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IC 305-2023: Shoulder Arthritis In Young Active Pa ...
IC 305 - Shoulder Arthritis In Young Active Patien ...
IC 305 - Shoulder Arthritis In Young Active Patients - What Are The Best Options? (2/4)
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the introduction. So first we're going to discuss a little bit about how we manage these patients arthroscopically, right? So obviously arthroplasty is a great option. Sam will tell you about that. Matt's going to talk about stuff that is probably over my head. But I'm going to talk to you about some of the arthroscopic things we can do in these younger patients. So the other thing we'll talk about is there a best arthroscopic option? How do I treat these patients? What do we do? And then what does the evidence show us? So the problem is this. Problem is early arthritis in the young patient, right? How do we deal with these patients? And as they continue to progress, we know they wind up at this stage at some point most of the time. And I like the surgery a lot. I love using this implant. Credit Dr. Romeo for it. It's excellent. These patients do fantastic. The problem with doing this in the younger patient is that when you start to put glenoids in younger patients, we know that there is a failure rate that has to happen with this. And if you look at some of the systematic reviews out there, and you look at quite a few patients that were included in this, what you find is that the number of radiolucent lines that happen after a total, these are not symptomatic. They're asymptomatic, but they happen at a rate at about 7% per year. And we think that as you continue to get more and more radiolucent lines, it probably portends a bad prognosis going down the road. The symptomatic glenoid loosening that they saw on this study was about 1% per year. So if you just think in your head, okay, if I'm going to put a glenoid in somebody, there's a 1% per year chance over the course of their lifetime that this is going to fail. So if I put this glenoid in a 25-year-old versus if I put it in a 75-year-old, my chance of failure by the time that 25-year-old gets to 75 is 50%, whereas at the 75-year-old, it's 0% on day one. So it's just a much different risk profile for glenoid loosening as you're younger. And so how do we try to avoid this problem of glenoid loosening? Well, there are a lot of arthroscopic treatment options that we can do for this. Certainly we've seen studies where you can just go in and do a joint lavage. If there's a loose body like this, you can go in and just take the loose body out. Sam has done a lot on biceps and biceps pathology. I believe the biceps is a pain generator. I tend to kill the biceps all the time. And so for me, a biceps tenonomy or tenodesis is a good option. I generally do a tenodesis almost all the time, but certainly this is a good treatment option. You can see quite a bit of inflammation on the biceps there. And this is what we see sometimes when we pull the biceps out. And you can see it's pretty thick and it's pretty beaten up. So you can see why this can cause these patients quite a bit of pain. And while you haven't addressed necessarily their arthritic problem, you've taken out one of the pain generators in their shoulder. Where you put the biceps, that's up to you. That can be a whole ICL in and of itself. I usually do it open subpec per Dr. Romeo's technique, but you can put it wherever you'd like. And then if we talk about, this is just what it looks like afterwards, but if you talk about what else can you do as far as a comprehensive management for these patients, you can do something called a CAM procedure. And this was popularized by some of Dr. Ventra's partners years ago. And this involves a combination of a chondroplasty of the humeral head and glenoid, taking out the loose bodies, taking off some of the osteophytes that have grown on the inferior side of the humeral head, releasing the capsule, doing a biceps tenodesis, potentially decompressing the axillary nerve, and then also doing a decompression plus minus the distal clavicle excision if they have pain. You don't need to do a distal clavicle excision in these patients if they're not symptomatic from it. My usually symptomatic test is just push over the distal clavicle, have them do a crossbody adduct in chest, have them push against you when their arm is adducted. And if that doesn't bother them, their AC joint's usually okay. So this is kind of what we look like when we're doing our CAM procedure, right. You see the biceps tending, you see the amount of inflammation that comes around it. I always like to show patients this picture just to say this is what it looked like from inside your joint. And then once we've let the biceps go and we've released the capsule, we come down inferiorly and you can start to see the inferior osteophytes that form. And you can resect these. I will tell you, I don't have quite the testicular fortitude that some of Dr. Ventra's partners do to decompress the axillary nerve arthroscopically. So I generally don't do that. But I do perform a circumferential capsule release and manipulate these patients to make sure that we can get their full motion. We always go up top, we do a subacromial decompression, and