I'd like to thank AOSSM for the opportunity to present our instructional course lecture on arthritis in the young patient. I'm going to talk to you a little bit today about arthroscopic management of shoulder arthritis in the young patient. I'm Dr. Brandon Erickson coming to you from New York. I apologize very much that I could not be there for this. This is certainly my favorite meeting of the year. I apologize I had to step out early. And so I have no disclosures that are relevant to this particular talk. The game plan for this is we're going to discuss pretty much all the options that we have for how to treat these patients arthroscopically and we'll kind of decide if there's a best option. And we'll also look at some of the current evidence that's out there, what the outcomes are and what we should be doing in these very challenging patients. So this is really our problem. We start to see a 40 to 45 year old patient that comes in with early arthritis in their shoulder. Maybe they're having some other symptoms that go along with it, aside from the dull ache. Maybe they're having pain with overhead maneuvers. Maybe they're having a lot of bicep symptoms, but this is a challenging problem to treat. And while I love doing this surgery, I very much think that a total shoulder arthroplasty is a very effective procedure, especially now that we've come out with stemless designs. I really like using the stemless eclipse here and I really like using the new augments that have come out. And a lot of systems have these available and so we can really correct a lot of deformity here. The problem with this is we know that this is going to wear out at some percentage per year over time. And if you look at some of the data that's been out there on this, you can see that there's about a 1 to 1.5% rate of symptomatic glenoid loosening per year. So this is relevant because we know that the earlier we put in a shoulder replacement, the higher the likelihood is that it's going to wear out and they're going to need a revision surgery. And so we know that a revision rate happens at a little bit less than 1% per year. So if you put a shoulder replacement in somebody who's 40 and they live to be, let's say 85, well there's a 45% chance that they're going to need a revision at some point. The issue with this is that their risk of having a revision or symptomatic loosening doesn't actually get better with time. So this 1% chance per year goes with them throughout their entire course of their life. So it's not like if we can get them to 75 years old or 60 years old or 70 years old, they're good. They're going to be good long term. That's not the case. The risk of needing a revision still happens every year. So you have to really be careful with this in these patients. So we don't want to jump to a total shoulder arthroplasty in young patients because we know that they have a much higher risk of needing a revision. So what can we do? How do we get these patients pain relief? These patients that come in with crepitation and loss of motion and bicipital symptoms, what do we do? Well arthroscopically, we can certainly do something as simple as a joint lavage. I'll tell you, I've never done a joint lavage in practice, but it's something that's reported. We see a lot of studies about this for the knee, comparing just a lavage to a meniscectomy, etc. And this is an option for the shoulder. I don't really think this is something that you should consider, but it's an option. The other option is you can remove loose bodies if this is something that's happening in the shoulder and they have loose body symptoms. Their only symptoms are that they feel like there's a joint mass in their shoulder. Well it's an option to go in arthroscopically and just take out the loose bodies. But I'd probably do more than that if you were in there. There's probably other things you should address at that same time. It'd be very unlikely that all of their symptoms were coming from one single loose body in their shoulder if they were starting to have early arthritis in their shoulder. So what else do we have? Well we know that the biceps tendon is a big pain generator in the shoulder. So certainly we can consider an isolated biceps tenotomy or tenodesis. And I would generally tell you in these patients that they should be getting a tenodesis because these are young, healthy patients, very active. And so in these patients we generally perform a tenodesis. You can see a lot of times when you have a significant amount of swelling and pain around the biceps tendon, the tendon gets significantly thickened. So this is a very significant source of pain for these patients. And oftentimes if you can take care of the biceps, you can buy them some period of time before they need to have something else done. The problem is you take a look here when you go in and look at their shoulder to do this biceps tenodesis, you see this glenoid and there's not a lot of cartilage there. So you know that you're going to buy them some amount of time from that biceps, but you know they're not going to have a perfect shoulder after this. And you can see here when we do our kind of mini open sub-pectenodesis, that biceps tendon can really look like trash. And you can see that if you were just looking at this tendon from inside the joint, you'd miss a lot of that inflammatory tissue here. So even if the tendon looks pretty good intra-articularly, you have to do a good preoperative exam to understand whether or not they have groove pain, whether or not they have, you know, kind of that three-pack of symptoms that Steve O'Brien talks about. Because a lot of times the biceps tendon can be a real source of pain in these patients. Now this is another one just to show you, give you an idea of how thickened and just tendinotic that biceps can