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Comprehensive Arthroscopic Management (CAM)

The Comprehensive Arthroscopic Management (CAM) procedure — a joint-preserving arthroscopic alternative to arthroplasty for glenohumeral osteoarthritis, combining debridement, capsular release, osteophyte excision, microfracture, loose-body removal and axillary nerve neurolysis.

82 citationsUpdated Oct 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Comprehensive Arthroscopic Management (CAM) is a systematic, inclusive arthroscopic approach recommended for the array of pathologies encountered in early glenohumeral arthritis [2]. It serves as a joint-preserving alternative to arthroplasty for young, active patients with advanced shoulder osteoarthritis [3, 4]. The procedure reliably improves pain and function in this demographic [1, 3, 4], providing a predictable short-term option for high-demand individuals [4]. In patients younger than 50 years, arthroscopic management achieves predictably good to excellent results regardless of tear size [5]. For elderly patients with modest functional demands, arthroscopic debridement remains an excellent treatment [17].

Clinical outcomes demonstrate significant midterm improvements and high patient satisfaction, with a 76.9% survivorship rate at a minimum of 5 years postoperatively [8]. Arthroscopic debridement improved clinical outcomes in 68% of patients with advanced glenohumeral osteoarthritis [6]. However, isolated arthroscopic debridement and capsular release may not provide substantial benefit to justify its use in most patients with glenohumeral arthritis [34]. In contrast, arthroscopic glenoid resurfacing provided superior results to previously performed arthroscopic debridement in patients with failed prior debridement [28]. The combined approach of arthroscopic rotator cuff repair and microfracture of the humeral head appears to be a viable joint-preserving option for select patients with concomitant rotator cuff tears and focal humeral head cartilage lesions [24].

CAM is a reasonable option for patients with localized cartilage defects and specific radiographic findings [10]. Arthroscopic debridement is a reasonable next-line treatment if antiinflammatory medications and therapy fail in patients with small, contained, unipolar lesions, providing good short-term results and minimal complications [12]. In the absence of substantial bone loss, arthroscopic posterior capsulolabral repair remains the gold standard for symptoms refractory to nonoperative treatment, with excellent clinical outcomes generally reported [22]. Arthroscopic reconstruction provides results equal to open procedures for patients age 22 and older with recurrent traumatic anterior instability [23]. It offers a 90% success rate in patients age 18 to 23 [23] and works approximately 80% of the time in patients 18 and younger, though it is not indicated in the latter group [23]. Surgical arthroscopic repair was possible in all cases of acute or recurrent instability in soccer goalkeepers with well-defined exclusion criteria [51]. Patients with less joint space and abnormal posterior glenoid shape are significantly more likely to progress to early failure after the CAM procedure [1]. Hemiarthroplasty or total shoulder arthroplasty are feasible options for patients with humeral head incongruity or large anterior osteophytes [10]. Long-term consequences of arthroscopic debridement for massive rotator cuff tears require further evaluation [17].

Anatomy & Pathophysiology

Glenohumeral Joint Anatomy

The glenohumeral joint is a ball-and-socket articulation where the large humeral head contacts, rather than sits within, the small glenoid cavity [73]. The glenoid is a shallow, convex structure shaped like an inverted pear, approximately one-third the size of the humeral head [60, 62]. Its subchondral bone is relatively flat, with articular concavity augmented by cartilage and a circumferential labrum [64]. The glenoid averages 5° of retroversion relative to the scapular body axis [64], and its articular surface radius of curvature is 2 to 3 mm larger than that of the humeral head [73].

The humeral head is spherical with a diameter of 37 to 57 mm [60] and a radius of curvature of approximately 25 mm, which is slightly larger in men than in women [73]. The articular surface covers an arc of approximately 160 degrees [73]. The most superior portion of the articular surface averages 8 mm above the greater tuberosity [60], with the superior margin normally positioned 8 to 10 mm superior to the top of the greater tuberosity [73]. The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [60]. The average neck-shaft angle is 45 degrees (±5 degrees), ranging from 30 to 50 degrees [73], while the head averages 41° of inclination [64]. Humeral retroversion averages 19° [64] or 29.8 degrees (range, 10 to 55 degrees) [60], though proximal humeral retroversion is highly variable, ranging from 0 to 55 degrees depending on measurement method [73].

The distance from the lateral base of the coracoid process to the lateral margin of the greater tuberosity is defined as the lateral humeral offset [73]. A significant decrease in this offset reduces the lever arms for the deltoid and supraspinatus muscles, weakening abduction and impairing function [73]. Conversely, a significant increase causes excessive soft-tissue tension ("overstuffing" of the joint), resulting in loss of motion and likely accelerating polyethylene wear [73].

The glenoid labrum, composed of dense fibrocartilaginous tissue, increases the socket depth by 50% around the humeral head [74]. Combined with the glenoid articular surface, the labrum creates a socket approximately 9 mm deep in the superoinferior direction and 5 mm deep in the anteroposterior direction [74]. This addition increases the glenoid surface to 75% of the humeral head vertically and 57% horizontally [74]. Consequently, the bony anatomy contributes little to stability, a relationship often compared to a golf ball on a tee [74].

Scapular Anatomy

The scapula attaches to the axial skeleton via the clavicle at the acromioclavicular (AC) and sternoclavicular (SC) joints [63]. It is separated from the chest wall by thin gliding fibro-fatty tissue, allowing smooth excursion [63]. The scapular body is triangular when viewed anteroposteriorly, with its base situated superiorly and its apex inferiorly [63]. The glenoid connects to the flat scapular body via the scapular neck [63]. The hook-shaped coracoid process curves forwards from the superior surface of the scapular neck [63], while the scapular spine arises from the posterior surface and ends in the acromion, which curves forwards [63].

The highest concentration of bony mass in the scapula is located in the glenoid, the scapular neck (including the base of the coracoid process), and the lateral border of the scapular body [63]. Two bony pillars transmit compressive forces from the glenoid fossa: the lateral pillar (connecting the inferior glenoid border to the inferior angle) and the spinal pillar (arising from the central glenoid to the base of the scapular spine) [63]. The triangle formed by these two pillars and the medial border constitutes the biomechanical body of the scapula [63]. The weakest bone in the scapula is located primarily in the central part of this biomechanical body, specifically in the infraspinous fossa [63]. The weakest area of the circumference of the biomechanical body is the spinomedial angle, where the scapular spine connects to the medial border [63].

Normal shoulder motion is approximately two-thirds glenohumeral and one-third scapulothoracic [64]. The scapula is anteverted on the chest wall approximately 30 degrees relative to the body [75].

Proximal Humerus Anatomy

The proximal humerus comprises the humeral head, greater tuberosity (GT), lesser tuberosity (LT), and humeral shaft [60]. The anatomic neck is located at the junction of the articular surface and the tuberosities [60]. The surgical neck represents an indistinct metadiaphyseal junction below the tuberosities but above the humeral shaft [60]. The greater tuberosity is located posterior-superiorly with respect to the humeral shaft and serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons [60]. The lesser tuberosity is located on the anterior aspect and serves as the attachment site for the subscapularis tendon [60]. The bicipital groove lies between the tuberosities and serves as a pathway for the long head of the biceps [60], with its distal aspect internally rotated with respect to the proximal portion [60].

The proximal humerus has three centers of ossification: the humeral head (4 to 6 months), the greater tuberosity (1 to 3 years), and the lesser tuberosity (3 to 5 years) [64]. These ossification centers fuse to the shaft at age 17 to 20 years [64]. The proximal humeral physis closes by 14 to 17 years of age in girls and by 16 to 18 years in boys [68]. Eighty percent of subsequent humeral growth comes from the proximal humeral physis, accounting for approximately 40% of the growth of the entire upper extremity [68]. The periosteum is thicker and stronger in the posteromedial portion of the proximal humerus compared to the anterolateral portion [68].

