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Orthopaedics usual and unusual

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This is a surgeons experience in prison, living under difficult situations, treating desperate patients, who had no where else to go. The studies conducted, discoveries made and new modalities invented.

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Orthopaedics usual and unusual

  1. 1. Orthopaedics, usual and unusual Thirty years of experience Dr L.Prakash M.S., M.Ch (orth) Liverpool Director. Institute for Special Orthopaedics Chennai 600106 (ISO 9001-2008 certified) 

  2. 2. Orthopaedics, usual, and unusual
 Thirty years of experience Dr L.Prakash M.S., M.Ch (orth) Liverpool
  3. 3. My life as an orthopaedic surgeon went through three phases 1985 to 2001: The Surgeon
  4. 4. My life as an orthopaedic surgeon went through three phases 2002 to 2015 April: The Learner
  5. 5. My life as an orthopaedic surgeon went through three phases May 2015 to present: The Teacher and Practitioner
  6. 6. First Phase ! Routine beginnings. M.S., M.Ch. etc, ! Training under greats like Freeman, Muller, Goodfellow, Monk, Wroblowski, Boyle, Klenerman, Owen, Taylor etc. ! Career as a Trauma and Joint replacement surgeon.
  7. 7. During this phase, I was: A prolific surgeon, innovator, and wrote four books and conducted 80 workshops.
  8. 8. During this phase, I operated in 106 operation theatres across the country and abroad, demonstrating surgical techniques and was the Secretary and Vice President of Indian Orthopaedic Association.
  9. 9. During this phase, VERY OCCASIONALLY TREATED A FRACTURE CONSERVATIVELY
  10. 10. Second Phase: ! Dramatic change in my life. ! From an orthopaedic surgeon, I became a life convict prisoner in the dreaded Chennai Central Prison.
  11. 11. 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.
  12. 12. 13 YEARS IN PRISON DESPITE BEING TOTALLY INNOCENT
  13. 13. 
 I spent 13 years as a prisoner, eight as an under trial and seven as a life convict, under difficult, desperate and depressing circumstances.
  14. 14. These are my experiences of practicing 
 orthopaedics in those times, with limited 
 or no facilities, treating desperate patients 
 who had nowhere else to go. My experiences gathered from studying a few thousand individuals, in a closed atmosphere with a hundred percent follow up, to tell me if my methods worked.
  15. 15. 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 narration is based

  16. 16. I also traced the X-Rays that I could lay hands on, and the pencil drawings are shown herewith.
  17. 17. Period spent in the prison 4831 days
 
 Total number of patients seen 11,248
 Conservative treatment Manipulations Suturing and minor surgery Implant removal under LA Intra-articular injections Local steroid injection Referral to other centers
  18. 18. Orthopaedic treatments ! Conservative treatment 2171 ! Manipulations under sedation, haematoma block, or just motivation 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
  19. 19. Surgeries inside the prison: ! Suturing ! Abscess drainage ! Removal of thorns and foreign bodies ! Skeletal traction ! Implant removal
  20. 20. UNIQUENESS ABOUT PRACTICING ORTHOPAEDICS IN PRISON ! No X-ray machine in prison hospital ! No POP bandages or traction items ! No Lignocaine or local anaesthesia, without special permission. ! No anaesthetic drugs ! No sedatives or tranquillisers ! Limited suture material ! No other facilities.
  21. 21. 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
  22. 22. Doing a blood sugar through prison bars is easy.
  23. 23. Taking BP a little tricky.
  24. 24. Injections are almost a circus or yoga for both doctor and patient

