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. 2026 Apr 7;11(4):328–337. doi: 10.1530/EOR-2023-0156

Comprehensive arthroscopic management versus total shoulder arthroplasty and hemiarthroplasty in patients with primary glenohumeral arthritis younger than 50 years old

Marko Nabergoj 1,2, Patrick J Denard 3, Philippe Collin 4, Alexandre Lädermann 5,6,7,✉
PMCID: PMC13087880  PMID: 41945567

Abstract

  • Glenohumeral osteoarthritis (OA) is a disabling disease that leads to poor shoulder function and pain. Primary or idiopathic osteoarthritis occurs in previously intact joints without any inciting agent. Its precise incidence is not known. If conservative treatment fails, there are a variety of surgical procedures described in the literature.

  • Total shoulder arthroplasty (TSA) is primarily indicated in patients above 60 years old with symptomatic glenohumeral OA and intact rotator cuff and failed conservative treatment. However, it is rarely recommended to young or active patients under the age of 50 due to its increased morbidity, limited lifespan, potential for revision surgeries, and difficulty achieving the same preoperative activity level, particularly in patients with high preoperative level of activity.

  • Comprehensive arthroscopic management (CAM), hemiarthroplasty (HA), and TSA provide good results even in the long term for treatment of primary OA in properly selected young patients.

  • A CAM procedure seems to be a reasonable option in case of conservative treatment failure, localized cartilage defect, tendinopathy of the long head of the biceps, stiffness, inferior osteophytes, and humeral head congruity.

  • However, in case of humeral head incongruity, large anterior osteophytes, and an intact rotator cuff, an HA or a TSA is a feasible option.

Keywords: arthroscopy, hemiarthroplasty, prosthesis, primary, glenohumeral, arthrosis, CAM

Introduction

Glenohumeral osteoarthritis (OA) is a disabling disease that leads to poor shoulder function and pain. OA presents in primary (or idiopathic) and secondary forms. The former occurs in previously intact joints without any inciting agent, whereas the secondary form is caused by underlying predisposing factors (e.g., trauma). Typical characteristics of symptomatic OA are narrowing of the joint space, osteophyte development, and capsule contracture (Fig. 1). It is a painful condition accompanied by a decreased range of motion (ROM), especially external and internal rotation. The precise incidence of glenohumeral OA is not known but is related to increased age and previous shoulder trauma (1, 2).

Figure 1.

Figure 1

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Anteroposterior view of a right shoulder of a 50-year-old patient. Observe the narrowing of the joint space and osteophyte development. Reproduced from www.Beemed.com, with permission.

Non-operative management is the first-line treatment of choice, and it consists of physical therapy, nonsteroidal anti-inflammatory medications, corticosteroid injections, and activity restrictions and modifications (3, 4). Platelet-rich plasma injections have demonstrated efficacy in the treatment of knee OA and have also been recommended for glenohumeral OA, but there is little evidence to guide treatment currently and this approach typically is an out-of-pocket expense for the patient. If conservative treatment fails, there are a variety of surgical procedures described in the literature.

Total shoulder arthroplasty (TSA) is primarily indicated in patients above 60 years old with symptomatic glenohumeral OA with intact rotator cuff and failed conservative treatment. It has been shown to predictably achieve excellent results in terms of pain relief and restoration of function in those types of patients. However, this treatment is rarely recommended to young or active patients under the age of 50 due to its increased morbidity, limited lifespan, potential for revision surgeries, and difficulty achieving the same preoperative activity level (5, 6). Moreover, several complications have been described in the literature associated with implantation of TSA in a young patient (1, 7, 8, 9). One of the most frequently documented complications was glenoid loosening as it has been reported in up to 100% of cases in midterm to long-term follow-up (10, 11). In order to avoid the potential for glenoid component loosening, hemiarthroplasty (HA) has been advocated in the young population with advanced glenohumeral OA, comminuted articular fracture of the humeral head, and avascular necrosis without cartilage lesion on the glenoid side (12). However, progressive glenoid defects and persistent pain have been shown to be the most important failure for young patients with shoulder HA.