Vascular Supply

The proximal humerus receives its blood supply from the anterior and posterior humeral circumflex branches from the third division of the axillary artery [60]. The posterior humeral circumflex artery travels with the axillary nerve, enters the quadrilateral space posteriorly, and anastomoses with a branch of the anterior circumflex to supply the posterior cuff [60]. Quantitative assessment shows that 64% of the humeral head blood supply arises from the posterior humeral circumflex artery [68].

The anterior humeral circumflex artery (AHCA) arises from the axillary artery at the inferior border of the subscapularis [60]. It provides vascular inflow to the humeral head via its terminal anterolateral branch, known as the artery of Laing (or arcuate artery) [60]. The ascending branch of the AHCA courses parallel to the lateral aspect of the long head biceps tendon and enters the humeral head at the interface of the bicipital groove and greater tuberosity [60]. Injury to the arcuate artery may result in osteonecrosis of the humeral head [60], although additional extraosseous collateral branches can permit humeral head perfusion despite complete ligation of the arcuate artery [60]. The primary blood supply to the clavicle is periosteal; no nutrient artery is present [64].

Ligaments and Static Stabilizers

The superior glenohumeral ligament (SGHL) is a primary static restraint against anterior translation with the arm at the side [64]. It is also the primary restraint to inferior humeral subluxation in 0 degrees of abduction and the primary stabilizer to anterior and posterior stress in that position [74]. With the coracohumeral ligament, the SGHL forms a pulley that provides restraint against medial subluxation of the long head of the biceps tendon [64].

The coracohumeral (CH) ligament restricts external rotation in adduction and is a static restraint to inferior and posterior translation in adduction and external rotation [64]. The middle glenohumeral ligament (MGHL) is a primary static restraint against anterior translation with the arm in external rotation and 45° of abduction [64]. It limits external rotation when the arm is in the lower and middle ranges of abduction but has little effect when the arm is in 90 degrees of abduction [74].

The inferior glenohumeral ligament is composed of a thick anterior band, a less thick posterior band, and a thinner intervening axillary pouch, creating a hammock-type sling [74]. The anterior band of the inferior glenohumeral ligament (AB-IGHL) is a primary static restraint against anterior-inferior dislocation in 90° of abduction and external rotation [64]. The posterior band of the inferior glenohumeral ligament (PB-IGHL) is a primary static restraint against posterior-inferior translation in internal rotation and adduction [64]. The anteroinferior glenohumeral ligament complex is the main stabilizer to anterior and posterior stresses when the shoulder is abducted 45 degrees or more [74].

The rotator interval is defined medially by the base of the coracoid, superiorly by the supraspinatus tendon, and inferiorly by the subscapularis tendon [64]. It contains the coracohumeral ligament, the superior glenohumeral ligament, and the intra-articular portion of the long head of the biceps tendon [64]. Laxity of the rotator interval results in inferior laxity (the sulcus sign), while contracture of the interval is seen with adhesive capsulitis [64]. The coracoacromial ligament contributes to anterosuperior stability in rotator cuff deficiency and should be preserved with irreparable cuff tears to prevent anterosuperior escape [75].

Bursae and Synovial Recesses

The subscapular bursa lies between the subscapularis tendon and the neck of the scapula, communicating with the joint cavity between the superior and middle glenohumeral ligaments [65]. It protects the subscapularis tendon where it passes under the base of the coracoid process and over the scapular neck [65]. This bursa often houses loose bodies and is a region where synovitis may be most intense [65]. In 28% of dissected specimens, the subscapular bursae merged with the subcoracoid bursae, forming a unique wide bursa [65].

DePalma described six common variations or types of recesses in the anterior capsule, representing variations in the opening of the subscapularis bursa [65]. Type 1 recesses (30.2%): One synovial recess above the middle glenohumeral ligament [65]. Type 3 recesses (40.6%): One recess above and one below the middle glenohumeral ligament [65]. Type 4 recesses (9.0%): One large recess above the inferior ligament, with the middle glenohumeral ligament being absent [65]. Type 6 recesses (11.4%): No synovial recesses, although all the ligaments are well defined [65].

DePalma believed that if the capsule begins farther medially on the scapula or glenoid neck, the synovial recesses are larger and more numerous, resulting in a thin, weakened anterior capsule that could predispose the shoulder to instability [65].

Pathophysiology of Glenohumeral Osteoarthritis

Posterior glenoid wear and posterior humeral head subluxation occur in up to 45% of shoulders affected by primary osteoarthritis [89]. The anterior soft tissues, including the anterior capsule and the subscapularis, become contracted in primary osteoarthritis, limiting external rotation [89]. Joint space narrowing and periarticular osteophyte formation occur most commonly on the inferior aspects of the humeral head, a result referred to as a "goat’s beard" [89]. Full-thickness rotator cuff tears are associated with primary osteoarthritis in only 5% to 10% of cases [89].

Arthritis usually involves the central aspect of the humeral head, with joint space narrowing most evident on the axillary "truth view" [36]. The "Friar Tuck" pattern of central baldness is commonly seen in primary degenerative joint disease, with remaining articular cartilage at the periphery [36]. Malcentering of the net humeral joint reaction force on the glenoid leads to posterior instability, posterior glenoid wear, and "rocking horse" loosening of prosthetic glenoid components [36].

Patients with less joint space and abnormal posterior glenoid shape are significantly more likely to progress to early failure after Comprehensive Arthroscopic Management (CAM) [1]. Pathoanatomic metrics with identified threshold values can be used to discriminate glenoid types in shoulders with primary glenohumeral osteoarthritis [107]. Measurement in the glenoid hull plane may be more accurate than in the scapular plane for analyzing humeral subluxation in primary glenohumeral osteoarthritis [110].

Altered mechanical loading after rotator cuff tears is the primary factor in cartilage degeneration after rotator cuff tears [130]. Shoulders with rotator cuff tears require considerable compensatory deltoid function to prevent abduction motion loss [102]. The coracoid extension over the glenohumeral joint can mechanically limit anterior translation of the humerus relative to the glenoid with the shoulder in 90 degrees of abduction [71].

Classification

Weinstein: The Weinstein radiographic classification defines shoulder osteoarthritis severity across four stages. Stage I presents with normal radiographs [20]. Stage II is characterized by minimal joint space narrowing with a concentric head and glenoid [20]. Stage III involves moderate space narrowing with early inferior osteophyte formation [20]. Stage IV demonstrates severe loss of joint space, osteophyte formation, and loss of concentricity between the humeral head and the glenoid [20]. Younger patients participating in high-demand shoulder activities in Weinstein stage III are ideal candidates for the CAM procedure [20]. Many patients in Weinstein stage IV may also be good candidates for the CAM procedure [20].

Walch: The Walch classification is used to classify glenoid wear in osteoarthritic shoulders [30]. Patients with a type B2 or C glenoid according to the Walch classification are suggested for total shoulder arthroplasty over the CAM procedure [15]. Type B2 or C glenoid morphology correlates with unfavorable outcomes in previous CAM studies [15].

Samilson–Prieto: The Samilson-Prieto classification was used to grade preoperative arthritis in one study included in a systematic review of arthroscopic treatment for glenohumeral arthritis [145].

Outerbridge: The Outerbridge classification was used to grade articular cartilage degeneration during arthroscopic evaluation in four studies included in a systematic review [145]. In three studies providing data on specific Outerbridge grades (n=122), there were 8 grade I, 14 grade II, 21 grade III, and 79 grade IV lesions [145].

