I really enjoyed that session and learned a lot from the authors and presenters, so thank you. I've been asked to talk about decision making in the young arthritic patient. This is something that I've been studying for many years and it's something near and dear to me. My disclosures are on the Academy website. I am a consultant, receive royalties from Arthrex, and you see the other disclosures there as well. This is a typical case. This is a patient who came to see me. He's a mixed martial artist, fighter, world champion, and he wants to continue doing this for a living. You can see, obviously, he needs his shoulder in order to do this. This is what his x-ray looks like. He's 40 years old. He's had a prior labral repair and he has this degenerative arthritic shoulder with large osteophyte and has a lot of pain associated with this and restricted range of motion. So we'll come back to that case later on in the presentation. But I think when you're treating these young patients, it's really important to think about the etiology of their arthritis. What's their anatomy and pathoanatomy? What are their symptoms? Is it pain? Is it a functional limitation? And what are their expectations? You have a patient like that who has high expectations. He wants to go back and compete at the highest level of sport. And then you need to think about the durability of what you choose, future options, because most likely these are bridging procedures, and then salvage. You certainly don't want to make anyone worse or make the total shoulder replacement significantly more difficult later on. So for focal defects, this is usually pretty straightforward. Obviously these can be treated in a variety of different ways. I think microfracture works pretty well. This is something I learned from Richard Stedman when I was a fellow with him, and I looked up Dr. Hawkins' results. And we found that we had significant improvements with these. It was better when it was on the humerus, then glenoid, then combined lesions did the worst. This is just an example here of a patient with a focal defect, preparing the defect. And then we use a motorized pick to drill and remove the calcified cartilage layer and perform a microfracture. In this type of lesion you can also advance the labrum into it as well to decrease the surface area. These are some second looks. These were Dr. Hawkins' patients many years ago, but you can see how you get the fibrocartilage covering the humeral head in this case. What do you do when there's bone involvement? I think this is an example of a patient, a 20-year-old with an OCD lesion, had removal of loose body, still has significant catching. I think these are the difficult types of Hill-Sachs defects when they're more central. You can't advance the infraspinatus into this. So what do you do and how do you preserve the joint? In this case, this is an example of one that's more central, large Hill-Sachs, and in this case underwent Oates grafting with an osteoarticular allograft. Here you can see that resurfaced. You could also use a partial prosthetic replacement as another option for this type of focal defect. This is a little bit older patient with a more arthritic joint, but a good glenoid. Diffuse disease, I think, is the more difficult situation. Here's some examples. This is a fireman here, or an iron worker actually, who has difficulty with his right shoulder as a severely arthritic shoulder with a very large inferior osteophyte. You see a paraplegic swimmer here with difficulty mobilizing for transfers because of shoulder pain. Total shoulder arthroplasty can certainly be great. This is a patient of mine who's after a total shoulder arthroplasty, anatomic replacement. You can see his function is normal. He's back rock climbing, very, very happy. I think it can be durable, but it's obviously concerning in these young patients. We know, as Dan Haber talked about, the longevity of the implants is a concern. Glenoid component loosening, revision total shoulder arthroplasty also has less optimal outcomes. These salvage procedures can be more difficult. We did a decision analysis looking at arthroscopy versus total shoulder arthroplasty using the best available outcome data we could come up with based on the literature looking at these young patients with osteoarthritis. What we found was above age 66, arthroplasty was clearly the preferred strategy. Below age 47, arthroscopy was preferred. But for this middle group, either could be reasonable. So there's a large middle group where I think depending on the patient factors, you may choose one or the other option. If we're going to choose joint preservation, what are we looking at and what can we achieve? I think we want to try and eliminate pain. We want to try and restore motion. Some of the patients come in and their only complaint is really functional. We'd like to delay the need for a total shoulder arthroplasty in a younger, active patient. We also want to be careful that we don't compromise a future total shoulder arthroplasty. If you've ever had the opportunity to do a total shoulder after some of the joint preserving procedures that have been performed, they can be very, very challenging. So I started thinking about what are the major pain generators. We know that obviously the cartilage and the loose bodies and the chondral injuries and synovitis, impingement can all be addressed arthroscopically. What about these large inferior osteophytes? They can impinge on the axillary nerve. Most of the patients who come in with shoulder pain usually present in the area of the axillary nerve distribution with posterior shoulder pain and lateral shoulder pain. And I started looking at this and then we did some studies looking at what happens to the axillary nerve. And we showed that the axillary nerve actually gets displaced by this spur. And we correlated this with Terry's minor atrophy, using Terry's minor as a surrogate for axillary nerve entrapment. We didn't have EMGs on these patients, but the Terry's minor was