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Comprehensive Arthroscopic Management (CAM)

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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.

Updated Sep 2026

Comprehensive Arthroscopic Management preserves the native joint — a joint-sparing option for younger, active patients with advanced shoulder arthritis. Kieran Hirpara 4.0

Why this operation has been suggested

Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. We assess you with a history, an examination, and imaging where needed.

For wear-and-tear arthritis of the shoulder, we usually try non-operative care first: changing your activities, physiotherapy, anti-inflammatory medicine, and injections. Surgery is considered when these have not given enough improvement.

Comprehensive Arthroscopic Management (CAM) is a keyhole operation that treats the damaged surfaces and soft tissues inside the shoulder joint. It is typically offered to younger, active people who have advanced arthritis but want to keep their own joint and delay a shoulder replacement. Some people with milder arthritis and significant pain may also be suitable.

The operation aims to reduce pain and improve how your shoulder moves and works. In studies, 76.9% of people who had this operation still had their own joint at a minimum of 5 years afterwards. We will discuss whether it suits you, and you share in that decision.

Before the operation

Before the day of surgery, your surgeon will give you clear instructions to follow. You will need to stop eating and drinking seven hours beforehand. This allows room to bring your operation forward if the theatre list runs early. Some medicines may need to be paused, and your surgeon will tell you which ones and for how long. Bring a written list of everything you take, including tablets, injections and natural remedies. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Wear loose, comfortable clothing that is easy to put on over your shoulder. Imaging such as X-rays, MRI or ultrasound may be needed to plan the operation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist.

On the day

You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will not go to a ward first. The anaesthetist will meet you before the operation and talk you through both parts. This operation is done under general anaesthetic combined with a regional nerve block. You will be fully asleep for the operation, and the block (an injection that numbs the nerves supplying the arm before you wake up) provides pain relief for the first 12 to 24 hours after surgery. You are then taken into the operating theatre, where the operation is performed.

You will wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. Because the nerve block can numb part of your arm for the first 12 to 24 hours, you will need someone to drive you home, as set out in the previous section.

What the operation involves

CAM is a keyhole operation. Your surgeon makes a few small cuts, each about 1 cm, around the shoulder. A thin camera and small instruments go through these cuts to work inside the joint.

Once inside, your surgeon cleans out the joint. This can include removing loose fragments of cartilage or bone, smoothing the worn joint surfaces, and clearing inflamed tissue. Tight tissue around the joint is released so the shoulder can move more freely. If a nerve at the front of the shoulder is being squeezed by scar tissue, it is freed. If the tendon at the top of the biceps muscle is worn, it is anchored down into the upper arm bone so it can no longer cause pain. Small holes are made in the bone where cartilage is worn away, which encourages new scar-like tissue to grow and cushion the joint. Bone spurs on the lower part of the ball of the joint are trimmed away.

The small cuts are closed with stitches and covered with a dressing. You will go home with instructions about caring for the shoulder, and the dressing stays on for about 10 days.

After the operation

Most patients stay one night in hospital after this operation, though some are able to go home the same day. You will wake up in the recovery area, then move to the ward. Your arm may feel numb or heavy for the first 12 to 24 hours because of the nerve block. As it wears off, you may feel some discomfort, and the nurses will give you pain relief to keep this manageable. You will go home with your arm supported in a sling. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. Most people can walk around and do light tasks at home straight away. Please arrange for someone to stay with you for the first 24 hours.

Recovery

For the first day or two, your arm will feel numb and heavy from the nerve block. As that wears off, expect some soreness and swelling around the shoulder. Rest, ice packs and the pain relief plan we give you will keep this manageable. Most people find the discomfort settles steadily over the first couple of weeks.

You will go home with your arm in a sling. Your physiotherapist will guide you through gentle movements early on, then build up to strength work as your shoulder allows. You can walk around and do light tasks at home straight away, but you will need help with things like dressing and reaching overhead at first. Sleeping upright or propped on pillows is often more comfortable in the early days. Keep the dressing dry and leave it alone; we will review it with you.

Recovery happens in stages, and each one is anchored on what your shoulder can do rather than a date on a calendar. As the swelling settles and movement returns, daily tasks become easier. Once your surgeon clears you, typically at the six-week review, you can drive again; see our guide on Driving after upper-limb surgery. Strengthening comes last, once your shoulder tolerates it without a flare of pain.

Everyone heals at their own pace, so your timeline may differ. Your surgeon and physiotherapist will check your progress at each visit and adjust the plan if needed.

What can go wrong

Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early.

Keyhole shoulder surgery has a low rate of complications overall. Even so, it helps to know what to watch for in the first weeks.

