Consumer pays, consumer risks’:
Florida ‘surgery mill’ plans for Australia
Alarge purple billboard greets travellers at Florida’s Palm Beach International Airport spruiking “World Class Orthopaedic Care”.
“Patient referrals from 50 states & 110 countries,” the back-lit banner reads. “You Deserve The Best Care, Too!”
More than a dozen surgeons are photographed in a row, smiling with their arms crossed – including, on the very end, Australian surgeon Munjed Al Muderis.
The billboard is promoting the Paley Institute, a global clinic selling “highly complex orthopaedic clinical services” around the world.
It is a subsidiary of Tenet, a Wall Street-listed healthcare juggernaut that provides resources to 640 hospitals and clinics across America and reported quarterly profits of $US3.9 billion ($5.94 billion) in April.
The Paley Institute announced in August that Al Muderis was joining its team, a self-styled “orthopaedics powerhouse” which employs 29 surgeons and 310 people to treat patients from more than 100 countries.
It proudly claims that its 15,000 hotel room nights generated a year makes it the world’s largest medical tourism orthopaedic group. Now Al Muderis plans to bring the company to Australia.
“One of my longer-term plans is to bring the Paley Institute to Sydney,” he wrote to doctors in a September letter, obtained by this masthead.
“This vision reflects my ongoing commitment to delivering world-class orthopaedic and reconstructive care locally, and to ensuring Australian patients benefit from the most advanced global surgical innovations.”
Australian surgeons and experts have expressed alarm over these plans, fearful of importing an American-style approach to private sector healthcare of high-pressure sales tactics that drive unnecessary and expensive surgeries.
Those fears echo some of the findings in a Federal Court of Australia judgment in August which found Al Muderis’ surgical practice was unethical and negligent and that he
prioritised fame, money and numbers over the safety and care of his vulnerable patients.
This masthead can also reveal details of several lawsuits against Paley and the Paley Institute in America in which patients complain of invasive, unnecessary and rushed surgeries that have gone wrong, including one on a 10-year-old child who was allegedly permanently disabled and a man who died on the operating table. Al Muderis is not involved in any of those cases.
“If you want corporate American, profit-generating medicine,” said one surgeon working at a major Australian children’s hospital who did not want to be named because the plans had not been made public yet, “this is what the Paley Institute will bring. It’s a corporate medicine approach.”
The Paley Institute has gained global recognition, and celebration in some quarters, for its innovative surgical techniques for children and adults suffering limb deformities.
Dror Paley photographed with Donald Trump and Ben Carson in 2013.
Dror Paley is the face of the company and known globally for “pioneering” limb-lengthening surgery, in which bones are broken and regrown using nails or rods to increase height for medical or cosmetic reasons, including controversially for people with (achondroplasia) dwarfism.
Al Muderis, Paley and the Paley Institute did not respond to requests for comment.
Like Al Muderis, Paley has passionate supporters online and an expansive network with decision-makers. In 2013, he was photographed with now US President Donald Trump and Ben Carson.
The Paley Institute website and social media pages are plastered with glowing patient testimonials (which are legal to provide in America but not in Australia), where Paley is called the “man of miracles” and “bone wizard”.
“When a case seems hopeless and there is no longer any hope, only one name remains: Paley, the last resort, the final hope,” one such testimonial on the website states.
“Children and young people unable to walk or affected by severe deformities regain function and mobility after his surgeries.”
Across press interviews, Paley has railed against bureaucracies preventing innovation in healthcare and is celebrated for inventing medical devices for limb-lengthening.
The Paley Institute has also been the target of several recent medical negligence cases and Paley’s limb-lengthening system was recalled globally in 2021 after patients reported nail corrosion caused metallosis, organ damage and toxicity in the blood stream.
The Australian paediatric surgeon said Paley had done some “incredible work” but warned there is little oversight or long-term research into some of his procedures, which he believes should be performed only in clinical trials.
“The Paley Institute promises everything and operates on everyone,” he said. “It’s so easy to have a kid with a horrible disease and say, ‘We’re going to do this and fix it’.”
Ian Woodruff, president of the medico-political organisation Doctors Reform Society, said importing the Paley Institute could fuel the “huge profits” of Australia’s private healthcare system.
“We need innovation,” he said. “But not in a profit-driven business, not for medicine. Because then [patients] get the kinds of things outlined in court by Al Muderis.”
‘World’s largest’
As Al Muderis has been fighting several lawsuits in Australia – from the failed defamation battle against this masthead to medical negligence cases brought by his patients – he has expanded overseas, opening the Al Muderis Osseointegration Clinic in Abu Dhabi in July in collaboration with the Paley Institute.
At the launch celebration, Paley praised Al Muderis for being “absolutely recognised as the number one in his field”.
“We have become the world’s largest orthopaedic medical tourism centre in the world,” Paley said. “This is such an important technology, and there are so few surgeons doing this and why not get the best?”
