Comprehensive arthroscopic management (CAM)

Shoulder pain and stiffness can significantly impact your daily life, making even simple tasks challenging. For many, especially younger, active individuals suffering from advanced shoulder arthritis, the prospect of a total shoulder replacement might seem daunting or premature. Fortunately, advancements in orthopaedic surgery offer alternative solutions. One such promising option is Comprehensive Arthroscopic Management (CAM), a minimally invasive procedure designed to alleviate pain and improve function while preserving the natural shoulder joint.

If you’re exploring treatments for shoulder arthritis and aren’t ready for a full joint replacement, the CAM procedure might be the answer. This article delves into what Comprehensive Arthroscopic Management (CAM) entails, who benefits most from it, what the surgery involves, and what to expect during recovery.

What is Comprehensive Arthroscopic Management (CAM)?

Comprehensive Arthroscopic Management (CAM) is a specialized, minimally invasive surgical procedure aimed at treating severe shoulder arthritis (glenohumeral osteoarthritis). Unlike traditional shoulder replacement surgery (arthroplasty), which replaces the damaged joint surfaces with artificial components, CAM focuses on preserving the patient’s own joint.

The core principle behind CAM is to address the various pathological changes within the arthritic shoulder using arthroscopic techniques. Arthroscopy involves using a small camera (arthroscope) and specialized instruments inserted through tiny incisions (‘keyholes’) around the shoulder. This allows the surgeon to visualize the inside of the joint and perform corrective measures without the need for large open cuts.

The main goals of the CAM procedure are:

  • Pain Relief: To significantly reduce the chronic pain associated with advanced shoulder arthritis.
  • Improved Function: To enhance the shoulder’s range of motion and overall usability.
  • Joint Preservation: To clean up the joint, address underlying issues, and potentially delay or even prevent the need for a future shoulder joint replacement.

This joint-preserving arthroscopic treatment is particularly valuable for individuals who wish to maintain an active lifestyle but are considered too young or not yet suitable candidates for arthroplasty.

Who is a Candidate for the CAM Procedure?

The CAM procedure isn’t suitable for everyone with shoulder arthritis. It’s typically considered for a specific patient profile:

  • Age: Primarily aimed at young, active patients (often under 55-60 years old) who find shoulder replacement less appealing due to potential activity restrictions and the limited lifespan of artificial joints.
  • Condition: Patients diagnosed with advanced shoulder osteoarthritis (OA) or glenohumeral arthritis, but who still have reasonably preserved joint structure (e.g., minimal bone erosion, intact rotator cuff).
  • Activity Level: Individuals who wish to remain active and potentially return to higher-demand activities or sports, which might be limited after a traditional joint replacement.
  • Symptoms: Patients experiencing significant shoulder pain, stiffness, and reduced function that hasn’t responded adequately to non-surgical treatments like physiotherapy, pain medication, or injections.
  • Alternatives: Those seeking alternatives to shoulder arthroplasty or wanting to postpone joint replacement surgery for as long as possible.

Contraindications (reasons why CAM might not be suitable) can include:

  • Severe bone loss or deformity in the glenoid (socket) or humeral head (ball).
  • Large, irreparable rotator cuff tears.
  • Significant joint instability.
  • Inflammatory arthritis (like rheumatoid arthritis) in some cases.
  • Previous failed surgeries that compromise the joint structure.

A thorough evaluation by an experienced orthopaedic surgeon, including a physical examination and imaging studies (X-rays, MRI), is crucial to determine if Comprehensive Arthroscopic Management (CAM) is the right choice.

The CAM Surgical Procedure Explained

The Comprehensive Arthroscopic Management (CAM) procedure is not a single technique but rather a combination of several arthroscopic interventions performed during the same surgery, tailored to the individual patient’s specific pathology. The surgeon uses the arthroscope to meticulously inspect the entire shoulder joint and addresses all identified issues.

