Orthopedic referral guidelines: Hip and knee joint replacement

The threshold for referral to an orthopedic specialist for possible joint replacement focuses on pain and disability

Primary care and sports medicine providers hear frequently from patients about hip and knee pain, especially among older adults. The threshold for referral to an orthopedic specialist for possible joint replacement focuses on pain and disability.

Most hip and knee replacements are done between ages 50 and 80, but hip and knee replacements have been performed successfully for a broad range of ages, from teenagers with juvenile arthritis to older adult patients with degenerative arthritis.

Osteoarthritis is the most common reason for knee or hip replacement. Age, female gender, weight, injury, repetitive use, lower bone density, muscle weakness and joint laxity are all factors in the development of osteoarthritis.

“If patients have difficulty walking or difficulty walking without a limp, if daily activity is limited by moderate to severe pain, if it persists even when resting, these are all signs a patient could benefit from a referral,” said Jeffrey D. Stimac, M.D., an orthopedic surgeon who focuses on hip and knee replacements with Norton Orthopedic Institute.

Orthopedic referral guidelines are similar for hips and knees. Both procedures can relieve painful discomfort, increase motion and return patients to their normal, everyday activities.

Major joint replacements such as hips and knees are the most common surgeries for Medicare beneficiaries. The patient’s health plan, including Medicare Advantage, will require a detailed patient history that shows symptoms have not responded to other treatments and that the procedure was reasonable and necessary for the patient.

Hip replacement

Osteoarthritis is the frequent diagnosis for hip pain that leads to hip replacement. Rheumatoid arthritis, post-traumatic arthritis, osteonecrosis and hip disease while a child that persists into adulthood are other common causes. These conditions can result in limited range of motion and impede daily activities. Hips that click, pop, catch or lock also could suggest the potential need for a referral to an orthopedic surgeon.

If anti-inflammatory drugs, physical therapy, modifications to daily activities and use of walking supports do not adequately alleviate symptoms, hip replacement surgery may be indicated.

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According to the American Academy of Orthopaedic Surgeons, patients might benefit from hip replacement surgery if pain limits everyday activities such as walking or bending, pain persists day and night, and stiffness limits the ability to move or lift the leg.

Knee replacement

Osteoarthritis is a frequent diagnosis for knee pain that leads to replacement. Rheumatoid arthritis and post-traumatic arthritis are other common causes. Knees that catch, lock or give way also may warrant a referral to an orthopedic surgeon.

When treatments such as anti-inflammatory medications, cortisone injections, lubricating injections, physical therapy or other surgeries do not substantially improve symptoms, knee replacement surgery might be indicated. Knee deformity — a bowing in or out of the knee — also may warrant knee arthroscopy.

According to the American Academy of Orthopaedic Surgeons, patients might benefit from joint replacement surgery if pain limits everyday activities such as walking, climbing stairs, and getting in and out of chairs, pain persists day and night, and chronic inflammation and swelling does not improve with rest.

Patients can receive either a total or partial knee replacement, also called a unicompartmental replacement, which has a shorter recovery time but increases the likelihood more surgery may be needed in the future.


An evaluation with an orthopedic surgeon consists of a physical examination looking at mobility, strength and alignment; medical history, including information about pain and disability; and imaging such as X-rays or MRI.

After joint replacement surgery, patients typically report a significant reduction in painful discomfort and improvement with everyday activities. There are limits to what can be expected from knee or hip replacement surgery. Joint replacement will not allow patients to do more than they could before developing arthritis.

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