then we do our biceps tenodesis. And I'll tell you that in these patients, you'll be able to gain quite a bit of motion. And I'll show you some studies in a minute with this. But my point of saying that is you also have to educate these patients preoperatively that as they gain motion, they're actually probably going to have some increase in the crepitation in their shoulder because their shoulder is going to start to engage in ways it wasn't engaging before the surgery. So they'll start to notice that. And their pain necessarily won't go up, but they'll just notice that the shoulder clicks and pops a little bit more as they get their motion back that they haven't had in quite a bit of time. So as far as the best option for this and what the literature has borne out, the majority of the studies out there are mostly looking at the CAM procedure, you know, just an isolated biceps tenodesis and then a setting of shoulder arthritis. That can certainly take care of, again, one of the pain generating problems. But if you think about addressing as many problems as you can arthroscopically, usually the CAM procedure is the way to go. And if you look at some of Dr. Millett's early work, obviously he was the one that popularized this, what you can see is he did this starting out on 30 shoulders. About six of them went on to have a shoulder arthroplasty. And of the other 24, what he found was if you had less than two millimeters of joint space, you were probably more likely to go on and need a shoulder arthroplasty after this. But he did find a great increase in ASES scores postoperatively in these patients. Pain levels went down. Satisfaction was pretty good. And so in the short term, at the one and two year follow-up, he had pretty good survivorship at 85% for two years. And he also found that those patients that had bigger osteophytes, as you'd imagine, when you resected those osteophytes, they gained more range of motion because you've increased the amount of space within the shoulder capsule. So then they published their study out and went a little bit further out. So then they went for the 10-year follow-up of these patients. And he had 38 patients in that underwent the CAM procedure that we just talked about. And their follow-up minimum was 10 years. So you can see 10 to 14 years, pretty good follow-up here. And again, their patient age is that kind of 50-year-old range. 27 to 68, 68 is probably a little bit aggressive to start doing this on, I think. 27, obviously, a good candidate for this. But in the mid-50s was their general range for an eight-year. And you can see that at five years, their survivorship was 75%, not having progressed to a shoulder arthroplasty. And at 10 years, it was 63%. So if you say, listen, you bought somebody 10 years before they needed a shoulder arthroplasty from undergoing a relatively simple arthroscopic procedure, that seems like a pretty big win. And if patients were going to progress to an arthroplasty, the average time for them to get there was about four and a half years after surgery. So again, even if you're buying somebody four to five years after this, you're decreasing that risk of glenoid loosening by 4% to 5%, which is not insignificant if their glenoid is going to come loose. And you can see here, they kind of talked about, in their study, who survived the CAM procedure and who was a failure, right? And if you look here, you don't see much in the way of any statistically significant differences between these groups in this particular study. Certainly, some things approach statistical significance with less joint space, humeral head incongruity, things like that. But none of these actually reach statistical significance here. The patients that didn't have to have an arthroplasty in this group, their ASCS scores actually did pretty well at five years and 10 years. So you can see they maintained their improvements. They went down a little bit at 10 years, but they were still maintaining a pretty good improvement in their ASCS score. And their satisfaction was pretty good at 7.5 out of 10. So the other thing we have to make sure with these patients is that we're not causing a problem down the road, right? So if we're going to do a relatively simple arthroscopic procedure on them, trying to buy them five to 10 years, we have to make sure that we're not going to negatively impact your shoulder arthroplasty down the road. Because then buying them those five years is irrelevant if you're going to cause them a bigger problem down the road. And so they basically looked at this. They said, OK, what are some of the factors that will predict failure after this? Are we negatively impacting our total shoulder arthroplasty down the road? What they found was in this, again, more women than men in this study. About 16% of these went on to have a shoulder replacement. So some of the predictors that these patients were going to fail, like we talked about before, less joint space, higher KO grade, older patients, Walsh B2 and C glenoids. We know that B2 glenoids continue to progress if you look at some of the studies out there. Once somebody starts to develop a B2 and you start to get some posterior subluxation, that's going to continue to get worse with time. And so sometimes managing that with this particular