Kupas Tuntas Cedera ACL, Operasi Lutut & Robotic Surgery dengan Dr. Kow Ren Yi dari ALTY Hospital

[00:00:00]So then only we can address the subsequent problem. There's no point if you repeat the same mistake and in case you go for a second surgery or in this case a revision surgery and the revision surgery might fail.

[00:00:18][music] [music] I've torn my ACL three times in my life.

[00:00:28]I've had two different surgical techniques. The third tear, my worst one, I chose to leave untreated. Which brings me to today to a very important conversation about not just orthopedics, but something that has been impacting my health for a very long time. My name is Kevin Cho. I'm the co-founder of Metafly, and this is the Metafly podcast. My guest today is Dr. consultant orthopedic and robotic joint surgeon at Alti Orthopedic Hospital in KL. One of Malaysia's first single specialty orthopedic hospitals. Dr. Cow has graduated as a top clinical specialist in the cohort with a masters in orthopedic surgery and he's an active researcher with a growing body of published work on robotic joint surgery.

[00:01:17]He's been an editor at the Malaysian Orthopedic Journal and from everything I have read from his public writing, he's one of the top surgeons and very rare surgeons who actually talks about uh what medicine costs, what a scan isn't need when a scan is not needed, when technology actually helps versus when it [music] is just marketing. So that's honestly why I wanted him to be on the show. And today we're going to be talking about number one, what actually separates a great orthopedic surgeon from a good one. Number two, where robotic surgery genuinely changes outcomes and where it is overhyped.

[00:01:55]Number three, what happens long-term [music] to knees like mine injured, repaired, and sometimes left alone. And the questions every single patient should be asking when they let a surgeon anywhere near their joints. So, Dr. Cow, welcome to the show. Would you mind giving a quick introduction of yourself first?

[00:02:13]>> Hi. Hello. I'm Dr. K from Ali Autoopetic Hospital in Koala Lumpo, Malaysia. I'm one of the robotic surgeons who specializes in hip and knee replacement surgeries. And I mainly treat patients with hip and knee joints problem as well as other joints problem. And my specialty is to help patients with uh knee problems such as cartilage problem, ligament problem as well as muscle problems.

[00:02:41]>> Yeah, thank you very much. First question I want to ask you is most surgeons pick their especially based on something personal. It's mentor, a case moment. [music] What pulled you specifically into joints and orthopedics?

[00:02:54]Okay. So actually uh my experience is almost like yours where I personally experienced uh autoetic problem before.

[00:03:03]Actually I have a fracture uh TBR which is the thigh bone before. Yeah. During my teenage days so that kind of like hooked me towards autotopedic. So since young I'm a bit uh I have some reading on it because me myself experienced that problem and since then I'm more interested to venture into that this field and that got me into the medical school in the first place and in the medical school I already uh have all this exposure to bone and joint diseases and since graduating as a medical doctors I further specializes in autotopedic where I become uh one of the youngest surgeons [music] and also uh because of my mentors who specializes in uh atroplasty which is joint replacement and that furthers enhances my uh interest in terms of uh this field and this is how I end up as aoproplasty surgeons.

[00:04:02]>> So pretty much uh you know uh from [music] an injury that all started. So uh another question I have is you are obviously very busy as a doing your clinical practice um but you're still very deeply involved in research and journal editing. A lot of surgeons drop the academic stuff and they when they go private is there a reason why you continue doing that?

[00:04:26]>> Actually uh I think that clinical practice is very important but your clinical practice all boils down to the underlying knowledge behind it. So whenever you practice something for example when I'm doing a surgery you need to have deep understanding in terms of the knowledge in terms of the skills as well as the knowhow and most importantly the physiology and underlying diseases behind it before you uh address the underlying problem. So this is why I actively involved in academic in terms of teaching the undergraduate as well as those uh incoming upcoming autotopedic surgeons as well as uh actively involved in researchers where I'm uh venturing myself into getting the knowledge as well as getting to know all the diseases because what we are dealing with the diseases is uh only 20% of them are known the other 80% percents which is largely unders surface are still unknown. So there are still a lot of things unknown in medical fields especially in toopenics. So that's why I'm actively involved in researches where we get to know more about the diseases and that is how we able to help our patient more.