  25. 25. NOW JUST IMAGINE REDUCING A DISLOCATED SHOULDER THROUGH THE PRISON BARS!! 
 IT IS INDEED UNFORTUNATE THAT I SIMPLY COULD NOT HAVE TAKEN ANY PICTURES!!
 However, my experiences, led to the discovery of a new method of reduction of shoulders; a simple easy method
  26. 26. INTERESTING PROBLEMS The torn ear
  27. 27. Shoulder dislocations ! Total 89 ! Anterior 83 ! Posterior 6 ! Associated with fractures 9 Patients
  28. 28. The Prakash method of reducing shoulder dislocations There is no role of traction in shoulder dislocations because shoulder dislocations are pure rotation, lateral translation injuries. Needs no assistant. Needs no anaesthesia or even analgesia. Gives consistent, reproducible results; wherever tried. Works in dislocations as old as three months. Simple effective method.
  29. 29. The patient sits on a chair, with scapula fixed. The shoulder is externally rotated. Held in external rotation for two full minutes
  30. 30. Keeping the shoulder in maximum external rotation for two full minutes, to relax the muscles is the key to the success of this procedure. The patient is reassured by engaging him in conversation.
  31. 31. Adduction followed by internal rotation; reduces the joint smoothly. There are no clicks or clucks. The head glides in majestically. The dramatic smile on the patient’s face is an indication of success.
  32. 32. PROBLEMS TREATED ! Colle’s and Smiths fractures ! Fracture clavicle ! Fracture shaft of humerus ! Fracture neck of femur ! Intertrochanteric fractures ! Fracture shaft of femur ! Calcaneal fractures ! Metacarpals and Meta tarsals
  33. 33. Fractures of humeral shaft ! In the past I operated on all shaft humerus fractures by AO methods. ! Surgery is not undertaken on prisoners unless it is a life threatening condition. ! So the burden of conservatively treating humeral fractures fell on me. ! At that time I was making drawings for my Anatomy Atlas.
  34. 34. I made some unusual observations about Humerus fractures, treated conservatively. 1, Fractures treated with elbow in flexion always malunited unless undisplaced, and on occasions went into non union due to plaster distraction. 2, Those treated with elbow in extension in full supination, for a short while in long arm casts, always invariably united soon.
  35. 35. ! At that time I was making drawings for my Anatomy Atlas. ! I had a large pool of a thousand volunteers for examination and study
  36. 36. Biceps and triceps during flexion and extension
  37. 37. Displacement in flexion, stability in extension Disruptive versus protective muscles
  38. 38. 56 cases treated in 13 years, all followed up to three years or longer. All fractures united, 30 with a little shortening. Elbow movements full at six months in every case. Full return to function within an average of two and a half months. Average time of clinical union was nine weeks. Only one complication of acute radial nerve entrapment and post fracture wrist drop recovered fully in six months.
  39. 39. Are we over-treating fractures shaft of humerus? Conservatively treated humeral shaft fractures never go into non union if treated in extension cast. Full return to function in three months. Light weight axilla to metacarpal head long cast in supination and full extension. Remove cast when patient is pain free; 3 to 4 weeks, and begin elbow movements. Fracture unites in average eight weeks.
  40. 40. 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 Closed fractures Open fractures Fractures infected after fixation who came to prison subsequently
  41. 41. 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
  42. 42. ! 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.
  43. 43. ! 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
  44. 44. When I was summoned to see him, his initial X-Ray looked something liked this.

