The pelvic x-ray shown belongs to one of Dr Samuel Hailu’s patients for whom he did bilateral total hip replacement for bilateral end stage hip disease.

[Ethiopian Herald] What about economic factors?

[Dr Samuel Hailu] Hip replacement surgery is one of the most cost-effective surgeries the world has seen in the century. The benefits and cost-effectiveness of hip replacement surgery can be compared to cataract surgery. When someone undergoes cataract surgery, one will be able to regain eye vision immediately and can be back to work in a short period of time. The same is true with hip replacement. Someone who was crippled, dysfunctional, and dependent on others for their activities of daily living, often wheelchair-bound due to a hip joint problem, will start to walk again and get back to work and become economically active. It is a very successful and life-transforming surgery, and that is why it is sometimes called the “surgery of the century”.

Yes, it is a demanding surgery economically in terms of infrastructure and equipment needed, as one should follow international standards. It demands a well-trained, skilled, and high-volume surgeon for the best possible outcome. Many studies have shown that the outcome is not the same when done by a sub-specialist as compared to a general orthopedic surgeon – comparing an orthopedist who does replacements once in a while vs. someone who does these surgeries regularly. The operating room is another critical factor as it should follow international standards, staying clean, and be continually maintained. It is also a demanding supply chain management, keeping the stock of prostheses needed. This is complicated by a shortage of hard currency in our country.

[Ethiopian Herald] What are the replacement materials made of?

[Dr Samuel Hailu] Replacement prostheses (parts) are made of different types of materials. The basic total hip replacement has four parts (acetabular shell, liner, femoral stem, and head) while the basic total knee has three components (femoral and tibial component with a special plastic articular surface in between). The metal parts are made of special high-strength alloys, titanium alloys, and stainless steel. The articulating parts are made to be durable and friction-resistant. Depending on the activity level and age of the patient, we use either metal on plastic, or ceramic on plastic, or ceramic on ceramic articulating parts. The plastic we use is a special type of plastic that is made to last a long time and is a highly cross-linked ultra-high molecular weight polyethylene material. While the ceramic is primarily made of aluminum and it can be zirconia toughened alumina. The damaged ball of the thigh bone (femoral head) is removed along with the preparation of the socket of the hip joint (acetabulum reaming), then both are replaced.

[Ethiopian Herald] Can we produce them locally?

[Dr Samuel Hailu] The short answer is-not at the moment. Producing them locally is not straightforward and is quite demanding, but as things progress and our technology grow there is no reason why we should not be able to produce these in Ethiopia. Even countries like India are known for making various orthopedic implants and materials, however, the quality of these does not meet the standard of the prostheses we use. The quality standards of the parts we used for joint replacement are very specific and quite critical for the longevity of the implant. The American or European brands we use here lasts 25 years and more while the Indian brands might not last more than 5 years. This suggests the Indian parts will be more than fourfold expensive in the long run, mainly because of the articulating parts, which require a meticulous process and fine work. Repeat surgery for a failed joint replacement is much more expensive and the outcome is not as rewarding as a well-done initial replacement with good material.

So, locally, the first materials we need to start manufacturing should be materials for the fixation of broken bones, as these materials are only needed while the fracture is healing. Once a fracture is healed, we no longer rely on the implant.

[Ethiopian Herald] How satisfied are those who attend the surgery here?

[Dr Samuel Hailu] Joint replacement is not just surgery; it needs good rapport between the surgeon and the patient both in the selection process of the surgery as well as during recovery and the follow-up period. Post-operative care is as important as the surgery itself and requires very close interaction with the surgeon and the patient. Patients have been missing this when they get their surgery done by traveling abroad or by visiting missionary doctors.

We need to closely follow our patients and the follow-up should be lifelong. This is an artificial joint and hence we need to see the patients continually, looking for specific things and recognize a possible issue early. This is an advantage for our patients who can have easy access to their surgeons, but which are unavailable to those who have traveled abroad or had their surgery performed by a visiting foreign doctor. This is a lifelong commitment for the surgeon as well as the patients.

Ethiopians now have that. They can be followed closely, receiving quality surgery with standard materials, and, yes, most are highly satisfied with quick recovery, while getting explanations and the surgery speaking their mother tongue, in addition to receiving the care of the relatives and close friends. One thing to note here is, each patient is peculiar in their way and each surgery, rehabilitation, and outcome is also dependent on a lot of factors and peculiar. Hence, the importance of individualized care, patient-specific physiotherapy, and close follow up is quite important and instrumental for the best outcome.

[Ethiopian Herald] What if many patients come looking for the service can you cater to the demand?

[Dr Samuel Hailu] Over the last five years, we have developed the means to expand capacity locally, both in human power as well as supply chain. For instance, we can do this minimally invasive hip replacement with special devices that allow this to be done efficiently; it is also very effective and can be done in less than an hour. This way we can do as many as 10 surgeries per day by purchasing more materials. However, there are many constraints, especially affordability for the average Ethiopian.

Unlike other countries where the insurance system is well established, most of our patients are expected to pay out-of-pocket. Had there been a well-established insurance system in Ethiopia, this could have been an accessible procedure to the many who are disabled with a curable problem. They could be contributing to the economic growth of the nation instead of staying dependent on others.

[Ethiopian Herald] How many people have you retained from traveling abroad?