also atrophied, suggesting that the nerve is experiencing some dysfunction. So we developed this procedure called a CAM procedure for comprehensive arthroscopic management. We came up with this acronym because I didn't want to write all this stuff on the booking slip when I had to schedule the surgery. So we just said CAM procedure, which was an extensive debridement, chondroplasty, synovectomy, removal of loose bodies, capsule release, plus this fluoroscopically and arthroscopically guided resection of the goat's beard deformity. The thinking was we could increase their abduction, which is a major problem that these patients experience. And we had either direct or indirect decompression of the axillary nerve. Here's an example. This is the inferior humeral head. This is viewing from posteriorly. Dan Haber showed this nicely as well. But you can see how you can create this in accessory posterior inferior portal, and then you can take off the inferior goat's beard deformity. Working from posteriorly, we usually use a shaver. I don't like to use burrs in this space. And then we can remove loose bodies and debris using a pituitary ronger and curettes working from posteriorly. You can see how close the axillary nerve can be. This is a case here where you can see we've resected it. We're using the curette to reach the anterior inferior point of the shoulders, the most difficult part to reach with the shaver. And you can see the axillary nerve is just under the capsule there. So obviously this can be encroached upon by these spurs and cause pain in these patients. Peter, can I just ask you a question? Do you ever do an accessory portal and put a retractor in, like a switching stick, like we do in elbow arthroscopy in these cases? I usually preserve the capsule so that the axillary nerve is protected throughout the procedure. In that case, the capsule was partially disrupted. But I think that would be an option if you're worried about it to put something in. But usually I try and preserve the capsule. Originally when I was doing them, I actually took the capsule down first thinking I'd have more space. But it actually makes it more difficult to view. So I actually, sometimes I have to shave out all the synovium, put the scope in the front and shave out all the posterior synovium first so that I can actually see in the axillary recess. But I want to have good visualization with the capsule intact. So this is the guy with bilateral osteoarthritis. He had six weeks on the right. And you can see his left side is diminished. The predictors of failure, we started to look at this now that we have larger numbers. This was a series of 100 patients. We found, as Dan showed, age greater than 50, higher Kellgren-Lawrence scores, less than two millimeters of joint space, and then WALCH B2 or C glenoids were worse. Early failure, as I mentioned, was significant with these four items here. So we look at that carefully now. This is the 10-year outcomes data, which was, Dan presented nicely, 63% survivorship. These were patients who otherwise would have met the radiographic and clinical criteria for a total shoulder arthroplasty. So I think it's pretty decent. We wondered at our earlier data points whether patients were just coping. But at 10 years, I think if they're still doing okay, then it's probably indicative that they're not just coping, that it actually improved them. As I mentioned, we don't want to compromise anything for the future. So we looked at patients who converted to a total shoulder after a CAM. And we did a comparison study with 42 patients and 21 that had CAMs that failed and went on to a total shoulder arthroplasty. And we didn't find any significant difference in the outcomes after the total shoulder arthroplasty. There's other options, glenoid bioaugmentation, which has had results that were mixed historically, a variety of grafts, plus or minus a hemiprosthetic replacement. The literature has results that showed it didn't work so well. Other results have shown that it worked well. So I think that the data is still out on this. Most of us, I think, have moved away from some type of bioresurfacing. We've looked at using kind of biologic total shoulder arthroplasty. We've shown that the medial tibial plateau actually can be a good source for a glenoid. The radius of curvature matches actually pretty well to the glenoid surface. So we can use this in a snowman-type graft or other types of instrumentation may be able to allow us to do large grafts. We don't know if this would impact glenoid fixation for a total shoulder arthroplasty later. Biologic total shoulder arthroplasty is something that's been looked at. Ruben Gobizzi had a series where he did a partial replacement of the humerus with an arthroscopic implantation on the glenoid. They had pretty good results in 20 patients, but they had 20% that failed and were converted to a total shoulder arthroplasty. So I think this is not quite as good as what we're getting with our CAM procedure. But it is kind of hopefully the future that we'd be able to do some type of biototal shoulder arthroplasty. So coming back to that case example that I started with, this is the fighter. You can see here his preoperative imaging. Here's his postoperative resection with a biceps tenodesis as well. And here he is at two-year follow-up. He's been able to restore his mobility to his left shoulder, which is the one we operated on, and he's been able to get back to competitive levels of mixed martial arts fighting. So in summary, my approach is for focal defects, I'll perform a microfracture. If it's a focal osteochondral lesion, I'll use a fresh graft or sometimes a partial prosthetic replacement. For diffuse disease, if they're young, joint preservation. More advanced, I usually do a total shoulder arthroplasty, rarely a HEMI. Again, thanks a lot to the AOSSM and Anna for inviting me and giving me this opportunity to share my experience. Thank you.

decision making

young patients

arthritis

treatment options

CAM procedure