38.1 Goals of Procedure

Glenohumeral osteoarthritis (GHOA) is a debilitating condition that can lead to shoulder pain, loss of function, and decreased quality of life. ¹ Cadaveric studies have demonstrated that the disease prevalence may be as high as 20 to 30% in patients older than 60 years. ² When nonoperative treatment fails, many patients seek surgical options for palliation of their pain and to improve their function.

Traditionally, surgical treatment for shoulder osteoarthritis with an intact rotator cuff is prosthetic joint replacement with either total shoulder arthroplasty (TSA) or hemiarthroplasty (HA). Arthroplasty options in this setting have the benefits of pain relief and functional improvements with good to excellent patient-reported outcomes, predictability, and durability. ³ In recent years, the number of TSAs performed has increased. In 2008, approximately 27,000 TSAs and 20,000 HAs were performed. ⁴ This increased to 30,000 TSAs and 15,000 HAs in 2011. ⁵ However, there remains a subset of patients with symptomatic GHOA in which shoulder arthroplasty may not be ideal or desirable. This is especially true in relatively young and active patients, manual laborers, or those with high demands for the upper extremity. ^{6 , 7} This patient population may benefit from arthroscopic and minimally invasive treatments for shoulder osteoarthritis in an attempt to relieve pain, restore function, and preserve the native anatomy. ⁸

This chapter presents the Comprehensive Arthroscopic Management (CAM) procedure, which was developed as a minimally invasive surgical intervention to address shoulder osteoarthritis arthroscopically. This is a joint-preserving procedure that attempts to surgically address the pain generators in GHOA, thereby decreasing patient pain and improving quality of life. Ultimately, the procedure strives to avoid or delay shoulder arthroplasty without compromising the local bony or soft-tissue anatomy in the event that an arthroplasty becomes necessary at a later time.

38.2 Advantages

The CAM procedure aims to address known pain generators about the shoulder with minimally invasive surgical techniques. The components of the CAM procedure include arthroscopic glenohumeral joint debridement, loose body removal, chondroplasty, synovectomy, inferior humeral osteoplasty, axillary nerve neurolysis, and capsular release when indicated. Subcoracoid decompression, subacromial decompression, and biceps tenodesis are also frequently performed when indicated.

38.3 Indications

Indications for the CAM procedure include patients with advanced symptomatic GHOA who are young, active, or desire joint-preserving treatment. Patients with osteoarthritic changes on either the humeral or the glenoid surface and who have failed an extensive course of nonsurgical management including activity modification, anti-inflammatory medications, physical therapy, viscosupplementation, or corticosteroid injections are good candidates for the CAM procedure ( Table 38.1 ).

38.4 Contraindications

Patients should not undergo CAM procedure if they are found to have mild or early-stage osteoarthritis or have not attempted conservative measures. Additional contraindications include severely incongruous joint space and severe deformity. Relative contraindications include less than 2 mm of glenohumeral joint space, acetabulization of the acromion, and significant superior humeral head migration. ⁹ Other factors that are often present and may lead to slightly inferior outcomes are severely limited passive glenohumeral motion (especially internal rotation), large osteophytes, bipolar chondral lesions, low critical shoulder angle, Kellgren–Lawrence grade III or IV arthritis, and Walch type B2 or C glenoid changes ( Table 38.1 ). ^{10 – 12} However, the CAM procedure does seek to arthroscopically address some of these clinical, physical examination, and radiographic findings.