Other Considerations: Radiographic classification systems commonly used to assess glenohumeral osteoarthritis severity include Kellgren-Lawrence, Samilson—Prieto, and Walch [147]. Patients with less than 2 mm of glenohumeral joint space are suggested for total shoulder arthroplasty over the CAM procedure [15]. Less than 2 mm of glenohumeral joint space correlates with unfavorable outcomes in previous CAM studies [15]. Two studies included in a systematic review of arthroscopic treatment for glenohumeral arthritis used 4-stage classification systems that were not validated or previously described [145]. The modified Patte classification system is used to predict reparability and tendon healing in arthroscopic rotator cuff repair [155]. A small lateral extension and less posterior rotation of the acromion is associated with shoulder osteoarthritis and is present in almost all types and subtypes of glenoid morphology [175].

Clinical Presentation

The CAM procedure is a systematic, inclusive approach designed to address the array of pathologies encountered in early glenohumeral arthritis [2]. It targets known pain generators of the osteoarthritic shoulder [15] and serves as a predictable short-term joint-preserving option for younger, high-demand patients with advanced glenohumeral osteoarthritis [4]. The procedure builds on previously described arthroscopic techniques, including debridement, chondroplasty, synovectomy, loose body removal, capsular release, and subacromial decompression [15]. It adds inferior humeral osteoplasty, a complete capsular release, axillary nerve neurolysis, long head of the biceps tenodesis, and microfracture to these foundational techniques [15].

Indications and Patient Selection

The CAM procedure is typically indicated for young patients (age younger than 60) with glenohumeral osteoarthritis who have failed nonoperative treatment [20]. Ideal candidates include younger patients participating in high-demand shoulder activities with stage III glenohumeral osteoarthritis [20]. Many patients in stage IV glenohumeral osteoarthritis may also be good candidates [20]. Indications extend to patients with capsular contractures [20] and those with or without large inferior humeral spurs [20]. The technique is technically easier in patients with inferior osteophytes [20]. Magnetic resonance imaging can be useful to confirm axillary nerve compression by showing neurogenic edema or fatty infiltration of the deltoid or teres minor [20].

Exclusion Criteria and Contraindications

Exclusion criteria for the CAM procedure include early-stage glenohumeral osteoarthritis (Kellgren-Lawrence grade 1 or 2) [15]. Patients must have undergone a trial of nonoperative measures [15]. Irreparable rotator cuff tears are an exclusion criterion [15]. Severe bipolar chondral lesions with diffuse flattening of the humeral head also exclude patients from the CAM procedure [15]. Total shoulder arthroplasty is suggested over the CAM procedure if patients have a type B2 or C glenoid according to the Walch classification [15]. Total shoulder arthroplasty is also suggested if patients have less than 2 mm of glenohumeral joint space [15]. Type B2 or C glenoid morphology and less than 2 mm of glenohumeral joint space were shown to correlate with unfavorable outcomes in previous studies [15]. Hemiarthroplasty or total shoulder arthroplasty are feasible options for patients with humeral head incongruity or large anterior osteophytes [10].

Clinical Outcomes and Survivorship

The CAM procedure is associated with significant improvements in midterm clinical outcomes and high patient satisfaction for glenohumeral osteoarthritis [8]. Most studies reported that arthroscopic treatment of glenohumeral osteoarthritis and related pathology provided overall symptomatic improvement in pain and function [18]. Most patients showed postoperative improvements in forward elevation and external rotation after arthroscopic treatment [18]. Most patients showed improvements in pain (e.g., VAS score) and function (e.g., ASES score) [18]. One study suggested that improvements in forward elevation and external rotation may regress over time [18].

Survivorship for arthroscopic management of primary glenohumeral arthritis is reported at 85% at 2 years postoperatively [7]. Survivorship is reported at 76.9% at 5 years postoperatively [7]. The CAM procedure has a 76.9% survivorship rate at a minimum of 5 years postoperatively [8]. It is unclear from the literature whether the reported survivorship rates represent the natural history of primary glenohumeral arthritis or whether arthroscopic management delays arthritis progression because no control group exists for previously published case series [7]. A placebo effect for shoulder arthroscopy may improve patient outcomes in the short- and mid-term after surgery [7].

Duration of Relief and Conversion Rates

The duration of symptom relief and subsequent conversion to arthroplasty after arthroscopic treatment of glenohumeral osteoarthritis varied among studies, ranging from approximately 8 weeks to 8 years [18]. Significant heterogeneity was observed in the rates of conversion to arthroplasty across all studies (I² > 75%) [18]. Studies with a longer duration of minimum follow-up (>2 years) showed greater agreement in conversion rates to arthroplasty [18]. Studies that excluded patients with absent preoperative radiographic evidence of arthritis showed greater agreement in conversion rates to arthroplasty [18]. Arthroscopic debridement with capsular release may provide a window of improved symptoms and function before deterioration of the joint leads to a more significant operation, especially in younger patients with mild or moderate osteoarthritic changes [43].

Technical Considerations and Complications

A certain skill level and proficiency with shoulder arthroscopy are required to undertake some of the components of CAM of primary glenohumeral osteoarthritis [7]. Releasing an axillary nerve arthroscopically is technically demanding and potentially dangerous in the hands of less experienced arthroscopists, who could risk nerve injury or transection [7]. Most studies on arthroscopic management of glenohumeral osteoarthritis are level IV with low patient numbers and relatively short follow-up [7]. Comprehensive arthroscopic management without axillary nerve release or subacromial decompression achieves satisfactory and durable results in young patients with glenohumeral osteoarthritis [21].

Adjunctive Procedures and Specific Pathologies

Arthroscopic debridement is a reasonable next-line treatment if antiinflammatory medications and therapy fail, with good short-term results and minimal complications in patients with small, contained, unipolar lesions [12]. Arthroscopic debridement and biological resurfacing of the glenoid is a minimally invasive therapeutic option for pain relief, functional improvement, and patient satisfaction in glenohumeral osteoarthritis in the intermediate-term [40]. Treating full-thickness symptomatic chondral defects of the glenohumeral joint with microfracture can result in long-term improved function and reduced pain for some patients [31]. Arthroscopic release resulted in normal motion in all cases of postoperative stiffness following arthroscopic rotator cuff repair [25]. Approximately 1 in 10 patients experienced atraumatic tear progression to a symptomatic full-thickness rotator cuff tear and ultimately underwent rotator cuff repair following arthroscopic debridement alongside adjunctive procedures for articular-sided, partial-thickness supraspinatus tears [115]. Tranexamic acid for visualization during arthroscopic rotator cuff repair showed no measurable improvement in arthroscopic visualization or early pain scores [9].

Investigations

Plain radiography: Standardized plain films are almost always sufficient to establish diagnosis, determine pathoanatomy severity, assist in surgical planning, and illustrate the condition to the patient [36]. The standard shoulder series includes a true AP view in the scapular plane, an AP view, an axillary view, and a scapular Y view [87]. The true AP view in the scapular plane visualizes the anterior greater tuberosity in profile and can reveal proximal humeral migration [87]. The AP view with the arm in internal rotation visualizes the posterior aspect of the greater tuberosity and the lesser tuberosity in profile [87]. The axillary view is necessary for evaluation of glenohumeral joint instability and enables determination of the humeral head position in the glenoid fossa [87]. It may detect occult, locked posterior shoulder dislocation in a patient who exhibits a lack of passive external rotation [87]. The axillary view is helpful in evaluation of glenoid morphology in glenohumeral osteoarthritis and provides good visualization of the coracoid process, acromion, and distal clavicle [87]. The scapular Y view provides visualization of the coracoacromial arch and can reveal coracoacromial spurs associated with rotator cuff pathology [87]. It is a reliable alternative for evaluation of glenohumeral subluxation and dislocation [87].