procedure may not be the best option in that patient. This is just them going over. You can see here the difference between, again, successful and failed CAMs. And they looked at potential risk factors for failure here. And you can see the lower the joint space was, the higher their risk of failure was, the higher the KO grade was, the higher their risk of failure was. And we'll go to this next one here. And so this gets to the point of, are we going to negatively impact our shoulder arthroplasty after this? And so you can see here they had 19 patients that underwent a CAM procedure and then underwent a total shoulder and then matched them with patients who just had a total shoulder without having a CAM procedure. They did a pretty good job matching this. And again, majority male, average age, mid-50s again. They found that four patients wound up failing after their total shoulder. So one in the CAM group, three in the patients that did not have a CAM procedure, so their control group. And they didn't see any difference between ASES, SANE, QuickDash at their outcome scores when looking at the patients that had a CAM procedure before their total and those that just wound up having a total. And they didn't see a real difference in surgical time. So having had the CAM procedure before didn't make your surgery necessarily more difficult when you were doing your shoulder arthroplasty down the road. And you can see here, this goes over their basically clinical outcome scores after their shoulder arthroplasty. And you can see really no significant difference between the patients that had a CAM procedure and those that did not. So the reality with the arthroscopic management of this is shoulder arthritis is a problem in our young patients. It can be very difficult to address. There's a lot of different arthroscopic treatment options you can choose. For me, if I'm going to do this, I'm going to do the full boat with the CAM procedure. I'm going to do the best I can when I go in there, try to treat as much as I can and hope for the best coming out of it with the understanding that the higher the arthritis that they have, the less joint space that they have, the higher the likelihood of failure is. So you just have to properly counsel these patients preoperatively. And I found that if you're pretty honest with them and you're up front and explain to them what the risks are, many of them say, listen, I'd rather have this procedure than a total. You're usually doing this on patients that are the crossfit nuts, the people who just will not stop lifting. Like I'd be very nervous to do a total shoulder on Dr. Romeo, right? Because he's going to keep lifting overhead. He's the ideal patient for this because he's somebody who I can hopefully help the pain on, but I don't have to worry about his glenoid failing if I put a total in him because he's going to keep lifting. And so you just really have to make sure that you're up front with these patients. These are some good references for you down the road. Thank you. I have a quick question, Brad, and that is that you mentioned that the Bs and Cs may or may not be a good candidate. One of the things I've found is that there's some of these younger people come in with fairly significant arthritis, but they still have maintained range of motion. Do you think this procedure works very well if their motion overall is pretty good, they just have pain, or is that also a concern? So that would concern me more than if they were starting to develop some stiffness too. I worry that if they've done a good job maintaining their motion, their pain is starting to come from some of their arthritis. The other thing we need to talk about is looking at imaging beforehand. None of these studies looked at MRI scans before and looked at the amount of humeral head edema or glenoid edema or cis formation that you see. As you start to develop cis within the humeral head, cis within the glenoid, those worry me with this procedure. I would agree. Thanks, Brandon. Appreciate it. All right. So Matt's going to talk to us what we can do with our patients to try to, again, preserve the joint as long as possible. And there's a lot of new and exciting ideas, and let's see what the evidence is and how this might be able to help us out. Thanks, Matt, for being here.
Video Summary
In this video, the speaker discusses arthroscopic management for young patients with early arthritis in the shoulder. They highlight the potential failure rate and challenges of using glenoids in younger patients. Various arthroscopic treatment options such as joint lavage, removal of loose bodies, biceps tenotomy/tenodesis, and CAM procedure are mentioned. The speaker emphasizes the importance of properly counseling patients about the risks and benefits of these procedures. They also discuss research studies, including one by Dr. Millett, that show positive outcomes and increased survivorship of the CAM procedure for up to 10 years. The speaker concludes by mentioning the need for further investigation and imaging to predict patient outcomes and determine the best treatment options.
Asset Caption
Brandon Erickson, MD
Keywords
arthroscopic management
early arthritis
shoulder
CAM procedure
patient outcomes
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