What are the next steps for treating bilateral glenohumeral joint Osteoarthritis (OA) after steroid injections have failed?

Treatment Options for Bilateral Glenohumeral Joint Osteoarthritis After Failed Steroid Injections

When steroid injections have failed for bilateral glenohumeral joint osteoarthritis, viscosupplementation injections should be considered as the next treatment option, followed by surgical interventions such as total shoulder arthroplasty if conservative measures fail to provide adequate relief. 1

Non-Surgical Options After Failed Steroid Injections

Viscosupplementation

• Injectable viscosupplementation is recommended as an option when treating patients with glenohumeral osteoarthritis who have failed steroid injections 1
• The American Academy of Orthopaedic Surgeons (AAOS) gives this a Grade C recommendation based on Level IV evidence 1
• Typically administered as three weekly injections of hyaluronic acid preparations (such as Hylan G-F 20) 1
• Studies have shown improvements in pain scores, Simple Shoulder Test (SST), and University of California, Los Angeles (UCLA) scores at 1,3, and 6 months after treatment 1
• Monitor for short-term pain relief after injection while continuing appropriate physical therapy 2

Physical Therapy and Rehabilitation

• While the AAOS is unable to make specific recommendations about physical therapy following shoulder procedures (Grade I recommendation, Level V evidence), it remains a common clinical practice 1
• Manual physical therapy combined with exercises has shown clinically meaningful improvements in self-reported function and pain in patients with glenohumeral OA 3
• Focus should be on improving range of motion, strengthening rotator cuff and scapular muscles, and progressive functional activities 3, 4

Pharmacological Management

• NSAIDs are recommended as first-line medications for osteoarthritis according to NICE guidelines, though specific evidence for glenohumeral OA is limited 4
• Consider topical NSAIDs as an alternative with potentially fewer systemic side effects 4, 5
• Be cautious with oral NSAIDs due to potential gastrointestinal side effects and cardiovascular risks, especially in older patients 5

Surgical Options When Conservative Treatment Fails

Arthroscopic Procedures

• The AAOS is unable to recommend for or against arthroscopic treatments for glenohumeral OA (Grade I recommendation, Level V evidence) 1
• Arthroscopic options may be considered for younger patients with early-stage OA who may not be candidates for arthroplasty 1

Total Shoulder Arthroplasty vs. Hemiarthroplasty

• Total shoulder arthroplasty (TSA) and hemiarthroplasty are both options for treating glenohumeral OA (Grade C recommendation, Levels IV and V evidence) 1
• TSA is recommended over hemiarthroplasty as it provides better outcomes (moderate-rated recommendation) 1
• TSA provides significant improvements in pain, global health assessment, function, and quality-of-life scores 1
• Hemiarthroplasty may be appropriate when the glenoid is naturally concentric or can be reamed to concentricity 1

Considerations for Surgical Intervention

• Concern exists about performing shoulder arthroplasty in patients under 50 years due to potential increased risk of prosthetic loosening and decreased survivorship 1
• Surgeons who perform fewer than two shoulder arthroplasties per year should avoid performing these procedures to reduce immediate postoperative complications 1
• When performing TSA, keeled or pegged all-polyethylene cemented glenoid components are recommended 1

Treatment Algorithm for Bilateral Glenohumeral OA After Failed Steroid Injections

1. First step: Try viscosupplementation injections (3 weekly injections) 1
2. Concurrent therapy: Continue physical therapy focusing on range of motion and strengthening exercises 3
3. Pharmacological management: Use appropriate oral or topical NSAIDs as needed 4, 5
4. If symptoms persist: Consider surgical options based on:
   • Patient age (under 50 vs. over 50) 1
   • Severity of symptoms and functional limitations 1
   • Radiographic findings 6
   • Medical comorbidities 6
5. Surgical decision:
   • For older patients with advanced OA: Total shoulder arthroplasty is preferred over hemiarthroplasty 1
   • For younger patients: Consider arthroscopic options or other joint-preserving procedures 1

Important Caveats and Pitfalls

• The quality of scientific data on management of glenohumeral OA is limited; none of the AAOS recommendations received Grade A ratings 1
• Ensure proper patient selection for each treatment modality based on age, activity level, and disease severity 6
• For surgical interventions, refer to high-volume shoulder surgeons (those performing more than two shoulder arthroplasties per year) to reduce complications 1
• Monitor for complications after injections, including post-injection pain flares 2
• Remember that glenohumeral OA is the third most common large joint affected by OA, with 16-20% of adults over 65 showing radiographic signs 7