KUALA LUMPUR, July 19 – Malaysia is beginning to see the advent of single-specialty hospitals that treat a particular specialty in medicine, such as orthopaedics.
Dr William Maloney, who is the Boswell chair of orthopaedics and a professor of orthopaedic surgery at Stanford University’s School of Medicine in the United States, said common medical specialties treated by single-specialty hospitals include orthopaedics, oncology, and cardiology.
He explained that in single-specialty hospitals that provide treatment in only one specialty, patients and hospital staff across physicians, nurses, and therapists are focused on the same protocols, giving the patient a single message.
“When you have a single-specialty hospital, everyone’s on the same page,” Dr Maloney told CodeBlue in a recent joint interview with President of MSHKS (Malaysian Society of Hip & Knee Surgeons) and ALTY Hospital consultant orthopaedic, hip and knee surgeon Prof Dr Azhar M. Merican at ALTY Hospital here.
“If I have a nurse in the operating room that I work with every time I’m there, it’s like a team. I don’t even have to ask you, you know what to hand me, or I know what to hand you. But if the nurse is doing general surgery one case, urology one case, it’s very inefficient. The cases take longer.”
The benefits of single-specialty hospitals are increased patient satisfaction, better patient outcomes, and more cost-effective treatments.
Dr Maloney explained that patients are more satisfied with single-specialty hospitals as such facilities are a “one-stop shop” for their problems.
Single-specialty hospitals are also linked to improved patient outcomes, such as shorter lengths of stay, fewer infections, and a lower complication rate.
In addition, single-specialty hospitals are able to negotiate better prices for medical devices, compared to general hospitals, due to bigger volumes purchased by facilities for their sole specialty.
“The three messages are: higher patient satisfaction, better outcomes, and lower cost,” Dr Maloney said.
Dr Azhar stressed that single-specialty facilities also have physicians from other specialties to ensure that a patient is fit for surgery. ALTY Hospital, for example, has a cardiologist even though the private facility is an orthopaedic hospital.
“We do joint replacement surgery. A lot of our patients are elderly, so we need to know whether they’re fit for surgery,” Dr Azhar said.
He added that even anaesthesia for orthopaedic surgery would be slightly different in a single-specialty hospital than a general hospital, as the former aims to reduce pain after surgery.
Dr Maloney, who is also clinical director at TE Asia Healthcare that invested into ALTY Orthopaedic Hospital, said the hospital sees mostly older patients with underlying health conditions, requiring physicians to address risk factors like diabetes, nutrition, cardiac status, and blood pressure control to prepare the patient for procedures.
“It’s not like we just look at your knee and don’t pay attention to the rest of your body.”
Treatments At ALTY Orthopaedic Hospital
ALTY Orthopaedic Hospital, which is one of Malaysia’s first single-specialty hospital focused on orthopaedics and musculoskeletal conditions, is currently treating conditions involving the hip and knee, as well as spine.
The musculoskeletal system of the human body comprises muscles and bones, as well as joints, ligaments, and tendons.
There are nine orthopaedic specialties, comprising hip and knee, spine, trauma, sports medicine, foot and ankle, hand, paediatrics, tumour, and shoulder and elbow.
According to Dr Azhar, ALTY Orthopaedic Hospital has also performed a number of ligament and reconstruction surgeries.
Tumour orthopaedic specialty generally involves orthopaedic surgeons who specialise in treating specific cancer cases that require large resections and reconstructions. Such treatments are generally provided at bigger medical centres.
Dr Maloney explained that single-specialty hospitals in orthopaedics provide both pre-surgical and operative care. The single-specialty hospital, for example, would communicate with the primary care physician of an arthritis patient, for example, but musculoskeletal care for the patient is provided at the orthopaedic facility.
“We have physical therapy here, we can do the injections, basically anything related to the musculoskeletal system. The idea is they can get it here.”
ALTY Orthopaedic Hospital has been operating for about a year, with its formal launch held last July 7.
Hospital Stay For Knee Replacement Surgery Shortened To Less Than A Week
About 90 per cent of knee replacement surgeries at ALTY Hospital are for patients with osteoarthritis, the most common form of arthritis that usually affects joints in one’s hands, knees, hips, and spine.
Dr Maloney noted that the percentage of patients who agree to have knee replacement surgery in Southeast Asia is lower than in the United States, but the procedure is slowly gaining acceptance in this region.
Dr Azhar attributed the hesitance for surgery to fear and misperceptions that the whole knee is removed during the procedure, as he stressed that only the surface of the bone is removed and hospital stays for the operation have increasingly grown shorter to less than a week now in Malaysia.
“When I started practice, my average patient was more like your current patient – very disabled – but now, people don’t want to live with that. They don’t want to wait that long,” Dr Maloney said.
Dr Azhar said he is also seeing Malaysians who refuse to delay knee replacement surgery: “We don’t see those really awful cases anymore. Those days, they really wait until they’re bedbound.”
