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

1. Orthopaedics, usual and unusual
 Thirty years of experience
Dr L.Prakash M.S., M.Ch (orth) Liverpool

2. My life as an orthopaedic surgeon
went through three phases
1985 to 2001:
The Surgeon

3. My life as an orthopaedic surgeon
went through three phases
2002 to 2015 April:
The learner

4. My life as an orthopaedic surgeon
went through three phases
May 2015 to present:
The teacher and practitioner

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. During this phase, I was:
A prolific surgeon, Innovator, and wrote four books and
conducted 80 workshops.

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. During this phase,
VERY OCCASIONALLY TREATED A FRACTURE
CONSERVATIVELY

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. 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. 13 YEARS IN PRISON
DESPITE BEING TOTALLY INNOCENT

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. 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. 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. I also traced the X-Rays that I could lay
hands on and the pencil drawings are
shown herewith.

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. 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. Surgeries inside the prison:
 Suturing
 Abscess drainage
 Removal of thorns
and foreign bodies
 Skeletal traction
 Implant removal

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. 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. Doing a blood sugar through
prison bars is easy.

22. Taking BP a little tricky.

23. Injections are almost a circus or yoga for
both doctor and patient

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. INTERESTING PROBLEMS
The
torn
ear

26. Using thin nylon sutures, he was operated under
local anesthesia on the jailor’s office table

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.  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. Wait for three minutes by the clock (this is
the most important step)

30. Adduction slowly and gently.

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. 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. 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.  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.  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. When I was
summoned to see
him his initial X-
Ray looked
something liked
this.

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. I used double olive wires on upper
tibia under local anesthesia

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. Fisk Traction

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.  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. The fourth
month X-ray
was
somewhat like
this

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. 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. PROBLEMS TREATED
 Low back ache
 Knee arthritis
 Knee injuries
 Frozen shoulders
 Fracture both bones forearm
 Fracture tibia/fibula

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. 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. 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. 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. 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.  All operative cases were
operated by orthopods or
neuro surgeons outside the
prison.

53.  All epidural injections were administered
inside the Prison Campus by me
 Conservative group treated either by me
or have taken no treatment

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. 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. Conclusions:
 No difference between Epidural injection and No
treatment

57. Conclusions:
 Surgery gave the worst results with
permanent complications in 19% of the
patients

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. 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. 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. 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. 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. Question?
Are Indian knees Narrower front to
back, than their Caucasian
counterparts?

64. Question?
Does Squatting since childhood alter
the condylar shape?

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. Question?
Is there a normal Tibial Varus?

67. Question?
Are Indian upper tibias wider from
side to side, but narrower from front
to back?

68. Question?
What is the tilt of
the tibial articular
surface vis a vis
the ankle joint in
the anterio-
posterior
direction?

69. Question?
Can anthropometric or Radiological
measurements predict the age of
onset of OA knees?

70. Question?
Relation between the severity of OA
and the state of ligaments in and
around the knee?

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. At one stage my bedroom had more
bones than the Anatomy department

73. Measurements taken
FEMORAL CONDYLE
 Mediolateral dimensions
 Anterioposterior dimension of medial condyle
 Anterioposterior dimension of lateral condyle
 Femoral valgus/varus

74. Measurements taken
UPPER TIBIA
 Mediolateral dimension
 Medial anterioposterior dimension
 Lateral Anterioposterior dimension
 Tibial varus/valgus

75. Dr Prakash’s modified Galton
anthropometric calliper

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. 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. 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. 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. These dimensional studies helped me
to design my knee joint

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. The steps: Plaster mould

83. Latex rubber pouring, hand casting, painting

85. Other things besides
orthopaedics
 106 books, 25 million hand written words.
 Fiction, non fiction, mythological, adventure stories, legal
thrillers, sensuous, and detective novels.

86. Twenty five million words look
like this

87. Twenty five million words look
like this as books

88. Twenty five million words look
like this as books

89. I was then bit by the art bug and
started doing water colours

90. More water colors

91. Water colors
 When the selfie bug hit the world, I
was in a small cell without even proper
electricity

92. And so I drew my own selfies

93. Water color selfies

94. Water color selfies

95. I progressed in art to acrylic
colors

96. Acrylic paintings

97. Charcol Skeches

98. Caricatures

101. Charcoal and oil painting

102. Nest stage was sculpting

103. 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.

104. Bronze sculpture work

105. My experience in metallurgy helped
me to cast my TKR prototypes.

106. I also did a lot of Material
research

107. Masking fluid

108. Invented PRAKLAY, an air drying
polymer clay with numerous
applications

109. Praklay creations

110. Creations with Praklay

111. Latex moulding compound

112. Latex and silicone masks and cinema
special efects

113. And then at last I won!!
 I was acquitted in all cases that were foisted on me

114. When I reached home I was really surprised
Five patients were waiting for me!!

115. 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

116.  Nature was kind on
me, my experiences
in art and sculpting
had probably made
my fingers more
accurate

117. 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

119. My Colleagues
 I also received a
wholehearted
welcome from my
orthopaedic
colleagues and the
Indian Orthopaedic
Association

120. 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.

121. Designed Ultralite Rings

122. Designed a Total knee for Indian
patient

123. Wrote three books

124. Got an ISO 9001-2008 for my
clinic

125. Began an ambitious painting project:
PRAKASH’S ATLAS OF ORTHOPAEDIC
EXPOSURES

126. Conclusions
 It is not where
you are that
matters.
 What matters is
what you do!!

127. 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

128. 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

129. Conclusions
 Keep meticulous records, you don’t
know when they will be useful

130. Conclusions
 Keep smiling, for no trouble lasts for
ever. The rainbow is out there.

131. Thank You