Does severe glenohumeral joint narrowing with erosion and hypertrophic spurring require orthopedic intervention for injections or surgery?

Severe Glenohumeral Joint Narrowing with Erosion and Hypertrophic Spurring: Orthopedic Referral Required

Yes, this patient requires orthopedic referral for surgical evaluation, as severe glenohumeral osteoarthritis with these radiographic findings typically necessitates total shoulder arthroplasty (TSA) when conservative management fails. 1, 2

Initial Conservative Management (First-Line)

Before orthopedic referral, attempt conservative measures unless symptoms are debilitating:

• Physical therapy should be trialed first, though evidence for glenohumeral OA specifically is limited (extrapolated from hip/knee literature) 2, 3
• Oral/topical NSAIDs can be used for symptomatic relief, though evidence is extrapolated from other joint OA 3
• Corticosteroid injections have insufficient evidence to recommend for or against (Grade I recommendation), but may provide temporary relief 1, 2
• Viscosupplementation (hyaluronic acid) is an option with weak supporting evidence (Grade C recommendation) 2

Critical caveat: Most conservative treatment recommendations for glenohumeral OA are extrapolated from hip/knee literature rather than shoulder-specific studies 2

When to Refer to Orthopedics

Refer for surgical evaluation when:

• Conservative management fails to provide adequate pain relief or functional improvement 2, 4
• Severe radiographic findings (joint narrowing, erosion, hypertrophic spurring) correlate with debilitating symptoms 2, 4
• Patient experiences progressive loss of function affecting daily activities 4

Surgical Intervention: The Definitive Treatment

TSA is superior to hemiarthroplasty for advanced glenohumeral OA (Grade B recommendation, moderate-strength evidence):

• TSA provides statistically superior pain relief and global health assessment scores compared to hemiarthroplasty 1, 2
• 14% of hemiarthroplasty patients require revision to TSA due to progressive glenoid arthrosis and pain, while no TSA patients required revision to hemiarthroplasty 1, 2
• Both procedures improve pain, function, and quality-of-life scores, but TSA demonstrates better outcomes 1
• All-polyethylene glenoid components have lower revision rates (1.7%) compared to metal-backed designs (6.8%) 1

Critical Contraindications and Special Considerations

Absolute contraindication:

• Do NOT perform TSA if irreparable rotator cuff tear is present (consensus recommendation) - this requires reverse total shoulder arthroplasty instead 1, 2, 5

Age considerations:

• Avoid arthroplasty in patients <50 years when possible due to increased risk of prosthetic loosening and decreased survivorship 1, 2
• In younger patients with severe symptoms, arthroscopic debridement may temporarily delay arthroplasty, though evidence is insufficient (Grade I recommendation) 1, 6

Surgeon Selection Matters

Choose a surgeon performing ≥2 shoulder arthroplasties per year to reduce immediate postoperative complications and length of stay (Grade C recommendation) 1, 2

Pre-Operative Requirements

Essential imaging evaluation before arthroplasty:

• Assess glenoid morphology, bone loss, retroversion, and bone quality 2, 5
• Evaluate rotator cuff integrity to determine TSA versus reverse TSA 5

Expected Outcomes and Complications

• Complications occur in up to 39.8% of cases, with revision rates up to 11% 2
• Most common complications for TSA: glenoid loosening (14.3%) 2
• Most common complications for hemiarthroplasty: glenoid erosion (20.6%) 2

Perioperative Management

Mandatory thromboembolism prophylaxis:

• Use mechanical and/or chemical VTE prophylaxis for all shoulder arthroplasty patients (consensus recommendation) 1, 2, 5

Post-operative rehabilitation:

• Physical therapy is commonly practiced but lacks high-quality evidence demonstrating improved outcomes (Grade I recommendation) 1, 2