  45. 45. ! 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.
  46. 46. I used double olive wires on upper tibia under local anaesthesia
  47. 47. ! 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 pulleys. ! The prison plumber and electrician helped. ! Traction was provided by three concrete bricks each about four kilos.
  48. 48. Fisk Traction
  49. 49. 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.
  50. 50. ! 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
  51. 51. The fourth month X-ray was somewhat like this
  52. 52. 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 analysed for publication. It is a real pity that the circumstances and situations did not allow me to get or copy the radiographs.
  53. 53. PROBLEMS TREATED ! Low back ache ! Knee arthritis ! Knee injuries ! Frozen shoulders ! Fracture both bones forearm ! Fracture tibia/fibula
  54. 54. 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.
  55. 55. Inclusion Criteria
 ! Patients with MRI proven single or more level prolapse with nerve or root impingement. ! 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
  56. 56. Age distribution ! 20 to 30 16 ! 31 to 40 18 ! 41 to 50 20 ! 51 and above 13 20 to 30 31 to 40 41 to 50 51 & above
  57. 57. Type of treatments
 ! Laminectomy/ Discectomy 19 ! Epidural injection 14 ! Pain killers, physiotherapy, exercises 34 Laminectomy/diskectom Epidural painkillers, physio
  58. 58. ! All operative cases were operated by orthopaedic or neuro surgeons outside the prison.
  59. 59. ! Six epidural injections were administered inside the Prison Campus by me, and eight by other surgeons. ! Conservative group was treated either by me or have taken no treatment
  60. 60. 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.
  61. 61. Final evaluation was done by
 ! Visual Rating Scale ! Visual analogue scale ! Oswestry disability index Visual Rating Scale Visual analogue scale Oswestry disability index
  62. 62. Conclusions: ! No difference between Epidural injection and No treatment
  63. 63. Conclusions: ! Surgery gave the worst results with permanent complications in 19% of the patients
  64. 64. Moral of the story: ! Never operate on any prolapsed disc. ! Even those with neurological deficit or bladder problems get well after some time.
  65. 65. Evidentiary value and scientific validation. Conservatively treated massive prolapsed discs: a 7-year follow-up RT Benson1, SP Tavares1, SC Robertson2, R Sharp1, and RW Marshall1 RCS Annals: Volume: 92 Issue: 2, March 2010, pp. 147-153 A massive disc herniation can pursue a favourable clinical course. The long-term prognosis is very good and even massive disc herniations can be treated conservatively
  66. 66. Evidentiary value and scientific validation. The Cochrane Review of Surgery for Lumbar Disc Prolapse and Degenerative Lumbar Spondylosis Gibson, J. N. Alastair MD, FRCS; Grant, Inga C. MSc; Waddell, Gordon DSc, MD, FRCS ! There is no scientific evidence on the effectiveness of any form of surgical decompression or fusion for degenerative lumbar disc prolapse, compared with natural history, placebo, or conservative management.
  67. 67. Lumbar Disc Herniation: A Controlled, Prospective Study with Ten Years of Observation.
 WEBER, HENRIK MD The controlled trial showed a statistically significant better result in the surgically treated group at the one-year follow-up examination. After four years the operated patients still showed better results, but the difference was no longer statistically significant. Only minor changes took place during the last six years of observation.
  68. 68. Results of Surgery Compared With Conservative Management for Lumbar Disc Herniations
 Postacchini, Franco MD
 ! Conservative management gives satisfactory results in a high proportion of patients with disc herniation in the course of a few months of treatment onset. ! Surgical treatment is significantly faster in yielding a satisfactory resolution of symptoms, but the results of surgery often deteriorate in the long and very long term because of recurrence of radicular, and especially low back, pain. ! Microdiscetomy appears to give slightly better results than standard operation in the first few weeks or months after surgery, but not successively
  69. 69. The Efficacy of Systematic Active Conservative Treatment for Patients With Severe Sciatica A Single-Blind, Randomized, Clinical, Controlled Trial
 ARTICLE in SPINE 37(7):531-42 · APRIL 2011  Active conservative treatment was extremely effective for patients who had symptoms and clinical findings that would normally qualify them for surgery.
  70. 70. 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!!
  71. 71. 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
  72. 72. 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
  73. 73. I had a large pool of subjects in a closed environment, enabling me to conduct numerous studies. Amongst other studies, I also performed physical and anthropometric measurements of over ten thousand inmates and prison officials. One of the studies enabled me to understand knee sizes, and plan the ideal dimensions for a TKR implant for the Indian population spread and also device a new operation for medial compartment arthritis, the PFO or Prakash Fibular Osteotomy.
  74. 74. But before that But why Varus scenario in Indian knees? Are our knees different? Is there a racial variation in coronal deviation of the knee joint?
  75. 75. Apparently yes. Apart from my studies I have found two references. One for adults and one for children. Varus and valgus deformities in knee osteoarthritis among different ethnic groups (Indian, Portuguese and Canadians) within an urban Canadian rheumatology practice Raman Joshi1, Nimu Ganguli2, Christopher Carvalho3, Faye de Leon4, Janet Pope5 Significantly more varus deformity was noted in the Indian-born group than the Canadian-born group (P = 0.002), and more valgus deformity was noted in the Portuguese-born than Canadian-born group (P = 0.009). Conclusions: Patient populations differed significantly in terms of varus and valgus deformities at the knee.
  76. 76. I could locate one study, in children Normal development of the knee angle in healthy Indian children: a clinical study of 215 children Uttam Chand Saini, Kamal Bali, Binoti Sheth, Nitesh Gahlot, andArushi Gahlot
