Rheumatologists and orthopedic surgeons must frequently collaborate to provide optimal patient care. Sometimes, they may even work at the same practice and form a care team for easy collaboration. Still, patient management from both specialties can be challenging, and specialists from both sides can learn from each other.
How Crossover Starts
Rheumatologists and orthopedic surgeons may collaborate under varied circumstances, but the most common scenario is for a patient under rheumatologic care on maximal medical therapy who is still not fully controlled, says hip and knee surgeon Michael L. Parks, MD, clinical director of orthopedic surgery, Hospital for Special Surgery (HSS), New York. Dr. Parks is also part of the Integrative Rheumatology and Orthopedics Center at HSS.
“When medical treatment fails, rheumatologists ask orthopedic joint replacement surgeons for joint replacement,” says Jorge Baez, MD, an orthopedic surgeon with the Center for Advanced Orthopedics at South Nassau Communities Hospital in Oceanside, N.Y., and the Central Orthopedic Group in Plainview and Rockville Centre, N.Y.
Another situation with common crossover is inflammatory arthropathies that have associated muscle tendon and joint issues, says orthopedic surgeon Alan M. Reznik, MD, MBA, The Orthopaedic Group, with four locations in Connecticut. Dr. Reznik is also an American Academy of Orthopaedic Surgeons spokesperson. He offers the following example: “Gout is associated with crystal deposits that can erode the skin, become infected or predispose to tendon rupture,” he says. Persistent nonrefractory synovitis, advanced loss of articular cartilage requiring a joint replacement and rheumatoid arthritis (RA) accompanied by hand deformity or tendon erosion and subluxation are other examples shared by Dr. Reznik. Care for osteoarthritis is yet another condition for which crossover is common.
At Shriners Hospital for Children–Chicago, treatment for juvenile idiopathic arthritis has a specialized clinic program involving both specialties. “We’re one of a handful of sites in Illinois that has a pediatric rheumatologist,” says Peter Smith, MD, attending orthopedic surgeon.
Nerve entrapment syndromes, such as carpal tunnel syndrome, typically lead to a referral to an orthopedic specialist, says rheumatologist Ronald Rapoport, MD, Southcoast Physicians Group, Fall River, Mass. Yet another opportunity for collaboration is when an orthopedic surgeon recommends surgery; rheumatological patients often will ask their rheumatologist for their perspective on the need for surgery, Dr. Rapoport added.
Sometimes, patients have bad joint arthritis and need joint replacement, but their systemic health is so bad (e.g., they have severe cardiovascular or pulmonary disease), they remain under rheumatological care, Dr. Rapoport says. “They can be particularly challenging. It ends up almost being pain control more than anything else.”
Special Surgical Concerns
When a patient with RA or another rheumatological condition requires a surgery—for example, a total knee or hip replacement—specialists from both sides must communicate well to plan when to stop biologic use or disease-modifying anti-rheumatic drugs in advance. Steroids also may need to be stopped because they can complicate the surgical process, says rheumatologist Syeda Maria Sayeed, MD, RhMSUS, Southcoast Physicians Group.