[Dr Samuel Hailu] Many people do not yet know the availability of the surgery here. Many patients tell me they had sought care in various hospitals and clinics before someone eventually directed them to our center. For instance, in the Southern part of Ethiopia, there is a missionary hospital where an American surgeon has been doing this surgery. Patients from Addis Ababa would go there not knowing that the service is available here, and would subsequently be referred back to us in Addis. We are working on creating awareness of this problem and how to get appropriate care.

I also remember a patient who went to South Africa and was told by the South African surgeon there “Why do you come here when there is Dr. Sami in Ethiopia.” They came back to me for surgery, had their hip taken care of, and are happy. There are others also who were first treated in India and Thailand that came for corrective repeat surgery required because of some complications.

I had patients who underwent one side of the surgery abroad and the other here, and they see the difference and tell me their stories, such as how much they suffered, the long recovery, using crutches for more than 3 months after one side hip replacement in India, but after minimally invasive hip replacement done here, they were able to go without support in a few days to weeks.

So far, we are able to retain about 10-20 percent of those who would have otherwise traveled abroad. We can expand the capacity following the demand, but still many people go abroad, not knowing the surgery can be provided here.

[Ethiopian Herald] Can we serve those who come from abroad?

[Dr Samuel Hailu] Yes, I have patients that come to me from Somalia, Djibouti, South Sudan. I have also operated Ethiopian patients that live abroad who come here to get joint replacements done at home with their family support. It looks like a paradox when many people travel abroad for care, but others travel from abroad to be operated here at home. Our goal is to make Ethiopia a center of excellence for joint replacement of East Africa.

What should we do to further improve the delivery of the service in Ethiopia?

We should improve the system to import medical materials and equipment. Foreign exchange should be given priority to import the materials needed for such services. We can save foreign currency when making such services readily available rather than having patients go abroad.

We should create a way to have a better health coverage system nationwide. Our insurance system should better accommodate coverage for the majority of our nation. At this time, only a limited number of company employees have insurance. Even as a physician, if I get sick, no insurance will provide care. We have seen this happen to our colleagues.

We should revisit our referral system of sending patients abroad when such services are rendered locally with quality. Referrals for specific surgeries abroad should only be offered by a sub-specialist in the field. We should not allow the foreign currency to be wasted.

In government hospitals, we cannot depend on donations for such services. We need to establish a system where services. can be provided, by covering all costs within Ethiopia. Many things can be done to keep our nation from disability and support the economy again. These services can be rendered in public hospitals in a self-sufficient manner at a very affordable cost to patients. We need the system to accommodate the change to make this a reality.

[Ethiopian Herald] What about developing human resources?

[Dr Samuel Hailu] We provide the basic teaching for our specializing doctors, and we are also providing subspecialty fellowship training for orthopedic surgeons for care of complex orthopedic trauma at the Black Lion Specialized Hospital, Addis Ababa University. To start joint replacement as a sub-specialty, we must not rely on a donation-based provision of joint replacement components; we need a sustained supply of materials before we start sub-specialty training. We are not yet able to provide knee replacement in any of the government hospitals, and can only provide a basic primary hip replacement at Black Lion Hospital, based on donations arranged by Dr. Alexis Falicov from the USA, mentioned above. This will not be adequate for joint replacement sub-specialty training.

[Ethiopian Herald] What do you feel when you see the surgery being delivered in Ethiopia capably?

[Dr Samuel Hailu] I am proud that we are able to provide the services by all-Ethiopian teams over the last 5 years. It is quite rewarding to see someone who was housebound and disabled return to independence. We are providing training to both Ethiopians and other African surgeons on complex orthopedic surgeries.

We have so far trained Orthopedic surgeons on complex pelvic and Acetabulum fracture fixation from South Sudan and Nigeria. We have others coming from Malawi, Tanzania, Kenya, and other parts of Africa. I have also traveled to various parts of Africa, the Middle East, India, Europe, and, yearly to the USA to share my experience on these complex surgeries.

We need to do better to create awareness on the type of quality health care services being provided in the country so people do not go through unnecessary trouble to go abroad for the same type of services. Agents who send patients abroad should do so in an ethical manner for those services only that are not provided in Ethiopia.

Joint replacement surgery is not a simple one-time event; we have seen patients that come to us after undergoing surgery abroad with undesirable outcomes, both from the index surgery as well as a lack of postoperative care. The surgery needs close monitoring and in-person follow-up by the primary surgeon. It is the surgeon that knows what he has done and it should be the surgeon that follows the patients.

Thank you for the opportunity given to me to share my experience in the field of joint replacement in Ethiopia!

By Zekarias Woldemariam
[Posted on Sep 05, 2020 by Ethiopian Herald]

6 thoughts on “Orthopedic Surgeon Brings Surgery of the Century to Ethiopia: Part 2”

  1. I feel so proud in having such a golden orthopaedist. I had an uncle having done hip treatment, not a replacement, but another type of surgery and can walk only with the supports.

    Reply
    • Dear Alayu,
      Thank you!
      Hip fractures are difficult to treat. The outcomes are variable. It is good to learn he can get around even if it is with support. Our main goal in treating these injuries is to keep the elderly out of bed as much as possible.
      Regards,
      Samuel

      Reply
  2. Dr. Sami,
    About 2 months ago, my husband Brhane G/Kidan had a broken hip surgery by you. Thank you for being there at critical time when we needed you most in treating both the medical side and our worries. Especially answering my children’s continuous questions arising from concern for their dad with compassion. You are the most understanding, competent and best doctor I ever dealt with. Thank you so much for being with us at the right time and place.
    Genet Tadesse Haile

    Reply

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