  77. 77. Normal development of the knee angle in healthy Indian children: a clinical study of 215 children The overall pattern of development might be slightly different in Indian children, especially in Indian girls, with early reversal of physiological varus (<2 years of age) and a late peak of maximal valgus at the knee (6 years of age). Varus after 3 years seems atypical for Indian children. We provide an elaborate set of data for the mean TFA of different age groups and believe that this data could be of potential benefit to the physicians while evaluating lower limb alignment in Indian children aged 2– 15 years.
  78. 78. Knee varus in Indian population There have been few demographic or anthropometric studies of the Indian knees in adult population. No study has been done on long term measurements of knee saggital deviation with an increase in age.
  79. 79. My anthropological study of Indian knee saggital and coronal positions Study conducted in prison Conducted over 12 years Fourteen thousand Indian Males were studied
  80. 80. Methods Instruments used were a Galton calliper, Long scale, Wall, Pencil and long sheets of paper.
  81. 81. Methods Patient stood with back to the wall. Second toe faced straight towards the observer Line drawn from hip centre to knee centre was allowed to bisect the line from centre of ankle to centre of knee.
  82. 82. Material All subjects were male Convict and under-trial prisoners. Age from 18 to 91 Only 9% complained of any problems Except for Sex, they represented the average Indian population
  83. 83. Results Saggital plane Total Knees studied 14,321 Varus alignment 7642 Valgus alignment 1387 Neutral alignment 5292
  84. 84. Varus knees Total knees Neutral knees Valgus knees
  85. 85. Relationship between age and Varus
  86. 86. Correlation between symptoms of medial compartment OA and knee varus
  87. 87. Progression of varus with age 1640 subjects over 40 years of age were progressively followed up for ten years or longer. Average rate of progression of varus was two degrees per year and increased exponentially with age.
  88. 88. Varus progresses with age and the progress is more rapid in obese individuals While less than 15% of those in twenties had varus knees, over 60% of those above 70 had varus knees. Varus progressed most rapidly between the ages of 60 to 80. Once a knee gets into varus disposition, it continues to progress till the patient’s death.
  89. 89. Important observation More than 50% Indian knees had a varus disposition, though not all varus knees had symptoms of medial compartment OA. Severity of symptoms had a direct correlation to the degree of varus, and after 30 degrees, all knees were symptomatic. Varus of the knee gradually and progressively increases with age.
  90. 90. Limitations of the study No facilities for radiographic co-relation It was only a clinico-anthropometric study. Large numbers give the findings credibility Study will be published soon.
  91. 91. What would you do in this case? 56 year old gyaenacologist Advised TKR by six surgeons. Severe pain on walking, no rest pain.
  92. 92. Pre and post surgery
  93. 93. PFO, something new Accidental discovery in 2004 Based on my experiences in prison An out of the box method which produces remarkable and startling results both functionally and radiologically.
  94. 94. How?? Prison riots happen infrequently. Wardens are instructed to hit rioting prisoners with a Lathi, Below the knees, to avoid grievous injuries. Fracture proximal fibula is an usual consequence.
  95. 95. Unique aspects of practicing orthopaedics in the prison Every single inmate has to come to you if he breaks a bone. Most orthopaedic problems come to you. There are absolutely no facilities available. But for a pure scientist, this is a wonderful opportunity for study. And these are my studies that lead to PFO
  96. 96. OA knee is very common in India. About 6% of above 70yrs old are considered essential candidates for TKR, due to the bad state of their knees. Its natural that a prison too would have its share of ideal TKR candidates on their waiting list. Unfortunately a convict prisoner seldom gets any surgery except for life threatening conditions
  97. 97. It is only natural that a few of these ripe candidates for TKR would indulge in riots and break their fibula. Miraculously, in all these patients, the symptoms of OA disappeared immediately after fractured fibula. Those waiting for surgery refused a knee replacement as their symptoms had disappeared!
  98. 98. Fractures below fibular neck cured pain from severe medial compartment OA How does it work? The single versus triple cortex theory. Whatever be the theory, it really works well in most patients.
  99. 99. Anatomical studies
  100. 100. Anatomical studies
  101. 101. The first patient
  102. 102. PFO, indications
  103. 103. PFO, Surgical steps Small 2cm incision, 6 to 8 cm below fibular head. 1.5 cm fibula is excised. Patient walks and climbs stairs the same day. Can be well done as an outpatient procedure
  104. 104. PFO, a day care procedure
  105. 105. PFO, observations so far Effective in all patients, even those with patellofemoral OA Patient remains pain free for three years or longer. My first patient operated in 2004, is still happy and refuses knee replacement. A multi-centre trial is being conducted presently and about 1800 surgeries have been done in the last one year.
  106. 106. PFO, the first case, nine years follow up
  107. 107. PFO, other references
  108. 108. PFO, other references Zong-You Yang, MD; Wei Chen, MD; Cun-Xiang Li, MD; Juan Wang, MD; De-Cheng Shao, MD; Zhi-Yong hou, MD; Shi- Jun gao, MD; Fei Wang, MD; Ji-Dong Li, MD; Jian-Dong hao, MD; Bai-Cheng Chen, MD; Ying-Ze Zhang, MD It is a safe, simple, and effective procedure that is an alternative to total knee arthroplasty for medial compartment OA of the knee joint. Care must be taken to avoid potential nerve injuries. Proximal fibular osteotomy may reduce knee pain significantly in the varus osteoarthritic knee and improve the radiographic appearance and functional recovery of the knee joint.
  109. 109. 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.
  110. 110. Question?
 Are Indian knees Narrower front to back, than their Caucasian counterparts?
  111. 111. Question?
 Does Squatting since childhood alter the condylar shape?
  112. 112. 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?
  113. 113. Question?
 Is there a normal Tibial Varus?
  114. 114. Question?
 Are Indian upper tibias wider from side to side, but narrower from front to back?
  115. 115. Question?
 
