N°272 - March 2018
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Where are you currently working?
I’m working in Cork, which is the 2nd biggest city in Ireland. It is located in southern Ireland which is a lovely area. I'm currently working in full-time private practice as an orthopaedic surgeon in Mater Private Hospital.
What is your current surgical practice?
80% of my work is now arthroplasty: both hip and knee replacements. Aside from that I do a lot of arthroscopy; mostly knee and shoulder because it was a large part of my training. During my time at the University Hospital I was actually really interested in the spine and traumatology. But when I went into private practice, the majority of my work became arthroplasty and arthroscopy. I still do certain procedures which I like, which is why I continue to do arthroscopy work.
Where did you do your medical studies?
I'm originally from the south of India, from Chennai, previously called Madras, province of Tamil Nadu. Like most of the children who went to school in India back then, I wanted to be a medical doctor. I studied at Madras University where I graduated my Bachelor of Medicine and Bachelor of Surgery.
How long was medical school in India at your time?
In the 70s, you finished school after 12 years of study. Then you had to do 1 year of a sort of introductory school, before going off to college to do a 1-year Pre-University Course. After the PUC you can choose to go into science, engineering, or other disciplines. I chose medicine. I applied, and I got into a college called Shingleford Medical College, which is nearer to Madras. My college fees were about 5 euros back then!
Was it just a school?
Only a school, a medical school attached to a hospital, but the first 3 years were just basic sciences, anatomy, physiology, there were no patients involved. But I knew right from the beginning that I would do surgery. I'm a hands-on kind of person, and I pick things up easily through observation. Reading was never my thing, and I wouldn’t have chosen to become a physician. The medical studies lasted 6 years. Then I did an internship in surgery and went into orthopaedics, general surgery and plastic surgery. I preferred plastic surgery because I got on particularly well with the consultant that I worked with. He taught me a lot of the basics: how to hold forceps, using scissors, so I remember him well. Then I went into orthopaedics and at the time, orthopaedics in India was mostly trauma.
Trauma and polio maybe?
No, at that stage polio was not a very acute problem. But we did have a lot of trauma back in ‘77 or ’78, which was when the AO Foundation first arrived. One of the consultants that I worked with went for an AO course and came back with the AO basic set and the small fragment set, which were a big thing at the time. There was a lot of technical gadgetry, and I loved gadgets; I always have.
What did it take to become a certified orthopaedic surgeon ?
To do orthopaedics in India you had to apply for post-graduate study and become a general surgeon. Then you had to apply for orthopaedics and become an orthopaedic surgeon. That’s how it worked. So I applied for general surgery, but I didn’t get past the selection process. By then I was working part-time as a Resident Medical Officer in an orthopaedic hospital, and I was also doing a similar job in a factory. So I was also the factory doctor, and I had all the luxury of working in a private company, such as playing tennis! That went on for about 2 or 3 years, until I became more and more involved in the orthopaedic hospital. Actually the original owner of that hospital was a friend of mine and he left that hospital to go to America, where he became an orthopaedic surgeon.
What kind of hospital was it?
His own private hospital. In India there are lots of doctors who own hospitals. They may not be very big hospitals: maybe just 15 beds, but they’re equipped with operating theatres and all of the necessary. He left to go to Delaware where he became a paediatric orthopaedic surgeon. In those days most of the Indian doctors or surgeons went either to the UK or America for their post-graduate. It was quite easy back then.
And what about you?
After 4 or 5 years of doing the same job I got fed up. I realized that a lot of my friends had already left and returned as surgeons. I thought, “Hold on, where is my life going? I have to do something.” Fortunately I had the opportunity to talk to the wife of one of my friends from Delaware during her vacation in India. She told me that her husband had a lot of fellows in training from England and Ireland and that they could explain how I should proceed. At that stage I didn’t actually know that Ireland was a separate country; for me it was all the UK. One day I finally made up my mind and applied for a clinical fellowship in about 15 different hospitals. I only got one response from Ireland, from a town named Sligo. It’s in the south-west of Ireland, about 200km from Dublin. They replied that they would give me a 3-month clinical attachment.
So it was good for you ?
Yeah. But I left for Ireland thinking that I was going to England! I landed in Dublin airport and by the time I got through security and everything, there was nobody there! I asked somebody how much a taxi to Sligo would be, and they answered that it would cost me nearly 300 pounds. That was more than I paid for the travel from India to Ireland! I was told that there were 2 trains, one in the morning and one in the evening. So I took a taxi from the airport to the train station with all my bags. But it was Sunday and the train station was empty as well! I couldn’t believe it; in India, there are people, buses and trains everywhere… It was December and I was so cold; a guy from the station told me to leave my bags and go to the pub opposite for a cup of coffee. So I left all my luggage right there in the empty train station and went to the pub! I don’t think that I would do that today. Then I came back and the guy gave me a ticket, showed me where the train was and told me to sit down. There were only 3 people in the whole train! When I arrived I took a bus. I showed the hospital accommodation address to the bus driver and he dropped me right in front of the apartment.