According to Dr Azhar, Malaysian osteoarthritis patients tend to be women. People who are not obese can also be diagnosed with the condition that often worsens over time.
In America, Dr Maloney said, there are more female than male osteoarthritis patients; the average age is 66 to 67 years old.
After knee replacement surgery, patients can resume physical activities like fast walking, hiking, cycling, downhill skiing, or playing golf or tennis.
Although individuals who undergo hip replacement operations can go jogging after the procedure, knee replacement surgery patients tend not to be able to do that, according to Dr Azhar and Dr Maloney, as a replaced hip feels more natural than a replaced knee. Knee replacement surgery patients may also still find it difficult to squat and pray.
“The knee doesn’t always feel like a normal joint — it’s better than the arthritic joint, but not quite as good as your God-given joint,” Dr Azhar said.
Dr Azhar, who used to practice at Universiti Malaya Medical Centre (UMMC), said the waiting list for knee replacement surgery in public hospitals used to be a year even before the Covid-19 pandemic. Elective surgeries across government hospitals were mostly suspended during the past two years of the pandemic.
He also described how orthopaedic surgery has developed over decades in Malaysia – beginning from orthopaedic operations being conducted by general surgeons, to hospitals setting up orthopaedic units, and then to orthopaedic units being divided into sub-specialties, and now to entire hospitals dedicated to single specialties like ALTY.
“Patients are becoming more educated,” Dr Maloney said.
“They seek out specialty care. It’s so easy — everybody knows why you’re here, you can get your X-ray done, therapists are here, inpatient beds right over here. You get familiar with it; you’re not checking into a big 1,000-bed hospital.”
Advances In Orthopaedic Treatment
Dr Maloney said the biggest advance in orthopaedic treatment in the United States is the surge of patients working together with their physician to shorten hospital stays and to accelerate rehabilitation.
He attributed this to a change in surgeons’ operative techniques, with less invasive surgery. In America, orthopaedic patients can even sometimes go home on the same day of their operation.
The second advance is robotics that has shown to increase accuracy in hip and knee replacement. However, Dr Maloney said it is not proven yet whether more accurate operations lead to better outcomes, such as fewer revision surgeries.
Revision surgery is a second procedure that may be needed when the implant in hip and knee replacement operations wears out.
Dr Azhar explained that robots in orthopaedic surgery in Malaysia help the surgeon to make more precise cuts for balanced ligaments, so that the knee can move normally but is also stable enough for support.
“Even if you get the cuts exactly right, sometimes there will be a little tight in flexion. You don’t want it too loose, otherwise your knee will be wobbly. But if there’s a little tight inflection, it won’t bend all the way,” he said.
“With a robot, you can figure out what are the cuts to make, to make it optimal — not too tight, not too loose.”
Dr Maloney said robots enable surgeons to finetune alignments for more personalised knee replacement. However, he stressed that the knee is a complex organ, unlike the hip.
Patients with hip replacements tend to forget about their operation years after, as it feels natural over time, but this is rarer for knee replacement patients whose knee may still not feel completely normal, even though they’re happy with the operation.
“A perfect knee is not as common as a perfect hip,” Dr Maloney said.
He explained that this “perfect” knee – where the patient forgets about having done surgery because the replaced joint feels normal – is an outcome measured by the Forgotten Knee Score.
“Research is going on now – does robotic tech actually improve your forgotten knee score? Does it improve outcomes?”
Dr Azhar noted, however, that ALTY Orthopaedic Hospital tends to receive complicated cases who most likely would not have a good chance of getting a “forgotten” joint to begin with.
Dr Maloney stressed that a “forgotten” knee is just one outcome, and that the progress of patients’ needs to be measured from where they were before they underwent surgery.
The third advance is biologics, although Dr Maloney said the promise of stem cell therapy in orthopaedics has yet to be realised for over a decade.
“A lot of what we take care of is dealing with degenerative tissue — worn out knees, worn out tendons, worn out muscles. We thought stem cells may help to regenerate some of that older worn-out tissue, but it really hasn’t come to fruition.”
He noted, however, that plastic implants have improved since the late 1990s and are much more durable now, lasting for more than two decades without wearing out.
Dr Maloney cited Australian data that showed new plastics reduced the rate for revision surgery in hip replacement at 14 to 16 years from 18 per cent to 6 per cent.
When To Get Knee Replacement Surgery?
Dr Maloney noted that although some say earlier interventions will lead to better outcomes, ALTY Orthopaedic Hospital advises patients to get knee replacement surgery when they feel that they can’t tolerate a bad knee anymore.
He pointed out that in public health care systems where wait lists can extend to more than a year, patients may get pain relief from knee replacement surgery, but they still might not be able to walk if their condition had worsened significantly by the time they underwent the procedure.
“So, I tell patients – you decide when, you weigh the risks and benefits. If you have a complication, you shouldn’t be mad about that because you’re in pretty bad shape to begin with.
“However, don’t wait till you get so sedentary that you can’t move. As we get older, once we lose muscle mass, it’s hard to get it back.”