For this reason, non-arthroplasty treatment options, such as arthroscopic debridement and biological interposition arthroplasty, have been used in an attempt to delay the need for arthroplasty in younger, more active patients or in those patients in whom arthroplasty is otherwise not an acceptable treatment option (1, 8, 13, 14, 15, 16). Several arthroscopic procedures have been proposed, including capsular release, joint debridement, synovectomy, chondroplasty, subacromial decompression, biceps tenodesis, microfracture (Fig. 2), loose body removal, humeral osteoplasty, osteophyte excision, and release of the axillary nerve (17). A combination of previously described procedures otherwise termed ‘comprehensive arthroscopic management’ (CAM) has been described by Millett et al. (18). Generally speaking, an arthroscopic procedure might remove causes for mechanical symptoms and stabilize any chondral lesions (19). The purpose of these surgical procedures has been to produce a temporary symptomatic improvement until arthroplasty would be considered as a more appropriate surgical treatment (20). Previous studies have reported that the aforementioned arthroscopic procedures may benefit patients with shoulder OA (1, 15, 17, 21, 22, 23).

Figure 2.

Figure 2

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Right shoulder, posterior viewing portal. (A) Severe chondropathy of the humeral head. (B) The same view after chondroplasty and microfractures. Reproduced from www.Beemed.com, with permission.

In younger patients, the choice between CAM, HA, and TSA requires careful evaluation of radiographic findings, cartilage status, humeral head morphology, rotator cuff integrity, and glenohumeral stability. Evidence indicates that CAM is most appropriate for young, active patients (<50 years) with early glenohumeral arthrosis who retain > 2 mm of joint space on true anteroposterior radiographs, demonstrate focal or asymmetric chondral defects, and show preserved or only mildly incongruent humeral head geometry (17, 18, 19, 24). Conversely, contraindications for CAM include humeral head flattening, bipolar cartilage loss, large osteophytes, and radiographic evidence of posterior subluxation or Walch B2/B3 morphology, all of which strongly correlate with early failure (16, 21).

HA is traditionally reserved for young patients with advanced humeral-sided cartilage disease, post-traumatic deformity, or avascular necrosis when the glenoid cartilage remains relatively preserved (12). Studies have shown that HA performs best in situations where glenoid wear is minimal (12, 25, 26, 27), humeral head anatomy can be restored, and rotator cuff function is intact. However, HA is contraindicated in the presence of static posterior subluxation or significant glenoid erosion, as these conditions predispose to rapid progression of glenoid wear and poorer functional outcomes (26, 28).

TSA remains the most predictable option for restoring pain relief and function in young patients with centered OA, preserved rotator cuff, and symmetric joint-line wear (5, 6, 7, 29). However, TSA should be used cautiously in younger, high-demand individuals due to the increased risk of glenoid loosening (10, 11) and is generally contraindicated in rotator cuff deficiency, uncontrolled instability, significant posterior glenoid deficiency, or cases with expected high mechanical loads (27, 30, 31).

The aim of this article is to review treatment and results of CAM, HA, and TSA procedures performed only after failure of conservative treatment for primary glenohumeral OA in patients below 50 years of age.

Study selection methodology

We performed a targeted narrative review of the literature using PubMed and Google Scholar, covering the period from 1990 to 2024. Peer-reviewed clinical studies reporting outcomes of CAM, HA, or TSA for glenohumeral osteoarthritis were considered for inclusion. Although not all studies exclusively evaluated patients younger than 50 years, articles were selected when their findings were directly relevant to surgical decision-making in this age group, particularly regarding functional outcomes, survivorship, complication patterns, and conversion rates.

Surgical technique – CAM

The CAM procedure without the axillary neurolysis is performed using the technique described by Millett et al. (18, 24, 32). Before the arthroscopy starts, ROM of the affected shoulder is first assessed. During arthroscopy, the following procedures are performed: debridement of degenerative labral changes, remnants of the cuff, unstable chondral injuries, and synovitis; microfracture in case of high-grade focal chondral defects (Fig. 2); removal of loose bodies; tenodesis of instable or pathologic long head of the biceps; resection of inferior humeral osteophytes; release of anterior and inferior glenohumeral capsule and of the rotator interval (Fig. 3); and acromioplasty if required (a large spur in the anteroinferior part of the acromion or close to the acromioclavicular joint) (Fig. 4) (33, 34, 35). ROM is then again assessed postoperatively.