If you already have carpal tunnel syndrome or tendon inflammation in your fingers or hand, tell us before your operation. These conditions make hand and finger problems after surgery more likely. Swelling in the hand can do the same. You might notice tingling, numbness or swelling in your fingers that was not there before. Mention it at your next review, or call the clinic if it gets worse quickly.

Stiffness is the most common problem after keyhole shoulder surgery. Your shoulder may feel tight and hard to move, and the tightness may not ease with rest. If simple movements stay painful and restricted after the first couple of weeks, bring it up at your review. Most stiffness settles on its own without another operation.

Having arthritis in the same shoulder raises the chance of problems, both soon after surgery and later on. This is one reason we talk through the options with you carefully before deciding on this operation.

During keyhole surgery, small tools carry the stitches through the tissue. One of these tools can occasionally break, leaving a small piece inside the joint. You would not usually feel this yourself. It is something your surgeon watches for during the operation and manages there.

The complications table on this page lists typical rates if you want the specifics.

When to call us

Most people recover without problems, but some symptoms need urgent attention. Call us straight away if you have a fever, or if the skin around the wounds becomes increasingly red or starts discharging fluid. Go to emergency if you have sudden severe pain, swelling in your calf, or shortness of breath. Call us if your hand or arm loses feeling, or if you cannot move it at all. If you are unsure whether a symptom is serious, call the clinic and we will help you decide.

Where to read more about the condition

This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Shoulder Arthritis page.

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Reviewed by Dr Kieran Hirpara · 7 August 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

• The Comprehensive Arthroscopic Management (CAM) procedure is a systematic, inclusive approach to the array of pathologies encountered in the setting of early glenohumeral arthritis [1].
• The CAM procedure reduced pain, improved function, and provided reasonable short-term durability for young, active patients with advanced shoulder osteoarthritis [2].
• The CAM procedure serves as a joint-preserving alternative to arthroplasty for young, active patients with advanced shoulder osteoarthritis [2].
• The comprehensive arthroscopic management procedure provides a predictable short-term joint-preserving option for younger, high-demand patients with advanced glenohumeral osteoarthritis [3].
• The comprehensive arthroscopic management procedure reduces pain and improves function in younger, high-demand patients with advanced glenohumeral osteoarthritis [3].
• The arthroscopic CAM procedure for glenohumeral osteoarthritis demonstrated significant improvements in midterm clinical outcomes [6].
• The arthroscopic CAM procedure for glenohumeral osteoarthritis demonstrated high patient satisfaction [6].
• The arthroscopic CAM procedure for glenohumeral osteoarthritis had a 76.9% survivorship rate at a minimum of 5 years postoperatively [6].
• Arthroscopic debridement improved clinical outcome in 68% of patients suffering from advanced osteoarthritis of the glenohumeral joint [7].
• Treatment of glenohumeral arthritis with arthroscopic glenoid resurfacing provided superior results to previously performed arthroscopic procedures in patients with failed previous arthroscopic debridement [9].
• Arthroscopic debridement is an excellent treatment for elderly patients with modest functional demands [10].
• Long-term consequences of arthroscopic debridement for elderly patients with modest functional demands require further evaluation [10].
• CAM is a reasonable option for patients with localized cartilage defects and specific radiographic findings [12].
• Hemiarthroplasty or total shoulder arthroplasty are feasible options for patients with humeral head incongruity or large anterior osteophytes [12].
• Isolated arthroscopic debridement and capsular release may not provide substantial benefit to justify its use in most patients with glenohumeral arthritis [15].
• Surgical arthroscopic repair was possible in all cases of acute or recurrent instability in soccer goalkeepers with well-defined exclusion criteria [19].