[00:05:43]>> Okay. Okay. And say if I am a patient that is coming in for knee or hip surgery, what is one question that I really should ask that uh often is overlooked?

[00:05:54]So actually uh it depends on the patient's profile. So if you're looking from uh younger perspective when we say young that means is 50 years and below then we are looking at joint preserving surgeries. And if we are talking about a patient who is 50 years and above uh which is considered elderly then we are considering those uh for replacement surgeries. So these are two different profile patients for for younger patients mainly they are having ligament issues like yourself and meniscus issues and also cartilage issues. So when we examine the patients we need to know what is the underlying problem behind that knee pain because most of the patients come with the knee pain. So we need to know what causes the knee pain in the first place and by addressing the underlying cause then only we can address the problem at it growth cause and for elderly patients 50 and above then we are talking about the disease progression at what stage they present with. So if it's a mild to moderate stage so most of the time we try to do joint preserving uh alternative but for those with very severe deformities that is affecting the their activities of uh daily living then we are talking about joint replacement surgeries. So um robotic surgery is marketed very very frequently like uh if anyone has got gotten off the plane from Pinang or KL they would see robotic surgery posters pretty much everywhere and nowadays if you go into every single hospital website um they have the big words robotic everywhere. So I want to ask you you know a question uh so cut food to all the marketing right when does a robotic surgery genuinely change the outcome and where does it where is it honestly overhyped?

[00:07:48]So actually from my point of view as a surgeon I think that robotic surgery definitely helps surgeons but robotic surgery is actually a tool where it assists the surgeon but not replacing the surgeons. It comes in it depends on how the surgeon uses the robotic system.

[00:08:07]So it's just like a knife for a surgeon.

[00:08:10]If you use it correctly, it can create a very good scar and uh you can perform a perfect surgeries. But if you are not skilled enough, you might even cut the wrong things. So in that sense uh robotics actually do help uh the surgeons and assist the surgeons but it also provide a false narrative that the surgery will be perfect. So it all boils down to the person behind the robotic system which is the surgeon itself. So if you know a surgeons who are experienced in it then you might get a good outcome. If not then it might actually give you a sense of of hope.

[00:08:51]How about yourself? How often do you do robotic versus like not and in what situations would you be choosing robotic?

[00:08:58]>> So for myself, I'm trained in robotic surgeries. So uh I uses multiple system.

[00:09:03]In fact, I'm trained in four systems of robots [music] and I that's how I know what are the pro and cons of each robots and depending on the patient profile, I uses different robots to help my patients. So obviously uh when I'm uh using it a lot actually I am I've done more than 300 cases uh on my own uh in terms of the surgeries using robotic systems. So that's how I gather my experience and help my patients.

[00:09:35]>> Okay. And I have another question about uh Alti. So Alti is a very very different hospital compared to everyone else. It's a single specialty hospital which means if I uh understand correctly as I saw on your website um that means eight orthopedic surgeons under one roof with a weekly multid-disciplinary case reviews [music] with uh all the different practice like anesthesiologists, physios, cardiologists and most private surgery happens in multipety hospitals when surgeons are solo operators. [music] from the patient side, what does that structural difference actually mean for patient outcomes?

[00:10:13]>> Okay, so uh actually the single specialty hospital uh concept actually help our patients more because if you look at it, our patients are mostly of the same demographic with the same kind of problem and most of them they undergone the same type of surgeries. So it helps in terms of our supporting staff to know them better in terms of the disease progression as well as how to do their rehabilitation uh protocol.

[00:10:42]So for example for a physiotherapist in other hospital they are being exposed to different kind of diseases for example heart disease, lung disease, abdominal problem, upper limb and lower limb or head and hand and legs problem. So they need to know everything but none of them they are expert in certain field.

[00:11:02]Whereas for our hospital with a single specialty concept our physiotherapist they are trained to do that simple one task only and which is to help autoopedic uh patients recover. So in that sense our patients will get a specialized care not only from the surgeons but also from our supporting staff in terms of the nurses as well as the physotherapist and that really helps our patients in terms of their outcome.