The first key radiographic view is the anteroposterior (AP) view in the plane of the scapula, taken so that the x-ray beam passes through the glenohumeral joint [36]. This view shows the superoinferior position of the humeral head relative to the glenoid, presence of osteophytes, joint space narrowing, degree of medial displacement of the humerus, bone quality, loose bodies, and humeral head collapse or deformity [36]. The second key radiographic view is the axillary view taken with the arm in the functional position of elevation in the plane of the scapula [36]. The axillary view is oriented so that both the spinoglenoid notch and the scapular neck are visible [36]. It demonstrates the amount of glenoid bone, shape of the glenoid, its version in relation to the plane of the scapula, and the relationship of the humeral head to the glenoid fossa [36]. The standardized axillary view is referred to as the "truth view" because it demonstrates glenohumeral relationships in the functional position of elevation [36]. Joint space narrowing is most evident on the axillary truth view as opposed to images made with the arm at the side [36]. The axillary truth view shows posterior subluxation or "functional decentering" that is not evident in images taken with the arm at the side [36].

The degree of posterior subluxation can be measured by the position of the center of the humeral head in relation to the plane of the scapula, the position of the center of the humeral head in relation to the glenoid face, or the point of contact of the humeral articular surface on the glenoid articular surface [36]. The point of contact of the humeral articular surface on the glenoid articular surface reflects the degree of centering of the net humeral joint reaction force on the glenoid [36]. Malcentering of the joint reaction force leads to posterior instability, posterior glenoid wear, and "rocking horse" loosening of prosthetic glenoid components [36]. Recognizing significant glenoid deficiency preoperatively is critical for the surgeon contemplating methods to deal with the bone loss [30]. In patients with osteoarthritis, it is important to assess the degree and location of glenoid bone loss and any associated humeral head subluxation [30]. Walch et al introduced a classification system for glenoid wear in osteoarthritic shoulders [30].

Specific radiographic measurements include the acromiohumeral distance, which is normally 7 to 14 mm [87]. The width of the glenohumeral joint space should be symmetric superiorly and inferiorly [87]. The coracoclavicular distance is normally 1.1 to 1.3 cm [87]. Neer classified acromial morphology as type I (flat), type II (curved), and type III (hooked) [87]. Type III acromial morphology has been shown to have a correlation with the presence of rotator cuff disease, but no direct causal relationship has been demonstrated [87]. The Neer classification of acromial morphology has shown relatively poor interobserver reliability [87].

Special views are indicated for specific pathologies. The West Point view is indicated for anterior glenoid bone loss and is taken with the patient prone with the involved shoulder raised above table level, centered on axilla with beam directed 25° downward and 25° medial [87]. The Stryker notch view is indicated to evaluate Hill-Sachs lesion after dislocation and is taken with the patient supine, affected arm placed on top of head with fingers toward back of head, beam centered over coracoid process with 10° cephalic tilt [87]. The apical oblique view is indicated to evaluate for glenoid rim fracture in instability and is taken with the patient seated, cassette placed posterior and parallel to the spine of the scapula, beam directed 45° to the plane of the thorax and 45° caudally [87]. The Zanca view is indicated for the AC joint and is taken as an AP with 10° cephalic tilt centered over AC joint with patient supine, using only one-half the voltage of a routine shoulder AP view [87]. The Serendipity view is indicated for the sternoclavicular joint and is taken with patient supine, 40° cephalic tilt view centered on sternum [87].

CT: CT imaging is frequently used to evaluate fractures of the shoulder, to assess for bony lesions in recurrent instability cases, or for preoperative templating for shoulder arthritis [86]. CT with three-dimensional reconstructions is the advanced imaging study of choice for determining the extent of glenoid bone loss in the setting of shoulder instability [87]. CT is helpful for planning fracture surgery and shoulder joint replacement [78]. CT scans may offer a few degrees of increased precision in the measurement of glenoid version, but this precision does not improve the quality of the surgery or the clinical outcome [36]. Three-dimensional reconstructions can reveal fine details of the shoulder anatomy, but this additional information rarely changes the planning or conduct of the arthroplasty [36]. CT scans have the disadvantage of being taken with the arm in the adducted position, unlike the axillary truth view [36]. A robust approach to imaging the shoulder needs to recognize that the shoulder is a three-dimensional structure that cannot be represented by a single planar view [81]. Surgeons need to develop a judicious approach to imaging that yields necessary information while avoiding the tendency to "over-image" [81].

MRI: MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [86]. Traditional magnetic resonance imaging (MRI) is utilized for evaluation of soft tissues, which can be performed with high contrast and spatial resolution [83]. The acquired multi-planar imaging allows for the detailed evaluation of the glenoid, labrum, joint capsule, and rotator cuff in different planes [83]. MRI is useful to identify osteonecrosis of the humeral head, or a bone tumour [78]. MRI can identify labral tears and rotator cuff tears, although the accuracy for these is enhanced by combining the scan with arthrography [78]. T1-weighted MRI can reveal Hill-Sachs lesions and is often used with magnetic resonance (MR) arthrograms to provide a more detailed picture of the joint surfaces [86]. T2-weighted MRI provides better visualization of full thickness rotator cuff tears [86]. MR accuracy in identifying labral and rotator cuff tears in the literature ranges from 70% to 100% [83].

Abduction and external rotation (ABER) of the arm is an alternative position utilized to increase the sensitivity and specificity for detecting anteroinferior labroligamentous injury [83]. Limited range of motion or pain may prohibit patients from performing the ABER provocative maneuver [83]. Full routine MRI or MRA examination had similar accuracy as the ABER sequence in evaluating the anteroinferior labral–ligamentous complex [83]. The sensitivity of MRA with the ABER position for detecting anteroinferior labral lesions was significantly higher than that of the MRA in neutral position [83]. MRA is more effective than neutral position MRA in identifying Perthes lesions [83]. MRAs can demonstrate a patulous capsule on the coronal, sagittal, and axial imaging in patients with multidirectional instability [83]. MRAs can be helpful in evaluating lesions of the rotator interval and other associated findings that may affect the eventual surgical plan [83]. The presence of glenoid dysplasia, increased capsular cross-sectional area, and increased glenoid retroversion have all been found to be associated with increased posterior labral tears and symptomatic instability [83]. Glenoid retroversion was significantly increased in patients with symptomatic posterior labral tears, but there was no significant association between instability and increased humeral head subluxation [83]. The diagnosis of multidirectional instability is a clinical one, and the need for expensive and/or invasive imaging should be weighed against the information that will be gained from these studies [83].

MR Arthrography: MR arthrography (MRA) refers to MRI of a joint that has been injected with an intra-articular contrast agent such as diluted gadolinium or saline solution [83]. The contrast material is injected prior to MRI by fluoroscopic or ultrasound guidance under strict aseptic technique [83]. By distending the joint capsule, the cartilage, ligaments, and labrum are outlined with contrast, increasing the sensitivity for detecting tears and other lesions [83]. In the acute dislocation setting, a joint effusion with distension of the joint may outline structures similarly, making the arthrogram unnecessary [83]. MRA has proven utility by increasing both sensitivity and specificity in detecting injuries to the capsulolabral–ligamentous complex as compared to traditional MRI [83]. In a meta-analysis of 6 studies including 4,667 shoulders, MRA had greater diagnostic test accuracy for the detection of glenoid labral lesions than MRI [83]. MRA sensitivity was 88% and specificity was 93% for the detection of glenoid labral lesions [83]. MRI sensitivity was 76% and specificity was 87% for the detection of glenoid labral lesions [83]. MR arthrography is considered the benchmark for evaluation for labral tears and rarely is indicated for evaluation of rotator cuff pathology [86]. When MRI or MR arthrography is contraindicated, CT arthrography is indicated [86].