Figure 3.

Figure 3

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Left shoulder, posterior viewing portal. Release of anterior glenohumeral capsule. *: capsule; G: glenoid; HH: humeral head; and SSc: subscapularis. Reproduced from www.Beemed.com, with permission.

Figure 4.

Figure 4

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Arthroscopic view through a lateral portal of a right shoulder. During a CAM surgery, a severe tendinopathy of the bursal side of the supraspinatus tendon will be an indication to perform an acromioplasty. Reproduced from www.Beemed.com, with permission.

Postoperative rehabilitation protocol consists of three phases. The first phase begins on the first postoperative day, where active assisted motion is started. The goal is to reduce stiffness that will increase pressure on the cartilage’s remnant. The second phase is between the 4th and the 6th week, and the emphasis is active ROM. The final phase is usually started after the 6th week, where the goal was to return to everyday activities.

Surgical technique – HA

HA is performed in beach chair position with the use of a deltopectoral approach. The goal is to remove humeral osteophytes followed by an anatomic humeral head cut and prosthetic replacement. Treatment of the glenoid is surgeon dependent and may vary from benign neglect, to subchondral drilling, to ream and run.

Postoperative rehabilitation protocols vary among authors, ranging from strict immobilization to early assisted active mobilization. Typically, it consists of three phases. The first phase consists in an immobilization for one month to allow subscapularis or lesser tuberosity healing (36). The second phase is between the 4th and the 8th week, and the emphasis is on active assisted ROM recovery. The final phase is usually started after the 8th week, where the goal was to return to everyday activities.

Surgical technique – TSA

TSA is performed in an open manner as with HA. Glenoid resurfacing typically consists of an onlay polyethylene component. Some authors have advocated for the use of inlay glenoid components in young patients given the improved biomechanics. However, there is no evidence that such components prevent medial erosion and trade-offs include increased violation of subchondral bone and a decreased amount of the glenoid that is resurfaced.

Postoperative rehabilitation protocol is the same as for the HA.

Discussion

Treatment of young active patients with advanced OA of the glenohumeral joint is challenging and remains debatable. TSA and, in some cases, reverse shoulder arthroplasty have become first choice for predictable clinical results in the appropriately indicated elderly patients (37). It is also worth noting that age is not the only factor that should be considered; the level of pain, the degree of degenerative changes, the condition of the soft tissues, and the patient’s level of activity are also crucial in the decision-making process.

HA and TSA for primary OA

Numerous studies published results of HA. At an average follow-up of 33 months, Cointat et al. analyzed 64 HAs. He reported a survival rate of 92%. Postoperatively, 91% of the patients (42 of 46) returned to work and 88% (15 of 17) returned to sport. Interestingly, the severity of preoperative and postoperative glenoid wear (Sperling grade 3 or 4) had no influence on the functional results (25). Wirth et al., who conducted an analysis of 50 HAs with a minimum five-year follow-up, observed a significant improvement in clinical outcome and pain scores (38). Levine et al. analyzed 25 HAs with an average follow-up of 17 years and reported a revision rate of 32%, and only 25% of patients were satisfied with the surgery at their final follow-up (39). These reports show that in the long-term, a decrease in the clinical outcome, most probably due to glenoid wear, is expected.

Concerns regarding long-term clinical results after HA exist, due to glenoid wear, loss of joint space, and subchondral sclerosis, all of which could lead to a TSA conversion (26, 28). It has been shown that conversion of HA to TSA may provide suboptimal results compared to the primary TSA (40, 41). It is important to consider in surgical planning the likelihood of subsequent conversion to another technique.

