By Scott Scanlon – Refresh Editor
Dr. Nicholas J. Violante might not be a dentist like his dad, but he puts in long hours and has made a big impact in the field of hip and knee replacement surgery since he landed a job in 2006 with Excelsior Orthopaedics, based in Williamsville.
Violante is the subject of today’s “In the Field” feature in WNY Refresh.
His family has built a legacy in the dental community in Lewiston, but he’s staked his ground south of the Niagara County border, though he does work out of Niagara Falls Memorial Medical Center at times.
Below are excerpts from questions that were not included in today’s WNY Refresh piece.
What is residency like for an orthopedic specialist?
I did a general residency the first year and then they decide the next year who they want to pick for their ortho residents. They took five interns for two spots and made you compete for it, which not a lot of programs do anymore. Now, most of the programs streamline you right in. Before, the thought was everybody ought to do a little bit of everything in that first year before you specialize. So you have some general surgery, pediatrics, general medicine. And our residency was different. Because we were based out of such a small hospital, we got sent out for a lot of things. We traveled quite a bit, which was tough. I was in Pittsburgh six months for trauma. We did our peds as Shriners, which was local in Erie at the time. I went to Cleveland, to the University Hospital System for six months. It’s like the Cleveland Clinic counterpart, sort of.
Then there were a bunch of small hospitals in Western Pennsylvania, like Meadville, Sharon, UPMC Northwest.
It was tough, but the nice thing about it is because we were all over the place, we got a nice variety of trainers.
If you’re in the same hospital, you might have eight or 10 trainers. In that setting, I had 35-plus trainers, and for me, doing total joint replacements, I saw every different system on the market. … That helped kind of groom my interest in total joints.
What was the first big case you had to address and how did it work out?
When you’re in residency and fellowship, you have a lot of help. My first big case on my own was a hip revision I did on a gentleman who owns a maple syrup farm. He came to me after having six failed hip surgeries. I looked at his X-rays, paused for a few minutes and had a conversation in my head of, ‘Can I do this on my own?’ I had the confidence, I had the skills to do it, but just making that leap of faith to say, ‘I know I can do this, be prepared, get all the equipment there.’ That was my biggest case. That was about six months ago. The guy’s doing fantastic. He’s brought me a case of maple syrup and offered to have me come out to his farm with my family to do a tour.
You operate out of Erie County Medical Center?
I have complete confidence taking big cases to ECMC. I know that if there are going to be complications, I have the support staff around me to manage them.
What special challenges do hip and knee joints present and why?
One of the things that makes my job tough is peoples’ overlap with pain, function and work. A lot of the things I get tied up in with my patients is pre- and post-operative disability, as far as return to work, return to life. There’s a lot of social issues surrounding pain and loss of function. When people come to me and say, ‘I need a hip replacement,’ it’s not something as easy as, ‘OK, I’ll replace your hip.’ They want to know, ‘How long am I going to be out of work?’ ‘When can I drive?’ ‘When can I go up the stairs; I have 12 sets of stairs in my house.’ ‘My bathtub is not well equipped.’ Those are some of my bigger challenges. It’s not the surgery. The surgery is fairly reproducable, it’s managing their social and life problems.
And how do you do this?
With people. We have a lot of people around: our physical therapists, our care coordinator, our nursing staff. Knowing that, at ECMC, we started a Total Joint Steering Committee out of necessity. When I started working there, there was a lot of disconnect between doctors, nurses, therapists, surgery department. All those people should be together to discuss a patient’s experience from start to finish, so that it’s reproducable, smooth, with less hiccups. When you have all those different people knowing what their jobs are, and what your expectations are, it makes things so much easier. It turns out the patients will ask the right people the right questions.
How has orthopedics changed during the last decade?
It’s changed a lot in terms of the subspecialties. When I was an intern, most people were doing fellowships, but there were 50 percent of the people who graduated still doing general orthopedics. When I graduated, and the classes below me, probably 100 percent of people were going into fellowships, going into more specialty training. People’s expectations of their surgery are higher, their expectations of return to function quicker, faster.
During my training, a lot of people going in for hip or knee replacements were in the hospital for five, six, seven days. They were out of work for three months. Part of it was just expectations. The post-operative complications were often (more common). We use different pre-operative medications now to prevent post-operative stuff. There’s more planning involved now, so that recipe has changed. Even in my fellowship, things changed. Us trying new things, what worked what didn’t work, and that eventually sort of thing kind of bleeds out into the community.
Are you seeing more computer-generated research where you’re looking at more best practices?
Yeah, at least theorectically. It’s coming. There’s all this talk about outcomes are going to determine reimbursement. I think people coming out of residency now are not as confident about managing everything. They’d rather focus in on one thing and be confident in one thing. ... The push for subspecialties really is all about confidence.
How will the Affordable Care Act change what you and your fellow orthopedic surgeons do?
It’s going to be all about outcomes. I think that’s the only way they can subjectively determine reimbursement.
Do you expect things to become more challenging or efficient?