38.5 Operating Room Setup, Preoperative Preparation, and Patient Positioning

An interscalene nerve block is used for postoperative analgesia. After induction of general anesthesia, the patient is positioned in the beach-chair position (Tenet T-Max Beach Chair and Spider arm positioner; Smith & Nephew, Memphis, TN; Fig. 38.1 ). The surgeon then performs an examination of the surgical and contralateral shoulders; in particular, the range of motion (ROM) is assessed for deficits. Capsular contractures resulting in an ROM deficit, which are noted on the examination under anesthesia, of more than 15 degrees in any plane are consistent with capsular contracture and may warrant the addition of a capsular release to the procedure. Loss of shoulder abduction is consistent with the inferior humeral osteophyte (known as the “goat’s beard”; Fig. 38.2 ) and resection/osteoplasty of this region improves movement in this plane of motion ( Fig. 38.2 ). ¹³

A dynamic fluoroscopic examination is then undertaken using intraoperative fluoroscopy. Prior to sterile preparation, the surgeon should ensure that the humeral head osteophyte can be completely visualized utilizing fluoroscopy of the shoulder in both internal and external rotations of the humerus ( Fig. 38.1 ). Standard preparation and draping are performed, to include sterile draping of the C arm, such that adequacy of osteophyte resection can later be radiographically confirmed ( Fig. 38.1 ).

38.6 Operative Technique

Standard arthroscopic portals are placed, including a posterior viewing portal (~2 cm inferior and 2 cm medial to the posterolateral corner of the acromion) and an anterosuperior working portal through the rotator interval. The procedure is performed with visualization using a standard 30-degree arthroscope. We avoid entry into the subacromial or subcoracoid spaces and do not release the capsule until after the inferior humeral head osteophyte is resected to avoid fluid extravasation. Similarly, the axillary nerve neurolysis and capsular releases ( Fig. 38.3 ) are performed prior to entry into the subacromial space to avoid excessive extravasation, as this makes surgical intervention in the inferior capsular recess difficult and potentially dangerous.

38.6.1 Diagnostic Arthroscopy and Extensive Debridement

Upon entry into the glenohumeral joint, and after establishment of the standard viewing and working portals, a diagnostic arthroscopy is performed to evaluate the humeral and glenoid articular surfaces, the labrum, biceps tendon, rotator cuff, and capsuloligamentous structures. An extensive debridement is performed including loose body removal, chondroplasty, and synovectomy ( Fig. 38.4 , Fig. 38.5 ). Following debridement, preparation for microfracture of any small focal chondral lesions with stable chondral borders is undertaken. Microfracture is generally not performed until just prior to leaving the joint, and thus the nascent clot is not disrupted. ⁹

Chondral loose body removal is facilitated either by morcellation with an arthroscopic shaver and suction or by removal with an arthroscopic grasper ( Fig 38.5a). Chondral surfaces that are unstable are stabilized via chondroplasty using a mechanical shaver. After addressing loose bodies ( Fig. 38.5 ) and the chondral surfaces of the glenohumeral joint ( Fig. 38.4 ), exuberant and hypertrophied synovitis can be addressed utilizing the radiofrequency (RF) electrocautery. The RF device is also utilized for release of rotator interval adhesions. The capsule is preserved at this point so as to avoid excessive fluid extravasation.

The long head of the biceps tendon is carefully assessed arthroscopically. In particular, the tendon is pulled into the joint with an arthroscopic probe and the length of the visualized tendon is examined for fraying, splits, tears, and tenosynovitis. When there is severe long head of the biceps tendon degeneration, biceps pulley incompetence, an hourglass deformity, or a superior labral anteroposterior (SLAP) injury, the long head of the biceps tendon is released and a tenodesis is subsequently performed after all the arthroscopic work is completed. Our preference is to perform a mini-open subpectoral biceps tenodesis with unicortical fixation with a polyetheretherketone (PEEK) tenodesis screw (Arthrex, Naples, FL) near the conclusion of the procedure.

Related posts:

45 Posterior Glenoid Wear in Total Shoulder Replacement: Eccentric Reaming 48 Convertible Components in Shoulder Arthroplasty 53 Internal Latissimus Transfer for Reverse Shoulder Arthroplasty 43 Stemless Anatomic Shoulder Replacement 47 Bone Grafting for B2/B3 Glenoid 39 Deltopectoral Approach for Shoulder Arthroplasty

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