TSA is recommended for young patients with a centered OA due to its good reported results (29, 31, 42). Reasonable short-term complication rates have been reported, between 12 and 15% at less than 5 years (10, 27, 30). Horizontal instability of a cuff tear was reported in 5–6% and infection in 4% (10, 27, 43, 44, 45). However, the potential need for long-term revisions raises concerns about its appropriateness for young individuals who have higher activity levels and greater functional demands compared to the elder population. Effectively, glenoid loosening (high complication rate for metal back glenoid components, cement-related way of failure) is one of the most commonly reported long-term complications and it has been described in up to 100% of cases in midterm to long-term follow-up (10, 11). Newly designed glenoid components might reduce the risk of glenoid failures.

Kany et al. conducted a retrospective study where they studied 273 shoulders with primary OA or post-dislocation arthropathy in under 50-year-olds who underwent TSA or HA procedure. They reported that TSA gives better clinical results compared to HA and has less complications (10% vs 24%) and revision procedures (10 vs 20%) at 94-month follow-up (29). Several studies showed that TSA results in better medium-term outcomes for pain, ROM, and survival rates compared to HA (29, 42, 46). Schoch et al. investigated the results of shoulder arthroplasty in patients younger than 50 years with a minimal 20-year follow-up and reported a survival rate of 82% for TSA vs 75% for HA (47). Similarly, a recently published systematic review and meta-analysis reported a higher survival rate at 10 years for TSA (86.1%) compared to HA (82.3%) (48). Christensen reported a higher rate of return to sport in patients with TSA compared to HA or RSA (49). The same findings were confirmed by Liu et al., who in their meta-analysis reported a higher rate in return to sport in patients with TSA (92.6%) compared with HA (71%) (50). Lapner et al. noted that TSA is more cost-effective than HA, also for patients under 50 years of age (51). Neyton et al. performed a retrospective analysis of 202 patients aged 60 or under that underwent HA or TSA with a minimum follow-up of two years. They observed significantly better functional and subjective outcome with TSA. However, they had no significant difference in longitudinal survivorship compared to patients treated with HA (42). A meta-analysis of randomized controlled trials comparing TSA with HA for treatment of patients with glenohumeral osteoarthritis reported that TSA is more effective than HA. Nevertheless, there were no significant differences in regard to revision rates (52). Moreover, indication for surgery plays a critical role. Effectively, remarkable results have been reported with HA for primary avascular necrosis compared to TSA (53). However, because of the previously reported issues with glenoid loosening, alternative treatment options have been looked upon for younger patients with higher demand and glenohumeral OA (54). The objective would be to restore the shoulder function, lower the pain, and provide longevity without jeopardizing a future TSA.

CAM for primary OA

The literature has shown that CAM procedures were commonly proposed for temporary arthroscopic management of shoulder OA as they have been associated with short-term significant improvements in some studies (7, 13, 22, 23, 55, 56, 57). In a systematic review, Williams et al. reported that CAM intervention could result in decreased pain and improvement in shoulder function immediately postoperatively with a minimum duration of relief of weeks to months but likely for up to two years. However, due to substantial study heterogeneity, different inclusion criteria, different follow-up durations, and different structures of postoperative follow-up make the comparison between studies analyzing the efficacy of arthroscopic procedures and arriving at clear conclusions very difficult. The procedures range from the simplest ones, such as lavage, debridement, and removal of loose bodies, to more complex ones, such as capsular release, microfractures, removal of the osteophytes, and axillary nerve release (58).

Simpson & Kelly showed that the combination of synovectomy, subacromial decompression, and debridement resulted in a satisfaction rate of 82% among the patients (59). Millett & Gaskill (17) and Richard & Burkhart (15) reported the same observation that capsular release does not stop advancement of joint degeneration; however, it leads to such functional and symptomatic improvement that an arthroplasty surgery is not justified.

Skelley et al. used debridement and glenohumeral ligament release in shoulder OA treatment and only reported temporary pain relief and improved ROM. They also observed that the highest failure rate and conversion to arthroplasty was at 42.4% at 8.3 months. However, the variability in the procedures performed and inclusion criteria makes it difficult to recognize which elements of the procedures provide the most benefits (16).

