Should an 88‑year‑old woman with mild bursal calcifications, mild acromioclavicular (AC) joint narrowing, and severe glenohumeral joint narrowing with erosion and hypertrophic bone spurring be seen by orthopedics?

Orthopedic Referral for Severe Glenohumeral Osteoarthritis

Yes, this 88-year-old woman should be seen by orthopedics given the severe glenohumeral joint narrowing with erosion and hypertrophic spurring, as this represents advanced osteoarthritis that may benefit from surgical evaluation, particularly if she has significant pain or functional limitation. 1

Clinical Context and Decision Framework

The imaging findings describe severe glenohumeral osteoarthritis with erosive changes and osteophyte formation, which represents advanced disease. 1 The American Academy of Orthopaedic Surgeons guidelines emphasize that treatment decisions for glenohumeral OA are dictated by:

• Severity of symptoms (pain level and functional impairment)
• Radiographic findings (which are severe in this case)
• Patient age and medical comorbidities
• Patient characteristics and goals 1

When Orthopedic Referral is Indicated

Refer to orthopedics if:

• The patient has persistent pain despite conservative management (physical therapy, NSAIDs, activity modification) 1
• There is significant functional limitation affecting activities of daily living or quality of life 1
• The patient has failed nonsurgical treatment, including injectable corticosteroids (though evidence for their use is inconclusive) 1
• The radiographic severity (severe joint narrowing with erosion) correlates with clinical symptoms 2

Important caveat: At age 88, the decision must weigh surgical risks against potential benefits. However, age alone should not preclude surgical evaluation, as total shoulder arthroplasty can significantly improve pain and function even in elderly patients. 1

Treatment Options Orthopedics Can Offer

Nonsurgical Management

• Physical therapy and activity modification 1
• Injectable viscosupplementation (weak recommendation, but an option) 1
• Structured conservative care if not yet attempted 1

Surgical Management

If conservative treatment fails and symptoms warrant intervention:

• Total shoulder arthroplasty (TSA) is preferred over hemiarthroplasty (moderate-level recommendation) for glenohumeral OA, providing better pain relief and lower revision rates (14% of hemiarthroplasties required revision to TSA vs. 0% for primary TSA) 1
• Both TSA and hemiarthroplasty provide significant improvements in pain, function, and quality of life 1
• Contraindication: TSA should not be performed if there is an irreparable rotator cuff tear (consensus recommendation) 1

Addressing the AC Joint Findings

The mild AC joint narrowing is a secondary finding. 3 Asymptomatic AC joint degeneration is extremely common in older adults and does not always correlate with symptoms. 3

• If AC joint symptoms are present (localized tenderness, pain with cross-body adduction), selective lidocaine injection can help determine if it contributes to pain 3
• Distal clavicle resection can be performed concurrently with shoulder arthroplasty if symptomatic 4
• Severe AC joint osteoarthritis with large spanning osteophytes may predispose to acromial fractures after reverse shoulder arthroplasty, though this is more relevant for reverse rather than anatomic TSA 5

Bursal Calcifications

The mild bursal calcifications likely represent calcific tendinopathy, a dynamic process involving hydroxyapatite crystal deposition. 6 These are generally managed conservatively unless causing significant symptoms. 6 This finding does not change the primary indication for orthopedic referral, which is the severe glenohumeral arthritis.

Common Pitfalls to Avoid

• Don't dismiss surgical options based solely on age – functional status and patient goals matter more than chronologic age 1
• Don't assume all shoulder pain is from the AC joint – the severe glenohumeral disease is the primary pathology here 3
• Don't delay referral if symptoms are significant – advanced radiographic changes with severe joint narrowing indicate established disease that won't improve with time 1, 2
• Ensure rotator cuff integrity is assessed before considering TSA, as irreparable tears contraindicate this procedure 1