Dr Mangal Parihar (Mumbai India)- Mangal Anand Hospital

Oh my mistake realized hes quoting times since the first surgery not frame removal.

Quote from: Roger Murdock on December 09, 2013, 04:46:36 AMHey Guys,

I have a friend I've been talking to on Emm Emm Tee who is meeting with Dr. Parihar tomorrow. Actually, it's TODAY for him, since he's already over there. Its REALLY last minute, but if you have any specific questions, post them and I will try to get them to him (possibly over the phone as he's said  the Internet in his hotel is really bad and he may not be able to get online again before his consultation.)

I don't have any particular questions but it would be excellent if he were to post his CLL experience on this site, should he decide to undergo surgery with Dr. Parihar.

Can you ask him why full weight bearing only begins after 4 weeks when the standard titanium nails can take 60-65kgs? Harry/Sringari do a similar practice which seems very strange considering one nail alone can take peoples weight.

Gladiator (Crazy+6) copied stuff and Sysop deleted post request from Shorty asking for removal of his LL photo, it's fair do the same back.   I have a prediction,  BigFaker will choose Dr. T. Sringari  when all his consultations are over, let's see what happens. 

From Big Faker


" PARIHAR:

FEES: 900,000 INR = $14,400 USD = €10,538 EUR (They quoted in Rupees)
INCLUDES : 1st Surgery (Osteotomy and Nail/Frame Installation), 5-7 Day Hospital Stay, Check-Ups, 2nd Surgery (Frame Removal), Consults after Patient returns home (might be a trial process, since most of their patients have been local)
Local Room & Board during Lengthening NOT INCLUDED
Physical Therapy During Lengthening and Consolidation Included? - Not Sure. Forgot to ask. Explanation and more on this later
NAIL REMOVAL - Price? Not Sure. Forgot to ask. Explanation and more on this later "

I think, in my mind, the decision of whether I would do my surgery in Mumbai was settled right then and there -- standing outside in the parking lot -- but I had come ALL that way, so I went in for my scheduled consultation.

The inside of the place looked just as old and run-down and scary as the outside. It really looked like they only served Indians of lesser means. For example, if you have seen barely-funded County/public hospitals in the US (like on the show "e.r."), this would be the Third World equivalent.

MY CONSULTATION
I had compiled a decent list of questions I planned to ask all three docs and I took copious notes, but when I am in rushed, it usually looks like I was writing with my feet, so some details may suck.

I had been in email contact with Dr. Divya Ahuja, one of Dr. P's staff members, since I had called for an appointment from back home. He came out to meet me a few minutes after my appointment time, and brought me back into his office.

I asked him to explain his take on Reconstructive LL vs Cosmetic:
He said the main difference is that Cosmetic is bilateral and rarely do they have to deal with reconstructive lengthening on both legs. Additionally, reconstructive patients start with muscle and soft tissue of a certain length already and the bone has become short (because of injury, infection etc). The patient has to lengthen his bone to reach the length of those tissues. With Cosmetic, we want to lengthen, but the limiting factors are different. The muscle and tendon tightness adds those factors which are not really as present in Reconstructive. He said the recovery for both is "almost the same". Complications for lengthening are all "correctable, eventually, by surgery". But we want to try to prevent the need for that by hard work through PT.

Other notes:
Dr. Parihar does NOT allow/encourage standing/walking/weight bearing during distraction because, as Dr. Ahuja said, when you stand, you compress. Once the frames come off, gradual weight-bearing is done as the callus develops.

They use Synthes nails. I asked how many rings the frame would have, considering that I am really heavy, and he said 3.

I asked about the pins going the muscle and he said they make a "track through muscle" to place the pins, so as not to catch them as they go through. He said they also "take care not to go close to the nerves"

For the osteotomy, they DO split the patellar tendon with a small incision. He said the knee's recovery from that is not a big deal.

They do not typically do ankle-locking, but now use the sandals strapped to the frame.