Finally, Mitchell et al. reported the results of 47 shoulders after the CAM procedure at 5-year minimum follow-up. They observed 76.9% survivorship and 26% progression to TSA at an average 2.6 years. The average ASES score was 84.5; SANE, 82; QuickDASH, 15; and SF-12, 51 at an average 5.7 years postoperatively. The median satisfaction of the patient was 9/10 (60). In the study where they analyzed the same procedure in the same cohort of patients but with a longer follow-up of ten years, they reported no significant decline in results, apart from the SANE score (73.4). They evaluated 38 shoulders with a minimum 10-year follow-up and noticed a 63.2% survivorship. Outcome scores were similar, as the ASES score was 80.6; SANE, 73.4; and QuickDASH, 17.7. The median satisfaction at an average of 11.2 years slightly dipped to 7.5/10. They also evaluated the preoperative radiographs and correlated the observed radiographic signs with the success of the CAM procedure. They found an association between the failed CAM procedure and the size of inferior humeral head osteophyte and also humeral head incongruity, as 93.3% of CAM failures had severe incongruity and central flattening in comparison with 50% of those that survived (21).

Even though arthroscopic procedures do not prevent the progression of OA, CAM might be an important surgical option due to its potential to provide symptomatic relief, improve function, and postpone arthroplasty while causing minimal surgical morbidity (17, 22), as substantiated by 0% of complication rate reported in the review by Sayegh et al. (46). In our hands, static posterior subluxation is a contraindication to CAM surgery as we observed a systematic worsening of patients’ condition.

HA and TSA vs CAM

A systematic review by Sayegh et al., who analyzed and compared surgical management of young patients (<60 years old) with glenohumeral OA, reported that TSA and CAM provided better clinical outcomes than HA. CAM procedures were shown to be clinically efficacious in the midterm follow-up while avoiding complications and long-term prosthetic loosening, bone loss, and wear related to arthroplasty. TSA achieved a greater average improvement in pain scores than HA, although patients were likely to be equally satisfied after undergoing TSA or HA. Complications were significantly less frequent after the CAM technique (0%) than after HA (13.2%) and the highest were reported for TSA (23.7%), although the revision rate was very similar at 18.3% for HA, 19.1% for TSA, and 20.2% for arthroscopy. TSA and CAM also provided better recuperation of active forward flexion and external rotation compared to HA. At radiological follow-up, the subluxation rate was similar between TSA and HA (46). Consequently, it seems that primary OA, even if rare under the age of 50 years can be treated safely with the CAM procedure (Table 1).

Table 1.

Summary of functional outcomes, survivorship, complications, and revision rates for CAM, HA, and TSA.

CAM HA TSA
Functional outcomes At ≥ 5-year follow-up: ASES 84.5; SANE 82; QuickDASH 15 (59). At ≥ 10 years: ASES 80.6; SANE 73.4; QuickDASH 17.7 (21) Early improvement in pain and ROM (25, 38, 39). Long-term decline associated with progressive glenoid wear (39) Best improvement in pain and ROM among the three techniques (29, 31, 42). Superior midterm functional scores compared to HA (29, 42, 46)
Survivorship 76.9% at minimum 5 years (59). 63.2% at ≥ 10 years (21) 92% short-term survivorship (25). 75% at minimum 20 years (47) 82% at minimum 20 years (47). 86.1% at 10 years (48)
Complication rates Very low; 0% complications reported in systematic review (46) 13–24% in most series, largely due to progressive glenoid erosion (25, 38, 39) 12–15% short-term (10, 27, 30). Up to 100% glenoid loosening in certain long-term series (10, 11). Highest complication rate of the three techniques
Revision/conversion rates 26% conversion to TSA at mean 2.6 years (59). 36.8% failure at ≥ 10 years (21) 18–32% long-term revisions; commonly for glenoid wear (26, 28, 39) 10–20% revisions; mostly due to glenoid loosening or cuff-related complications (29, 47, 48)
Return to work/sport Improvement in pain and function maintained up to 2 years; temporary symptom relief common (57). Median satisfaction 7.5–9/10 (21, 59) 91% return to work and 88% return to sport in short-term series (31). RTS 71% in meta-analysis (50) Best performance: RTS 92.6% (49, 50). Highest rate of return to sport across procedures
Key clinical characteristics Provides short- to midterm symptom relief; delays arthroplasty; minimal morbidity (17, 22) Good short-term outcomes; long-term deterioration due to glenoid wear (25, 26, 28, 38, 39) Most predictable improvement in young patients with centered OA (29, 31, 42); long-term concerns relate to glenoid longevity
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CAM, comprehensive arthroscopic management; HA, hemiarthroplasty; and TSA, total shoulder arthroplasty.