Anatomy & Pathophysiology

Bony Anatomy

• The proximal humerus comprises the humeral head, greater tuberosity, lesser tuberosity, and humeral shaft [29].
• The articular head of the humerus is spherical with a diameter of 37 to 57 mm [29].
• The most superior portion of the articular surface of the humeral head averages 8 mm above the greater tuberosity [29].
• Humeral version averages 29.8 degrees, with a range of 10 to 55 degrees [29].
• The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [29].
• The bicipital groove lies between the greater and lesser tuberosities and serves as a pathway for the long head of the biceps [29].
• The distal aspect of the bicipital groove is internally rotated with respect to the proximal portion [29].
• The anatomic neck of the proximal humerus is located at the junction of the articular surface and the tuberosities [29].
• The surgical neck represents an indistinct region below the tuberosities but above the humeral shaft [29].
• The greater tuberosity is located in a posterior-superior location with respect to the humeral shaft and serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons [29].
• The lesser tuberosity is located on the anterior aspect of the proximal humerus and serves as the attachment site for the subscapularis tendon [29].
• The glenoid is a convex structure of shallow depth shaped like an inverted pear [29].
• The glenoid cavity is a shallow socket, approximately one third the size of the humeral head [30].
• The neck-shaft angle of the proximal humerus measures an average of 135 degrees [30].
• The humeral head is retroverted an average of 30 degrees [30].
• The humeral head averages 19° of retroversion and 41° of inclination [32].
• The glenoid averages 5° of retroversion in relation to the axis of the scapular body [32].
• The subchondral bone of the glenoid is relatively flat, with articular concavity augmented by cartilage and a circumferential labrum [32].
• The scapula is attached to the axial skeleton by the acromioclavicular and sternoclavicular joints [31].
• The scapular body is triangular when viewed anteroposteriorly, with its base situated superiorly and its apex inferiorly [31].
• The glenoid is connected with the flat body of the scapula by the scapular neck [31].
• The coracoid process curves forwards from the superior surface of the scapular neck [31].
• The scapular spine ends in a flattened bony process, the acromion, which curves forwards [31].
• The lateral pillar connects the inferior border of the glenoid with the inferior angle of the scapula [31].
• The spinal pillar arises from the central part of the glenoid and continues medially to become part of the base of the scapular spine [31].
• The weakest bone in the scapula is located primarily in the central part of the biomechanical body, specifically in the infraspinous fossa [31].
• The weakest area of the circumference of the biomechanical body of the scapula is the spinomedial angle [31].
• The acromion has three ossification centers: the metacromion, mesoacromion, and preacromion [32].
• The proximal humerus has three centers of ossification: the humeral head, greater tuberosity, and lesser tuberosity [32].

Vascular and Neural Anatomy

• The proximal humerus receives its blood supply from the anterior and posterior humeral circumflex branches from the third division of the axillary artery [29].
• 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 [29].
• The anterior humeral circumflex artery arises from the axillary artery at the inferior border of the subscapularis [29].
• The anterior humeral circumflex artery provides vascular inflow to the humeral head by way of its terminal anterolateral branch, known as the artery of Laing or arcuate artery [29].
• The ascending branch of the anterior humeral circumflex artery 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 [29].
• Injury to the arcuate artery may result in osteonecrosis of the humeral head [29].
• Additional extraosseous collateral branches can permit humeral head perfusion despite complete ligation of the arcuate artery [29].
• The anterolateral ascending branch of the anterior humeral circumflex artery provides the primary blood supply to the humeral head [32].
• The terminal intraosseous portion of the anterior humeral circumflex artery enters at the proximal aspect of the intertubercular groove as the arcuate artery [32].
• The axillary nerve passes from anteromedial to posterolateral toward the quadrilateral space just inferior to the joint [5].
• An axillary nerve injury from proximal humeral fracture or fracture-dislocation results in paralysis of the deltoid muscle and anesthesia over the “badge” region at the lateral proximal arm [30].
• The brachial plexus and axillary artery are located anterior to the coracoid process of the scapula and humeral head [30].

Soft Tissue and Joint Structures

• The rotator cuff consists of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles [30].
• The teres major is not a rotator cuff muscle [30].
• The rotator cuff muscles serve as depressors of the humeral head to allow the deltoid to efficiently abduct the humerus [30].
• The infraspinatus and teres minor are external rotators, while the subscapularis is an internal rotator of the humerus [30].
• The acromion, coracoacromial ligament, and coracoid process form the coracoacromial arch [29].
• The rotator cuff, subacromial bursa, and subdeltoid bursa pass underneath the coracoacromial arch [29].
• The glenohumeral joint is stabilized dynamically by the rotator cuff via joint compression and by the positioning of the scapulothoracic joint [32].
• Static stabilizers of the glenohumeral joint include articular congruity, the glenoid labrum, concavity-compression, negative intra-articular pressure, and the glenohumeral capsule and ligaments [32].
• The glenoid labrum provides concavity and up to 50% of marginal glenoid socket depth [32].
• The rotator interval is defined medially by the base of the coracoid, superiorly by the supraspinatus tendon, and inferiorly by the subscapularis tendon [32].
• The rotator interval contains the coracohumeral ligament, the superior glenohumeral ligament, and the intra-articular portion of the long head of the biceps tendon [32].
• Laxity of the rotator interval results in inferior laxity, known as the sulcus sign [32].
• Contracture of the rotator interval is seen with adhesive capsulitis [32].
• The coracohumeral ligament restricts external rotation in adduction and is a static restraint to inferior and posterior translation in adduction and external rotation [32].
• The superior glenohumeral ligament is a primary static restraint against anterior translation with the arm at the side [32].
• The superior glenohumeral ligament and coracohumeral ligament form a pulley that provides restraint against medial subluxation of the long head of the biceps tendon [32].
• The middle glenohumeral ligament is a primary static restraint against anterior translation with the arm in external rotation and 45° of abduction [32].
• The anterior band of the inferior glenohumeral ligament is a primary static restraint against anterior-inferior dislocation of the glenohumeral joint in 90° of abduction and external rotation [32].
• The posterior band of the inferior glenohumeral ligament is a primary static restraint against posterior-inferior translation in internal rotation and adduction [32].
• The subscapular bursa lies between the subscapularis tendon and the neck of the scapula [33].
• The subscapular bursa communicates with the joint cavity between the superior and middle glenohumeral ligaments [33].
• The subscapular bursa protects the tendon of the subscapularis at the point where it passes under the base of the coracoid process and over the neck of the scapula [33].
• The subscapular bursa often houses loose bodies in the shoulder [33].
• Synovitis of the shoulder may be most intense in the subscapular bursa region, where small fringes or villi can project into the joint cavity [33].
• A soft tissue sheath consistently covers the long head of the biceps tendon to the level of the proximal margin of the pectoralis major tendon [33].
• The fibro-osseous bicipital tunnel consists of three distinct anatomic zones: Zone 1 (bony groove), Zone 2 ("no man's land"), and Zone 3 (subpectoral region) [33].
• Zone 1 of the bicipital tunnel represents the traditional bony bicipital groove beginning at the articular margin and ending at the distal margin of the subscapularis tendon [33].
• Zone 2 of the bicipital tunnel extends from the distal margin of the subscapularis tendon to the proximal margin of the pectoralis major tendon and is not viewable from arthroscopy above or from subpectoral exposure below [33].
• Zone 3 of the bicipital tunnel is distal to the proximal margin of the pectoralis major tendon and represents the subpectoral region [33].

