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Orthopaedics Usual and unsuual

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Describes the thirty years experience of an orthopaedic surgeon whose career has seen many ups and downs. Invaluable lessons in orthopaedics.

Published in: Health & Medicine
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Orthopaedics Usual and unsuual

  1. 1. Orthopaedics, usual and unusual  Thirty years of experience Dr L.Prakash M.S., M.Ch (orth) Liverpool
  2. 2. My life as an orthopaedic surgeon went through three phases 1985 to 2001: The Surgeon
  3. 3. My life as an orthopaedic surgeon went through three phases 2002 to 2015 April: The learner
  4. 4. My life as an orthopaedic surgeon went through three phases May 2015 to present: The teacher and practitioner
  5. 5. First Phase  Routine beginnings. M.S., MCh etc,  Training under greats like Freeman, Muller, Goodfellow, Monk, Wroblowski, Boyle, Klenerman, Owen, Taylor etc.  Career as a Trauma and Joint replacement surgeon.
  6. 6. During this phase, I was: A prolific surgeon, Innovator, and wrote four books and conducted 80 workshops.
  7. 7. During this phase, I operated in 106 operation theaters across the country and abroad, demonstrating surgical techniques and was the Secretary and Vice President of Indian Orthopaedic Association.
  8. 8. During this phase, VERY OCCASIONALLY TREATED A FRACTURE CONSERVATIVELY
  9. 9. Second Phase:  Dramatic change in my life.  From an orthopaedic surgeon, I became a life convict prisoner in the dreaded Chennai Central Prison.
  10. 10. Life convict in Central prison Chennai  Accused of grave charges and convicted of offences that I would never even imagine committing, I was sentenced to numerous terms of imprisonment including life imprisonment.
  11. 11. 13 YEARS IN PRISON DESPITE BEING TOTALLY INNOCENT
  12. 12. I spent 13 years as a prisoner, eight as an under trial and seven as a life convict, under difficult, desperate and depressing circumstances.
  13. 13. This is my experience of practicing orthopaedics in those times, with limited or no facilities, treating desperate patients who had nowhere else to go.
  14. 14. You are not allowed to carry X-Rays out of the prison, and so I have no pictures of fractures, but I maintained meticulous records, on which this paper is based
  15. 15. I also traced the X-Rays that I could lay hands on and the pencil drawings are shown herewith.
  16. 16. Period spent in the prison 4831 days Total number of patients seen 11,248 0 500 1000 1500 2000 2500 3000 Patients 2171 702 648 3 2670 1121 87 Treatments Conservative treatment including skeletal traction Manipulations with or without sedation Suturing and minor surgery Implant removal under local anesthesia Intra-articular injections Local steroid injection Referral to other centers
  17. 17. Orthopaedic treatments  Conservative treatment including skeletal traction 2171  Manipulations with or without sedation 702  Suturing and minor surgery 648  Implant removal under local anesthesia 3  Intra-articular injections 2670  Local steroid injection 1121  Referral to other centers 87
  18. 18. Surgeries inside the prison:  Suturing  Abscess drainage  Removal of thorns and foreign bodies  Skeletal traction  Implant removal
  19. 19. UNIQUENESS ABOUT PRACTICING ORTHOPAEDICS IN PRISON  No X-ray machine in prison hospital  No POP bandages or traction items  No Lignocaine or local anesthesia  No anesthetic drugs  No sedatives or tranquilizers  Limited suture material  No other facilities.
  20. 20. UNIQUENESS ABOUT PRACTICING ORTHOPAEDICS IN PRISON  If I was taken out of my cell, I had to treat the patients through the bars.  If warders during night rounds wanted consultations, I would be on this side of the bars
  21. 21. Doing a blood sugar through prison bars is easy.
  22. 22. Taking BP a little tricky.
  23. 23. Injections are almost a circus or yoga for both doctor and patient
  24. 24. NOW JUST IMAGINE REDUCING A DISLOCATED SHOULDER THROUGH THE PRISON BARS!! IT IS INDEED UNFORTUNATE THAT I SIMPLY COULD NOT HAVE TAKEN ANY PICTURES!!
  25. 25. INTERESTING PROBLEMS The torn ear
  26. 26. Using thin nylon sutures, he was operated under local anesthesia on the jailor’s office table
  27. 27. Shoulder dislocations  Total 89  Anterior 83  Posterior 6  Associated with fractures 9 Anterior dislocations Posterior dislocations Associated with fractures 83 6 9 Patients Patients
  28. 28.  This my modified Kocher’s method. No huffing and puffing. Only precise application of biomechanics.  Patient needs to be relaxed with or without tranquilizers.
