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| Call Us at : 203-598-0700 |
| Office Visit Before Surgery and Initial
Evaluation
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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).
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| 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.
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 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.
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| 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.
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| 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.
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