Ultrasonography: Ultrasonography is a simple and accurate test for identifying rotator cuff tears and calcific tendinitis [78]. It can be useful in guiding injections or barbotage (aspirating calcific deposits in the rotator cuff) [78]. Ultrasonography is a low-cost alternative to MRI and arthrography for evaluating both skeletal and soft-tissue structures of the shoulder [86]. It can provide immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [86]. Ultrasonography can be used to measure the subacromial space and detect atrophy of rotator cuff muscles [86]. As a result of providing images in real-time, ultrasonography can evaluate impingement in various positions and motions [86]. Ultrasonography is highly operator dependent and is not as useful for evaluating labral tears or rotator cuff tears that are very small or larger than 3 cm [86]. Accuracy of rotator cuff ultrasonography depends on the skill of the scanner operator and an awareness of pitfalls that are encountered [77]. The most commonly performed joint examination using ultrasonography is the shoulder examination [77].

Arthroscopy: Arthroscopy is useful for diagnosing and treating subacromial impingement, intra-articular lesions, detachment of the glenoid labrum and rotator cuff tears [78]. The authors recommend a systematic, inclusive approach to the array of pathologies encountered in the setting of early glenohumeral arthritis: the Comprehensive Arthroscopic Management (CAM) procedure [2]. The CAM procedure reduced pain, improved function, and provided reasonable short-term durability for young, active patients with advanced shoulder OA, serving as a joint-preserving alternative to arthroplasty [3]. The comprehensive arthroscopic management procedure provides a predictable short-term joint-preserving option for younger, high-demand patients with advanced glenohumeral osteoarthritis by reducing pain and improving function [4]. The CAM procedure reliably improves pain and function in active patients with advanced GHOA, but patients with less joint space and abnormal posterior glenoid shape are significantly more likely to progress to early failure [1]. This study demonstrates significant improvements in midterm clinical outcomes and high patient satisfaction after the arthroscopic CAM procedure for GHOA, with a 76.9% survivorship rate at a minimum of 5 years postoperatively [8]. CAM is a reasonable option for patients with localized cartilage defects and specific radiographic findings, while HA or TSA are feasible options for those with humeral head incongruity or large anterior osteophytes [10]. Arthroscopic debridement improved clinical outcome in 68% of patients suffering from advanced OA of glenohumeral joint [6]. Arthroscopic management in patients younger than 50 can achieve predictably good to excellent results regardless of tear size [5]. The authors state they have increasingly used all-arthroscopic techniques with satisfactory results for rotator cuff tears in active duty military personnel [13].

Successful management of glenohumeral instability requires a full understanding of all responsible pathologic components, typically involving reattachment of the fibrocartilaginous labrum and re-creating proper tension of the capsuloligamentous structures [14]. In the absence of substantial bone loss, arthroscopic posterior capsulolabral repair remains the gold standard for the surgical management of symptoms refractory to nonoperative treatment, and excellent clinical outcomes have generally been reported [22]. The combined approach of arthroscopic rotator cuff repair and microfracture of humeral head appears to be a viable joint-preserving option for select patients with concomitant rotator cuff tears and focal humeral head cartilage lesions [24]. Radiographs at 6 month follow-up demonstrate a space between the humeral head and the glenoid in all cases of surgical treatment for glenohumeral arthritis in the young patient [54]. Radiographic changes occurred in 40% of patients within 5 years after arthroscopic rotator cuff repair [59]. No significant differences were found between the 2 arthroscopic repair techniques in terms of functional and radiological results [53]. The benefits of physeal-sparing transosseous-equivalent arthroscopic rotator cuff repair far exceed those of previously described open procedures without radiographic guidance [50]. We recommend routine radiographic follow-up after use of metallic anchors to ensure identification of early failure by anchor pullout [174]. Repair failure on MRI does not correlate with clinical outcome at 6 months or 1 year [172]. The reliance on a single magnetic resonance imaging scan at 6 months limits the ability to draw conclusions regarding the long-term structural integrity of the repair [173]. The clinical and radiological outcomes at the 10-year follow-up show a substantial uniformity of results between the 2 groups in platelet-rich plasma in arthroscopic rotator cuff repair [176]. Prospective studies stratified by instability chronicity and with standardized imaging surveillance are needed for concomitant arthroscopic rotator cuff repair and anterior shoulder stabilization [178]. There was no measurable improvement in arthroscopic visualization or early pain scores with the use of tranexamic acid for visualization on pump pressure and visualization during arthroscopic rotator cuff repair [9].

Treatment

Non-Operative

Conservative management serves as the prerequisite for surgical intervention in glenohumeral arthritis. An adequate trial of nonoperative care, including activity modification, physical therapy, anti-inflammatory medication, and corticosteroid injections, must precede any surgical treatment [38]. Injectable viscosupplementation represents an additional nonoperative option, although evidence supporting its use in the shoulder is limited and it is not currently approved by the U.S. Food and Drug Administration for injection in joints other than the knee [38]. For patients with small, contained, unipolar lesions where anti-inflammatory medications and therapy have failed, arthroscopic debridement is a reasonable next-line treatment [12]. Nonsurgical modalities remain the mainstay of management for glenohumeral osteoarthritis in young patients [118].

Operative

Indications: The Comprehensive Arthroscopic Management (CAM) procedure is recommended as a systematic, inclusive approach for the array of pathologies encountered in early glenohumeral arthritis [2]. Younger patients participating in high-demand shoulder activities with Weinstein stage III glenohumeral osteoarthritis are ideal candidates [20]. Many patients with Weinstein stage IV glenohumeral osteoarthritis may also be good candidates [20]. Arthroscopic management is indicated for patients with persistent pain, stiffness, and weakness despite attempted nonoperative management [132]. Surgical delay does not improve patient outcomes, and failure to improve with conservative treatment is an indication for surgical intervention [132]. Arthroscopic treatment may be the best alternative when joint reconstruction is not desirable, possible, or practical [38]. It might be more suitable for elderly patients with significant medical comorbidities who are unable to tolerate the stresses of major surgery [38]. Young patients with early-onset arthritis might not be the best candidates for total shoulder arthroplasty due to concerns related to prosthesis longevity and high functional demands [38]. Arthroscopic treatment may be indicated for patients with significant pain but only mild arthritic changes on diagnostic studies, making arthroplasty difficult to justify [38]. It is also indicated for patients in whom total shoulder arthroplasty is otherwise not an acceptable treatment option [15].

Contraindications and Alternative Procedures: Patients with type B2 or C glenoid morphology according to the Walch classification or less than 2 mm of glenohumeral joint space are suggested to undergo total shoulder arthroplasty rather than the CAM procedure [15]. Patients with humeral head incongruity or large anterior osteophytes are feasible candidates for hemiarthroplasty or total shoulder arthroplasty rather than CAM [10].

Surgical Approach / Technique: The CAM procedure builds on previously described arthroscopic techniques including debridement, chondroplasty, synovectomy, loose body removal, capsular release, and subacromial decompression [15]. The procedure adds inferior humeral osteoplasty, a complete capsular release, axillary nerve neurolysis, long head of the biceps tenodesis, and microfracture to the standard arthroscopic techniques [15]. It can be technically demanding to release an axillary nerve arthroscopically and potentially dangerous for less experienced arthroscopists who could risk nerve injury or transection [7]. Arthroscopic glenoid resurfacing provided superior results to previously performed arthroscopic procedures in patients with failed previous arthroscopic debridement [28].