[00:11:30]So uh I want to get personal here. So my experience is I've torn my ACL and three times and my miniscus once. So it happened like 2017 once on my right leg and 2020 on my left. And the third time I tore it was just uh two three years ago. Yeah. 2023 October specifically. Um so it's uh obviously you know very very um painful to go through these surgeries. When is it uh when would you recommend a patient to undergo surgery and when would you recommend the patient like not to do an ACL surgery?

[00:12:06]>> So when we encounter problem like this we are talking about revision surgeries.

[00:12:10]So first of all I would like to identify what causes it to fail in the first place. So that is very important. You need to under understand what causes the P4 in the first place. So then only we can address the subsequent problem because there's no point if you repeat the same mistake and in case you go for a second surgery in this case a revision surgery and the revision surgery might fail. So first of all you need to understand what causes it to fail in the first bit. Is it uh too fast in terms of the rehabilitation protocol? Is it because of the graph size uh that is in adequate or is it because uh the way of mechanical alignment is being uh adjusted that is being uh faulty. So these are all the factors that need to be addressed uh before we embark on the revision surgery. Okay. So after we have identified the underlying problem then we talk about the subsequent solutions.

[00:13:09]So in your case in a young patient like you normally we try to preserve whatever native structures that is in this case the ligament which is the anterior crucet ligament ACL. So why is it important? This is because ACL in terms of the maintaining the knee stability.

[00:13:27]So when the ACL is ruptured, your knee lost the the stability and that causes the knee to be unstable. And when the knee is unstable, it causes two things.

[00:13:38]One, when it's move about every time you walk or every time you run, it causes damages to the surrounding structures and especially your meniscus as well as your cartilage. And over time this uh degenerative uh tear or the degenerative uh problem can compound over time and causes early osteoarthritis.

[00:14:02]And this is what we are trying to prevent in the first place. So in your case uh first of all we need to identify the underlying root cause. Second we need to examine your condition whether there are any associated injuries in the first place and in this case maniscus and cartilage. And thirdly, after we have uh examined clinically as well as uh performed my MRI to evaluate radiologically, then we'll talk about the treatment which is revision surgery.

[00:14:31]So revision surgery normally we'll do the ACL reconstruction but in this case is not using your own graph which is your own body uh tendon. This time we will use a allograph where we harvest from uh normally the dead bodies to replace your ACL and at the same time we address whatever surrounding structures that are being damaged in the first place.

[00:14:56]>> H oh so the graph doesn't need to come from my own body. It could be come from coming from somewhere else. Can you explain that? Because uh for so long I thought it was only from hamstring or my kneecap. I didn't know I I can skip that part.

[00:15:11]>> So, uh actually ACL uh when it's being ruptured, we normally do a reconstruction surgery. Reconstruction meaning we replace the ACL with something new and in this case we have a few graph options. So graph is something that we replace the ACL and the graph can come from a few sources. One is the autograph which is what we harvest from your own body and the autograph can be from the patella tendon or from the hamstring tendon. Okay. And these are the autograph which is from your own body. Second one is allograph. Yeah. So all graph is uh something that we harvest from other people's uh in this case bodies and by using that graph we replace uh whatever uh autograph cannot provide and in this case we already exhausted all the options so we need to use allograph. There are another alternative which is uh synthetic one.

[00:16:06]So in this case uh it's a biobrace and biobrace is normally used in combination with autograph and in this case we use it uh normally in patient where the graph size is inadequate. So just for your information generally we wanted an 8 mm kind of a size of graph. So let's say when we harvest your own hamstring graph or patella tendon graph we find that the size is inadequate. In that case we'll add the biob brace to increase the diameter of the graph size because if the graph size is inadequate it run the risk of failing. So that might be one of the cause that you have a failure of ACR reconstruction in the first place. So I hope that this uh addresses [music] your point.

[00:16:51]>> Yeah. Yeah. Absolutely. And uh say for example, if I look 20, 30 years down the road, uh someone like me who has torn an ACL three times, left one untreated, what does my knee look like when I'm 55?

