Dr L.Prakash M.S. orth M.Ch, orth

13 YEARS IN PRISON ORTHOPAEDICS AND A LITTLE MORE

13 YEARS IN PRISON

DESPITE BEING TOTALLY INNOCENT

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.

Life convict in Central prison Chennai

Life convict in Central prison Chennai

I spent 13 years as a prisoner, eight as an under trial and seven as a life convict, under difficult, desperate and depressing

circumstances.

This is my experience of practicing orthopaedics in those times, with limited or no facilities, treating desperate patients who had nowhere else to go.

You are not allowed to carry X-Rays out of the prison, and so no pictures of

fractures, but I maintained meticulous records, on which this paper is based

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

shown herewith.

Period spent in the prison 4831 days

Total number of patients seen 11,248

Patients0

500

1000

1500

2000

2500

3000

2171

702 648

3

2670

1121

87

Treatments

Conservative treatment including skeletal tractionManipulations with or without seda-tionSuturing and minor surgeryImplant removal under local anes-thesiaIntra-articular injectionsLocal steroid injectionReferral to other centers

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

Suturing

Abscess drainage

Removal of thorns and foreign bodies

Skeletal traction

Implant removal

Surgeries inside the 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 Iimited suture material No other facilities.

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

UNIQUENESS ABOUT PRACTICING ORTHOPAEDICS IN PRISON

Doing a blood sugar through prison bars is easy.

Taking BP a little tricky.

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

NOW JUST IMAGINE REDUCING A DISLOCATED SHOULDER THROUGH THE PRISON BARS!!

IT IS INDEED UNFORTUNATE THAT I SIMPLY COULD NOT HAVE TAKEN ANY PICTURES!!

The torn ear

INTERESTING PROBLEMS

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

Total 89 Anterior 83 Posterior 6 Associated with fractures

9

Shoulder dislocations

Anter

ior dis

locati

ons

Poster

ior dis

locati

ons

Associ

ated w

ith fra

ctures

83

6 9

PatientsPatients

This my modified Kocher’s method. No huffing and puffing. Only precise application of biomechanics.

Patient needs to be relaxed with or without tranquilizers.

External rotation, slow and sustained to the maximum extent.

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

Adduction slowly and gently.

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.

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

Fractures of the femoral shaft

77%

16% 7%

Closed fractures

Open fractures

Fractures infected after fixation who came to prison subsequently

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

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.

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

And then I was summoned to see him. His initial X-Ray looked something liked this.

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.

I used double olive wires on upper tibia under local anesthesia

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.

Fisk Traction

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.

The Karuppuswamy story

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

The fourth month X-ray was somewhat like this

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.

Femoral fractures

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.

Dislocated hips

Low back ache Knee arthritis Knee injuries Frozen shoulders Fracture both bones

forearm Fracture tibia/fibula

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

PROBLEMS TREATED

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.

THE BACKACHE STUDY

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

Inclusion Criteria

20 to 30 16 31 to 40 18 41 to 50 20 51 and above 13

Age distribution

No Of Patients02468

101214161820

1618

20

13

20 to 30 31 to 40 41 to 50 51 & above

Laminectomy/ Discectomy 19

Epidural injection 14

Pain killers, physio, excersices 34

Type of treatments

28%

21%51%

Patients

Laminectomy/diskectomy

Epidural

painkillers, physio

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

All epidural injections were administered inside the Prison Campus by me

Conservative group treated either by me or have taken no treatment

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.

Visual Rating Scale

Visual analogue scale

Oswestry disability index

Final evaluation was done by

No Treatment Injection Operation0

5

10

15

20

25

30

35

40

1 1.33.8

1.4 2.14.6

11

18

40

Visual Rating Scale Visual analogue scaleOswestry disability index

No difference between Epidural injection and

No treatment

Conclusions:

Surgery gave the worst results with permanent complications in 19% of the patients

Conclusions:

Never operate on any prolapsed disc.

Even those with neurological deficit or

bladder problems get well after some time.

Moral of the story:

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!!

Principal indications for disc surgery:

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

Dr Prakash’s SC index or B/B Ratio

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

INVALUABLE LESSONS LEARNT

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

Artificial hand, and foot prosthesis

The steps: Plaster mould

Latex rubber pouring, hand casting, painting

106 books, 25 million hand written words. Fiction, non fiction, mythological, adventure

stories, legal thrillers, sensuous, and detective novels.

Other things besides orthopaedics

Twenty five million words look like this

Twenty five million words look like this as books

Twenty five million words look like this as books

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

More water colors

When the selfie bug hit the world, I was in a small cell without even proper electricity

Water colors

And so I drew my own selfies

Water color selfies

Water color selfies

I progressed in art to acrylic colors

Acrylic paintings

Charcol Skeches

Caricatures

Dr L.Prakash’s Hundred sculpture project

Bronze sculpture work

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

I also did a lot of Material research

Masking fluid

Invented PRAKLAY, an air drying polymer clay with numerous applications

Praklay creations

Creations with Praklay

Latex moulding compound

Latex and silicone masks and cinema special efects

I was acquitted in all cases that were foisted on me

And then at last I won!!

When I reached home I was really surprisedFive patients were waiting for me!!

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

Patients were awaiting my return

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

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

The surgery went off brilliantly

I also received a wholehearted welcome from my orthopaedic colleagues and the Indian Orthopaedic Association

My Colleagues

It is not where you are that matters.

What matters is what you do!!

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

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

Conclusions

Keep meticulous records, you don’t know when they will be useful

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

Conclusions

Thank You