Pathophysiology

• Stability and function of the glenohumeral joint are provided by the interaction of structures that promote a near global range of motion and purposeful function [29].
• External loads transferred to the shoulder girdle are initially offset by joint surface anatomy, joint volume, atmospheric pressure, and joint fluid cohesion and adhesion [29].
• Moderate and large loads are counterbalanced by the deltoid and rotator cuff and by the capsulolabral and bone structures, respectively [29].
• Pathologic humeral fractures alter complex interactions in the shoulder girdle, resulting in pain, decreased range of motion and stiffness, and disability [29].
• Displacement of proximal humeral fracture fragments occurs in a predictable manner based on the deforming forces created by the tendinous insertions of the pectoralis major, subscapularis, supraspinatus, and infraspinatus [29].
• The subscapularis inserts on the lesser tuberosity and causes medial displacement of fracture fragments [29].
• The supraspinatus and infraspinatus insert on the greater tuberosity and cause superior and posterior displacement of fracture fragments [29].
• The pectoralis major inserts on the humeral shaft and displaces it medially [29].
• Fractures involving the anatomic neck are prognostically worse than fractures involving other regions of the proximal humerus with respect to the potential disruption of the vascular supply to the humeral head and subsequent development of avascular necrosis [29].
• Normal shoulder motion is approximately two-thirds glenohumeral and one-third scapulothoracic [32].
• The superior shoulder suspensory complex provides a stable connection between the scapula and the axial skeleton [32].
• The superior shoulder suspensory complex is composed of the glenoid, coracoid process, coracoclavicular ligaments, distal clavicle, acromioclavicular joint, and acromion [32].
• The superior strut of the superior shoulder suspensory complex comprises the middle clavicle [32].
• The inferior strut of the superior shoulder suspensory complex comprises the lateral scapular border and spine of the scapula [32].
• Arthritis usually involves the central aspect of the humeral head [22].
• Joint space narrowing is most evident on the axillary "truth view" as opposed to images made with the arm at the side [22].
• The axillary "truth view" demonstrates posterior subluxation or "functional decentering" that is not evident in images taken with the arm at the side [22].
• Malcentering of the joint reaction force leads to posterior instability, posterior glenoid wear, and "rocking horse" loosening of prosthetic glenoid components [22].
• 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 [22].
• 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 [22].
• Loss of humeral lateral offset due to medial joint erosion is observed in glenohumeral arthritis [22].
• A "Friar Tuck" pattern of central baldness is commonly seen in primary degenerative joint disease, with remaining articular cartilage at the periphery [22].

Classification

• Patients are excluded from CAM if they have early-stage glenohumeral osteoarthritis defined as Kellgren-Lawrence grade 1 or 2 [8].
• Patients are excluded from CAM if they have not undergone a trial of nonoperative measures [8].
• Patients are excluded from CAM if they have irreparable rotator cuff tears [8].
• Patients are excluded from CAM if they have severe bipolar chondral lesions with diffuse flattening of the humeral head [8].
• Total shoulder arthroplasty is suggested over CAM for patients with a type B2 or C glenoid according to the Walch classification [8].
• Total shoulder arthroplasty is suggested over CAM for patients with less than 2 mm of glenohumeral joint space [8].