[00:17:07]At 55 um or 65, like more importantly, is there anything I can do right now as a 32 year old to change uh that trajectory or is it quite necessary for me to do a surgery? Okay. So, uh we need to look at two from two perspective. So, the first one is when you have the first injury. So, you already develop the risk factor. So, the first injury is an insult to your knee. So whatever damages uh has been done and subsequently when you undergo the surgery irrespective of how perfect your surgeries uh is let's say you end up with a perfect condition 100% return to sports everything the first insult itself it run the risk of you uh getting the osteoarthritis uh in the later years especially in the 50s.

[00:17:58]>> What is a osteoarthritis? Osteoarthritis is actually a degeneration of the knee joint where your cartilage has already worn off in terms of the uh cartilage on the thigh bone as well as the shin bone area. So this is very common in elderly population especially for those with age 55 and above. So up to onethird of them will develop osteoarthritis and in your case because of the initial insult you are your risk of developing this is even higher. So that's the first perspective.

[00:18:34]>> So by performing the surgery you are able to reduce the risk to a bare minimum. Okay I'll bet no up to zero but still we reduce the risk. But now when you have another second uh insult in in the case of uh ACL rupture then your wrists are being compounded and if you left it uh untreated so your knee become unstable and just now we talked about unstable knee will cause damages to the surrounding structures especially the meniscus as well as the cartilage and your risk of developing osteoarthritis is even higher. So this is what we wanted to avoid and we want to delay the uh knee from getting into the osteoarthritic state as much possible >> because when you reach that stage especially stage three to stage four then we are talking about replacement surgery.

[00:19:30]>> What are three questions that someone should be asking a orthopedic surgeon if they're doing a knee replacement or a hip replacement?

[00:19:39]So the first thing uh I would like to them to ask is the whether there's any alternative. So a surgeon who doesn't offer any other alternative doesn't know the uh the the problem well. So you need to know what are the spectrum of uh treatment options. Okay. Starting from non-surgical to minimally invasive up to the most invasive one. So when you know the spectrum then only you can apply that to the patients depending on the stage of the disease. Okay. Secondly, uh you need to ask like what are the uh pro and cons of each. So this will be very important in terms of deciding which one uh which surgeries or which treatment plans is the most stable for that patients because at the end of the day each patients is different depending on his his or her uh medical conditions his or her activity or level and the expectation. So when you are able to assess this and only then only you can uh use the treatment plan on the patients. And thirdly I would like to ask whether the surgeons has performed the similar condition similar procedure before and whether there are any uh successful stories to share. So if you have personally done it many times obviously there are a few uh case series or case examples that can show to the patient so that they know what to expect when they undergo the surgery.

[00:21:08]>> I think a lot of doctors would say that they have done it before. Yeah. Yeah.

[00:21:12]How do you tell between someone who has done it a lot before and is an expert versus someone who is you know doing similar surgeries but not an expert in doing the particular surgery that the patient is looking for. So this one we can uh get from two sources. The first one is obviously from internet. When you just type the name of that surgeon in then if that surgeon is uh well known among the world and he or she is uh reputable among their fraternities then obviously uh he or she is surgeons to be uh known as expert. Okay. The second thing is when you do a consultation with the surgeon, the surgeon are able to show you his or her patients and how well they do it. So for example, when I'm doing my consultation, this is how I will consult my patient and show them.

[00:22:04]This is how I will show. So in AI autobedic hospital this is how I do the surgery and the alignment technique that I will do for my patients and the a few examples of how my patients perform after the surgery.

[00:22:24]So when you are able to show with the real life example that give the patients more confidence in undergoing these kind of surgeries.

[00:22:35]>> So you have uh quite a lot of displays here. Is there anything you want to highlight here?

[00:22:40]>> Okay. So uh when we talk about knee replacement a lot of people they only talk about total knee replacement. So this is totally knee replacement where we replace the whole thigh bone and the shin bone. Okay, this one is indicated when the cartilage wear and tear or cartilage damages has already involved all compartments of the knee joint.