Shortly afterwards, on August 8, the Federal Court of Australia delivered the 771-page judgment that found Al Muderis downplayed risks of surgery, made false promises, mistreated staff, had poor patient selection and negligent after-care for a significant cohort of patients.
Two weeks later, the Paley Institute announced on social media that Al Muderis had formally joined the ranks of its Florida operation to “continue pushing the boundaries of what’s possible” in orthopaedics.
As Paley promotes medical tourism and recruits surgeons from around the world, he has also fought his own battles.
Medical negligence lawsuits are not uncommon, particularly in the US, but claims examined by this masthead raise allegations of high-pressure sales tactics and devastating consequences for patients and their families.
In one lawsuit before US courts this year against Paley and other doctors, documents obtained by this masthead allege that botched surgery left a 10-year-old girl with mental pain, scarring, disfigurement, permanent injury, loss of bodily function and “the capacity for enjoyment of life”.
The documents outline the girl’s consultation with Paley on October 31, 2022, when it is alleged he said she needed to undergo a surgical procedure for limb-length discrepancy “NOW” and the parents agreed for Paley to perform the surgery.
But on the operating day, the parents were told another surgeon, Claire Shannon, would conduct the surgery despite not having spoken to or examined the patient.
The parents were informed that Paley would be “popping in” but court documents allege he “did not show up” and the new doctor “failed to appreciate” the child’s anatomy and caused a “life-threatening injury”.
A timeline included in the statement of claim details the child’s alleged post-operative experience, where she woke up with “10/10” pain and was provided fentanyl to doze back to sleep but woke within five minutes again complaining of “10/10” pain.
She was given more rounds of fentanyl, but kept waking up with the same level of “pain and crying”, so was given oxycodone and a muscle relaxant causing her to go back to sleep.
After the surgery, Paley and Shannon flew to Warsaw for “the grand opening” of the Paley European Institute so “were unavailable to care for and/or treat” the child for any surgical complications, according to the documents
The patient was discharged but continued reporting “agonising pain as well as severe cramps”, despite being prescribed Valium then morphine by the Paley Institute before needing further surgery.
The case alleged Paley was negligent because he agreed to “examine, diagnose and treat” the minor, and had a “duty to exercise” with professional standards of care.
“Dr Paley was careless, negligent and breached [his] duty” by failing to plan, treat and perform the surgery, then respond to severe pain complaints, resulting in “significant injuries resulting in permanent disability”, the complaint document filed in US courts states.
Paley and the other defendants have denied the claims. A settlement was reached for some of the allegations, but the matter remains ongoing, according to documents.
Another case was brought against the Paley Institute in October by Mohamed Yakout over a limb-lengthening surgery from 2022 that allegedly went horribly wrong.
Court documents allege the 30-year-old presented with “mild” limb-length discrepancy but was given an unnecessary and “invasive and complex limb-lengthening procedure” without proper investigation, explanation of risks or discussion of conservative alternatives.
The Paley Institute surgeon allegedly failed to diagnose a deep infection until many months after the surgery despite Yakout showing symptoms, the documents state, which caused “permanent and catastrophic” injury, pain and mental anguish after the surgery failed and the hardware was removed.
A third case detailed in court documents was brought against the Paley Institute and other parties in July by Florida resident Sandra Freia. She alleges doctors negligently performed a high-risk and elective spinal surgery on her husband, without proper investigation, which resulted in his death on the operating table on August 7, 2023. The parties deny the claims and the matter is continuing.
A separate Florida-based medical negligence firm this year posted social media advertisements soliciting patients harmed by limb-lengthening procedures performed at the Paley Institute.
The law firm, Freedland Harwin Valori Gander, said it “represents numerous patients of the Paley Institute that have undergone unnecessary or failed surgery”.
“We limit our practice to catastrophic injury and wrongful death cases,” the law firm claims.
The Paley Institute criticised these posts publicly, accusing the firm of “ambulance chaser behaviour”.
This masthead interviewed two lawyers from another US firm, who could not be named for confidentiality reasons, who alleged the Paley Institute is a “surgery mill” where profits influence decisions.
“This is about the consolidation … within the healthcare system to the detriment of patients,” one lawyer said, who could not be named due to client confidentiality.
The lawyer said the Paley Institute is a “symptom of a much bigger problem” in US healthcare, where corporate structures drive unnecessary surgeries and patients suffer physically and financially.
“They’re going to have some patients that are going to get good treatment, but it’s the unnecessary procedures that are being done on patients that’s generating a lot of money for Tenet,” he said. “It’s all about volume. There’s a big incentive to upsell.”
Tenet’s most recently quarterly report states it spun $US2.4 billion in profits from its operations business (out of $US3.4 billion total profit) which included 65,902 surgeries across its network of hospitals.
University of Sydney law health expert Chris Rudge said negligence claims were not necessarily an indicator of poor practice, and even good doctors may face several lawsuits over their career “because surgery is dangerous”.