Clinical Presentation

• The Comprehensive Arthroscopic Management (CAM) procedure is recommended as a systematic, inclusive approach to the array of pathologies encountered in the setting of early glenohumeral arthritis [1].
• The CAM procedure provides a predictable short-term joint-preserving option for younger, high-demand patients with advanced glenohumeral osteoarthritis [3].
• Arthroscopic management of glenohumeral osteoarthritis is an emerging and evolving procedure to treat the challenging problem of glenohumeral osteoarthritis in young and high-demand patients [4].
• Patients undergoing the CAM procedure met the clinical and radiographic criteria for total shoulder joint replacement but elected to undergo a joint-preserving technique to avoid or delay total shoulder arthroplasty [8].
• Exclusion criteria for the CAM procedure include early-stage glenohumeral osteoarthritis (Kellgren-Lawrence grade 1 or 2) [8].
• Exclusion criteria for the CAM procedure include no trial of nonoperative measures [8].
• Exclusion criteria for the CAM procedure include irreparable rotator cuff tears [8].
• Exclusion criteria for the CAM procedure include severe bipolar chondral lesions with diffuse flattening of the humeral head [8].
• Total shoulder arthroplasty is suggested over the CAM procedure if patients have a type B2 or C glenoid according to the Walch classification [8].
• Total shoulder arthroplasty is suggested over the CAM procedure if patients have less than 2 mm of glenohumeral joint space [8].
• Preoperative symptoms consistent with axillary nerve impingement or compression include posterior and lateral shoulder pain [5].
• Preoperative symptoms consistent with axillary nerve impingement or compression include atrophy of the teres minor or posterior deltoid [5].
• Preoperative symptoms consistent with axillary nerve impingement or compression include weakness in external rotation without the presence of a rotator cuff tear [5].
• Axillary nerve decompression is considered if an inferior humeral osteophyte changed the course of the nerve as determined on preoperative MRI [5].
• Axillary nerve decompression is considered if the nerve is observed intraoperatively by displacement of the inferior capsule [5].

Investigations

Radiographic Evaluation

• The purpose of imaging the shoulder is to help establish the diagnosis, determine the severity of the pathoanatomy, assist in surgical planning, and enable the surgeon to illustrate the condition of the shoulder to the patient [22].
• Unless a specific research protocol is in place, the temptation to “overimage” should be resisted, obtaining only the scans or reconstructions that are necessary for the care of the patient [22].
• Standardized plain films are almost always sufficient to garner the information needed for glenohumeral arthritis evaluation [22].
• Proper radiographic technique is as important as proper surgical technique to achieve the desired outcome [22].
• The first key radiographic view is the anteroposterior (AP) in the plane of the scapula taken so that the x-ray beam passes through the glenohumeral joint [22].
• The AP view in the plane of the scapula shows the superoinferior position of the humeral head relative to the glenoid, the presence of osteophytes on the humeral head and glenoid, narrowing of the joint space, and the degree of medial displacement of the humerus in relation to the lateral acromial line [22].
• The AP view in the plane of the scapula also shows the quality of the humeral and glenoid bone, the presence of loose bodies, and whether there is humeral head collapse or deformity [22].
• 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 [22].
• The axillary view is oriented so that both the spinoglenoid notch and the scapular neck are visible [22].
• The axillary view shows a different perspective of the humeral anatomy, the amount of glenoid bone, the 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 [22].
• The axillary view is referred to as the “truth view” because it demonstrates the glenohumeral relationships in the functional position of elevation [22].
• CT scans have the disadvantage of being taken with the arm in the adducted position, whereas the axillary truth view is taken with the arm in elevation [22].
• Many “axillary views” sent for consultation are taken without standardization, making it impossible to determine the important features of the glenohumeral joint [22].
• When taken properly, standardized anteroposterior and axillary views indicate the thickness of the cartilage space between the humerus and the glenoid, relative positions of the humeral head and the glenoid, presence of osteophytes, degree of osteopenia, and extent of bony deformity and erosion [22].
• Joint space narrowing is most evident on the axillary truth view as opposed to images made with the arm at the side because arthritis usually involves the central aspect of the humeral head [22].
• The standardized axillary view enables the detection of posterior subluxation or “functional decentering” that is not evident in images taken with the arm at the side [22].
• The degree of posterior subluxation can be measured as the position of the center of the humeral head in relation to the plane of the scapula [22].
• The degree of posterior subluxation can be measured as the position of the center of the humeral head in relation to the glenoid face [22].
• The degree of posterior subluxation can be measured as the point of contact of the humeral articular surface on the glenoid articular surface [22].
• At least two X-ray views should be obtained for shoulder imaging: an anteroposterior in the plane of the glenoid and an axillary projection with the arm in abduction to show the relationship of the humeral head to the glenoid [37].
• CT scans may offer a few degrees of increased precision in the measurement of glenoid version, but this precision does not necessarily improve the quality of the surgery or the clinical outcome [22].

