Rheumatology and Orthopaedics - never the twain shall meet or speak to each other

jamieA

Last year when an issue with my fingers led me to contact my rheumatology clinic I first became aware of the term 'mechanical issue' and was told to get a referral to orthopaedics. I had to do this through my GP. So time is wasted whilst the GP waits for the letter from rheumatology before making the referral. This year I've had a problem with my right ankle which the rheumatology physio said was due to my left knee which was a 'mechanical issue' and to contact my GP for a referral to orthopaedics. Orthopaedics has a 42 week wait time for first appointment here so adding in the delay between rheumatology physio wait for appointment, GP referral and 42 week wait time it's well over 9 months since my problem started and still no sign of an appointment. I do not understand why there is no direct contact between rheumatology and orthopaedics - after all it's my PsA that's caused the deterioration of my knee joint.

Is this the same everywhere? Surely when a rheumatologist determines that inflammatory arthritis has resulted in joint deterioration - a 'mechanical issue' - there should be direct contact between them and orthopaedics. If, for no other reason, it would hopefully ensure there is no misunderstanding and the patient wouldn't have to start from scratch.

stickywicket

There used to be. Way back in the early '80s it was my rheumatologist who got the orthopaedic surgeon to look at my knees. It was then just a matter of TKRs asap.I have a vague feeling that the change was all to do with money. (Sound familiar?) Docs of any ilk are keen to sort out their patients and direct referrals meant too many were being referred. Maybe without first even attempting physio etc. Although I'm sure that's not the case with you, once the system is changed, it's changed.

Down here i the Borders we have an excellent private physio service which is thorough, cheap and efficient. My go-to place every time now.

jamieA

Hi @stickywicket

I think I'm just getting frustrated by it all. The trigger finger problem has been going on since June 2019 and I wasn't seen for 18 months due to my then GP forgetting to make the orthopaedics referral and then the covid pandemic occuring. It was treated November 2020 but recurred last summer - my fingers were locking and I couldn't straighten them. I was seen by an orthopaedics consultant in March who requested an MRI which was done in June. I took an adverse reaction to the contrast agent and ended up in hospital for 8 days and was left with issues in both my hands and feet joints. I saw my rheumatologist in September and she suggested a steroid injection which worked for both my hands and feet and also allowed me to straighten my fingers - which was one of the reasons I was seeing the orthopaedics consultant. I then had a follow up with the orthopaedics consultant in October who said since my fingers were working ok due to the steroid injection he wouldn't do anything and would see me again in February 2024. I'm well aware the effects of the steroid injection will probably wear off before then.

stickywicket

I can understand your frustration. Painful frustration too.

My experiences are probably way out of date but, for what they're worth, I have only ever been given steroid jabs by my rheumatology team. I thought the depo medrone ones only worked for inflammatory forms of arthritis and, yes, I'd expect one to work for both hands and feet. It sounds to me as if your PsA isn't fully under control and that's what needs fixing.

I've only ever been referred to an orthopaedic surgeon when replacement joints were deemed probably necessary though, once I had two TKRs and one THR (I think) , the ortho guys had me down for an annual check up.

I'm wondering what the ortho surgeon will do in February. To my way of thinkinģ - which could be way out - it's your PsA thst needs attention not your hands and feet that need surgery.

Do feel free to ignore this if it's totally irrelevant.

jamieA

Hi @stickywicket

The treatment for trigger finger is a steroid injection to the base of the finger into the tendon/sheath and that's what the orthopaedics consultant did in 2020 and it worked. However they will only do it a maximum of twice as there is the possibility of the sheath collapsing and leaving the finger immobile. The problem with my hand and feet joints was one of the adverse reactions I had to the MRI contrast agent. It's documented as one of the adverse reactions - pain in joints, mainly in the extremeties. Along with loss of balance, severe headaches and very high blood pressure - all of which I also had - were the reasons I was admitted to hospital after the MRI scan. When I told my rheumatologist I still had the issue with my finger and toe joints 3 months later in September she suggested a general Kenalog injection which is done into your rear. She suggested the adverse reaction to the contrast agent had caused an increase in inflammatory cytokines and the steroid could dampen them down.This worked and my finger and toe joints aren't hurting now. A side effect of this is that I'm able to straighten my fingers - which was the very issue that the orthopaedics consultant wanted the MRI scan for. So he didn't see the problem when I saw him on 9th October. I think the February 2024 appointment is to see if it comes back after the Kenalog injection wears off.

My biologic is an anti TNF alpha biologic. In a published peer reviewed scientific paper lab tests on rats had shown a 5 fold increase in TNF alpha after contrast agent injections. So I don't think it's my PsA that's not under control - more likely the contrast agent upset the balance of treatment and disease.

Emmasknackeredjoints

I feel the same. My knee has IA and the rheumatologist says it's now a mechanical pain so I need orthopaedics but ortho team say it's all soft tissue inflammation so it's a rheumatology issue. I feel rheumo just want to get rid of me and blame it on a ortho condition.

My answer was if you leave IA it is painful to walk on so how is it orthopaedic issue.

Its crazy how the 2 departments dont mix well . But having worked in healthcare yes it is to do with money. Unfortunately

jamieA

Well I eventually got a number to contact regarding an orthopaedics appointment for my knee. My local health board doesn't publish telephone numbers so I had to go through about 3 different numbers to be eventually pointed in the correct direction. One orthopaedics department I spoke to is in one of the two major hospitals in the city and the person I spoke to confirmed I wasn't on their patient list but if I was it is an 8 month wait for initial appointment. When I eventually got through to the smaller hospital my case is assigned to I was told it's a 58 week wait for initial appointment as my GP had put the referral through as 'routine'. I explained that my knee issue was due to PsA causing OA and that my rheumatologist had stated in February 2022 I'd need a knee replacement 'sooner rather than later'. The person I spoke to said that to get the referral changed from 'routine' I'd need go back to my GP. If rheumatology spoke directly to orthopaedics this wouldn't have been the case.

Arthuritis

@Emmasknackeredjoints @Jamie @stickywicket Unfortunately the problem re consultants not being able to refer across, and can only go “radial”, unless you have been admitted is more to do with NHS management structure, which is probably the most inefficient that could be created. It’s not direct lack of cash, just that so much gets wasted that there isn’t enough left after wasting huge percentages of it. Like a woodsman complaining about being exhausted trying to meet his quota, with a blunt axe, but claiming he hasn’t the time to sharpen his axe or improve his technique.

On the rare occasions that my employer provided private healthcare cover, referral direct between consultants was never an issue, and in PLC land, no money was wasted in going to & fro consultant to gp, as the gp adds no incremental medical value, just paperwork and admin costs. Even booking was highly automated & efficient, no battleaxe to fight at 8:00am! The initial engaging consultant acts as the central coordinator and when they are all done a final summary was sent to the nhs gp.