Referral Letter for Orthopedic Surgical Consultation
This elderly male patient with chronic knee pain refractory to conservative management should be referred to orthopedic surgery for evaluation of joint replacement, as he has exhausted appropriate non-surgical treatments including physical therapy, acetaminophen, and topical NSAIDs. 1
Clinical Justification for Referral
Before referring for surgical consideration, guidelines mandate that patients have been offered core treatment options—which this patient has completed. 1 The evidence-based treatment hierarchy for knee osteoarthritis progresses from:
- Core treatments (exercise, weight management if applicable, education) 1
- First-line pharmacologic therapy with acetaminophen and topical NSAIDs 1
- Advanced options including intra-articular corticosteroid injections 1, 2
- Surgical referral when symptoms substantially affect quality of life and remain refractory 1
This patient has appropriately completed the conservative pathway with physical therapy, acetaminophen (Tylenol), and topical diclofenac (Voltaren cream) since [DATE]. Referral for joint replacement should occur before there is prolonged and established functional limitation and severe pain. 1
Key Points to Address in Referral Letter
Patient Demographics and Comorbidities
- State his age explicitly (as elderly status is relevant but should not be a barrier to referral) 1
- List any comorbidities that may affect surgical planning
- Note that patient-specific factors including age should not prevent referral for joint replacement surgery 1
Conservative Treatments Completed
- Physical therapy duration and response
- Acetaminophen dosing and efficacy (up to 4g/day is appropriate) 1, 3
- Topical diclofenac (Voltaren) cream application and response 4, 5
- Document whether he has tried or been offered intra-articular corticosteroid injections for moderate-to-severe pain 1, 2
Current Functional Status
- Describe how knee symptoms (pain, stiffness, reduced function) substantially affect his quality of life 1
- Specify activities of daily living that are impaired
- Note any mechanical symptoms like true locking (not just "giving way" or gelling, which are inappropriate referral reasons) 1
Addressing Trust Issues
Given his documented trust issues, include:
- His active participation in requesting this referral (demonstrates patient preference, which strongly influences appropriateness of referral) 6
- His engagement with conservative treatments
- Request a surgeon who takes time to explain options thoroughly
- Note that referral decisions should be based on discussions between patient, referring clinician, and surgeon 1
Sample Referral Language
"I am referring [Patient Name], a [age]-year-old male with chronic knee osteoarthritis for orthopedic surgical evaluation. He has completed appropriate conservative management including physical therapy since [DATE], acetaminophen, and topical diclofenac cream with inadequate pain relief. His knee symptoms substantially impair his quality of life and daily function [specify examples]. He actively requests surgical consultation to explore additional treatment options. Please note he benefits from detailed explanations of treatment options. No recent trauma. Radiographic evidence [if available] shows [grade]. He has exhausted non-surgical options per NICE and EULAR guidelines and meets criteria for surgical evaluation."
Additional Considerations Before Referral
If not yet attempted, consider offering intra-articular corticosteroid injection for short-term pain relief (1-24 weeks) before or concurrent with surgical referral, especially if there is clinical effusion. 1, 2 This can provide symptomatic relief during the wait for surgical consultation and does not preclude surgical evaluation.
Do not refer for arthroscopic lavage and debridement unless there is a clear history of mechanical locking, as this is not indicated for routine osteoarthritis management. 1