Magnetic Resonance Imaging

• Magnetic resonance imaging (MRI) is useful to identify osteonecrosis of the humeral head, or a bone tumour [37].
• MRI can identify labral tears and rotator cuff tears, although the accuracy for these is enhanced by combining the scan with arthrography [37].
• Preoperative MRI is used to determine if an inferior humeral osteophyte changed the course of the axillary nerve [5].
• Preoperative symptoms consistent with axillary nerve impingement or compression include posterior and lateral shoulder pain, atrophy of the teres minor or posterior deltoid, and weakness in external rotation without the presence of a rotator cuff tear [5].

Computed Tomography

• Computed tomography (CT) is helpful for planning fracture surgery and shoulder joint replacement [37].
• Three-dimensional reconstructions based on CT scans of the arthritic shoulder are currently discussed in comparison to imaging consisting only of two standardized plain films [39].

Ultrasound

• Ultrasound is a simple and accurate test for identifying rotator cuff tears and calcific tendinitis [37].
• Ultrasound can be useful in guiding injections or barbotage (aspirating calcific deposits in the rotator cuff) [37].
• The most commonly performed joint examination using ultrasonography is the shoulder examination [35].
• Accuracy of rotator cuff ultrasonography depends on the skill of the scanner operator and an awareness of pitfalls that are encountered [35].

Arthroscopy

• Arthroscopy is useful for diagnosing and treating subacromial impingement, intra-articular lesions, detachment of the glenoid labrum and rotator cuff tears [37].
• Diagnostic arthroscopy is performed to identify and treat all intra-articular pathologic abnormalities during the CAM procedure [5].
• Fluoroscopy is used to confirm adequate resection of inferior humeral head osteophytes during the CAM procedure [5].

Treatment

Indications and Patient Selection

• The Comprehensive Arthroscopic Management (CAM) procedure is recommended as a systematic, inclusive approach for pathologies encountered in early glenohumeral arthritis [1].
• CAM serves as a joint-preserving alternative to arthroplasty for young, active patients with advanced shoulder osteoarthritis [2].
• CAM provides a predictable short-term joint-preserving option for younger, high-demand patients with advanced glenohumeral osteoarthritis [3].
• CAM is indicated for patients who meet clinical and radiographic criteria for total shoulder joint replacement but elect to undergo a joint-preserving technique to avoid or delay total shoulder arthroplasty [8].
• Exclusion criteria for the CAM procedure include early-stage glenohumeral osteoarthritis (Kellgren-Lawrence grade 1 or 2), no trial of nonoperative measures, irreparable rotator cuff tears, and severe bipolar chondral lesions with diffuse flattening of the humeral head [8].
• Total shoulder arthroplasty is suggested over the CAM procedure if patients have a type B2 or C glenoid according to the Walch classification or less than 2 mm of glenohumeral joint space [8].
• CAM is a reasonable option for patients with localized cartilage defects and specific radiographic findings, while hemiarthroplasty or total shoulder arthroplasty are feasible options for those with humeral head incongruity or large anterior osteophytes [12].
• Arthroscopic treatment may be the best alternative when joint reconstruction is not desirable, possible, or practical [23].
• Arthroscopic intervention may be more suitable for elderly patients with significant medical comorbidities who might be unable to tolerate the stresses of major surgery [23].
• Arthroscopic treatment may be suitable for young patients with early onset arthritis who are not ideal candidates for total shoulder arthroplasty due to concerns related to prosthesis longevity or high functional demands [23].
• Arthroscopic treatment may be indicated for patients with significant pain but only mild arthritic changes in the glenohumeral joint, making it difficult to justify arthroplasty [23].
• Arthroscopy provides an opportunity to diagnose and treat coexistent soft tissue pathology in patients with osteoarthritis, which may eliminate the need for arthroplasty [23].
• Arthroscopic treatment is an option when significant arthritis is noted intraoperatively that was not observed on preoperative workup [23].