[00:23:03]Okay, actually a lot of people don't know that they are such what we call joint preserving surgeries where we replace only half of the knee joint. So this is the model of partial knee replacement where we replace only half of the knee joint because when we do the surgery actually we found that most of our patients their cartilage wear is only located at the inner side of the knee joint and the outer joint 90% of the time they remains intact. So if you do the total knee replacement you are replacing the normal cartilage on the outer aspect. So why is it uh important to do partial knee replacement instead of a total knee replacement? This is because when we do a partial knee replacement, we are able to preserve all the ligaments and the most important thing is to preserve the ACL. So by preserving the ACL and also the PCL we are able to retain all the stability of the joint without sacrificing all the uh intact structures. So why a lot of patient don't know about this partial knee replacement is because even doctor itself most of them they don't know how to do this. So they'll just skip this treatment. They'll ask the patient to do injection uh multiple times in the knee joint until the knee joint becomes so severe that they'll do the uh totally knee replacement. So they skip this stage all together because they don't know how to do. So this is one of the advantage of uh single specialty hospital where all of our joint surgeons they are specializing in joint replacement. they are able to do this uh partially knee replacement and this is how we uh get the patient back to normal working as soon as possible. In fact those patient who have done partially knee replacement 95% of them can be can walk within the same day or the next day. I want to ask you a question about stem cells. So I've heard a lot of people doing surgeries and then going to Thailand or going to uh some other countries to do stem cells. So they inject themselves and where they did their surgery uh just hoping that they can get healed quicker. Do you have any opinions on uh on on doing that?

[00:25:28]>> Yes. [clears throat] So the stem cells actually helps but you need to know what is the underlying basis behind that. So for all the treatments you need to know what is the underlying basis. So and not just okay when the patient have pain just prescribe medication without knowing what is the underlying uh issues behind it. So in this case we are looking at two uh cohort of patients.

[00:25:53]The first one is the young patients and the second cohort is the elderly patients. So for young patient like we discussed earlier we try to preserve all the native structures back to normal. So this is where all these uh stem cells PRP PRSV stand for platelet rich plasma and uh these are the two uh treatments that are rehabilitative and also regenerative in nature where it helps the uh joint structures to regrow back.

[00:26:24]Okay. So actually how they regrow back is by stimulating inflammation.

[00:26:30]So by stimulating inflammation it recovers and regenerate the cartilage.

[00:26:36]Okay. So this is applicable for younger patients. Whereas for older patient especially those 55 and above this is actually not applicable because their metabolism has slower and the regenerative properties has been much lower compared to the uh younger populations. So that's why PRP, stem cells, protootherapy, all these are not very effective uh in elderly population.

[00:27:07]So we need to know how and what causes the problem in the first place whether is uh trauma or ACL tear maniscus tear in younger patient or cartilage wear osteoarthritis in elderly patients. So two type of co two type of uh two different type of co patients require two different uh interventions. So just to answer your questions yes stem cells uh is effective but only effective in certain patients where you have chosen it for those who are indicated and not just blank gladly given to all the patients and normally stem cell will not be effective in the elderly population.

[00:27:52]>> Okay. So I know you still do quite a lot of research in journaling. Um can you tell us a tiny bit more about the research that uh that you're particularly interested in?

[00:28:02]>> So I'm mainly uh involved in uh research where we are dealing with hip and knee diseases uh specifically uh for knee diseases. So I'm me myself are one of the members of a group where we are analyzing the knee phenotypes as well as uh how robotic surgeries helps in terms of our uh patient recovery and particularly uh I'm interested and actively involved in analyzing uh how the different alignments affect uh the patient's outcome uh after the knee replacement and from My initial results we found that those who have undergone chynatic alignment they perform better especially in the short term uh they have less pain they recover faster and they feel more natural after the surgery >> and uh looking 5 years ahead what's coming in orthopedics that most patients don't know about yet and uh what should people be consider uh what should people who are considering surgery today know about before they come back.

[00:29:12]>> Actually, I am quite uh hopeful about the future because of the advancement of technology. So, uh recently you have heard about the obesity treatment where they have this kind of injection and oral therapy to help with the obesity in terms of the weight control. So weight control is very important in uh this kind of this population cohort where when you reduce the weight it reduces the stress and forces transmitted through the hip and knee joint. So in that sense it helps in terms of their recovery. In fact some of them uh with osteoarthritis they remains asymptomatic that means they have no longer feeling pain after they have reduced the weight.

