Referring Knee Osteoarthritis Patients to a Specialist
FEBRUARY 21, 2018
MD Magazine Staff
Peter Salgo, MD: Let’s say that our primary care colleagues are great. They’re doing everything right. They got the x-ray, got the MRI, got physical therapy engaged, and got the right diagnosis. At some point, somebody needs to go to a specialist. What’s the trigger? What sends somebody from the primary care setting to the specialist setting?
Richard Iorio, MD: As we’ve discussed, if the diagnosis is osteoarthritis, the patient has exhausted their conservative treatment they’ve had, they’ve taken their pills, and they’ve done some disease activity modification, if those things aren’t working, they have symptoms now, they’re having trouble sleeping at night, they’re having trouble going to their job, or they have instability or deformity that’s really interfering, then it’s time to come see us. We can help them with that.
Peter Salgo, MD: There are various places to go. There are orthopedics. There’s rheumatology. There’s still primary care. Are there different approaches in each of these specialties? How do they approach the problem?
Andrew Spitzer, MD: I don’t really think there’s different approaches, per se. I think there’s a relative comfort level for many primary treating physicians (primary care physicians), that is low, quite frankly. They’re not comfortable treating osteoarthritis of the knee. I think, at the end of the day, if you have somebody who’s comfortable with musculoskeletal disease, musculoskeletal illnesses, osteoarthritis of the knee, the menu of options that we’ve all described are things that are very easy and very helpful for patients, particularly early on in the disease.
Paul Lachiewicz, MD: Peter, I want to emphasize that. If there’s an internist, or a family practice doctor who feels comfortable with aspirating a swollen knee, then more power to you. That’s what I see, in my practice. Many of the internists are uncomfortable with aspirating a knee, for whatever reason. If the knee is swollen, the patient has pain with every step, or the patient has night pain or rest pain, that’s the type of patient that should be referred to an orthopedic surgeon or physician assistant.
Peter Salgo, MD: I could see a primary care physician not necessarily worrying about the actual procedure of aspirating a knee—which, I think, is pretty straightforward. But, what do you do with the fluid? Who looks at it? Do you have a lab that’s going to make any sense out of that?
Richard Iorio, MD: Rheumatologists are very comfortable with that, if it’s purely an aspiration. There are a number of orthopedic surgeons that do joint replacement, who don’t want to take care of the type of patient who just wants an aspiration. But, I think we all are comfortable doing that. There are others, who are more general orthopedic surgeons, that have no problem doing that. We’re very comfortable doing that. This is our disease and we’re glad to take care of it.
Peter Salgo, MD: You told me that this is an enormous problem. Is it 60 million people? Twenty percent? Something like that?
Paul Lachiewicz, MD: Fifty-three million people, probably, now, in the US.
Peter Salgo, MD: With that many folks, it occurs to me that primary care is going to have to get comfortable. There are not enough of you guys.
Paul Lachiewicz, MD: I would think so. I would hope, as time goes on, that the primary care physicians will be more comfortable with aspirating knees and trying injections if the first-line treatments don’t work.
Peter Salgo, MD: Especially if you can get this down to some sort of algorithm, couldn’t you make this the job of a physician’s assistant or nurse practitioner, in your practice? You could say, “You’re the arthritis person.”
Paul Lachiewicz, MD: In one of the hospital clinics that I follow, the injections are delegated to a physician’s assistant. They can decide when this patient has reached the end of the line and should go see the surgeon. In my own personal office, I don’t delegate. I will do my own aspirations and injections. I don’t know about you guys?
Richard Iorio, MD: In the routine patient, I’ll have the nurse practitioner do the injections. There are some patients who are difficult—the very heavy patients, or someone that has extreme arthritis, where getting the needle in the joint is sometimes difficult. We do a biomarker analysis in a lot of our aspirated joints, which isn’t going to be done in a routine office setting. So, we oftentimes will enroll those patients in research studies. Routinely, it isn’t really necessary, unless you’re trying to rule out the other diagnoses of gout, or Lyme disease, or rheumatoid disease.
Paul Lachiewicz, MD: You may disagree with me, but if I see a new osteoarthritis patient and that knee is swollen, has an effusion, I will tap that knee. It’s surprising what you find. You may make the diagnosis of gout or calcium pyrophosphate disease. Occasionally, there may be a hemarthrosis, associated with trauma to an arthritic joint. So, I will do that the first time I see a new patient. I don’t know if you do that?
Richard Iorio, MD: This is a little bit off the track, but we think there are phenotypes of arthritis. We think there are osteoarthritis patients that are more inflammatory at the point of their arthritis. There are some osteoarthritis that don’t—that have a dry joint. Perhaps, it is just the wear and tear type of arthritis? So, we’re very interested in those biomarkers, and we’re very interested in seeing what kind of profile they have. We use that to guide our treatment. Many of the treatments we’re going to discuss may work in small subsets of patients, that we don’t characterize well, right now. We think that the biomarker profile will have something to do with that.
Peter Salgo, MD: Now, you mentioned weight as 1 patient variable. Are there others?
Paul Lachiewicz, MD: Sure. I think the very elderly patient, someone with severe cardiac disease, chronic smokers, diabetics, people who are very depressed, or those who are on chronic opioids all need to be considered. I think you have to take these other comorbidities into consideration when you’re planning treatment—especially if you’re considering surgical treatment. Would you guys agree on that?
Andrew Spitzer, MD: I would agree. To your point about patient cohorts, Rich, I think you mentioned metabolic disease earlier. If you look at cardiovascular disease, diabetes, there’s a similar pathophysiology that’s occurring—with low-grade inflammation, oxidative injury. When that happens in the pancreas, you get insulin resistance and diabetes. When it happens in the muscles, you get other issues. When it happens in the joints, you get osteoarthritis. So, I think that these comorbidities oftentimes come together, and they must absolutely be considered in conjunction with a decision algorithm when deciding what direction forward we should move.
Peter Salgo, MD: Of course, the final common pathway has got to get buy-in from the patient. In other words, you can sit here and discuss pathophysiology all day long, but you’ve got to have a patient who wants to do X, Y, or Z.
Andrew Spitzer, MD: Yes. One of the important points is that the patient does not necessarily direct their treatment. For a patient who has all of these problems and comorbidities, you don’t take them to the operating room and say, “Listen, you’re just at increased risk.” Many of those factors are modifiable risk factors. We are learning, very clearly in orthopedics, that myocardial infarction, for instance, is a huge risk factor. Diabetes, out of control, is a huge risk factor. From a patient outcome standpoint, and from a health economic resource standpoint, you can’t take those patients and subject them and the entire system to a high risk of complications. So, those are things that you need to certainly get buy-in from—the patients, but also a partnership.
Transcript edited for clarity.