 What is the tilt of the tibial articular surface vis a vis the ankle joint in the anterio-posterior direction?
  116. 116. Question?
 Can anthropometric or Radiological measurements predict the age of onset of OA knees?
  117. 117. Question?
 Relation between the severity of OA and the state of ligaments in and around the knee?

  118. 118. Methodology employed ! Measurement of actual bones 640 ! Anthropometric measurements 8400 knees (4200 patients) ! Radiological measurement of 1300 Radiographs ! Total knee joints measured 10340 Osteology Radiography Clinical
  119. 119. At one stage my bedroom had more bones than the Anatomy department
  120. 120. Measurements taken FEMORAL CONDYLE ! Mediolateral dimensions ! Anterioposterior dimension of medial condyle ! Anterioposterior dimension of lateral condyle ! Femoral valgus/varus
  121. 121. Measurements taken UPPER TIBIA ! Mediolateral dimension ! Medial anterioposterior dimension ! Lateral Anterioposterior dimension ! Tibial varus/valgus
  122. 122. Achieving consistency in radiographic measurements, and ensuring that they correspond to actual knee measurements. Each X-ray was scanned and digitized. The patients knee girth, mid thigh girth and upper calf girth were measured. The AP and Side to side dimensions of the limb were thus calculated. Using computer software, the X-rays were resized so that the outer soft tissue shadow measured the exact dimensions of the limb in each case. Consistency in measurements was thus ensured.
  123. 123. Dr Prakash’s modified Galton anthropometric calliper
  124. 124. 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. Mediolateral Numbers
  125. 125. 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. Femur AP inmm 0 22.5 45 67.5 90 1 51 101151201251 Anterioposterio Numbers
  126. 126. Conclusions of the above study UPPER TIBIAL DIMENSIONS WITH SPREAD ! Mediolateral 55.2 to 81.3mm, and thus the tibial trays should be available in 55mm, 60mm, 63mm, 66mm, 71mm, 75mm and 81mm Tibial dimensions M-Ldimension 0 22.5 45 67.5 90 1 20 39 58 77 96 115134153172191210229248267
  127. 127. 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
 