In hospital: 5-7 Days
Distraction: after 7-10 Days
There is NO Care Home/Guest House, they have been looking for one, but basically I inferred that we would need to figure it out ourselves.
PTs would be sent from hospital.  I asked the difference between an LL physical therapist and a standard one. He said "communication", as the ones they work with will treat within the LL doctor's instructions, rather than going off on their own

X-Rays are done every 10-14 days during lengthening

Dr. Ahuja then did a physical exam, checking my flexibility and my problem ankle and old knee injury. The total time with him was about 35 minutes. After this, he sent me back to the waiting room. I waited there for another 20 minutes or so -- needing to go to the bathroom -- but I opted to wait until after I got back to the hotel....maybe that says something about the place.

I then got in to see Dr. Parihar. He went over the intake Dr. Ahuja did, discussed risk factors, and so on. We talked about him training with Paley in Baltimore (in the early 90s), the tremendous costs of LL in Europe and the US. He expressed that he did not discourage LL patients, but was not actively seeking them, either. It's just not his primary practice/business. All of his lengthening patients have been Indian, and most had no knowledge of the risks and downsides. He talked about the fact that many lengthening docs are doing primarily cosmetic work and deemed it "a paradox" because (in his opinion) the people doing lengthening should be the ones with very solid backgrounds in Ilizarov (which I took to mean Reconstructive/Deformity specialists like himself). An example he gave: if he treats a guy with an infected non-union, heals his bone, gets him to where his functionally is much improved...but still having a 1cm length discrepancy between legs... it's a success, a great positive result from where he was.
With a cosmetic patient, if a doctor gives him 6cm gain, but reduces the dorsiflexion of the knee to just neutral, he has "made that patient abnormal". The margin for error in cosmetic lengthening is much less. Furthermore, he said, cosmetic patients are "probably the most demanding subgroup of patients". But they will be aware of the potential risks and complications. I think the most memorable thing he said is that any of the complications (non-union, neurological injuries) that can come up in cosmetic are "part-and parcel of the Ilizarov techniques", so he would give the edge to a doc who has done 1000 reconstructive Ilizarovs over one who had 50 cosmetic. I WISH I had thought to ask about (touching on what Dr. Ahuja had mention earlier) how (or whether) a strictly reconstructive doc would have the knowledge and experience with the soft tissue stretching issues. Cr*p. Sorry, Peeps. That would have been a good one.

We discussed the frames and he also said the nail is much more significant factor than the frame. He said he is only a proponent of standing and walking in terms of reducing Ballerina.

Dr. Parihar said he was aware of the "LL community", but claimed he had never been on any of the "bulletin boards" and I really believed him. He's very much an Old School, no-nonsense, conservative doctor. Also evidenced by the fact that he then talked about the lack of peer-reviewed studies out there (and yes, you may sense a drastic difference between this consultation and the one I had with Sarin two days later). Dr. Parihar said he usually favors "function over length". 6cm is the general limit he practices, but if he sees a patient with equinus at 5cm, he would advise the patient "to call it a day". The amount of complications goes up "exponentially" after 6cm. I was pretty shocked though, that he said a patient can come back for a second round of tibia lengthening! I had never heard of this, aside from Jungle.

I asked (because of what I had read here, in one of the Sringari diaries) of where he would do a re-break, in the case of preconsolidation. He would do the 2nd osteotomy "slightly higher or lower".

Lastly, Dr. Parihar was pretty humble, as opposed to some other doc (to be named later). The total time with him was around 30 minutes as well. So I did not in any way feel rushed through there.

They had told me previously (over email), that there was a fee for the LL consultation. I had seen the $350 - €400 listed under those doc interviews and took a big gulp...until I kept reading and it said 800INR. That's like 12 bucks! I emailed them back to make sure it wasn't a typo (but didn't get a reply). Anyway, when I went to pay, they said it was 1500 INR. Not thrilled at the bait-and-switch (possibly once they realized I was American?), but still, only about 1/20th the cost of a consultation with Paley or Betz.

But anyway, if you hadn't guessed by now:


The discouragement of weight-bearing is a debatable subject and goes against so much of what I had been learning. I know how much SysOp encourages it and how Sweden seems to have had a rougher recovery for lack of it. Still, that was not the factor that ruled this doctor out. The hassle and work of having to find my own place to stay and arranging basic domestic care (in Mumbai no less) would have been hard enough to accomplish....but having to pay for that on top of the surgery and (possibly) the daily PT made this doctor an no-go. Anyway, if you hadn't gleaned from the beginning, I knew I could never have surgery at Mangal Anand from the moment I caught sight of it from the taxi.