How was your life at the hospital in Sligo?
Oh it was good, everyone was very friendly and medicine was very satisfying in those days, back in 1985. There was both a general surgery and an orthopaedics department, which were both very busy. I did a 3-month clinical attachment in orthopaedics, during which I realized that I already knew a lot about traumatology, and that it was that kind of surgery I wanted to do. Three months later they told me that I couldn’t do an orthopaedic fellowship. There were no separate orthopaedic diplomas or fellowships in Ireland or the UK. You have to become a general surgeon first and then specialize into orthopaedics. So I applied for a general surgery job in the same hospital in Sligo.
I got a primary fellowship from Edinburgh, then came back and worked. By 1989 I got my final fellowship. By then I was nearly working as a registrar in general surgery so I was doing a lot of abdominal surgery, endoscopies and colonoscopies. That was the time when endoscopic surgery was starting to become popular. When I got my fellowship I went into orthopaedic training in Ireland. I went to different hospitals for the rotation. I then went to Beaumont, and from there I went to Cork University Hospital in 1993. I was supposed to finish that job, then go to the UK. But they advertised for a temporary orthopaedic consultant position. I was already doing hips and knees and they asked me to apply for the job. I applied, got the temporary job, and then stayed for 13 years.
You liked the place?
Yes I liked it. It was a good job and I was one of the 6 consultants on trauma. I was doing spine arthroscopy work and both primary and revision hips and knees. Cork is one of the major trauma centres in the country, because it’s got a level 3 trauma centre with cardio-thoracic surgery, neurosurgery, orthopaedics and all other specialities. Very few hospitals in Europe have everything in one place.
Why did you move from this practice to private practice?
We all move on at some stage. I had one or two issues with the job, and for me it was time to go into private practice.
When you started in Ireland, what kind of THA you would use?
Oh we were very religious in those days and the only thing we did was Charnley prosthetics by transtrochanteric approach. We had three trays: one for the instruments, one for implants implants (with only 3 stems) and a third tray for closing. And to tell you the truth, we were so comfortable with the cemented Charnley hip replacement. We had a wonderful view of all of the anatomy and everything worked perfectly. We used hand reamers, chisels, placed three anchor holes, and put in the cement and the cup. By the time this was finished we would immediately mix second lot of stem cement. Then the trochanteric wire - I used to be so good at handling trochanteric wire.
So why did you change?
Like in everything in life – we have to keep challenging ourselves. It’s fundamental for any surgeon. You have to constantly innovate. Yes, sometimes we make mistakes by doing that, but that’s the way we are. You know, the transtrochanteric approach is a concept that is still relevant. There were very few dislocations. You could balance the muscles, replace the trochanter any way you wanted to; and with the cementing you could adjust your neck any way you needed to. I think there were a lot of advantages. Yet I still moved on to the Hardinge approach because in those days it was very popular. The Hardinge approach uses an avascular plane, blood loss is greatly reduced and it’s nearly an intra-capsular approach. You're peeling everything out and going straight down the canal. I did it for so many years. But when we started revising, we found that the anterior part of the trochanteric was empty and that the abductors never really re-attach to the trochanter. Then the posterior approach became popular from southern England. But again, when you do a posterior approach with a 22.2 head, dislocation is more common.
How did you come to adopt the minimally invasive approach of the hip?
I’ve always believed in a minimally invasive approach, even when I was in general surgery. When I was working on the spine I went to Berlin, immediately after the Wall was taken down. My children were small, I think Ben was 2, Cathy was 3 or 4, and I took my whole family for a one-week holiday to Berlin. I went to see one of the spinal neurosurgeons, who was a director of orthopaedic spinal surgery. He taught me ALIF – Anterior Lumbar Intervertebral Fusion. Because I was a general surgeon before, I was very comfortable with the abdominal approach of the spine. When you do a double level fusion through the back with the instrumentation we had, the paraspinal muscles are ravaged by the time you finish your operation. So even if your treatment is right, what you're left with is a mass of scar tissue at the back. That’s why I thought that a small anterior approach would improve the post-operative course. I actually saw some of my early ALIF patients recently: 23 years later, fused and non-instrumented by a 3-inch incision and they’re doing very well. Anyway, I always believed in the concept of sparing as much tissue as possible. So I was one of the earliest guys to go with Zimmer when they promoted minimally invasive surgery of the hip with a double approach.
For how long?
Not for very long; I never liked it. Then when I heard about a direct anterior hip approach, I was thrilled because it made a lot of sense. You’re going in between two neurovascular bundle areas and it’s a natural cleavage play. It is a natural, front-door approach to the hip. On top of that, I was an acetabular surgeon and was already familiar with the anterior procedures for acetabular fractures. So in 2008 I went to one of the courses organized by Medacta in Paris.
