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Referrals for Musculoskeletal Disorders

Clinic patients who present with musculoskeletal complaints that are not adequately addressed by their PCP can be referred for consultation to the HMC Spine and Sports Center, HMC orthopedics or the UWMC Bone and Joint Center depending on the complaint or diagnosis.

Individuals presenting to HMC-based primary-care practices who have acute fractures should be referred to HMC orthopedics (either through the ED or orthopedic clinic).

Those with a diagnosis of avascular necrosis (AVN) with collapse or severe degenerative arthritis requiring joint replacement should be referred to the orthopaedic surgeons at the UWMC Bone and Joint Center provided they meet criteria (see below).  Those who have AVN without collapse can also be referred to the Bone and Joint center for consultation and are not required to meet attached criteria.  These patients will likely not be offered surgery, and it would helpful to the surgeon if the PCP would “prep” the patient for that likely outcome. For patients who have AVN without collapse, there are some promising data using alendronate, which is something the PCP might be able to manage after the orthopaedic consultation is performed.

Patients with other musculoskeletal complaints or diagnoses can be referred to the HMC Spine and Sports Center for evaluation and treatment and for possible subsequent referral to the UW Bone and Joint Center or to the Sports Medicine Surgeon who practices part-time at HMC (Dr. Wahl).

Referral for Elective Orthopaedic Surgery

25 August 2009

In contrast to trauma surgery, which is performed to save life or limb, most elective orthopaedic surgery is not life  or limb-saving, and, therefore, needs to be considered as a set of trade-offs between the potential benefits of the surgery, and the risks of undergoing the proposed procedure. Most of the serious complications of elective orthopaedic surgery – and in particular those of joint replacement surgery (JRS) – are worse than the condition for which the surgery was performed. Patients with deep prosthetic infections and peri-prosthetic fractures, in particular, frequently have outcomes inferior to the arthritic condition for which they were originally treated surgically. For that reason, steps must be taken to avoid such complications whenever possible.

As such, responsible surgeons recommend that all patients undergoing either JRS or elective orthopaedic surgery meet a favorable bio-psychosocial profile before recommending the intervention.

As the UWMC currently has only six or seven call-taking full-time orthopaedic surgeons, we try to use the capacity we have to help those patients who meet generally accepted criteria for elective orthopaedic surgery.

No clinical guideline can anticipate all possible scenarios; however, below is a summary of the criteria that will be considered when evaluating referrals from HMC in general, and the Madison clinic in particular. This document represents the consensus of the faculty who practice at the Madison clinic and the Hip/Knee and Shoulder/Elbow services at UWMC.

1) Homelessness. Being homeless often leads to unstable sleeping and living accommodations that frequently require patients to rest or sleep in awkward positions, which may predispose them to prosthetic dislocation and failure. Homeless patients also typically live in substandard sanitary conditions, which may predispose them to skin and soft tissue infections leading to bacteremia and subsequent prosthetic infections. Finally, homeless patients are subject to accidents and assaults which put them at risk of peri-prosthetic fracture. Therefore, to be considered for JRS, patients would have to secure stable housing for 3 months before and agree to remain in a stable housing for 3 months after planned operation. Complications that arise in patients who are non-compliant with this arrangement may best be treated by resection arthroplasty, and will be told this in advance.

2) Recreational drug and alcohol use.  Drug and alcohol use are associated with poor adherence to medical/surgical recommendations, which, in turn, can result in prosthetic failure. Therefore, to be considered for JRS, patients would a) have to be "drug free" for 1 year, b) if alcoholic, be sober for 1 year or c) if they use alcohol but are not alcoholic - agree to abstain from alcohol entirely for 1 month prior to and for 3 months after operation. Patients need to agree to drug and alcohol testing if their providers are concerned that these conditions are not being met. Complications arising from drug or alcohol recidivism may best be treated by resection arthroplasty, and patients will be told this in advance.