Other Considerations: Preoperative radiographs and clinical examination were unreliable in predicting osteoarthritis that was intraoperatively documented [38]. Coexistent soft tissue pathology is common in patients with osteoarthritis [38]. Arthroscopy provides an opportunity to diagnose and treat secondary conditions, perhaps eliminating the need for arthroplasty [38]. The benefits of a lower complication rate and quicker return to normal activities after arthroscopy compared with total shoulder arthroplasty make the scenario of treating coexistent soft tissue pathology quite appealing [38]. In the absence of substantial bone loss, arthroscopic posterior capsulolabral repair remains the gold standard for the surgical management of symptoms refractory to nonoperative treatment for posterior glenohumeral instability [22]. Arthroscopic reconstruction would only work approximately 80% of the time in patients 18 and younger with recurrent traumatic anterior instability [23]. Arthroscopic debridement with microfracture has yielded good-to-excellent results with significant improvements in motion, pain reduction, and high levels of patient satisfaction for unstable, contained osteochondritis dissecans lesions of the capitellum [105]. The authors have increasingly used all-arthroscopic techniques with satisfactory results for rotator cuff tears in active duty military personnel [13]. Arthroscopic repair was safe and effective in both elderly and younger groups, even for those with massive tears [104].

Outcomes and Survivorship: The CAM procedure reliably improves pain and function in active patients with advanced glenohumeral osteoarthritis [1]. It demonstrated significant improvements in midterm clinical outcomes and high patient satisfaction for glenohumeral osteoarthritis [8]. The CAM procedure demonstrated a 76.9% survivorship rate at a minimum of 5 years postoperatively [8]. Most patients showed improvements in both pain (e.g., VAS score) and function (e.g., ASES score) after arthroscopic treatment of glenohumeral osteoarthritis [18]. Studies with a longer duration of minimum follow-up (>2 years) showed greater agreement in conversion rates to arthroplasty after arthroscopic treatment of glenohumeral osteoarthritis [18]. Studies that excluded patients with absent preoperative radiographic evidence of arthritis showed greater agreement in conversion rates to arthroplasty after arthroscopic treatment of glenohumeral osteoarthritis [18]. Arthroscopic debridement is an excellent treatment for elderly patients with modest functional demands, though long-term consequences require further evaluation [17].

Limitations and Evidence Quality: Debate remains regarding the durability of managing primary glenohumeral arthritis arthroscopically [7]. Some of the 2- and 5-year follow-up data for arthroscopic management of primary glenohumeral arthritis remain limited to level IV series [7]. Previously published literature places survivorship at 85% at 2 years postoperatively after arthroscopic management of primary glenohumeral arthritis [7]. Previously published literature places survivorship at 76.9% at 5 years after arthroscopic management of primary glenohumeral arthritis [7]. It is unclear whether the reported survivorship rates represent the natural history of primary glenohumeral arthritis or whether arthroscopic management delays arthritis progression because no control group exists for the previously published case series [7]. There may be a placebo effect for shoulder arthroscopy that may improve patient outcomes in the short- and mid-term after surgery [7]. Future studies are needed to critically evaluate CAM of primary glenohumeral osteoarthritis versus a standardized control group [7]. Additional high-level studies are warranted to evaluate long-term outcomes of arthroscopic management of glenohumeral osteoarthritis [7]. The most common sources of possible bias in noncomparative studies of arthroscopic treatment for glenohumeral osteoarthritis were lack of blinding or an unbiased assessment of endpoints, greater than 5% loss of patients at final follow-up, and absence of any prospective calculation of study sample size [18]. The current American Academy of Orthopaedic Surgeons clinical practice guidelines classifies the use of arthroscopy for the treatment of glenohumeral arthritis as grade I, implying that they are unable to recommend for or against this option [38]. A systematic review of the literature showed that arthroscopic debridement for glenohumeral arthritis lacks high-quality evidence to support its routine use [38]. Glenohumeral osteoarthritis in young patients is a difficult condition with higher failure rates after surgical management compared to older patients [118]. Surgical options for glenohumeral osteoarthritis in young patients include arthroscopic débridement, humeral head replacement, and total or reverse total shoulder arthroplasty [118]. Arthroscopic debridement and capsular release may not provide substantial benefit to justify its use in most patients with glenohumeral arthritis [34].

Adjuncts: There was no measurable improvement in arthroscopic visualization or early pain scores with the use of tranexamic acid for visualization during arthroscopic rotator cuff repair [9]. Judicious use of nonoperative treatment modalities among patients who would not benefit from nonoperative care will be an effective way of reducing costs [141].

Complications

CAM-Specific Complications and Risks

Nerve injury: Axillary nerve release during the CAM procedure is technically demanding and potentially dangerous for less experienced arthroscopists, who risk nerve injury or transection [7]. A certain skill level and proficiency with shoulder arthroscopy are required to undertake some of the components of the CAM procedure [7].

Survivorship: The CAM procedure is associated with a 76.9% survivorship rate at a minimum of 5 years postoperatively [8]. Alternative data report an 84% survivorship at 3 years and a 72% survivorship at 5 years [46]. Some patients undergoing the CAM procedure progressed to arthroplasty at long-term follow-up [45].

General Arthroscopic Complications and Device Issues

Device complications: Suture passing needle breakage is a reported complication associated with the use of specific suturing devices during arthroscopic rotator cuff repair [55].

Upper extremity soft tissue: Complications of the fingers and hand, including carpal tunnel syndrome, flexor tenosynovitis, and complex regional pain syndrome, occur more easily in patients with a past history of carpal tunnel syndrome or tenosynovitis and in patients with edema as per a subjective assessment [177].

Concurrent pathology: The presence of concurrent glenohumeral osteoarthritis is associated with a significant increase in the odds of both short- and longer-term complications following arthroscopic rotator cuff repair [136].

Outcomes and Durability Limitations

Durability debate: Debate remains regarding the durability of managing primary glenohumeral arthritis arthroscopically, with some 2- and 5-year follow-up data limited to level IV series [7]. It is unclear whether arthroscopic management delays arthritis progression or represents the natural history of primary glenohumeral arthritis because no control group exists for previously published case series [7].

Conversion variability: The duration of symptom relief and subsequent conversion to arthroplasty after arthroscopic treatment of glenohumeral osteoarthritis varies among studies, ranging from approximately 8 weeks to 8 years [18]. Significant heterogeneity was observed in the rates of conversion to arthroplasty across studies of arthroscopic treatment for glenohumeral osteoarthritis [18].

Functional regression: One study suggested that postoperative improvements in forward elevation and external rotation after arthroscopic treatment of glenohumeral osteoarthritis may regress over time [18].

Recovery

Light activity (weeks): The provided evidence does not specify a distinct timeline for light activities such as desk work, driving, or light activities of daily living.

Full activity (months): The provided evidence does not specify a distinct timeline for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The provided evidence does not specify a distinct timeline for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: Evidence regarding physical therapy timing is limited to arthroscopic rotator cuff repair rather than the CAM procedure itself. Patients in early and delayed postoperative physical therapy groups demonstrated very similar clinical outcomes and range of motion at 1 year after arthroscopic rotator cuff repair [167]. No clinically discernible differences in active range of motion at 1-year follow-up were found between patients assigned to early or delayed motion protocols after arthroscopic rotator cuff repair with biceps rerouting [183].