Operative Technique

• The CAM procedure involves placing patients in the beach-chair position and performing diagnostic arthroscopy to identify and treat all intra-articular pathologic abnormalities [5].
• Degenerative labral tissue and unstable chondral injuries are debrided during the CAM procedure [5].
• Loose bodies are removed during the CAM procedure when present [5].
• Areas of synovitis are addressed with either a mechanical shaver or a radiofrequency device during the CAM procedure [5].
• Microfracture is performed if a focal chondral defect is noted on either the glenoid or humeral head during the CAM procedure [5].
• An accessory posteroinferior portal is established under spinal-needle localization during the CAM procedure [5].
• Inferior humeral head osteophytes are resected with a high-speed bur through the accessory posteroinferior portal during the CAM procedure [5].
• Curettes are used to remove bone from areas that are difficult to reach with motorized instruments, such as the anteroinferior quadrant, during the CAM procedure [5].
• Inferior capsular release is performed during the CAM procedure [5].
• The axillary nerve is identified just inferior to the joint, where it passes from anteromedial to posterolateral toward the quadrilateral space, if preoperative symptoms and imaging suggest axillary nerve compression [5].
• The axillary nerve is carefully decompressed from proximal to distal, taking care to identify and preserve all arborizing branches [5].
• Axillary nerve decompression is considered if an inferior humeral osteophyte changed the course of the nerve as determined on preoperative MRI, if observed intraoperatively by displacement of the inferior capsule, or if preoperative symptoms consistent with axillary nerve impingement or compression were present [5].
• The CAM procedure builds on previously described arthroscopic techniques for glenohumeral osteoarthritis, including debridement, chondroplasty, synovectomy, loose body removal, capsular release, and subacromial decompression [8].
• The CAM procedure adds inferior humeral osteoplasty, a complete capsular release, axillary nerve neurolysis, long head of the biceps tenodesis, and microfracture to previously described techniques [8].
• Comprehensive arthroscopic management without axillary nerve release or subacromial decompression achieves satisfactory and durable results in young patients with glenohumeral osteoarthritis [14].
• 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 [4].
• A certain skill level and proficiency with shoulder arthroscopy are required to undertake some of the components of CAM of primary glenohumeral osteoarthritis [4].

Outcomes and Survivorship

• The CAM procedure demonstrates significant improvements in midterm clinical outcomes and high patient satisfaction for glenohumeral osteoarthritis [6].
• The survivorship rate after the arthroscopic CAM procedure for glenohumeral osteoarthritis is 76.9% at a minimum of 5 years postoperatively [6].
• Arthroscopic treatment of glenohumeral osteoarthritis provides improvements in range of motion and patient-reported outcomes with minimal complications [13].
• 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 [24].
• Treatment of glenohumeral arthritis with arthroscopic glenoid resurfacing provided superior results to previously performed arthroscopic procedures in a series of patients with failed previous arthroscopic debridement [9].
• Arthroscopic debridement is an excellent treatment for elderly patients with modest functional demands, though long-term consequences require further evaluation [10].

Limitations and Evidence Quality

• Debate remains regarding the durability of managing primary glenohumeral arthritis arthroscopically [4].
• Some 2- and 5-year follow-up data for arthroscopic management of primary glenohumeral arthritis remain limited to level IV series [4].
• Previously published literature places survivorship at 85% at 2 years postoperatively after arthroscopic management of primary glenohumeral arthritis [4].
• Previously published literature places survivorship at 76.9% at 5 years after arthroscopic management of primary glenohumeral arthritis [4].
• 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 [4].
• There may be a placebo effect for shoulder arthroscopy that may improve patient outcomes in the short- and mid-term after surgery [4].
• Most studies on arthroscopic management of glenohumeral osteoarthritis are level IV with low patient numbers and relatively short follow-up [4].
• The American Academy of Orthopaedic Surgeons clinical practice guidelines classify 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 [23].
• A systematic review of the literature showed that arthroscopic debridement for glenohumeral arthritis lacks high-quality evidence to support its routine use [23].
• A systematic review shows that arthroscopic debridement for glenohumeral arthritis lacks high-quality evidence to support its routine use [16].
• 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 [15].

Axillary Nerve Injury Risk

• Arthroscopic release of the axillary nerve is technically demanding and potentially dangerous for less experienced arthroscopists, who risk nerve injury or transection [4].
• A certain skill level and proficiency with shoulder arthroscopy are required to undertake some components of the CAM procedure [4].

General Complication Profile

Recovery

• The CAM procedure reduced pain, improved function, and provided reasonable short-term durability for young, active patients with advanced shoulder OA [2].
• 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 [3].
• Arthroscopic debridement improved clinical outcome in 68% of patients suffering from advanced OA of glenohumeral joint [7].
• 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 [17].
• The CAM procedure demonstrated significant improvements in midterm clinical outcomes and high patient satisfaction after the arthroscopic CAM procedure for GHOA [6].
• The CAM procedure demonstrated a 76.9% survivorship rate at a minimum of 5 years postoperatively [6].
• After the CAM procedure, an 84% survivorship was found at 3 years [25].
• After the CAM procedure, a 72% survivorship was found at 5 years [25].
• The majority of patients demonstrated sustained improvement in patient-reported outcomes and satisfaction without conversion to total shoulder arthroplasty at long-term follow-up [18].
• Some patients progressed to arthroplasty after the CAM procedure [18].