One of the things that concerns me the most – right now, we take all insurance ... so eventually you get busy with people who want to see somebody who does a good job – the concern is if it becomes financially too strenuous. … There was a push when I was in residency to stop taking Medicare because the reimbursement rates weren’t as good as the private insurance payers. The thing I like is to just take care of people. I don’t want to decide not to take care of people because I can’t afford to. I want to generally show up to work, solve whatever problem’s in front of me and help that person. I don’t want it to be what their insurance is. I would tell you, most doctors feel the same way. You don’t want finances to influence the people that you help.
What are the youngest and oldest patients you’ve operated on?
I had a 26-year-old patient who I did both hips at the same time on. He had auto-immune hepatitis and the amount of medications and steroids he was on post-operatively from a liver transplant ended up secondarily killing the cartilage in his hips. Complete success so far. It’s been less than a year. He stood up the day after surgery and walked down the hallway and he did not use a walker, a cane or a crutch. It was truly remarkable. The oldest patient was an 89-year-old who I did a total knee replacement on. He was sent by one of my partners. He was a very healthy 89-year-old who still had a very good quality of life. I talked with him multiple times before I made the decision to operate on him. He said, ‘Doc, you’ve gotta fix me.’ He felt he still had a lot of good years in him.
I tell people, ‘I don’t know how long this joint replacement is going to last you,’ and I tell them about the risks ahead of time.
Can you talk a bit about when surgery shouldn’t be considered versus when it should?
Part of it depends on their medical status. If patients are at high risk for anesthesia, it should definitely not be considered. When I talk to people about their medical status, I often ask, ‘How many subspecialists are you seeing?’ If they have a laundry list of doctors on speed dial, usually that’s a bad sign. The second thing is diabetes management. A lot of things can subtlety get missed. Someone can tell you they’re a controlled diabetic when they’re really uncontrolled. Those are very risk, very dangerous. ... Risk of infection is considerably higher. (That has to be addressed first)
Does a joint have to degenerate to a certain point?
If I see a patient who says they have an enormous amount of pain and their X-rays seem completely normal, they’re not a candidate for a knee replacement. It usually means you don’t have the right diagnosis. … There has to be degeneration in the joint.
What should someone consider when confronted with the prospect of replacing a joint with a prosthetic?
Number 1, I tell everybody, ‘It’s never going to be the knee God gave you,’ ‘It’s never going to be the hip God gave you.’ I tell most people, ‘It should restore your function, but it may not always get rid of all of your pain.’ People have pain for different reasons. If you restore a replace a joint, the ultimate goal is pain relief, but part of it is functionality. ... If they couldn’t walk before, now they can walk but they still have pain, it wasn’t necessarily unsuccessful, but it’s all about people’s perception. If someone has no pain but it’s not functioning, most people aren’t happy about that either. Most of the time, patients experience both, but I may relieve your pain, but not restore your function. I may restore your function but not relieve all of your pain. That’s somewhat on the patient, somewhat on the doctor. If it’s a perfect surgery and a patient doesn’t do any of their rehab, they may not have a great outcome. So part of what I tell people is, ‘You can expect to have pain for X amount of time, but you have to have somewhat of the onus on your own care.
What’s the threshold in determining whether a full or partial hip or knee replacement is needed?
Partial knee versus a total knee is based on the diagnosis. So, you have X-rays and degree of pain, history and physical exam. If the pain is slowly on one side of the knee and X-rays confirm their arthritis is only on one side of the knee, then typically that person is a candidate for a partial knee. If their pain is on both sides of the knee and they have significant problems with function, and the X-rays confirm that, they’re a candidate for a total knee. Typically, age has nothing to do with that.
I don’t do a lot of joint preservation. That’s unveiling into a category of its own, and that’s usually sports medicine.
How does a replacement differ from someone who’s broken a hip?
Hip fractures typically involve patients who have more illness. They’re generally older. They generally are more functionally declined to begin with. Their bones are typically not as healthy. You can give them the same procedure but they tend not to do as well. ... If I have a debilitated older patient that has advanced arthritis and is not functionally doing so well, I don’t think they’re a good candidate for joint replacement. They may fall post-operatively. But in this case, they’ve beaten me to the punch. They’ve made me operate because they fell and now they can’t walk. There’s a couple different ways to look at it. Typically, functionally, they’re older, they’re not as mentally there, they have other medical problems, so their functional outcome is not as good for a variety of reasons.
You have an emergency center here in the Williamsville office. Are you ever on call for that?
All the folks in the group take general call. Mostly, I deal with lower extremity fractures: ankles, femurs, tibias.
What is your typical work week like?
Our group also takes general call at Kenmore Mercy Hospital. Generally, if we’re on call here, we’re also on call at Kenmore Mercy. I’m always generally on call for my own patients. During my normal work week, I have two OR days. I do two days a month at Niagara Falls Memorial and the rest of my time is mostly ECMC as far as those OR days. I have a half day a week in the Buffalo Surgery Center here, if I have an ankle fracture or a knee scope. I do partial knee replacements at the surgery center. Mondays, Thursdays and Fridays I see patients in the office and I’m on call every 10th night, every eighth weekend, so it’s not bad. I probably put in 70 to 75 hours a week. I’m putting in minimum 12 hours a day. I’m usually here at the office or making my rounds in a hospital around 6 a.m.