Functional milestones: The CAM procedure reliably improves pain and function in active patients with advanced glenohumeral osteoarthritis (GHOA) [1]. It reduced pain, improved function, and provided reasonable short-term durability for young, active patients with advanced shoulder osteoarthritis [3]. Significant improvements in midterm clinical outcomes and high patient satisfaction were demonstrated after the arthroscopic CAM procedure for GHOA [8]. Arthroscopic debridement improved clinical outcome in 68% of patients suffering from advanced OA of the glenohumeral joint [6]. Radiographs at 6 month follow-up demonstrate a space between the humeral head and the glenoid in all cases [54].

Other Considerations: Survivorship rates after the CAM procedure were 84% at 3 years and 72% at 5 years [46]. Another study reported a survivorship rate of 76.9% at a minimum of 5 years postoperatively [8]. Previously published literature places survivorship at 85% at 2 years postoperatively and at 76.9% at 5 years after arthroscopic management of primary glenohumeral arthritis [7]. The majority of patients demonstrated sustained improvement in patient-reported outcomes and satisfaction without conversion to total shoulder arthroplasty at long-term follow-up, although some patients progressed to arthroplasty [45]. Patients with less joint space and abnormal posterior glenoid shape are significantly more likely to progress to early failure after CAM [1]. Most studies on arthroscopic management of GHOA are level IV with low patient numbers and relatively short follow-up [7]. A certain skill level and proficiency with shoulder arthroscopy are required to undertake some of the components of CAM of primary GHOA [7]. It can be technically demanding to release an axillary nerve arthroscopically and potentially dangerous to perform this procedure in the hands of less experienced arthroscopists who could risk nerve injury or transection [7].

Adjunctive procedures and rehabilitation data from related arthroscopic shoulder procedures include the following. At short-term follow-up, subacromial decompression did not seem to significantly affect the outcome of arthroscopic rotator cuff repair [139]. Emerging evidence suggests that arthroscopic rotator cuff repair with concomitant acromioplasty may contribute to superior functional outcomes and reduced reoperation rates in the long-term postoperation, particularly in patients with Type III acromion morphology [138]. The clinical and radiological outcomes at the 10-year follow-up show a substantial uniformity of results between groups receiving platelet-rich plasma and those not, with clinical differences observed at 2 years disappearing at long term [182]. Highly significant clinical improvement of the shoulder was observed in the entire population 2 weeks after arthroscopic debridement of calcific rotator cuff tendinitis, with excellent radiological results observed until the 9 months follow-up [184].