Common components of the CAM procedure include:

  1. Glenohumeral Chondroplasty: Smoothing down damaged or roughened articular cartilage (the joint’s lining) on the ball (humeral head) and socket (glenoid) to reduce friction and pain.
  2. Synovectomy: Removal of inflamed or thickened synovium (the joint’s inner lining). In arthritis, the synovium often becomes inflamed (synovitis) and contributes to pain and swelling.
  3. Loose Body Removal: Extracting any fragments of bone or cartilage that may have broken off within the joint, which can cause catching, locking, and further damage.
  4. Microfracture/Nanofracture: Creating tiny holes in the exposed bone surface where cartilage has worn away completely. This stimulates bleeding and encourages the formation of fibrocartilage (a scar-like cartilage) to cover the bare bone, potentially reducing pain.
  5. Capsular Release: Releasing parts of the thickened and contracted joint capsule (the fibrous tissue surrounding the joint). This helps to improve range of motion and reduce stiffness. Both anterior and posterior releases may be performed.
  6. Humeral Osteophyte Resection: Removing bone spurs (osteophytes) that commonly form around the edge of the humeral head in arthritis. These spurs can limit movement and cause impingement.
  7. Glenoid Osteophyte Resection/Glenoidoplasty: Similar removal of bone spurs from the glenoid rim and potentially reshaping the socket slightly.
  8. Biceps Tenotomy or Tenodesis: If the long head of the biceps tendon (which runs through the shoulder joint) is frayed or inflamed, it may be released (tenotomy) or released and reattached elsewhere (tenodesis) to eliminate it as a pain source.
  9. Subacromial Decompression: If there is evidence of impingement in the subacromial space (above the main shoulder joint), this may also be addressed by removing bone spurs from the acromion (part of the shoulder blade) and releasing the coraco-acromial ligament.
  10. Axillary Nerve Neurolysis: In some cases, releasing the axillary nerve if it’s thought to be contributing to pain.

The exact combination of these steps varies based on the surgeon’s findings during the arthroscopic surgery. The entire procedure is performed through small keyhole incisions, minimizing soft tissue disruption compared to open surgery.

Recovery and Outcomes after CAM

Recovery after Comprehensive Arthroscopic Management (CAM) is a gradual process and requires commitment to physiotherapy.

  • Immediate Post-Op: Patients typically go home the same day or after a short overnight stay. The arm will be placed in a sling for comfort and protection, usually for a few weeks. Pain relief is managed with medications and often nerve blocks administered during surgery.
  • Early Weeks (0-6 weeks): The focus is on controlling pain and swelling, gentle passive and active-assisted range of motion exercises guided by a physiotherapist, and protecting the healing tissues. The sling is gradually weaned off as comfort allows.
  • Mid-Phase (6-12 weeks): Physiotherapy progresses to more active range of motion and light strengthening exercises. The goal is to restore movement and begin rebuilding muscle control.
  • Later Phase (3-6+ months): Strengthening exercises become more intensive. Gradual return to daily activities, work, and eventually, sports, is guided by the surgeon and physiotherapist based on individual progress. Full recovery and maximum benefit can take 6 months to a year.

Outcomes:

Clinical studies on the CAM procedure have shown promising results, particularly in the short to medium term for carefully selected patients:

  • Pain Relief: Many patients experience a significant reduction in shoulder pain.
  • Functional Improvement: Improvements in range of motion and the ability to perform daily activities are common.
  • Durability: Studies indicate good “survivorship” (meaning the patient hasn’t needed a shoulder replacement) at 2 and 5 years post-surgery for a majority of patients. For example, one study reported 85% survivorship at 2 years.
  • Patient Satisfaction: High levels of patient satisfaction are often reported.

However, it’s important to understand that CAM is not a cure for arthritis. It’s a joint-preserving technique aimed at managing symptoms and improving function. The underlying arthritis remains, and the joint may continue to degenerate over time. Some patients may eventually require a shoulder joint replacement later in life. Predictors of less successful outcomes or earlier failure can include more severe pre-operative arthritis, significant bone loss, and older age.

Key Takeaways and Next Steps

Comprehensive Arthroscopic Management (CAM) is a valuable, minimally invasive surgical option for younger, active individuals suffering from advanced shoulder arthritis who are not yet ready for or wish to delay joint replacement. By combining multiple arthroscopic techniques, the CAM procedure aims to provide pain relief, improve function, and preserve the natural shoulder joint.

Key Points to Remember:

  • CAM is a joint-preserving, arthroscopic management technique.
  • It’s best suited for young, active patients with advanced shoulder osteoarthritis.
  • It involves a combination of procedures like chondroplasty, synovectomy, loose body removal, and osteophyte resection.
  • Recovery involves significant physiotherapy over several months.
  • Outcomes generally include good pain relief and functional improvement, potentially delaying the need for shoulder replacement.

If you are experiencing persistent shoulder pain due to arthritis and believe you might be a candidate for the CAM procedure, the next step is to consult with an orthopaedic specialist experienced in shoulder arthroscopy.

Ready to explore your options for shoulder pain relief?

Take the first step towards managing your shoulder arthritis and regaining your active life.