be from just getting beaten up over time. And when we do the biceps tenodesis, there's a lot of different ways you can do it. I personally do a mini open sub-pec, but certainly there's super pec, there's top of the groove, there's lots of different ways you can do this. But the bottom line with when you do this is you really want to make sure that you properly restore the length-tension relationship of the biceps tendon. And restoring this properly really means putting the muscle-tendon junction of the biceps at the inferior border of the pectoralis major. Now the way I generally do this is with a biceps button, okay, and this is a unicortical button, and I put two retractors in place, and this was a trick Dr. Romeo taught me many years ago. I put a pointed Holman through the pec tendon parallel to its fibers and turn this so that it hooks the humerus and basically retracts the pec out of the way. And then I place a Chandler retractor immediately because you don't want to place anything that sharp immediately. And if you need to, you can place an Army-Navy superiorly, but generally you don't need this. And with these two retractors, you can see the bicipital groove quite well. So you clean this off with an electrocautery device, and then you put your unicortical hole and you put your biceps tendon back down. And this can actually help these patients quite a bit. Now, the other thing to remember in these patients is that if they have some biceps issues, they can also wind up with an upper border subscap issue. And so generally in these patients, I'm pretty aggressive in fixing an upper border subscap tear, but I'm very meticulous in making sure that I don't over-constrain them because one of the issues with these patients is obviously they're very tight and you don't want to fix the upper border subscap with their arm in neutral rotation because you're going to over-tighten them. So if you're going to fix this, you really want to make sure that you put their arm in 30 degrees of external rotation when you put your anchor in to avoid over-tensioning them. And so we kind of talked about the lavage, the loose bodies, the biceps tenodesis, plus minus looking at that cuff, but the main option I would tell you for this and the one that has the most data and the one that kind of makes the most sense is doing a CAM procedure. And this was popularized by, you know, Dr. Millett, by Peter Millett. And this involves a combination of a glenohumeral chondroplasty, taking out any loose bodies, taking out any osteophytes that are there, doing a circumferential capsular release, as well as potentially an axillary nerve neuralysis, and then performing a biceps tenodesis, and of course a distal clavicle excision, you know, if this is needed based on their preoperative symptoms. And this is what it looks like when you do the CAM procedure. You can see here pulling the biceps tendon in, you can see the lipstick sign that we see in all of these biceps tendons we're very familiar with. You can see here getting low on the humerus, starting to take away some of that osteophytic bone that's down there, and then performing your capsular release, and it's in this area that you can generally perform your axillary nerve neuralysis, which is not something that I commonly do when I do the CAM procedure. Then you can go above and do your decompression, you know, making sure you get a nice flat acromion surface, and then you see how these patients do. And to the point of, is there a best option based on what I just told you, there's not a lot of data out there on a lot of these different procedures in patients who have glenohumeral arthritis. So I would tell you, sometimes it's kind of a coin flip on what you're going to do. For me personally, I do think the CAM procedure is probably the best option in these patients. You take care of the most pathology in the shoulder, and so while you can do the other surgeries that I discussed with you, I do think the CAM procedure is probably the best option for these patients, because it takes care of several different things. Now if we look at a lot of the data that's out there on this, a lot of the data has really come out of a single person, and it's Dr. Millet, because he's the one who's published the most on this. And it was back in 2013 that he kind of put his first study out on looking at the results of 30 shoulders that had end-stage glenohumeral arthritis that had a CAM procedure, and these were patients between their 30s and their 60s, the average age was about 52, and the majority were men, as you'd expect, because of the arthritis. Now of the 30 shoulders that he included, 6 went on to needing a total shoulder arthroplasty at an average of 2 years after surgery. So it was somewhere between 1 to 3 and a half years after surgery, so a pretty high rate had to progress, so 20% wound up progressing. And what he saw was, was that patients that had less joint space preoperatively, so those with more significant arthritis, were more likely to need a shoulder replacement. And this makes intuitive sense. If you take a look here at what the kind of procedures that he did during his CAM procedure, looking a lot at, of course, the debridement and the capsular release, the loose bounties, the synovectomy. He did a microfracture in a few patients, axillary nerve release in, you know, a little less than 25% of patients, and then, of course, the decompression. And interestingly, didn't do a bicep stenodesis in many, only did that in 8 of the 30 patients. For me, I would have thought this would have been a little bit higher, because for me, I'm very much a biceps killer, it's how I train, it's what I've been doing in practice since I've started, and I've found it to be, you know, very effective over the last several years. And so for me, I like doing a