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Explore This IssueAugust 2018
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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.
“These medications are effective for controlling symptoms and preventing disease progression. Unfortunately, they also can interfere [with] and slow down surgical incision healing after surgery and can be associated with increased infection risk for joint replacement surgery,” says orthopedic surgeon Amer Mirza, MD, co-founder, Go To Ortho, Lake Oswego, Ore. The orthopedic surgeons interviewed for this article rely heavily on their rheumatologist colleagues to provide guidance on when to stop medications before surgery.
Guidance may vary for each individual patient, but generally speaking, Dr. Rapoport stops biologic medications for two half-lives before surgery and sometimes two half-lives after. Methotrexate is not always stopped before surgery. Non-steroidal anti-inflammatory drugs (NSAIDs) are typically stopped five half-lives preoperatively, he added.
Most patients will not have a bad disease flare during the brief time they are off their medications, Dr. Rapoport says. In fact, it’s important the patient have their disease under control even as surgery is in the planning stages, Dr. Sayeed says. “If there is active disease, especially in someone with RA, we discourage them from having surgery because [surgery has been] shown to cause more infection and inflammation. We tend to recommend holding off on surgery until the disease is more controlled or in remission prior to surgery,” she says.
At the Center for Advanced Orthopaedics/Mid-Maryland Musculoskeletal Institute, Frederick, Md., rheumatologists and orthopedic physicians are both on staff and work together to plan when to stop medication use, says orthopedic surgeon Matthew J. Levine, MD. “Once we get surgical recovery done, we continue disease management with the rheumatologist,” he says.
It’s also important to let the surgeon know what medications the patient was using prior to surgery and when they were stopped. For example, sometimes a patient who has used steroids in the six months before surgery may need stress-steroid dosing in the operating room to avoid adrenal issues, Dr. Reznik says.
Surgical timing can also be a concern if a patient receives extra-articular corticosteroid injections, Dr. Reznik says. Mounting evidence shows these injections could increase the risk for infection during surgery if they were done three to six months prior to knee or hip surgery. During the waiting time between injections and surgery, Dr. Reznik may recommend other treatments, such as NSAID use, icing, bracing, strengthening and decreased use of impact load activities, such as jumping and running.
Some patients with joint disease require special care during surgery itself. “Bone quality is often poor and osteopenic, requiring gentle manipulation and hammering,” Dr. Baez says. “It is more likely in these cases to consider cementing components because of poor quality bone.”
A preoperative cervical spine assessment also can provide insights into cervical conditions inherent to rheumatoid patients, such as cervical instability, Dr. Baez says. “Anesthesiologists often use a GlideScope for intubation to protect cervical spine manipulation,” he says.
In addition to softer bones, other systemic concerns could become a factor during surgery, says Timothy Gibson, MD, orthopedic surgeon and medical director, MemorialCare Joint Replacement Center at Orange Coast Medical Center, Fountain Valley, Calif. For example, the patient may have pulmonary issues or skin issues that increase the risk for complications. “They can be much more complicated than the general osteoarthritis patient,” he says.
Although special surgical concerns may exist for patients under rheumatological care, outcomes can be quite good.
“Usually, rheumatologic patients are low demand, and joint replacements are a fantastic option,” Dr. Baez says.
However, that hasn’t always been the case.
“Historically, patients with rheumatoid arthritis were challenging medically and needed to be more closely followed,” Dr. Parks says. “Now, with the excellent treatment available with many medications, patients are not as likely as they were in the past to present with destructive arthritis requiring surgery.”
“I’ve found that people who have RA have dealt with pain for a long time, so they have a certain temperament that’s positive. If you can avoid the complications of surgery, they tend to do great and have good range of motion. And they tend to be the most satisfied patients,” Dr. Gibson says.
Overall, surgical treatment seems to have decreased due to better medical management. “We don’t do nearly as many surgical procedures for contracture release or synovectomy or even joint replacement as in the past,” Dr. Smith says.
The patients who do best are those with specific areas that need targeting with surgery, Dr. Levine says. “If they have systemic problems and multi-pain issues, they don’t do as well,” he says.
From Orthopedics to Rheumatology
Orthopedic surgeons share some advice to keep the constant collaboration with rheumatology humming well.
1. Meet with your potential orthopedics referral partner, Dr. Mirza recommends. “Open a line of communication, and develop collaborative treatment pathways for management of patients with osteoarthritis and end-stage arthritis from inflammatory arthropathies,” he says. If you’re new to an area, a newer physician or, perhaps, just looking for a new referral partner, get to know a local orthopedic surgeon or practice face to face.
Some orthopedic surgeons relish their organization’s direct connection with rheumatologists. Dr. Smith says the team-based approach at the Shriners Hospital for Children in Chicago means that rheumatologists are right down the hall and that patients often can be seen for a same-day initial appointment with the physician from a cross specialty.
“Having rheumatologists and orthopedists in the same practice has been a really successful model,” Dr. Levine says. Still, even if you can’t partner directly with an orthopedic peer, you can identify someone for a good flow of communication, he says.
2. Know when to refer. As you might expect, orthopedic surgeons want to see rheumatological patients when medications and interventions are no longer effective and a patient’s pain and functional status continue to get worse, Dr. Parks says. “This is often the best time to refer a patient to the orthopedic surgeon to discuss surgical options, specifically, hip or knee replacement,” he says.
If a total replacement isn’t necessary yet, the orthopedic surgeon can discuss other options such as arthroscopic synovectomy, Dr. Reznik says. This option is often underused but can provide up to three years of relief and may be a good way to get a patient off higher dose medications in the short term, he explains.
Other treatments provided by the orthopedic surgeon include brace prescriptions and fusions, says Dr. Smith.
3. Refer early. “For many conditions, earlier intervention, before significant deformity occurs, is less complex and has better outcomes,” Dr. Reznik says. “If we wait too long, sometimes the damage is irreversible, or the bone stock is destroyed—and replacement of the joints is less likely to be possible or work well.”
4. Think beyond just rheumatological disease. “Just because the patient has an inflammatory disease does not mean they don’t have a meniscus tear, loose body, malalignment or a ligament tear,” Dr. Reznik says. On a similar note, Dr. Reznik has observed that many patients want magnetic resonance imaging (MRI) for their problem, and they often ask their rheumatologist to order one. Because an MRI is not always necessary, he advises referring the patient to an orthopedic surgeon and letting them decide if one is actually needed.
5. Pick up the phone. “If you’re worried about something specific, send me a consult note. However, it’s easy in a big consult note to miss a little point. If there’s a specific issue, a phone call is best,” Dr. Gibson advises.
Dr. Levine agrees. “The main thing [the rheumatologist] needs to do is identify what they need us to do,” he says. “Make it clear in the notes and any conversation. Then we can have a productive time with the patient.”
Vanessa Caceres is a medical writer in Bradenton, Fla.
5 Things Orthopedic Surgeons Want Rheumatologists to Do
- Meet them.
- Know when a referral is needed.
- Refer early.
- Think broadly.
- Pick up the phone.