[00:29:58]Okay. So that's one thing uh which is quite promising. The other thing is uh in terms of the supplementation. So when we talk about supplements a lot of people they only focus on all this chondroin uh and then glucosamines.

[00:30:15]Actually these are all the building blocks for the cartilage regeneration but actually they are not that helpful whenever the osteoarthritis already develop but a lot of people don't know is uh what happened it in the first place what triggered the inflammation and what triggered the osteoarthritis in the first place and early studies found that actually we do have uh some role in terms of the probiotics in our gut flora So this one is still in the early stage.

[00:30:47]Uh but now we are venturing into preventive medicine where we are trying to prevent the osteoarthritis from happening and early studies uh showed to pointing towards this kind of uh gut flora and how probiotic uh avoid inflammation in the first place. So this one is I think you can just put in but just now when I talk about the partially when we do surgeries.

[00:31:13]Yeah. So these are the stages of uh osteoarthritis from grade 1, grade three, grade four and then these are the difference in terms of uh total versus pass replacement.

[00:31:25][snorts] And for cartilage wear and tear most of the time when we do the surgery the wear is located on the inner side. The outer side cartilage remains uh intact.

[00:31:41]So that's why for this kind of patients uh partially is indicated.

[00:31:48]So this is and then how robotic systems helps in terms of uh our surgeries uh we are able to get the accuracy up to 0.0 0 mm in terms of the bone cut >> because how we do the bone cut actually uh determine where the implant sits in terms of the metallic implant how it sits depends on how we cut the bone.

[00:32:13]Yeah. So if we are able to do it uh with a very accurate bone cut then it reduces multiple trial of bone cut and that reduces a lot of uh soft tissue trauma.

[00:32:28]Okay.

[00:32:31]And then this is another example of partially knee replacement where on an X-ray it shows maybe like grade two to grade three but actually when we do the surgery we notice that the cartilage wear is uh almost grade four where the cartilage worn is uh almost total and up to the bare bone already. So that's why uh with this kind of uh cartilage wear all the supplementation pain medic control and also injection will not help and this is why we perform the partion replacement where we replace the uh catilage test have been worn off. Okay.

[00:33:14]Yeah. So actually uh when I use uh robotic system to do my total knee replacement, I actually practices uh chyntatic knee alignment. So what [snorts] kynatic knee alignment is uh we replace the knee joint based on the patient's native uh knee anatomy. So normally when we do uh total knee replacement for conventional surgeons normally they practice mechanical alignment technique. So what is the difference in terms of mechanical element as well as chynatic? So mechanical alignments it reto the joint back into 90 90° which is 90° at the thigh bone 90° at the shin bone. So that in that sense you get a very straight knee whereas for kyatic knee alignment technique we restore back based on the patient's native anatomy. So based on studies we have found that 98% of the population they do not have this what we call 9090 degree uh knee alignment. So 98% of them they have a bit of variation. So that's why after knee replacement a lot of them they have a lot of pain and after the surgery even though they are able to return to function like walking up and downstairs but they don't feel natural in terms of their uh knee movement. So by performing the chynatic knee alignment we are able to uh get the patients to walk faster able to reduce the pain after the surgery because of less tissue stretches and after the surgery normally they will feel more natural because we didn't alter the patient's uh native anatomy.

[00:35:01]>> Dr. Cal thank you very much. I came into this conversation with my knees in mind and uh now I'm leaving with a much better understanding of what it means to do a knee surgery and uh what the next 20 years is going to look like for me.

[00:35:15]So for anyone who is listening who wants to learn more about Dr. Cow's work, he's at Alti Orthopedic Hospital in Koala Lumpur. I'll link I'll link everything in the show notes. And if you took something away from today's conversation, if you're in that group of people who have been putting off a joint consult like myself or researching surgeons for a family member, this is exactly what Medifi exists for. We don't match patients to hospitals. We match patients to the right surgeon for their specific case. And if that is you, come find us at metify.ai.

[00:35:48]Thank you for listening. Until next time, don't forget [music] to like, comment, and subscribe.