Who was the performer?
Frederic Laude in his private hospital. He was using a traction table and I was very impressed by his techniques; he’s a good surgeon and is very encouraging to those he teaches. So I came back, and Medacta helped me a lot with my first cases. There was a steep learning curve, but at the same time I had a good track record in the initial cases. One thing is that although the table is a help, I didn’t use it for my routine. Then I used different models of hip prosthesis from different companies. But for your procedure to be a success, you have to have a good feel about the stem, and I never really was until I started using the UTF from United Orthopaedics. I learned with time that a minimally invasive approach is not about a small incision technique. It’s more about ensuring that the physiological approach is where you need it to be, which is also true in other branches like laparoscopic and cardiology. Yes there is a benefit to the patient, but you still have to do the surgery the same way. A good hip replacement is a good hip replacement. It doesn’t matter how you do it. You can’t use the approach as an excuse for not doing a hip replacement properly. A surgeon should be good enough to understand that if things are not going well, they should make a bigger incision and finish the job that they started in good conditions.
Small incisions approaches require a lot of surgical knowledge…
I accept that. That’s one of the arguments that I’ve had with the medical companies. From the beginning I've always told them not to focus on younger practitioners for new techniques. They need to go and convince a senior, more experienced surgeon – bring the wiser man to the new technique. I know that they might say: “Why should I change now?”. But it’s a better choice, because they’re the ones who can apply the technique, make it much safer, and also correct certain disparities and risk factors. Then it can be passed on to the next generation. There's no point in bringing in young, enthusiastic surgeons. They're very intelligent, but they lack the experience of the senior practitioners.
You have had a good experience with the anterior approach?
Yes, very satisfying.
But it’s a vertical scar and you make it horizontal, why?
Well, it’s simply because of the tension lines of the skin: the Langer’s line or Kraissl's lines. Whenever you go along the Langer’s line, your incision heals much better. Moreover, whenever you do a small incision or a minimally invasive approach you do end up stretching the corners a little more and once in a while you might have to excise the skin. Once I adopted the Bikini approach I never had to excise the wound skin before closure again. The skin of that area is mostly fine, and it’s a very skin-friendly incision. Doing the femur is the most difficult part of the operation. If you have a vertical incision, the retractors keep stretching all the time. So why not just twist the incision where the force is likely to be?
And when did you start to use a Bikini incision?
September 2013, and I never changed after. I think I have the largest number of consecutive bikini hip replacements.
What was your evolution on knee surgery?
I've been doing arthroplasty of the knee with cemented implants since 1989, and I’ve tried a number of different models. I was doing subvastus by medial approach for nearly 20 years, even for valgus knee. But I think every surgeon goes through the phase where changing the technology is the possible solution for the 15% of patients that are not satisfied with their operation. You try to find the ideal configuration, maybe changing from one type of knee to another knee, moving from fixed to mobile or from mobile to ultracongruent …. You concentrate on one concept, and another side of you keeps telling you that maybe if you change your surgical technique just a little, it could make a difference. Tourniquet - no tourniquet, pain management, keeping the knee looser or maybe a little tighter – it’s just the way my mind works. But I remember in the early time of knee replacement the main problem was wound healing, wound problems. And in those days you knew very well that you wouldn’t have had a problem with a lateral wound incision. Never, because predominantly the vascularity comes from the medial side. So now I am interested in the lateral subvastus approach. I just started using it for selected patients because the majority of the tibial height is about 20 millimetres and you don’t have this space. You can’t dislocate the tibia to put the stem in directly from the lateral approach so it’s very difficult. You have to have a good tibial plate with a short peg.
You want to go back to Miller-Galante knee?
Exactly! And that’s the first knee I did. I loved the Miller-Galante model. Personally I believe that the knee fails because of the tibia. I don’t know why we are still cementing the tibia even though we know that all knees, if left long enough, only fail on the tibia. So why are we still cementing it? Cement works better in a cylinder, like the femur. It doesn’t work very well on flat surfaces but we keep doing it.
Come on, they’re not doing so badly…
Yeah they don’t do so badly for 10 to 15 years. Have you ever seen a knee after 15 years standing straight? No. They’ll all be a little bit sloped. It fails on the medial side. Yet the concept of revision is already there: use a cone to reconstruct the metaphysis. I think that the metaphyseal cone concept will be applied to the tibia in primary knees and that one day all knees will be cementless. It’s a question of time.
Don’t you miss the Indian climate ?
No, no, I love Ireland, I love my wife Mary that I met in Sligo and my children. I love cold countries. I hate hot weather, and I enjoy rain as long as I can play a bit of golf. I think that Ireland is a good country to live in.
What are the differences between the Irish and the English?
Don’t go there! The Irish will tell you what they think straight away. The English won’t tell you, you will never know how the English mind works. They're too gentlemanly.
Published in N°272 - March 2018