  29. 29. Wait for three minutes by the clock (this is the most important step)
  30. 30. Adduction slowly and gently.
  31. 31.  Slow internal rotation to touch the hand to the opposite shoulder. (most often there are no clicks or sounds. Only the dramatic smile on the patient’s face tells you about the reduction.
  32. 32. Fractures of the femoral shaft I had a wonderful opportunity for a study.  Total femoral fractures treated in twelve years 70  Closed fractures 54  Open fractures 11  Fractures infected after fixation who came to prison subsequently 5 77% 16% 7% Closed fractures Open fractures Fractures infected after fixation who came to prison subsequently
  33. 33. Typical femoral shaft fractures seen in prison  Of these; 65 cases happened inside the prison.  Most open fractures were compound from within out.  Most happened after a fall from tree, building watch tower etc
  34. 34.  In 2002, a patient named Karuppuswamy climbed up a tree and threatened to jump down.  He slipped, fell and broke his right femur. With a splint, he was sent to the Government hospital, where as a first aid, he was immobilized in a Thomas’s splint.  He was posted for surgery in a few days.
  35. 35.  He was in the general ward. And on both his sides were patients with old fractured femurs. Discharging sinuses, foul smell, exposed metal, and heart wrenching stories of months or years of misery.  Karuppuswamy was petrified. He did not allow any surgeon to touch him and was brought back to the prison in a Thomas’s splint
  36. 36. When I was summoned to see him his initial X- Ray looked something liked this.
  37. 37.  I thought about it for a day and then asked my assistant outside to get me an Ilizarov half ring, couple of olive wires, couple of wire fixation bolts, and a length of clothesline.
  38. 38. I used double olive wires on upper tibia under local anesthesia
  39. 39.  The prison authorities allowed me to use traction on him and I gave an upper tibial traction somewhat like a Fisk traction using fan hooks and locally designed pullies.  The prison plumber and electrician helped.  Traction was provided by three concrete bricks each about four kilos.
  40. 40. Fisk Traction
  41. 41. The Karuppuswamy story  Traction was provided by three concrete bricks each about four kilos.  I would measure the femoral length daily, and ensure that there was no rotation.  Knee was kept flexed most of the time over pillows to traction level.
  42. 42.  He was sitting up in a week and moving in the bed in two. He was out of the bed by the fifth week, walking with a six feet bamboo cane.  In three months he was walking and by fourth month back to playing football.  No locking plates, no flexible nails, no rigid locking nails, no protruding stubs, no scars, full function, three degree valgus and half an inch shortening
  43. 43. The fourth month X-ray was somewhat like this
  44. 44. Femoral fractures  From that time on no convict would get his femur operated.  I managed eleven open (punctured wounds from inside) and 54 closed femoral fractures all with excellent results.  The scientific data is being analyzed for publication. It is a real pity that the circumstances and situations did not allow me to get or copy the radiographs.
  45. 45. Dislocated hips  11 cases in thirteen years.  Three associated with acetabular fractures.  All treated by closed reduction  Excellent results in all but one who developed OA after four years. He is coming to me shortly for a hip replacement.
  46. 46. PROBLEMS TREATED  Low back ache  Knee arthritis  Knee injuries  Frozen shoulders  Fracture both bones forearm  Fracture tibia/fibula
  47. 47. PROBLEMS TREATED  Colle’s and Smiths fractures  Fracture clavicle  Fracture neck of humerus  Fracture neck of femur  Intertrochanteric fractures  Fracture shaft of femur  Calcaneal fractures  Metacarpals and Meta tarsals
  48. 48. THE BACKACHE STUDY  By luck, I had an opportunity to monitor and study a group of 67 patients with CT or MRI proven Prolapsed intervertebral discs treated by various means and could study them for periods up to 13 years, with a mean follow-up of 10 years.
  49. 49. Inclusion Criteria  Patients with persistent symptoms, pain and some neurological deficit  SLR below 40 degrees  Patients who were convict prisoners and could be closely followed up for at least 7 years or more
  50. 50. Age distribution  20 to 30 16  31 to 40 18  41 to 50 20  51 and above 13 0 2 4 6 8 10 12 14 16 18 20 No Of Patients 16 18 20 13 20 to 30 31 to 40 41 to 50 51 & above
  51. 51. Type of treatments  Laminectomy/ Discectomy 19  Epidural injection 14  Pain killers, physio, exercises 34 28% 21% 51% 0% Patients Laminectomy /diskectomy Epidural painkillers, physio
  52. 52.  All operative cases were operated by orthopods or neuro surgeons outside the prison.