biceps stenodesis, so I probably would have done a higher percentage than what they show here. Now, if you take the shoulders that did not go on to needing a replacement, which was 24 shoulders, they found that actually these patients did quite well. Their ASES scores went up, their pain levels went down, their median satisfaction went up, and basically they showed that there was a 92% survival rate at a year, and 85% at two years. And what they found was that the patients that had larger osteophytes actually had greater improvements in postoperative major motion, but interestingly, they were less satisfied. And I've actually seen this in a few patients that I've done this surgery on, because when you get them more motion doing this CAM procedure, their shoulder cracks more, and they have a lot more crepitation. And while it doesn't necessarily hurt them to move the shoulder, they are uncomfortable with the amount of cracking and clicking that the shoulder has. Once their shoulder motion was limited for so long, they actually haven't noticed how much cracking and crepitation their shoulder could have. So when you improve their motion, you resect their osteophyte and do a capsule release and you gain the motion, you think you're doing a great job for them, they're happy with their motion, but they don't always love the crepitation, which is something you have to talk to them about preoperatively that I've learned over time. You can see here, in regards to their range of motion, they had a significant increase in their elevation and rotation from pre to postoperative. And actually, these patients maintain that improvement pretty well. They lost a little bit of the rotation, but from a forward elevation standpoint, they really did quite well after the capsule release and osteophyte resection. So you really can get these patients quite good motion after this. And this is similar to what we know, because when we're doing our shoulder arthroplasty and we're doing our releases and we're taking out the osteophytes, we generally get very good motion afterwards. And so this is just doing it, but in an arthroscopic manner. Again, if you're looking at the pre to postoperative outcome measures, you can see patients did quite well. Their pain got better. Their ASES and SF scores got better, and their limitations because of their shoulder got better as well. They didn't feel like their shoulder limited them in as many things in regards to what they were doing. Now, Dr. Millett then followed this up with a 10-year follow-up study. So looking at 38 patients that had a CAM procedure and a mean follow-up of 10 years, again, age was about 53 for an average range from 27 to 68. And what they found was that five years, 75% of these patients actually had not had an arthroplasty yet, and at 10 years, about 63%. So that's pretty good if you're thinking about trying to buy people a little bit of time. If you're thinking in your head, okay, I bought them 10 years, that means there's a 10% less risk that they're going to fail from the shoulder arthroplasty that I did. That's pretty good if you can do that. And what they found was, again, that patients that did progress to an arthroplasty did so at about four and a half years after surgery. And these are some patient characteristics that you can see here between the patients who did well from their CAM surgery and the patients that didn't. And what you'll see really is that when you get down to less joint space, less incongruity between the humeral head and the glenoid, these were significant risk factors for not doing well. And of course, worst classification from the Walsh perspective, they did not do quite as well also. So from a CAM failure perspective, this is kind of associated with severe preoperative humeral head incongruity that we just kind of talked about in regards to failure. So if they're very incongruous beforehand, you may not want to even attempt the CAM procedure. They're probably not going to do great. And these are just some kind of, if you look here, these are just concomitant procedures that they looked at versus CAM survivors versus CAM failures. And from a percentage perspective, you can see the survivors, only 42% had a long head of the biceps tenodesis. The failures actually more of them had a tenodesis, which is interesting to me. Otherwise, not really any significant differences for any of these. And if you take a look at the outcome parameters, just looking at how the survivors did, they actually did quite well from a functional outcome perspective. And so the question is, which of these patients are going to fail, right? So we don't want to do unnecessary surgery on people when they're not going to get better. And so if you look at Dr. Mills' study back in 2017, just looking at preoperative factors that were predictive of treatment failure in regards to the CAM procedure, they looked at 107 shoulders and a mean two-year follow-up, and again, majority men, and what they found was that 15% progressed to a total shoulder and an average of two years. And they came up with kind of this population tree here. This is kind of how their inclusion-exclusion criteria looked. And what they found was from a radiographic perspective was that more arthritis, so less preoperative joint space, a higher Kelvin-Lawrence grade, older age, and Walsh B2 and C-type glenoids were much more likely to fail a CAM procedure, okay? So again, worse arthritis, they're not going to do quite as well. And you can see here when you're looking at successful versus failed CAMs, again, you're getting into less joint space, higher KL grade, more significant Walsh classification. These are all significant risk factors for failure. When you look at some of the demographic issues, the age actually was a higher risk factor for failure. So if