The newer biologic drugs like tumor necrosis factor (TNF) blockers have made joint replacement surgery less common, but might also make it more difficult to recognize when referral to an orthopedic surgeon is necessary. Even when it is clear that surgery is needed, medications can negatively impact post-surgical healing, further underscoring the need for a team approach between specialties to navigate the complexities of treatment. 

Rheumatology Advisor had the opportunity to speak with Michael M. Alexiades, MD, associate attending orthopedic surgeon at the Hospital for Special Surgery, New York City and associate professor of clinical orthopedic surgery at Weill Cornell Medical College, New York City, about common causes of referral delays and how to improve interdisciplinary collaboration. 


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What has been your experience regarding timely and appropriate referral from rheumatologists to orthopedic surgeons?

Coming from an institution [Hospital for Special Surgery] where our rheumatologists are fairly aggressive in terms of treatment, my experience has been excellent overall. It has always been a team approach here, with the various specialists working together–the orthopedic surgeon, rheumatologist, internist, physical therapist, and social worker. 

Most rheumatologists in general are very well-trained. The issue tends to be more with primary care physicians who may think they can treat rheumatic conditions with medication and may not recognize the need for referral to a specialist.

What are some common factors that may cause delays in referral from rheumatologists to orthopedic surgeons?

Today, the newer drugs really can target the cells that cause rheumatoid arthritis, so the really aggressive forms are few and far between now. More patients are getting treated early on, before they develop the level of joint destruction we used to see more commonly. 

Many rheumatologists out in the community tend to look at referral for surgery as a failure of their treatment. They may try different drug regimens over a period of several months or a year, and the patient may have partial resolution of symptoms that prolongs attempts to manage the condition with medication, when surgery might actually be warranted.

Other factors that may cause delays: issues with insurance coverage in certain settings, and some patients hear the word “surgery” and run the other way. So here it’s really about educating the referring doctor to convince the patient to at least see the surgeon–it doesn’t mean they’re going to end up having surgery.

What are some issues that may result from delayed referral?

There are instances in which keeping a patient on medication for too long affects the results of surgery. We like to see patients when they need surgery, but ideally when they still have good functioning muscle and soft tissue around the joint that’s going to be replaced. It may be that getting an evaluation by an orthopedist earlier can determine that the drug won’t help the damaged joint–or it may show that it could. Just getting the evaluation may help guide the rheumatologist to the appropriate treatment.


Medication won’t make a bad joint better. When it comes to a hip or knee with no cartilage–bone on bone, it’s very unlikely that [medications] will help, so in some cases joint replacement is more appropriate before starting a patient on antirheumatic drugs. In that case, the decision to start antirheumatic drugs depends on when the surgery is scheduled, because the medication can interfere with healing after surgery. 

For example, I had a patient with bad hips and knees who had never seen a rheumatologist and clearly had RA and really needed joint replacements. I referred him to a rheumatologist, who agreed that the patient would need TNF blockers but the surgery should be done first, and then the patient could start the [medications] once they were healed from surgery. The drugs work on the joints that are savable as well as the ones that are reconstructed.


What are some specific situations or signs that may call for more urgent referral for consultation with an orthopedist?

One situation calling for urgent referral is when a patient with tenosynovitis is not responding to treatment. The ideal time to get it fixed is before tendons have ruptured. If the patient is treated with relatively aggressive pharmaceutical treatment for 3 to 6 months without response, the wrist is still very swollen and actively inflamed, that’s an indication to refer the patient so they can be assessed for the need for surgery.

As another example, when a patient typically walks well and then suddenly has trouble, it could indicate the need for evaluation of the cervical spine and potential need for a spinal fusion. We don’t see this type of scenario as much with the new drugs, but we need to be aware that it can still happen. The fact that it happens less often may lull physicians into a false sense of security, and we have to keep the infrequent complications of the disease in mind.

What are some ways to improve collaboration between the two specialties?

Part of it is working out relationships with physicians in your geographic area, perhaps having combined conferences and having an orthopedist speak at the hospital about their approach to treatment of rheumatoid patients. A lot of it is about educating rheumatologists, and also orthopedic surgeons, who may not see many patients with rheumatic disease but still need to know what to look for.

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The real challenge is getting to these patients early on when medication can be effective and it’s more likely that they can avoid surgery and live functional lives. This is the most cost-effective approach, and keeping patients independent and self-sufficient is certainly a major goal. It’s important to look at it from a team approach, always being ready to say, “My treatment is not working as well as I’d hoped, and it may be time to get a second set of ears and eyes to see whether there’s something I’m missing, even though I’m treating the patient appropriately.” We have to be ready to do what’s best for the patient, to always keep a patient-first perspective.


Summary and Clinical Applicability

Collaboration between rheumatologists and orthopedic surgeons can improve outcomes for patients with rheumatic disease. Early referral can help prevent further damage, and medication must be timed according to date of surgery in order to avoid negative effects on healing.

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Disclosures

As of March 23, 2015, Dr Alexiades served as a consultant with Biomet, Inc.

References

1.       Nystad TW, Fenstad AM, Furnes O, Havelin LI, Skredderstuen AK, Fevang BT. Reduction in orthopaedic surgery in patients with rheumatoid arthritis: a Norwegian register-based study. Scand J Rheumatol. 2015; 25:1-7. 

2.       Gogna R, Cheung G, Arundell M, Deighton C, Lindau TR. Rheumatoid hand surgery: is there a decline? A 22-year population-based study. Hand (N Y). 2015; 10(2):272-8. 

3.       Harty L, O’Toole G, FitzGerald O. Profound reduction in hospital admissions and musculoskeletal surgical procedures for rheumatoid arthritis with concurrent changes in clinical practice (1995-2010). Rheumatology (Oxford). 2015; 54(4):666-71. 

4.       Ito H1, Kojima M, Nishida K, et al. Postoperative complications in patients with rheumatoid arthritis using a biological agent – A systematic review and meta-analysis. Mod Rheumatol. 2015; 25(5):672-8.

5.       Goodman SM, Menon I, Christos PJ, Smethurst R, Bykerk VP. Management of perioperative tumour necrosis factor α inhibitors in rheumatoid arthritis patients undergoing arthroplasty: a systematic review and meta-analysis. Rheumatology (Oxford). 2016; 55(3):573-82. 

6.       Clay M, Mazouyes A, Gilson M, Gaudin P, Baillet A. Risk of postoperative infections and the discontinuation of TNF inhibitors in patients with rheumatoid arthritis: A meta-analysis. Joint Bone Spine. 2016; pii: S1297-319X(16)30004-5.