  53. 53.  All epidural injections were administered inside the Prison Campus by me  Conservative group treated either by me or have taken no treatment
  54. 54.  Though this is a prospective study, it is neither double blind nor controlled. I had no control over patients falling into a particular group. Situations determined the group into which the patient fell.
  55. 55. Final evaluation was done by  Visual Rating Scale  Visual analogue scale  Oswestry disability index 0 5 10 15 20 25 30 35 40 No Treatment Injection Operation 1 1.3 3.8 1.4 2.1 4.6 11 18 40 Visual Rating Scale Visual analogue scale Oswestry disability index
  56. 56. Conclusions:  No difference between Epidural injection and No treatment
  57. 57. Conclusions:  Surgery gave the worst results with permanent complications in 19% of the patients
  58. 58. Moral of the story:  Never operate on any prolapsed disc.  Even those with neurological deficit or bladder problems get well after some time.
  59. 59. Principal indications for disc surgery:  Holiday for the surgeon and spouse  College admission for surgeon’s son  A new car or holiday home  Or possibly even a speed boat if he operates every back!!
  60. 60. Dr Prakash’s SC index or B/B Ratio  Scrotum/cerebrum×100  Balls over brains ratio  While our testosterone urges us to rush into surgery, cerebral serotonin urges caution  We must make our choices wisely
  61. 61. INVALUABLE LESSONS LEARNT  Don’t operate in  1, Fracture clavicles  2, Fracture calcaneum  3, Fractures in Children below ten  4, Prolapsed intervertebral disc  There are a few exceptions however
  62. 62. How I tackled the knee design of an Indian Knee?? Many questions had intrigued me for a long time. Now was the time to search for answers.
  63. 63. Question? Are Indian knees Narrower front to back, than their Caucasian counterparts?
  64. 64. Question? Does Squatting since childhood alter the condylar shape?
  65. 65. Question? What is the normal orientation of the femoral condyles in relation to the femoral head? What is the Varus/valgus spread in average population?
  66. 66. Question? Is there a normal Tibial Varus?
  67. 67. Question? Are Indian upper tibias wider from side to side, but narrower from front to back?
  68. 68. Question? What is the tilt of the tibial articular surface vis a vis the ankle joint in the anterio- posterior direction?
  69. 69. Question? Can anthropometric or Radiological measurements predict the age of onset of OA knees?
  70. 70. Question? Relation between the severity of OA and the state of ligaments in and around the knee?
  71. 71. Methodology employed  Measurement of actual bones 640  Anthropometric measurements 8400 knees (4200 patients)  Radiological measurement of 1300 Radiographs  Total knee joints measured 10340 640 8400 1300 Data Osteology Radiography Clinical
  72. 72. At one stage my bedroom had more bones than the Anatomy department
  73. 73. Measurements taken FEMORAL CONDYLE  Mediolateral dimensions  Anterioposterior dimension of medial condyle  Anterioposterior dimension of lateral condyle  Femoral valgus/varus
  74. 74. Measurements taken UPPER TIBIA  Mediolateral dimension  Medial anterioposterior dimension  Lateral Anterioposterior dimension  Tibial varus/valgus
  75. 75. Dr Prakash’s modified Galton anthropometric calliper
  76. 76. Conclusions of the above study LOWER FEMORAL DIMENSIONS WITH SPREAD  Mediolateral 64.5 to 91.2  So Femoral component should be available in 53mm, 56mm 59mm 62mm 64mm 67mm 70mm and 75mm medio-lateral dimensions. 0 50 100 1 46 91 136 181 226 Mediolateral Numbers
  77. 77. LOWER FEMORAL DIMENSIONS WITH SPREAD Anterioposterior 63.1mm to 86.4mm  So Femoral component should be available in 50mm, 53mm, 56mm 58mm 59mm 63mm 66mm and 70mm AP dimensions. 0 20 40 60 80 100 1 16 31 46 61 76 91 106 121 136 151 166 181 196 211 226 241 256 inmm Femur AP Numbers Anterioposterior
  78. 78. Conclusions of the above study UPPER TIBIAL DIMENSIONS WITH SPREAD  Mediolateral 54.2 to 81.2mm and thus the tibial trays should be available in 55mm, 60mm, 63mm, 66mm, 71mm, 75mm and 81mm 0 20 40 60 80 100 1 16 31 46 61 76 91 106 121 136 151 166 181 196 211 226 241 256 271 M-Ldimension Tibial dimensions
