Top 5 things to know when referring patients for chronic joint pain or replacement

“Referring physicians should know that they can do many nonsurgical interventions for knee and hip arthritis like NSAIDs, Tylenol, physical therapy and injections prior to an orthopedic referral,” said Dustin Hambright, MD, orthopedic surgeon at Charleston Institute for Advanced Orthopedics in Mount Pleasant. “In regard to arthroscopy, arthroplasty and robotic surgery, the referring physician can send the patient to the orthopedist to determine the best course of action for the patient and their specific joint injury.”

“We always try to have same- and next-day appointments available for patients with acute pain, which could indicate simple arthritis flare or something more serious like a fracture, infection or dislocation,” said James Fraser, MD, orthopedic surgeon at Novant Health Orthopedics & Sports Medicine in Charlotte. “I would always suggest emergent issues be referred to the ER, urgent issues placed as stat referrals to our office, and more chronic issues referred for scheduling at the patient’s discretion.”

So, when does a referral to an orthopedist become necessary with arthritis and potential joint replacement, and what should referring physicians keep in mind? Here are 5 considerations.

1. A referral to an orthopedist for chronic joint pain becomes necessary when outside modalities fail. If a patient’s symptoms are unmanageable despite ice, rest, physical therapy, bracing, activity modification and NSAIDs, it’s time to refer them to an orthopedist to determine the next step in their treatment plan. Novant Health physicians can provide the full spectrum of nonsurgical and surgical interventions in-office, so a simple referral for anyone who has hip or knee pain is sufficient. “The key to chronic issues is to manage them to allow a patient to continue daily life,” Dr. Hambright said. “At some point, the chronic joint issue will be at a level that will impact the patient’s quality of life, activity of daily living and ability to do activities they enjoy despite conservative care. At that point, the patient will need an orthopedic surgeon to discuss potential surgical options.”
2. Prior to referral, you can skip diagnostic imaging, which can be potentially unnecessary. “If your patient is complaining of hip and/or knee pain, that is enough for the referral,” Dr. Fraser said. “While radiographs and advanced imaging like CT or MRI can occasionally be helpful, I often find that we need to redo the X-rays anyways to get specific views and often find that MRIs ordered by PCPs were not necessary to take care of the patient.”
3. Keep a surgeon’s subspecialty level of training in mind when directing a referral. Specifically, look at whether orthopedists did a fellowship in joint replacement surgery. “While many sports and general orthopedic surgeons perform some joint replacement as part of a wider surgical practice, fellowship-trained joint replacement surgeons have completed an extra year of training and often dedicate their entire practice to high-volume primary and revision arthroplasty cases,” Dr. Fraser said. “Literature has repeatedly shown that high-volume fellowship-trained surgeons have the best outcomes in hip and knee replacement.
4. Let patients know that, post-referral, they can continue with nonsurgical interventions if they want. If patients want to continue with nonsurgical treatment, an orthopedist can manage steroid injections and gel injections, among other interventions. Injections can provide additional pain relief so patients can be more productive with physical therapy or rehab.
5. Prep patients to understand that, with arthritis, partial or total replacement may be needed to cure their symptoms. While less-invasive procedures like arthroscopy can be an option for certain joint conditions, that’s not the case when arthritis is a factor. “Arthroscopy is not a good intervention for a patient with arthritis as it could worsen the outcome of a TKA, or progress the arthritis,” said

   Howard Homesley, MD, Novant Health Orthopedics & Sports Medicine in Charlotte. That’s why joint replacement should be anticipated. “Hip and knee replacements have been among the most successful operations for decades with high success rates, low complication rates and generally a huge improvement in patient quality of life due to improved function and decreased pain,” Dr. Fraser said. “Emerging trends in the past 10 years have included a shift to less-invasive techniques, more outpatient surgery and increased use of robotic technology.”

Computer navigation and robotics have improved accuracy and precision. This helps with alignment in knee replacements while optimizing stability for hip replacements.

Ultimately, though, physician experience is key. “The most important aspect of the surgical approach remains that the surgeon should have experience with the approach and is doing many joint replacements in their practice,” Dr. Hambright said.