The majority of patients are referred to the orthopaedic surgeon by their primary care provider, although an increasing number of educated patients today make appointments directly with our office for hip and knee problems. While some HMO's may require referral to see a specialist, many patients make the appointments on their own. Some patients are also referred by physical therapists, nurse practitioners, chiropractors, or other specialists (rheumatologists or spine surgeons).
History and Physical Exam
At the first visit with the orthopaedic surgeon, a detailed history and a physical examination will be taken. The history is in many ways the most important part, and most practices that specialize in hip and knee surgery like ours will have a two or three page history and intake form. We usually mail this form to patients before surgery or ask them to print it from our website. It has many of the questions that we need to ask already included, and additionally provides important information on other health issues, allergies, and medications.
In our office and in many orthopaedic offices, the preliminary history and examination may be performed by a physician assistant. This is a professional with at least graduate level education who can help gather information, perform a physical examination, and provide many physician extender functions.
The history is supplemented by asking a number of detailed questions, primarily to gain additional insight into the exact symptoms and limitations patients are experiencing and to help the surgeon formulate a diagnosis. This interview can sometimes be completed by telephone for patients who live far away and by having the medical history and x-rays available ahead of time. However, it does not eliminate the need for a physical examination.
The physical examination in an orthopaedic office is somewhat different from a physical examination at the primary care provider's office. Much can be determined simply from observing how a patient sits, stands, and walks. This gives the surgeon a very good idea of what may be going on with the hips and knees. The range of motion of these joints will be checked, and joints are usually tested for ligamentous stability (for example, most knee ligament injuries can be diagnosed by testing each of the ligaments physically).
The joints are examined for evidence of erythema (redness), effusion (or fluid collection), signs of new or old injuries/scars, and for internal derangement. Specific tests and maneuvers may be used to check for problems such as a meniscal tear, etc.
Radiographs (X-rays)
Radiographs (x-rays) are often obtained. Not all orthopaedic problems require x-rays (such as diagnosing bursitis or tendinitis), but most arthritic conditions - especially when surgery is being contemplated - require imaging of the joints. Surgeons assess many things on x-rays, including bone quality, joint space / articular cartilage, the presence of cysts or spurs, findings of loose bodies in the joints, new or healed fractures, and anatomic deformities (such as the degree of varus - or "bowleggedness" - and other anatomical variations or evidence of congenital problems like hip dysplasia).
If you have had previous x-rays or other studies (such as MRI's or bone scans), it is a good idea to bring the actual films with you to the office. Many patients have arrived with just a copy of a radiologist's report and do not understand why the surgeon needs to see the actual x-rays or needs to repeat the x-rays in the office when they have been done elsewhere. Having a radiologist's report that simply says "degenerative joint disease" or "osteoarthritis" does not tell me as a surgeon what the exact problem is, how severe it is, and most importantly, whether surgery may be needed to correct it. That can only be determined from actually reviewing the films themselves - a picture really is worth a thousand words.
Increasingly, many radiology centers and physician's offices are able to place all of a patient's x-rays and other images onto discs that can be easily transported (much more so than a heavy jacket full of MRI films) and viewed on any computer.
In addition, we often may repeat the x-rays if the previous films are not of sufficient quality or taken with the wrong technique to show what we need to see. A very common example of this is standing x-rays with knee problems; many primary care providers may order knee films with the patient lying down, and for diagnosing many orthopaedic conditions we need the knee films to be taken with the patient standing, in order to see how much cartilage gap remains in the knee and to determine knee alignment when weightbearing.
Other Tests
Other tests may be ordered after the first visit, depending on the exact problem being investigated. Most patients needing hip or knee replacement do not require any further imaging beyond the x-rays, but we may sometimes order an MRI to evaluate specific conditions (such as evaluating for a meniscal tear in the knee - or "torn cartilage" - which will not be evident on x-rays) or a bone scan to determine if a prosthesis is loose.
We usually will have patients return a week or two after the tests to discuss the results. Some tests may be simple - such as a Lyme disease test - but most imaging tests such as an MRI will yield complex results and frequently determine what we do next. For that reason, we usually will ask patients to come back to discuss the results and the next step unless it is a simple, confirmatory test that we can relate over the telephone.
Discussing Surgery
Many patients can be diagnosed on the first visit without the need for additional tests or imaging (such as for knee or hip arthritis), and we can discuss their options on that first day. For the vast majority of patients needing hip or knee surgery, there is no immediate emergency in scheduling hip or knee replacements or arthroscopy, and we will usually present the options, discuss the surgery, and recommend that patients go home and think about it.
When patients do need hip or knee replacement, hip resurfacing, or knee arthroscopy, we will usually discuss the surgery itself, the hospitalization, the common risks and benefits, and alternatives to surgery. Clearly, this information can fill a book like the one you are reading now, and so we usually try to present the pertinent information and may provide additional reading materials.
Sometimes a more detailed visit to discuss surgery is needed. Many insurance plans will cover this, although Medicare will not in most cases. (Medicare will not typically cover additional preoperative visits to discuss surgery once it has been recommended. Unfortunately, most patients are not aware of this, but hopefully this policy can be changed eventually if enough citizens voice their concerns to Medicare about it.) It is best to take family or friends with you to the office visit if they will be involved in your care or decision making process. This is important for several reasons; the first is that a large amount of information may be conveyed during the visit, and two people are more likely to remember it than one! The second reason is that HIPPA (Health Information Privacy and Portability Act) enacted by Congress severely limits healthcare providers' ability to discuss patient information over the telephone with anyone other than the patient or their designated power of attorney. The third reason is that other family members (usually children of older patients) may have questions, but it is difficult to answer those questions over the telephone if the patient and their medical chart are not immediately present (e.g., the day after the visit). The best time and place to ask those questions (by far!) is at the office visit with everyone present.
Please remember the information on this site is for educational purposes only and should not be used to make a decision on a condition or a procedure. All decisions should be made in conjunction with your surgeon and your primary care provider.