However, Rudge is concerned about importing US culture and business practices in healthcare.
“You’re effectively importing not just a service but a whole business,” he said. “It’s the American-style consumer pays, consumer risks model.”
‘Toxic chemicals’
Al Muderis has been promoting cosmetic limb-lengthening in Australia this year, described as “booming” in a recent Mamamia article.
He is quoted as claiming the controversial procedure was increasingly popular among women, to address confidence and bullying and improve chances of career success.
“When you look at psychological history, you see a lot of short people get bullied at school,” Al Muderis said. “It’s much harder to bully a taller person.”
Paley has helped refine the procedure by designing new nails to reduce recovery time.
The procedure’s popularity surged this year after the Hollywood film The Materialists featured a main character who underwent the surgery.
The Paley Institute’s website describes Paley as the world’s “most experienced limb-lengthening surgeon” having performed more than 20,000 surgeries over 30 years.
Paley is credited for bringing the Ilizarov method to the west, a Russian technique for increasing height by attaching a metal brace around the limb to pierce wires through the skin to break and regrow bone over several months.
Surgical nails have been an alternative to the Ilizarov method since the 1990s where large nails are inserted into the bone and external remote controls or magnets move the nail externally to cause fractures, eliminating the metal cage and associated infection risks.
Paley invented the Stryde Nail with manufacturer Nuvasive in 2018, which used stainless steel instead of titanium, allowing heavier patients to weight-bear immediately after surgery.
A 2020 research paper by Paley stated 106 patients had been implanted with this system since May 2018, more than half of which were cosmetic.
“Successful outcomes were achieved in all patients,” the paper stated. “There were no issues related to biological incompatibility.”
However, behind the scenes, trouble was brewing.
American patient Alyssa Osos was implanted with the nail in 2018 after which she experienced “heavy menstrual bleeding and reproductive organ pain”, according to court documents, and an ultrasound found a large cyst on her right ovary.
“Three follow-up appointments revealed that Osos suffered from toxic chemicals in her liver, bone damage to her tibia, and chromium toxicity in her blood,” the documents state.
In its defence, Nuvasive argued none of Osos’ “smattering of random facts… are tethered to any legal cause of action” and unsuccessfully tried to get the case thrown out. Nuvasive and Paley did not respond to questions about this case.
The first Stryde nail used in an Australian patient was implanted in June 2019 at Macquarie University Hospital and the Limb Reconstruction Service.
“We look forward to helping many other patients with this emerging technology,” the centre’s website published on 8 July 2019.
The Therapeutic Goods Administration started receiving adverse reports related to the nail from March 2020. A year later it was formally recalled and is no longer used in patients.
There are nails produced by other manufacturers that do not cause these side effects.
The TGA did not recommend removing the Stryde devices, but said pregnant patients or those under 18 years should be monitored and further testing for carcinogens and toxicity would be completed.
There are 11 reports lodged on the TGA’s adverse events database related to the Stryde nail and system between March 2020 and May 2022, with reports describing “findings of significant corrosion”, “metal on metal wear” and “metallosis” – a condition where metal debris causes tissue damage and other problems.
The UK regulator released a notice in January 2021 that claimed the long-term safety of the Stryde devices remains unknown, and the manufacturer had failed to adequately assess for safety.
“Several biological endpoints have not been adequately assessed and others have failed to be considered, including chronic, reproductive and developmental toxicity, and carcinogenicity,” the UK regulator stated.
In a YouTube interview in March 2021 with limb-lengthening influencer Cyborg 4 Life, Paley said the recall was voluntary after a British doctor had reported a patient whose tissue around the implant looked “like a rusted iron”.
“Everyone is freaking out over this but I want to reassure everyone – corrosion from stainless steel is not new,” he said.
“It’s not the first implant... It may be one of the first that’s been recalled. But many implants have corrosion before... I don’t think it’s caused serious harm… the odd patient may get a little symptomatic.”
Healthcare regulators pledged to review August’s Federal Court judgment against Al Muderis, which he is appealing, but no action has been taken, and he retains full operating rights in Australia. According to social media posts, he is currently in Florida but will return to Sydney to see patients in January.
Still, Rudge said Al Muderis’ foray into limb-lengthening procedures raised issues.
“It’s not particularly inspiring to learn that another seemingly risky procedure is the next step for a surgeon who has faced scrutiny.”
Macquarie University Hospital, which is named on Al Muderis’ letter to GPs outlining his Paley Institute plans, said the surgeon remains on “indefinite leave”.
“Macquarie University Hospital has not been informed of plans by Dr Al Muderis to bring the Paley Institute to Sydney,” it said in a statement.
“Quality and safety standards are applied to all procedures at [Macquarie University Hospital], including limb-lengthening and other orthopaedic procedures, and we have nothing to report relating to this type of work.”
Nuvasive and Tenet did not respond to requests for comment.