Key Evidence

• [L3] The CAM procedure reliably improves pain and function in active patients with advanced GHOA, but patients with less joint space and abnormal posterior glenoid shape are significantly more likely to progress to early failure. [1] (10.1177/0363546516668823)
• [L4] The authors recommend a systematic, inclusive approach to the array of pathologies encountered in the setting of early glenohumeral arthritis: the Comprehensive Arthroscopic Management (CAM) procedure. [2] (10.1016/j.arthro.2022.01.033)
• [L4] The CAM procedure reduced pain, improved function, and provided reasonable short-term durability for young, active patients with advanced shoulder OA, serving as a joint-preserving alternative to arthroplasty. [3] (10.1016/j.arthro.2012.10.028)
• [Paper] The comprehensive arthroscopic management procedure provides a predictable short-term joint-preserving option for younger, high-demand patients with advanced glenohumeral osteoarthritis by reducing pain and improving function. [4] (10.1016/j.eats.2015.04.003)
• [L4] Arthroscopic management in patients younger than 50 can achieve predictably good to excellent results regardless of tear size. [5] (10.1016/j.jse.2007.05.006)
• [L3] Arthroscopic debridement improved clinical outcome in 68% of patients suffering from advanced OA of glenohumeral joint. [6] (10.1186/s12891-015-0741-9)
• [L5] [7] (10.5435/jaaos-d-17-00214)
• [L4] This study demonstrates significant improvements in midterm clinical outcomes and high patient satisfaction after the arthroscopic CAM procedure for GHOA, with a 76.9% survivorship rate at a minimum of 5 years postoperatively. [8] (10.1177/0363546516656372)
• [L2] Additionally, there was no measurable improvement in arthroscopic visualization or early pain scores. [9] (10.1016/j.jse.2022.06.027)
• [L4] CAM is a reasonable option for patients with localized cartilage defects and specific radiographic findings, while HA or TSA are feasible options for those with humeral head incongruity or large anterior osteophytes. [10] (10.1530/eor-2023-0156)
• [Paper] Arthroscopic debridement is a reasonable next-line treatment if antiinflammatory medications and therapy fail, with good short-term results and minimal complications in patients with small, contained, unipolar lesions. [12] (10.1016/j.csm.2018.05.003)
• [L4] The authors state they have increasingly used all-arthroscopic techniques with satisfactory results. [13] (10.1053/j.otsm.2005.10.003)
• [L4] Successful management requires a full understanding of all responsible pathologic components, typically involving reattachment of the fibrocartilaginous labrum and re-creating proper tension of the capsuloligamentous structures. [14] (10.1177/03635465000280042801)
• [L3] [15] (10.1177/0363546520962756)
• [L3] Arthroscopic debridement is an excellent treatment for elderly patients with modest functional demands, though long-term consequences require further evaluation. [17] (10.1007/s00402-004-0738-6)
• [L1] [18] (10.1016/j.arthro.2020.02.036)
• [L5] [20] (10.1097/bte.0b013e31825ce947)
• [L4] Comprehensive arthroscopic management without axillary nerve release or subacromial decompression achieves satisfactory and durable results in young patients with glenohumeral osteoarthritis. [21] (10.1007/s00167-023-07377-0)
• [L5] In the absence of substantial bone loss, arthroscopic posterior capsulolabral repair remains the gold standard for the surgical management of symptoms refractory to nonoperative treatment, and excellent clinical outcomes have generally been reported. [22] (10.1016/j.arthro.2020.05.018)
• [L2] By the criteria of this study, arthroscopic reconstruction provides results equal to those of the open procedure for patients age 22 and older, would provide a success rate of 90% in patients age 18 to 23 but would only work approximately 80% of the time in patients 18 and younger and is not indicated in patients in this age range. [23] (10.1016/s1058-2746(96)80205-9)
• [L3] The combined approach appears to be a viable joint-preserving option for select patients with concomitant rotator cuff tears and focal humeral head cartilage lesions. [24] (10.1177/23259671261436439)
• [L4] Arthroscopic release resulted in normal motion in all cases. [25] (10.1016/j.arthro.2009.01.018)
• [L4] Treatment of glenohumeral arthritis with arthroscopic glenoid resurfacing provided superior results in this series to their previously performed arthroscopic procedure. [28] (10.1016/j.arthro.2009.04.015)
• [L5] [30] (10.1097/bte.0b013e31818d1e52)
• [L4] Treating full-thickness symptomatic chondral defects of the glenohumeral joint with microfracture can result in long-term improved function and reduced pain for some patients. [31] (10.1177/0363546517750627)
• [L4] Although there are limited nonarthroplasty surgical options available for glenohumeral arthritis, isolated arthroscopic debridement and capsular release may not provide substantial benefit to justify its use in most patients. [34] (10.1016/j.arthro.2014.08.025)
• [L4] Arthroscopic debridement and biological resurfacing of the glenoid is a minimally invasive therapeutic option for pain relief, functional improvement and patient satisfaction, in glenohumeral osteoarthritis, in the intermediate-term. [40] (10.1007/s00167-010-1155-8)
• [L4] Arthroscopic debridement with capsular release may provide a window of improved symptoms and function before deterioration of the joint leads to a more significant operation, especially in younger patients with mild or moderate osteoarthritic changes. [43] (10.1016/j.arthro.2006.11.016)
• [L4] The majority of patients demonstrated sustained improvement in patient-reported outcomes and satisfaction without conversion to total shoulder arthroplasty at long-term follow-up, although some patients progressed to arthroplasty. [45] (10.1177/2325967121s00213)
• [L4] After the CAM procedure we found an 84% survivorship at 3 years and 72% survivorship at 5 years. [46] (10.1177/2325967116s00104)
• [Paper] The benefits of this physeal-sparing arthroscopic technique far exceed those of previously described open procedures without radiographic guidance. [50] (10.1016/j.eats.2019.02.012)
• [L4] Surgical arthroscopic repair was possible in all cases of acute or recurrent instability with well-defined exclusion criteria. [51] (10.1055/s-0032-1327656)
• [L1] No significant differences were found between the 2 arthroscopic repair techniques in terms of functional and radiological results. [53] (10.1177/0363546517695789)
• [L4] Radiographs at 6 month follow-up demonstrate a space between the humeral head and the glenoid in all cases. [54] (10.1097/01.bte.0000135965.23606.f0)
• [L4] This is the first reported complication associated with the use of this type of suturing device, highlighting the need for careful examination of all devices during and after arthroscopic surgery. [55] (10.1016/j.arthro.2007.10.010)
• [L3] Radiographic changes occurred in 40% of patients within 5 years after arthroscopic rotator cuff repair. [59] (10.1177/23259671221126095)
• [L5] Shoulders with rotator cuff tears require considerable compensatory deltoid function to prevent abduction motion loss. [102] (10.1177/0363546518768276)
• [L3] Arthroscopic repair was safe and effective in both groups, even for those with massive tears. [104] (10.1016/j.jse.2018.10.010)
• [Paper] Arthroscopic debridement with microfracture has yielded good-to-excellent results with significant improvements in motion, pain reduction, and high levels of patient satisfaction. [105] (10.1016/j.eats.2020.01.001)
• [L4] Pathoanatomic metrics with the identified threshold values can be used to discriminate glenoid types in shoulders with primary glenohumeral osteoarthritis. [107] (10.1016/j.jse.2021.03.140)
• [L4] Measurement in the glenoid hull plane may be more accurate than in the scapular plane. [110] (10.1016/j.jse.2017.01.027)
• [L4] Despite improvements in pain relief and functional outcomes, approximately 1 in 10 patients experienced atraumatic tear progression to a symptomatic full-thickness rotator cuff tear and ultimately underwent rotator cuff repair. [115] (10.1002/ars2.70011)
• [L5] Glenohumeral osteoarthritis in young patients is a difficult condition with higher failure rates after surgical management compared to older patients; nonsurgical modalities are the mainstay of management, while surgical options include arthroscopic débridement, humeral head replacement, and total or reverse total shoulder arthroplasty. [118] (10.5435/jaaos-d-16-00657)
• [L5] Our results suggest that altered mechanical loading after rotator cuff tears is the primary factor in cartilage degeneration after rotator cuff tears. [130] (10.1016/j.jse.2013.03.014)
• [Paper] [132] (10.1016/j.eats.2016.04.002)
• [L3] The presence of concurrent glenohumeral osteoarthritis was associated with a significant increase in the odds of both short- and longer-term complications following ARCR. [136] (10.1016/j.xrrt.2025.100659)
• [L5] Emerging evidence suggests that arthroscopic rotator cuff repair with concomitant acromioplasty may contribute to superior functional outcomes and reduced reoperation rates in the long-term postoperation, particularly in patients with Type III acromion morphology, although outcomes remain dependent on patient and surgical factors. [138] (10.1016/j.arthro.2024.09.007)
• [L1] At short-term follow-up, subacromial decompression did not seem to significantly affect the outcome of arthroscopic rotator cuff repair. [139] (10.1016/j.arthro.2006.10.011)
• [L3] Judicious use of nonoperative treatment modalities among patients who would not benefit from nonoperative care will be an effective way of reducing costs. [141] (10.1177/2325967120937016)
• [L1] [145] (10.1016/j.arthro.2013.02.022)
• [L4] [147] (10.1016/j.xrrt.2026.100778)
• [L3] The modified Patte classification system can be easily implemented in clinical practice for planning surgical procedures and counselling patients in the day‐by‐day clinical work. [155] (10.1002/ksa.12162)
• [L1] Patients in the early and delayed groups demonstrated very similar clinical outcomes and range of motion at 1 year. [167] (10.1016/j.jse.2012.01.025)
• [L1] Repair failure on MRI does not correlate with clinical outcome at 6 months or 1 year. [172] (10.1177/2325967116s00194)
• [L5] Additionally, the reliance on a single magnetic resonance imaging scan at 6 months limits the ability to draw conclusions regarding the long-term structural integrity of the repair. [173] (10.1002/arj.70326)
• [L3] We recommend routine radiographic follow-up after use of metallic anchors to ensure identification of early failure by anchor pullout. [174] (10.1016/j.arthro.2009.08.015)
• [L3] A small lateral extension and less posterior rotation of the acromion is associated with shoulder osteoarthritis and is present in almost all types and subtypes of glenoid morphology. [175] (10.1016/j.jse.2021.01.018)
• [L2] The clinical and radiological outcomes at the 10-year follow-up show a substantial uniformity of results between the 2 groups. [176] (10.1016/j.arthro.2021.05.017)
• [L2] Complications of the fingers and hand after arthroscopic rotator cuff repair easily occurred in patients with a past history of carpal tunnel syndrome or tenosynovitis and in patients with edema as per a subjective assessment. [177] (10.1016/j.jseint.2021.07.001)
• [L4] Prospective studies stratified by instability chronicity and with standardized imaging surveillance are needed. [178] (10.1016/j.xrrt.2026.100868)
• [L1] The clinical and radiological outcomes at the 10-year follow-up show a substantial uniformity of results between the two groups, with clinical differences observed at 2 years disappearing at long term. [182] (10.1177/2325967121s00245)
• [L1] This study's findings reveal no clinically discernible differences in active range of motion at 1-year follow-up between patients assigned to either early or delayed motion protocols. [183] (10.1016/j.jse.2024.01.029)
• [L1] Highly significant clinical improvement of the shoulder was already observed in the entire population 2 weeks after surgery, with excellent radiological results observed until the 9 months follow-up. [184] (10.1007/s00402-014-1927-6)

See Also

• Capsular Release for Frozen Shoulder
• Rotator Cuff Repair
• Rotator Cuff
• Total shoulder arthroplasty
• Subacromial Decompression
• Biceps Tenodesis
• Shoulder Arthroplasty
• Shoulder Arthroscopy
• Fractures
• Shoulder Arthritis
• Shoulder Instability
• Calcific Tendinitis

References

[1] Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis: Preoperative Factors Predictive of Treatment Failure. The American Journal of Sports Medicine. 2016. DOI: 10.1177/0363546516668823

[2] Comprehensive Arthroscopic Management of Shoulder Arthritis. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.01.033

[3] Comprehensive Arthroscopic Management (CAM) Procedure: Clinical Results of a Joint‐Preserving Arthroscopic Treatment for Young, Active Patients With Advanced Shoulder Osteoarthritis. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2012.10.028

[4] The Comprehensive Arthroscopic Management Procedure for Treatment of Glenohumeral Osteoarthritis. Arthroscopy Techniques. 2015. DOI: 10.1016/j.eats.2015.04.003

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