Secondary OA

Patient selection and surgical indication rather than the type of management is crucial to achieve long-term success. More often, secondary diagnosis consists of aseptic avascular head necrosis (Fig. 5) (53), multiple epiphyseal dysplasia (Fig. 6), dislocation arthropathy (Fig. 7) (61), post-traumatic arthropathy (Fig. 8) or post-infectious arthropathy, iatrogenic OA, or static posterior subluxation (62, 63). In our hands, HA should not be attempted for static posterior subluxation as this procedure does not correct posterior instability (Fig. 9). Treatment of secondary forms differs from primary OA, and a valuable comparison cannot be drawn.

Figure 5.

Figure 5

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Anteroposterior X-ray of a right shoulder. The patient sustains an isolated greater tuberosity fracture at the age of 37. He developed one year later signs of avascular necrosis. He has been treated conservatively for the last ten years with a good functional result. Reproduced from www.Beemed.com, with permission.

Figure 6.

Figure 6

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(A) Pre- and (B) post-operative anteroposterior X-rays of a young patient with multiple epiphyseal dysplasia. Such deformity contraindicates a CAM or an anatomic procedure. (B) A reverse shoulder arthroplasty has been implanted despite the young age. Reproduced from www.Beemed.com, with permission.

Figure 7.

Figure 7

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Patient that sustains a right glenohumeral stabilization in 1988. (A) Preoperative anteroposterior X-ray of a patient suffering from dislocation arthropathy. (B) Postoperative X-ray after reverse shoulder arthroplasty. Reproduced from www.Beemed.com, with permission.

Figure 8.

Figure 8

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Patient suffering from a left post-traumatic arthropathy (A). (B) Post-operative X-ray after HA. Reproduced from www.Beemed.com, with permission.

Figure 9.

Figure 9

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A right shoulder computed tomography scan (A) of a 45-year-old patient suffering from static posterior subluxation. A HA failed to restore stability (B and C). A reverse shoulder arthroplasty has been finally implanted. Reproduced from www.Beemed.com, with permission.

Conclusion

CAM, HA, and TSA all provide good results even in the long term for treatment of primary OA in young patients. In case of conservative treatment failure, localized cartilage defect, tendinopathy of the long head of the biceps, stiffness, inferior osteophytes, and humeral head congruity, a CAM procedure seems to be a reasonable option. Conversely, concerning humeral head incongruity, large anterior osteophytes, and an intact rotator cuff, HA and TSA are the procedures of choice with the latter having slightly better results. Secondary pre-operative conditions require HA, TSA, or reverse shoulder arthroplasty.

ICMJE Statement of Interest

MN has no relevant financial or non-financial interests to disclose. AL is a paid consultant for Arthrex, Stryker, Medacta, and Enovis. He received royalties from Stryker and Medacta. He is the (co-)founder of FORE, Med4Cast, and BeeMed. He owns stock options in Follow Health. He is on the board of the French Arthroscopic Society. PJD receives royalties from and is a consultant and paid speaker for Arthrex. He is the co-founder of Med4Cast. PC receives royalties from and is a consultant and paid speaker for Stryker and Enovis. He is the co-founder of Med4Cast and Follow Health. He is on the board of SECEC and IBSES.

Funding Statement

This work was funded by FORE (Foundation for Research and Education in Orthopaedics, Sports Medicine, Trauma and Imaging in the Musculoskeletal System) under Grant No. FORE 2023-66.

Author contribution statement

AL conceptualized the article. The literature search and data analysis were performed by AL and MN. The first draft of the manuscript was written by AL and MN, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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