Mind you, this removal from consideration as my LL surgeon has NOTHING to do with Dr. Parihar as a doctor, nor with him personally. He has a very impressive resumé:
http://ilizarov.in/about-us/dr-mangal-parihar.html
...and is clearly well-respected. I think because he trained extensively in the West (2 stints in the UK, as well as 2 in the US -- including a postdoc fellowship with Paley), we communicated very easily.

And, though he came off as somewhat cold/distant (or maybe just all-business) at first, he turned out to be a pretty cool guy. After the bulk of the consultation, we chatted a bit and somehow got onto the subjects of music, Vocal Live and Garage Band, and then audio/video production. He edits and narrates those surgery videos himself. Interesting, multi-talented man. Undoubtedly a good doctor. If, God forbid, a loved one or I were in a serious accident next time in Mumbai, I would have no qualms with Dr. P being my doctor.......just hope it would be at a different hospital.

I was trying to figure out where I had read the exact phrase in which Dr. P stated that he's "not a fan of weight-bearing" and I found it: it was on the interview that he did on that other site. I distinctly remember reading those words because it tipped me off that his English would be pretty good.

Anyway, in my consultation, he specifically said wants standing and walking "to the extent that it helps minimize equinus deformity". And he said in my case (with my considerable weight), he would want to go much much slower in getting back to weight bearing. There is, he explained, a need for being more conservative with cosmetic nails than with ones used for traditional fractures, because he would not ream out the bone canal to use a bigger nail in a cosmetic patient (would not want to harm a person's natural biology in that way, I think he said.) Basically, there is already enough risk in regenerative healing that he doesn't want to push it.

Also: keep in mind that these statements were from two different guys and each one said something sliiightly different.
Dr. Ahuja said the thing about "when you stand you compress it"
And when I asked "not even standing with crutches or a walker?"
He said "Just a little bit. Only so that it allows you go to the toilet"...and then, after frame removal, it is still just a gradual process.
I asked about ankle locking and he said they sometimes do that in Recon patients. I mentioned the sandals and he replied that they do that currently.
When they notice the foot dropping, they have the patient stop distracting for a few days to "work on it". It was actually a somewhat funny moment (for me) because I wasn't sure if he was saying "work" or "walk" and I even tried to have him repeat it, but despite his English being very good, I just couldn't make it out and gave up (probably because I knew deep-down I wasn't going to do LL there....and because I really had to go to the bathroom)

About tackling issues promptly, it's confusing because he said something like "any troubles that are supposed to happen will have come up during distraction".
ME: Isn't Ballerina the major issue that comes up?
Doc A: :That's actually what happens during distraction. Whatever has not been corrected during distraction and whatever remains and then becomes fixed.
(not sure if I wrote that part down exactly right)

So, in the end, I am not really clear on Dr P's work as a cosmetic LL surgeon. If I had met one of his PTs there, that might have given me a better idea of what one his LL patients would be in for. As he has no international patients, and so few cosmetic ones to boot, we really have no idea of his "success rate". Quotes because I am still not sure how LL "success" is actually defined. Eye Of the Beholder, I guess?"

Quote from: Carter on December 15, 2013, 10:04:51 AMGladiator (Crazy+6) copied stuff and Sysop deleted post request from Shorty asking for removal of his LL photo, it's fair do the same back.   I have a prediction,  BigFaker will choose Dr. T. Sringari  when all his consultations are over, let's see what happens. 

From Big Faker

Makes for very interesting reading.  And it is right.  If you feel reluctant to go to the bathroom in one of those hospitals you don't want surgery in them!

This LL game is full of twists and turns.  I am constantly oscillating between thinking "this is my life target, do it and live happily" to "do I want to risk all I have for 2-3 more inches?" absolutely confusing and frustrating as hell all this.

Dr Mangal Parihar is a specialist and respectable doctor in india regarding Limb lengthening , deformaty correction , complex trauma , reconstruction .... and i m not bluffing i did my research .
i m from india delhi and i have visited a doctors who is also specialist in Limb Lengthening and he told me that Dr Mangal Parihar is
most famous doctor in india regarding these issues .
he is like the Dr Paley of india .

And if anyone wants to do surgery in india then they should consider him as the first options.