3) IVDU. IVDU is the single greatest risk factor for bacteremia leading to infection of joint prostheses.  There are numerous studies to support this serious concern. Therefore, to be considered for JRS, patients who have used IV drugs must have been abstinent (and preferably in a treatment program) for 2 years prior to surgery. Patients need to agree to drug testing if their providers are concerned that this condition is not being met. Complications arising from drug recidivism may best be treated by resection arthroplasty, and patients will be told this in advance.

4) Immunologic status.  There is considerable conflict on this point. The literature is mixed, with some studies indicating reasonable likelihood of success, while others providing a much more cautionary message, demonstrating infection rates considerably higher than seen in HIV negative patients.  While it is preferable to operate on patients who are immunologically normal and have undetectable plasma HIV RNA level, there is no absolute CD4 count below which or HIV RNA level above which surgery is contraindicated.  Instead, the goal before proceeding to surgery will be that the patient be immunologically and virologically stable.  This determination will be reached by discussion between the patient's HIV provider and the operating surgeon.  It is likely that HIV infection itself carries an increased lifetime risk of bacteremia as is true of organ transplantation, diabetes, and other immunosuppressing conditions.    HIV infected patients need to be informed, that bacteremia and septicemia are potentially life- and limb-threatening events that must be considered prior to committing to JRS. The responsibility to make patients aware of this potential complication is shared between the primary-care provider and the orthopaedic surgeon.

5) Long-acting narcotic use.  Use of long-acting narcotics such as oxycontin, MS contin, or methadone, or high doses of short-acting narcotics presents difficulties with respect to analgesia in the immediate post-operative period and often prevents full participation in rehabilitation after surgery which, in turn, leads to delayed and incomplete joint function, persistent pain, arthrofibrosis, and clinical dissatisfaction.  Most patients with these unfavorable outcomes are not suitable for revision or salvage surgery, and the failures are usually permanent.  For this reason the use of long acting narcotics to control joint pain before JRS is strongly discouraged.   For patients who do take long-acting narcotics for joint pain, every effort should be made to wean patients from these drugs and control their pain with non-narcotic remedies, activity modifications (if need be with a cane or crutches), and limited doses of short acting narcotics.  Patients on long-acting narcotics for reasons other than joint pain (e.g., methadone for long standing narcotic addiction or HIV associated neuropathy) present a unique challenge.  All patients who stay on long acting narcotics should be referred to the HMC pain clinic for consultation and the development of a “pain plan” to cover the pre-, peri- and post-operative periods.  PCPs should contact the pain specialist prior to the patient’s visit to the pain clinic to begin formulating the plan.  Patients who remain on long acting narcotics need to be counseled that they are at particular risk of having persistent pain and clinical dissatisfaction from the surgery. The responsibility to make patients aware of this kind of failure is shared between the primary-care provider and the orthopaedic surgeon.

6) HIV transmission.  The risk of occupational HIV transmission from infected patients to members of the surgical team is real. Several members of the UW orthopaedic surgery department have contracted blood-borne viral illnesses from patients. JRS poses special risks to surgeons and surgical teams, given the invasive nature of the operations, the use of particular instruments and presence of cutting bone edges and bone shards.  The risk of occupational HIV transmission is reduced when the source patient's plasma HIV level is low or undetectable.  Therefore, it is preferable to operate on patients who are taking HAART and have a low or undetectable plasma HIV RNA.  Furthermore, in those patients not on HIV therapy it is reasonable to consider initiating HAART months prior to planned surgery with the goal of complete viral suppression at the time of operation.  Patients on HAART who have not been adherent to their regimen must agree to disclose this fact to the operating surgeon.

7) Mental Illness. Patients with uncontrolled mental illness pose a special problem for JRS. Many patients with serious psychiatric illnesses including depression, anxiety, schizophrenia, and bipolar disorder can benefit from JRS and elective orthopaedic surgery.  However, the stress of the surgery and the arduous aftercare can destabilize patients who were previously well controlled on medications. Elective orthopaedic surgery is contraindicated in the setting of poorly controlled psychiatric illness and should be considered in patients with well controlled psychiatric disorders only after consultation with the patient’s mental-health provider.

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