 Anterioposterior Numbers
  128. 128. These dimensional studies helped me to design my knee joint
  129. 129. Soon to be launched TKR and THR prosthesis in the price range of 15,000 to 20,000,
  130. 130. Artificial hand, and foot prosthesis I used my learnings in the fields of sculpting and rubber moulding to make hand prosthesis ( cosmetic) for two below elbow amputee convict prisoners. I also developed a method of making silicon rubber feet
  131. 131. The steps: Plaster mould
  132. 132. Latex rubber pouring, hand casting, painting
  133. 133. This helped me to make models for this conference. The worlds first silicone flexible workshop models.
  134. 134. Other things besides orthopaedics ! 106 books, 25 million hand written words. ! Fiction, non fiction, mythological, adventure stories, legal thrillers, sensuous, and detective novels.
  135. 135. Twenty five million words look like this
  136. 136. Twenty five million words look like this as books
  137. 137. Twenty five million words look like this as books
  138. 138. I was then bit by the art bug and started doing water colours
  139. 139. More water colors
  140. 140. Water colors ! When the selfie bug hit the world, I was in a small cell without even proper electricity
  141. 141. And so I drew my own selfies
  142. 142. Water colour selfies
  143. 143. Water colour selfies
  144. 144. I progressed in art to acrylic colours
  145. 145. Acrylic paintings
  146. 146. Charcoal Sketches
  147. 147. Caricatures
  148. 148. Paintings from photographs
  149. 149. Charcoal and oil painting
  150. 150. Next stage was sculpting
  151. 151. Dr L.Prakash’s Hundred sculpture project Clay, Plaster of 
 Paris, Resins, Acrylic, Marble, Granite, Epoxy, PMMA, Bronze Aluminium, Dental cement, Gypsum. I experimented with all materials.
  152. 152. Bronze sculpture work
  153. 153. My experience in metallurgy helped me to cast my TKR prototypes.
  154. 154. I also did a lot of Material research
  155. 155. Masking fluid
  156. 156. Invented PRAKLAY, an air drying polymer clay with numerous applications
  157. 157. Praklay creations
  158. 158. Creations with Praklay
  159. 159. Latex moulding compound
  160. 160. Latex and silicone masks and cinema special effects
  161. 161. My experiments in non surgical reversal of heart disease and diabetes Knowledge under duress
  162. 162. And then at last I won!!
 ! I was acquitted in all cases that were foisted on me
  163. 163. When I reached home I was really surprised
 Five patients were waiting for me!!

  164. 164. 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
  165. 165. ! Nature was kind on me, my experiences in art and sculpting had probably made my fingers more accurate
  166. 166. 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
  167. 167. My Colleagues ! I also received a wholehearted welcome from my orthopaedic colleagues and the Indian Orthopaedic Association
  168. 168. In The last nine months ! I began my practice again and now specialise in complex and referral cases only. Presently I do revision joints and Ilizarov surgeries.
  169. 169. Since then, I have designed Ultralite Rings
  170. 170. Designed a Total knee for Indian patient
  171. 171. Wrote five books and more are coming
  172. 172. Got an ISO 9001-2008 for my clinic
  173. 173. Began an ambitious painting project:
 
 PRAKASH’S ATLAS OF ORTHOPAEDIC EXPOSURES the test marketing of which has just begun
  174. 174. This is a simplified surgical exposures text book.
  175. 175. Future plans Orthopaedic teaching and education Workshops and conferences. Design and development of instruments to make your life easy. World Class made in India knees for below 20,0000 Rs Museum of orthopaedic implants IOA orthopaedic history museum Streamlining orthopaedic teaching and fellowships Sculpting the future of IOA
  176. 176. Orthopaedic teaching and education
  177. 177. Books
  178. 178. Surgical DVDs, and technique videos
  179. 179. Workshops and conferences. Delhi - November 2016 - Ilizarov Workshop Chennai - December 2016 - Ilizarov Workshop Chennai - Feb 2017 - TKR Workshop I am planning to organise 4 to 5 workshops, nationally and internationally every year for the next five years.
  180. 180. Design and development of instruments to make your life easy.
  181. 181. Developments in pipeline ! Ultralite rings ! Polyaxial telescope hinges ! Prakash Cement Removal set ! Generic TKR implant ! Prakash Knee instruments ! Prakash Gap balancer
  182. 182. Developments in pipeline ! 3 D printed implants and jigs ! Silicone limb models ! Special chisels ! Silicone die for PMMA spacer ! Low cost bone cement ! Bangle fixator
  183. 183. World Class made in India knees for below 20,0000 Rs
  184. 184. Museum of orthopaedic implants A travelling museum to be donated to IOA
  185. 185. IOA orthopaedic history museum
  186. 186. Streamlining orthopaedic teaching and fellowships, in India
  187. 187. Sculpting the future of IOA
  188. 188. Conclusions ! It is not where you are that matters. ! What matters is what you do!!
  189. 189. 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
  190. 190. 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
  191. 191. Conclusions ! Keep meticulous records, you don’t know when they will be useful
  192. 192. Conclusions ! Keep smiling, for no trouble lasts for ever. The rainbow is out there.
  193. 193. Thank You

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