are looking to delay joint replacement.²³ Regarding age, previous studies suggest that total shoulder arthroplasty has increased rates of complications such as implant loosening, osteolysis, and polyethylene wear in patients younger than 50 years.²⁴^, ²⁵ ^and ²⁶ Furthermore, results after hemiarthroplasty remain suboptimal, with a recent study on the outcomes following hemiarthroplasty in patients younger than 60 years showing that a third of the patient population required revision surgery at less than 5 years after primary surgery.²⁷ This study reflects a trend in hemiarthroplasty outcomes research, with reported results ranging from a >80% success rate to a >90% failure rate, suggesting that results after hemiarthroplasty in young, active patients are inconsistent.¹⁴^,²³ Studies suggest that total shoulder arthroplasty and hemiarthroplasty have suboptimal outcomes in younger patients, whereas studies of arthroscopic management of glenohumeral arthritis have found that patients older than 50 years have an increased risk of early progression to total shoulder arthroplasty. Integrating rates of surgical complications, revision surgery, and death after shoulder arthroplasty and CAM, a Markov decision model found that CAM was preferable in patients younger than 47 years, whereas TSA is preferred in patients older than 66 years.²⁸ Thus, age is an important consideration in the indication of CAM over total joint arthroplasty or hemiarthroplasty, with previous research suggesting that younger patients would benefit from CAM more so than arthroplasty.

Particularly in patients with a high activity level, surgical management of glenohumeral arthritis with CAM over arthroplasty should be considered. It has long been posited that manual laborers and active patients have inferior outcomes after arthroplasty, due to increased demands on the arthroplasty components.²³^,²⁹ Recent systematic reviews of outcomes after total shoulder arthroplasty identified strong correlation between heavy labor occupations and poor postoperative outcomes,³⁰ with patients in heavy labor occupations returning to work at a low rate.³¹ However, studies of arthroscopic management of glenohumeral arthritis have found high rates of return to sport and work after the procedure, suggesting that CAM is preferable in patients with a high activity level and/or occupational demands.¹⁴^,³²

CONTRAINDICATIONS

Comprehensive arthroscopic management is not recommended in patients over the age of 65 years with less than 2 mm of glenohumeral joint space (Figure 44-2A and B), loss of glenoid or humeral head concentricity, or Kellgren-Lawrence grade IV osteoarthritis.²³ In recent studies of outcomes after the CAM procedure, decreasing joint space, higher Kellgren-Lawrence grades for osteoarthritis, and joint incongruities, such as Walch B2/C glenoids and humeral head flattening, were significantly correlated to failure after the procedure.¹⁵^,³² These studies built upon previous research performed by Van Thiel et al³³ and Weinstein et al,¹¹ which found that failure after arthroscopic management of glenohumeral arthritis was correlated with the presence of large osteophytes, joint space of less than 2 mm, bipolar lesions of the glenoid, and diffuse flattening of the humeral head. CAM is also not indicated in patients with severe rotator cuff pathology,²³ such as irreparable rotator cuff tears. Patients with rotator cuff arthropathy may be contraindicated if superior escape of the humerus with or without acetabularization of the acromion is present.²³ Similarly, inflammatory arthritis is a contraindication due to associated rotator cuff dysfunction and joint incongruity.²³^,³⁴ Patients should be excluded from consideration for the CAM procedure if nonsurgical treatment has not been attempted or their glenohumeral arthritis is considered mild.²³

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