Key Evidence

• [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. [1] (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. [2] (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. [3] (10.1016/j.eats.2015.04.003)
• [L5] [4] (10.5435/jaaos-d-17-00214)
• [L3] [5] (10.1177/0363546516668823)
• [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. [6] (10.1177/0363546516656372)
• [L3] Arthroscopic debridement improved clinical outcome in 68% of patients suffering from advanced OA of glenohumeral joint. [7] (10.1186/s12891-015-0741-9)
• [L3] [8] (10.1177/0363546520962756)
• [L4] Treatment of glenohumeral arthritis with arthroscopic glenoid resurfacing provided superior results in this series to their previously performed arthroscopic procedure. [9] (10.1016/j.arthro.2009.04.015)
• [L3] Arthroscopic debridement is an excellent treatment for elderly patients with modest functional demands, though long-term consequences require further evaluation. [10] (10.1007/s00402-004-0738-6)
• [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. [12] (10.1530/eor-2023-0156)
• [L1] Arthroscopic treatment of glenohumeral osteoarthritis provides improvements in ROM and patient-reported outcomes with minimal complications. [13] (10.1016/j.arthro.2020.02.036)
• [L4] Comprehensive arthroscopic management without axillary nerve release or subacromial decompression achieves satisfactory and durable results in young patients with glenohumeral osteoarthritis. [14] (10.1007/s00167-023-07377-0)
• [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. [15] (10.1016/j.arthro.2014.08.025)
• [L1] This systematic review shows that arthroscopic debridement for glenohumeral arthritis lacks high-quality evidence to support its routine use. [16] (10.1016/j.arthro.2013.02.022)
• [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. [17] (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. [18] (10.1177/2325967121s00213)
• [L4] Surgical arthroscopic repair was possible in all cases of acute or recurrent instability with well-defined exclusion criteria. [19] (10.1055/s-0032-1327656)
• [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. [24] (10.1007/s00167-010-1155-8)
• [L4] After the CAM procedure we found an 84% survivorship at 3 years and 72% survivorship at 5 years. [25] (10.1177/2325967116s00104)

References

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[2] 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

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

[4] Arthroscopic Management of Glenohumeral Arthritis: A Joint Preservation Approach. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-17-00214

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

[6] Survivorship and Patient-Reported Outcomes After Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis. The American Journal of Sports Medicine. 2016. DOI: 10.1177/0363546516656372

[7] Relationship between probability of future shoulder arthroplasty and outcomes of arthroscopic debridement in patients with advanced osteoarthritis of glenohumeral joint. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0741-9

[8] Survivorship and Patient-Reported Outcomes After Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis: Minimum 10-Year Follow-up. The American Journal of Sports Medicine. 2020. DOI: 10.1177/0363546520962756

[9] Arthroscopic Glenoid Resurfacing: Results in Patients With Failed Previous Arthroscopic Debridement (SS‐14). Arthroscopy. 2009. DOI: 10.1016/j.arthro.2009.04.015

[10] Arthroscopic debridement of massive rotator cuff tears: negative prognostic factors. Archives of Orthopaedic and Trauma Surgery. 2004. DOI: 10.1007/s00402-004-0738-6

[12] Comprehensive arthroscopic management versus total shoulder arthroplasty and hemiarthroplasty in patients with primary glenohumeral arthritis younger than 50 years old. EFORT Open Reviews. 2026. DOI: 10.1530/eor-2023-0156

[13] Outcomes and Survivorship After Arthroscopic Treatment of Glenohumeral Arthritis: A Systematic Review. Arthroscopy. 2020. DOI: 10.1016/j.arthro.2020.02.036

[14] Comprehensive arthroscopic management without axillary nerve release or subacromial decompression achieves satisfactory and durable results in young patients with glenohumeral osteoarthritis. Knee Surgery, Sports Traumatology, Arthroscopy. 2023. DOI: 10.1007/s00167-023-07377-0

[15] Arthroscopic Debridement and Capsular Release for the Treatment of Shoulder Osteoarthritis. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.08.025

[16] What Is the Role of Arthroscopic Debridement for Glenohumeral Arthritis? A Critical Examination of the Literature. Arthroscopy. 2013. DOI: 10.1016/j.arthro.2013.02.022

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[18] Survivorship and Patient-Reported Outcomes After Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis: Minimum 10-Year Follow-up. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121s00213

[19] Arthroscopic Treatment of Glenohumeral Instability in Soccer Goalkeepers. International Journal of Sports Medicine. 2012. DOI: 10.1055/s-0032-1327656

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[25] Survivorship after Arthroscopic Management of Glenohumeral Osteoarthritis with a Minimum 5 year Follow-up. Orthopaedic Journal of Sports Medicine. 2016. DOI: 10.1177/2325967116s00104

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