they were a little bit older, they had a higher likelihood of failing a CAM procedure than if they were younger, which is a good thing because we really want the CAM procedure to work very well on our younger patients. And you can see here, this is kind of the algorithm that they made up here looking at their decision tree. So older patients, higher KL grade, less joint space, probably going to be better served with a total shoulder. Younger patients, more joint space, not quite as significant deformity of the glenoid, they're much better candidate for a CAM procedure. Now, the other question we have to think about is, are we negatively impacting our outcomes after a total shoulder if we're going to treat these guys arthroscopically to start off? And so this really is very important because we want to make sure we're not causing a problem down the road by trying to buy them a year or two. So if we're only going to save them a 2% or 3% risk of the glenoid loosening, but they're going to have a much higher complication rate after their total shoulder, well, that's not really worth it. And so if you look at this case control study here, again, of course, by Dr. Millett, he looked at 19 patients that had a CAM procedure followed by a total shoulder, and then 37 patients who just had a primary total shoulder and matched them based on age, sex, grade of osteoarthritis, et cetera. And so what they found was that four patients failed their total shoulder. One of those had a prior CAM surgery, and three had no prior CAM procedure. And they didn't see any difference between postoperative ASES, SANE, or quick dash scores, and they didn't see any difference in surgical time between patients that had had a prior CAM procedure and those that did not. So it did not significantly increase their risk of failure. It didn't increase the amount of surgical time, and it did not increase their risk of having a poor clinical outcome after a total shoulder based on whether or not they had a prior CAM procedure. So at least from a progression to shoulder arthroplasty perspective and a risk of failure after shoulder arthroplasty perspective, doing a CAM procedure does not negatively impact your results down the road. So this is at least something we can hang our hat on and say, at least we're not harming these patients by doing this CAM procedure. Even if it doesn't work, we didn't make them worse by doing it. We didn't run the risk of compromising their total shoulder down the road because they're likely going to need one, but we didn't run the risk of having them fail that surgery afterwards. So the bottom line with this is shoulder arthritis in young patients is a very difficult problem. There's a lot of different surgical options for this. We talked about the arthroscopic ones here. You'll hear Matt talk about other ones. You'll hear Sam talk about doing a shoulder arthroplasty in a little bit. But there's a lot of treatment options, but it's a very difficult patient population. From an arthroscopic procedure perspective, the goal is basically to delay shoulder arthroplasty. And we can do that with our CAM procedure, provided we're not dealing with patients that have a significant amount of shoulder arthritis beforehand. We just know that if patients start off with a really, really bad shoulder and we progress and we try to do something like an arthroscopic lavage or a CAM procedure or a biceps, there's a high likelihood that they're going to fail. Now, if they fail in five years, that's great. We bought them five years from needing their shoulder replacement. But if they fail after a year, you can really question whether or not you did them a service or a disservice. Again, you don't make them worse off from their shoulder arthroplasty after the CAM procedure, but you didn't make them significantly better and you put them through a surgery and a rehab. So it may or may not be worthwhile to do that. And patients have to understand that really the goal of these arthroscopic procedures is to improve their pain, right? These are not going to eliminate their pain. We are not going to hit the home runs that we hit after a total shoulder, after I showed you that anatomic total shoulder at the beginning here. We're not going to hit that home run with these arthroscopic procedures. We are trying to buy them time to let them do the things they want to do, whether or not they're a crazy CrossFit athlete and they want to continue to bench 450 pounds and they want to continue to do squat jerks and snatches and clean and jerks. And we don't want to run the risk of hurting our total shoulders and we want to get them some pain relief. This is a good option for those patients. It's not going to make them pain free, but it can help improve their function. So here are some references in case you had any questions about some of the bicep stuff we were talking about. This is an interesting app that we've kind of started to look into recently. It's actually a pretty good chat forum for discussing interesting cases or issues that come up. It can help with your resonance when you're teaching resonance and things like that. It's just for surgeons, so you have to have an MPI number to get on it, so you can share cases pretty securely here. So thank you very much for your time. I'm interested to hear what Matt and Sam and Dr. Romeo have to say, and I have to of course give a big shout out to my wife and daughter. Certainly without my wife doing the lion's share of the work taking care of our beautiful now 16 month old daughter, I certainly wouldn't be able to chat with you guys today. And so I'm very much looking forward to the discussion. I'll certainly be available through the telephone to chat.

arthroscopic management

shoulder arthritis

young patients

total shoulder arthroplasty

CAM procedure