  79. 79. UPPER TIBIAL DIMENSIONS WITH SPREAD Anterioposterior 38.1 to 55.4 So tibial trays should come in AP dimensions of 38, 40, 43, 45, 47, 51 and 55mm 0 10 20 30 40 50 60 70 80 1 15 29 43 57 71 85 99 113 127 141 155 169 183 197 211 225 239 253 267 Numbers Anterioposterior
  80. 80. These dimensional studies helped me to design my knee joint
  81. 81. Artificial hand, and foot prosthesis  I used my learnings in the fields of sculpting and rubber mouding to make hand prosthesis ( cosmetic) for two below elbow amputee convict prisoners. I also developed a method of silicon rubber feet
  82. 82. The steps: Plaster mould
  83. 83. Latex rubber pouring, hand casting, painting
  84. 84. Other things besides orthopaedics  106 books, 25 million hand written words.  Fiction, non fiction, mythological, adventure stories, legal thrillers, sensuous, and detective novels.
  85. 85. Twenty five million words look like this
  86. 86. Twenty five million words look like this as books
  87. 87. Twenty five million words look like this as books
  88. 88. I was then bit by the art bug and started doing water colours
  89. 89. More water colors
  90. 90. Water colors  When the selfie bug hit the world, I was in a small cell without even proper electricity
  91. 91. And so I drew my own selfies
  92. 92. Water color selfies
  93. 93. Water color selfies
  94. 94. I progressed in art to acrylic colors
  95. 95. Acrylic paintings
  96. 96. Charcol Skeches
  97. 97. Caricatures
  98. 98. Charcoal and oil painting
  99. 99. Nest stage was sculpting
  100. 100. Dr L.Prakash’s Hundred sculpture project Clay,Plaster of Paris, Resins, Acrylic, Marble, Granite, Epoxy, PMMA, BronzeAluminium, Dental cement, Gypsum. I experimented with all materials.
  101. 101. Bronze sculpture work
  102. 102. My experience in metallurgy helped me to cast my TKR prototypes.
  103. 103. I also did a lot of Material research
  104. 104. Masking fluid
  105. 105. Invented PRAKLAY, an air drying polymer clay with numerous applications
  106. 106. Praklay creations
  107. 107. Creations with Praklay
  108. 108. Latex moulding compound
  109. 109. Latex and silicone masks and cinema special efects
  110. 110. And then at last I won!!  I was acquitted in all cases that were foisted on me
  111. 111. When I reached home I was really surprised Five patients were waiting for me!!
  112. 112. Patients were awaiting my return  The newspapers and televisions had buggered up my reputation  But these patients cared a dam  The next day of my release, I had begun operating
  113. 113.  Nature was kind on me, my experiences in art and sculpting had probably made my fingers more accurate
  114. 114. The surgery went off brilliantly  To my luck, I attracted only complex and unusual cases.  And nature has helped me so far, as I have now learnt to respect nature
  115. 115. My Colleagues  I also received a wholehearted welcome from my orthopaedic colleagues and the Indian Orthopaedic Association
  116. 116. In The last nine months  I began my practice again and now specialize in complex and referral cases only. Presently I do revision joints and Ilizarov surgeries.
  117. 117. Designed Ultralite Rings
  118. 118. Designed a Total knee for Indian patient
  119. 119. Wrote three books
  120. 120. Got an ISO 9001-2008 for my clinic
  121. 121. Began an ambitious painting project: PRAKASH’S ATLAS OF ORTHOPAEDIC EXPOSURES
  122. 122. Conclusions  It is not where you are that matters.  What matters is what you do!!
  123. 123. Conclusions  They can take away your liberty, only you can take away your freedom.  They can imprison your body, only you can imprison your mind
  124. 124. Conclusions  A physician is never off duty. He is there 24/7/365  A scientist finds research material wherever he is; even in a prison
  125. 125. Conclusions  Keep meticulous records, you don’t know when they will be useful
  126. 126. Conclusions  Keep smiling, for no trouble lasts for ever. The rainbow is out there.
  127. 127. Thank You

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