MDNews - Central New York

Q Q Q : What type of orthopedic specialty do you practice? Dr. Izant: Primarily hip- and knee-replacement surgery. : How has joint replacement surgery changed recently? Dr. Izant: Over the term of my practice, we have seen exponential growth in individuals, especially baby boomers, requiring joint replacement. The American Academy of Orthopedic Surgeons predicts there will be a shortage of orthopedic surgeons who do joint replacement surgery. We train orthopedic residents at Crouse Hospital and are producing a steady number of orthopedic surgeons, with a portion of those choosing joint replacement surgery as a subspecialty. However, due to the physical and mental stress of practicing medicine today, many surgeons are retiring at earlier ages. Additionally, replacements are being done in younger patients — in their 30s and 40s — resulting in a growing number of revision operations. : Could you give us some of your observations on popular orthopedic consumer issues of the day — for example: 30-year knee replacement, direct patient marketing and hip recalls? Dr. Izant: Technology in orthopedics is one of the reasons I chose to go into this field. Technology is expanding, and we are significantly improving the quality of life for our patients. That's what got many of us interested in the subspecialty in the first place. This has created a huge industry that has become very competitive. The implant companies have been appropriately scrutinized by the U.S. Justice Department over the past six years, which has further driven up their cost to stay afloat. Several companies have been making claims of longer-lasting implants based upon lab data and no clinical data. Some make claims that cannot be substantiated in clinical trials in peer-review journals. Implant companies have adopted the pharmaceutical model of direct patient marketing, somehow thinking that the patients will be able to comprehend the data and determine what is the best procedure or implant. Patients should choose the surgeon who is best for them and allow the physician to use what he/she thinks is best. Another downside to marketing forces is that it subjects the patients and surgeons to higher risks, including complications and class-action suits. We all desire high-quality outcomes for our patients, often achieved with new technology. Whenever a new product is brought to market, failures are quickly recalled, which is good medicine, but they are quickly followed by massive advertising by lawyers looking to cash in. Q : Tell me how Crouse Hospital and your orthopedic group utilize new techniques in pain management? Dr. Izant: Techniques in pain management, particularly in knee replacements, are challenging. Just prior to entering the operating room, we give patients a variety of medications that will block the pain before it starts — this is called preemptive analgesia. The second thing we find is that the type of anesthesia used will affect the pain management after surgery. I encourage regional anesthesia, which involves injecting numbing medicine around the nerves, both in the back and the leg. During surgery, we also find that doing an injection of a cocktail of medications in the soft tissue of the knee has a tremendous effect on post-op pain. After surgery, there are several different ways to manage pain. The challenge is that everyone perceives pain differently, and no one formula works for everybody. In general, we try to mobilize patients quickly, use a combination of intravenous medications and get them on pills as soon as we can. We find there are many complications with narcotics, so we try to use a0s few as possible to avoid side effects such as nausea, vomiting, constipation and confusion. There's been a development in pain medications that are not classic narcotics, but are as effective and without side effects. Additionally, we utilize a pain scale and monitor the pain as an additional vital sign. The orthopedic team of nurses, nurse practitioners and therapists constantly communicates to optimize and balance mobility with pain control. Q : With the growing number of people carrying drug-resistant bacteria on their skin, how do you, as a surgeon, and the hospital in general, reduce the risk of surgical infections? Dr. Izant: This is a huge issue. The incidence of drug-resistant organisms in the community, such as methicillin-resistant staphylococcus aureus (MRSA), is fairly high. These patients are usually asymptomatic, and when hospitalized, they expose a risk for transmission to other patients. Crouse Hospital has a brand new OR and utilizes laminar airflow techniques and space suits to reduce infection rates. We follow all of the federal guidelines for use of antibiotics prior to surgery and proper management after surgery. Crouse Hospital has addressed MRSA-infected or colonized patients by allocating an entire floor for managing their treatment. It is a program for which the Infectious Disease department has received national recognition. Recently, many of the hospitals, including Crouse Hospital, have started to screen patients prior to surgery to see if they are colonized and treat them appropriately before surgery. Additionally, Crouse Hospital has started a program where all joint patients are asked to shower with a solution, chlorhexidine, every day for five days prior to admission. This helps to reduce the bacterial counts on the skin. Due to the nature of joint replacement surgery, with the implantation of metal devices, it is imperative to use all techniques to eliminate the risk of infection. Crouse Hospital has been very supportive of this approach, both financially and through implementing this program with the leadership of Dr. Dennis Brown, Senior Surgical Quality Director, and Lyn Johnson, Senior Analyst for the Quality Improvement Department. Editor's Note: Dr. Izant is a pioneer in computer-assisted knee surgery in New York state. ■ MDNEWS.COM ■ MD NEWS Central New York | 19

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