Quote from: Machine on December 19, 2013, 06:45:57 PMDr Mangal Parihar is a specialist and respectable doctor in india regarding Limb lengthening , deformaty correction , complex trauma , reconstruction .... and i m not bluffing i did my research .
i m from india delhi and i have visited a doctors who is also specialist in Limb Lengthening and he told me that Dr Mangal Parihar is
most famous doctor in india regarding these issues .
he is like the Dr Paley of india .

And if anyone wants to do surgery in india then they should consider him as the first options.

I'd certainly feel more comfortable getting my surgery done with him than any of the other currently known doctors in India. I think it's just the location and lack of accommodation provided that urges people to go elsewhere. Still, I'd rather deal with the hassle of finding a place to stay and get my surgery done by the most credible LL specialist in the country than going to someone with hardly any real training but have a guesthouse to stay in.

Of course Sysopotheosis found a reason to criticize Dr. Parihar after Bigfaker posted his consultation with him on old forum .

who know about dr Milind Chaudhary and dr tejwanin?

I'm going to have a consultation with Dr. Parihar later. Here's information I received from him in a few e-mail exchanges recently.


Kilokahn:Hello, I saw on www.limblengtheningforum.com that the estimated total cost for the cosmetic lengthening procedure at your clinic is 900,000 INR. I'm assuming that is considering lengthening with a standard Ilizarov frame. If one were to opt for lengthening using the Taylor Spatial Frame, what would the difference in cost be? Thank you.

Dr Parihar: We do the lengthening with the LON technique. The Taylor Spatial Frame is not available in India. We have used the TSF in the past, but with donated frames from friends in the UK and USA, as six axis systems were not available in India. We now use the Ortho-SUV six axis system which is locally manufactured under licence, (http://pitkar.com/orthosuvframe.html), (https://www.youtube.com/watch?v=M4U2M4VpXhc&list=UU0eT2D9Wv88GFeCx-BJS0vA ), but that is more for deformity correction, and i do not see any major advantage to using it in a LON scenario.

Kilokahn: Thank you for the information. The reason I asked about TSF was because I had heard that it will help better prevent malalignment than traditional frames. Regarding the use of LON, I have read some studies that said there is a probability of having permanent knee pain even after rod removal due to having to split the patellar tendon to insert the nail. Because my interest in this is cosmetic, the possibility of permanent knee pain is somewhat worrying. Would doing plate fixation after frame removal be a possibility?

Dr Parihar: TSF vs Ilizarov - when frames are properly applied and stable, the likelihood of malalignment is quite small. One advantage of the ortho-suv we use is that it can be applied on standard ilizarov rings (unlike the TSF). So if there is a deviation, it can be corrected by exchanging the straight rods for ortho-suv struts at the end of lengthening when the regenerate is still ‘plastic’, correct the deformity, and then put on straight rods (with coupled washers to accommodate the deformity correction) again.

plate/LON/frame - there are upsides and downsides to every option.

fixator only -
plus - . no incision, no knee pain, early weight bearing, ?quicker healing
minus - frames need to be stronger i.e. more components, more wires/pins,  long fixator time

LON -
plus - relatively lesser number of wires / pins, shorter fixator time, ?earlier weight bearing compared to plate.
minus - some more scars, possibility of knee pain (can be minimized by technique), very small but real chance of IM infection, second surgery for implant removal

Plate -
plus - relatively lesser number of wires / pins, shorter fixator time, no chance of IM infection,
minus - some more scars, very small but real chance of infection around plate, not enough data of use in CLL to definitely predict how it will affect healing (most studies are about children and / or unilateral lengthening), i would not allow early weight bearing with plates on both legs, till reasonable amount of ossification  - so functionally patient could still be relatively impaired for a longer time, second surgery for implant removal, implant removal a little more difficult than nail removal.

Quote from: Kilokahn on March 28, 2014, 12:03:51 AMI'm going to have a consultation with Dr. Parihar later. Here's information I received from him in a few e-mail exchanges recently.

Thank you very much for posting this Kilokahn! Considering Dr Parihar's knowledge and experience in LL and trained by Dr.Paley, I believe that he is the best option for tibia LL in India. That is if you can cope staying in his hospital for a few days and then renting an apartment or hotel in Mumbai.   

I am keeping him as an option for tibia LL once I recover from my femur LL