The Multimorbid Orthopaedic Patient: Staging Referrals and Surgical Priorities

Managing orthopaedic patients with multiple joint pathologies—commonly known as multimorbid orthopaedic patients—can be intricate. These patients often have several co-existing joint issues such as hip osteoarthritis, knee degeneration, and shoulder impingements. Each condition demands attention, but without a clear strategy, care can become disjointed. This post offers a practical guide on coordinating referrals, determining surgical sequencing, and ensuring patient-centred outcomes.

1. Understanding the Patient’s Whole Health Profile

Before any decision-making, having a comprehensive picture of the patient's health is crucial. That means:

1. Complete clinical history: Identify existing joint problems, chronic conditions (e.g., diabetes, cardiovascular disease), and functional limitations.
2. Current investigations: Imaging (X-rays, MRI), lab results (e.g., HbA1c, inflammatory markers), and functional assessments (e.g., gait, range of motion).
3. Patient priorities: What bothers them most—pain, mobility limitations, functional independence?

This broad view helps set the stage for collaborative care.

2. Coordinating Referrals Effectively

Multidisciplinary communication is the backbone of well-orchestrated care. Here’s an effective approach:

• Primary care physician (GP): Often the first contact and coordinator. Communicate clearly and encourage periodic review.
• Specialist physicians: Rheumatologists or general physicians for medical optimisation, especially for comorbid conditions like diabetes or cardiovascular disease.
• Allied health: Physiotherapists, dietitians, occupational therapists support preparation and recovery.
• Anaesthetist and pre-admission clinic: Evaluate surgical risk, medication review, and prehabilitation.

Tip: Use shared-care plans and electronic records to ensure everyone knows who’s doing what.

3. Sequencing Surgical Priorities

When multiple joints need surgery, deciding which to address first requires careful thought. Here’s a stepwise way:

• Evaluate pain and function: First address the joint causing most limitation.
• Assess complexity and risk: Prioritise less risky, quicker recovery procedures if they meaningfully improve quality of life.
• Impact on rehabilitation: If your patient has severe knee arthritis that will hamper rehab after hip surgery, consider fixing the knee first—or vice versa.
• Patient goals: Some may value pain relief, while others prioritise mobility or independence.
• Comorbidity control: Delay elective surgery until conditions (e.g., uncontrolled diabetes or hypertension) are stable.

In practice: For a patient with both hip and knee arthritis, I usually begin with whichever joint impairs walking the most and offers the greatest functional gain.

4. Case Example: Mrs. T

Background: 72-year-old with bilateral hip osteoarthritis, right knee osteoarthritis, type 2 diabetes, and mild heart disease.

Assessment:

• Hip pain is most severe affecting walking
• Diabetes under reasonable control (HbA1c ~7.2%)
• Cardiac assessment deemed low risk with optimisation.

Referral sequence:

1. Rheumatologist: Reviewed diabetic and cardiac medication adjustment.
2. Anaesthetist: Approved a hip-first approach.
3. Physiotherapist: Started prehabilitation focusing on hip muscle strength.

Surgery plan:

1. Right hip replacement.
2. Strength training and rehab.
3. Reassess and proceed with right knee replacement.
4. Consider future left hip procedure as needed.

Outcomes: Patient improved gait after hip surgery, easing rehab for subsequent knee surgery.

5. Practical Steps for Clinicians

1. Multidisciplinary meeting: Essential for planning complex cases.
2. Patient-centred discussion: Involve patients in sequencing decisions.
3. Provisional scheduling: Block multiple procedure dates ahead of time; flexibility is key.
4. Reassess pre-surgery: Update medical status before each surgery.
5. Coordinate rehab: Ensure therapy pathways are continuous between procedures.

Frequently Asked Questions (FAQ)

Q: Can two joint replacements be done in the same hospital admission?

A: Yes, in select cases like bilateral knee replacements. But the increased length of anaesthesia and risk may outweigh benefits. Staging across separate admissions is often safer.

Q: How long should I wait between surgeries?

A: Typically 3–6 months, depending on recovery, medical optimisation, and patient goals. Some patients may benefit from earlier or later intervals.

Q: What if the patient’s medical conditions worsen between surgeries?

A: Reassess prior to each procedure. You may need to delay, modify the plan, or involve specialist input for optimisation.

Q: Does sequencing affect final outcomes?

A: It can—especially when rehab from one surgery influences recovery from another. Proper sequencing facilitates smoother recovery and better long-term function.

Q: Do insurance and cost impact the sequence?

A: Yes—public vs. private system, waiting lists, and concessional status can shape timing. Discuss pragmatic options with patients up front.