No More Mal-Kahn-Tent - External Tibias - Dr Parihar

This is a pretty random question, but do you still feel short in India?

Quote from: Tall on June 12, 2014, 10:13:34 PMThis is a pretty random question, but do you still feel short in India?

No. I feel completely average. That's why even at 5'5 one doc told me I don't really need lengthening. On the whole, India isn't a tall nation. I only felt particularly short when Dr Parihar stood in front of me. He was a whole head and neck taller. Then again he was taller than everyone in the lobby by far.

Good luck  kilo

Great photos, Kahn! Good luck.

Day 4: Switching Hotels and Frustration in Mumbai
Checked out of The Fern Hotel and got myself booked into Hotel Maharana Inn. I decided to get myself the best room they had for the three days before I downgrade to another room. The executive suite is really nice and the HDTV inside it is larger than any of the TVs I've seen in any of the hotels so far. Ordered  a cheese pizza and chicken masala, which were decent. I had no idea what pizzas in India were made like but I found that they were very different from the ones in the States. I had a laugh when I saw that they put peppers underneath the cheese in the pizza. Later I walked back to the phone store I went to the other day that said I needed photos for a sim card, but once I went in and told them I wanted a sim card the employee just said "no" and told me to go. By that point I got pissed because it was just about impossible to get a sim card without someone who could speak to people in the local language for you.

I decided to go and see Dr Shah afterwards and had the hotel receptionist call a cab for me. The staff explained to the driver where to go but he ended up dropping me off somewhere that was completely far away from it, as I found out from someone that I was really 6 km from Dr Shah’s clinic. I found that most of the cab drivers in Mumbai have no idea where the hell anything is. If you tell them an address they won’t have a clue unless it’s a famous monument or center and even then they still have to stop and ask for directions. It’s as of anybody in Mumbai can get a taxi and call himself a driver. It was much easier in Delhi to manage on your own and any tourist coming to Mumbai will probably have a difficult time alone. It would be much better to go as a group because at least you can have comfort in having people there with you when things don't go to plan. It started to rain hard, which made the weather even more humid and left me drenched. I eventually gave up trying to find Dr Shah’s clinic because I didn’t even have a working phone to call and ask them for directions. Maybe I’ll have better luck with that on Monday, but I’m not leaving the hotel until I’m sure I can see Dr Shah. It took forever to find a cab that knew how to get to my hotel even after telling the address and showing them the hotel card.

When I finally got back there was not much to do, so I ordered a mushroom cheese pizza, cold coffee with ice cream, and an orange juice and then watched some "Married…With Children" episodes on my laptop before connecting my PS3 to the HDTV. I saw that I had forgotten to pack the HDMI cable but I was at least able to get the composite cables to work. I do need to find an electronics shop with an HDMI though as Fallout 3 won't be the same without it. Played some Resident Evil 3: Nemesis and Final Fantasy IX for a bit before deciding to go back to sleep.

Photos of Day Four
 

Another great entry.  It feels like I'm right there with you.  The excitement is palpable.

I hear Mumbai is a lot more confusing than Delhi. If I did lengthening in India I would want to do with a good doctor in Delhi because of that.
Also how come you have the website name and corner picture on all your photos?

Wow the hotel room and the pizza looks aswesome

So I've decided which doctor I'll be doing surgery with. Before I reveal who I decided on, I'll start by sharing what I remember from notes I took down during the consultations.

First Consultation: Rockland Hospitals with Dr Rajesh Verma
Toward the end of my first day in New Delhi I was driven to Rockland Qutab by a driver at Indira International Inn named Chacha. As soon as I entered the hospital lobby, I heard my name called from the receptionist area. A young woman greeted me and had an employee get me a large bottle of water. I gave her my passport and she filled out a form with my relevant information before I was greeted by Mr Maini, the representative from Rockland who I had been communicating with by e-mail. He told me that in a few minutes we would go see Dr Talwar and after I paid the consultation fee (1,050 INR) he brought me down a floor to an office where I saw Dr Talwar's name on top with two others below it, Dr Gurdeep Singh Ratra and Dr Rajesh Verma. I sat down with Ishan and waited for Dr Talwar’s arrival, but a different doctor ended up coming in. He asked my height, how much I wanted to lengthen, and had me step on a scale. I was then told to take off my jeans and sit on the examining table while he went to go get a tape measure. While he was out the room I asked Ishan who the doctor was and whether or not I’d be seeing Dr Talwar. He told me that Dr Talwar was not at the clinic now but should I really wish to see him I could come back another time when he is available. For now, he wanted me to see Dr Rajesh Verma, as he would be the main surgeon during all cosmetic lengthenings, not Dr Talwar, though he would be part of the surgical team. Dr Verma came back and looked at my legs dangle for a bit before having me lie down on my back. He grabbed each tibia one at a time and had me bend my knees toward my body. Once that was over he started squeezing various sections of my tibias. I put my jeans back on and he told me that he thought tibias would be more appropriate for me to lengthen than my femurs. He sat at his desk and told me to ask him any questions that I have. The consultation lasted a full hour and I was able to get a good amount of information from him. Here's the gist of what I learned.

1) For cosmetic surgeries, Dr Verma much prefers monorail fixation to Ilizarov fixation because they're less heavy and bulky than the ring fixators and will restrict your movement less. He believes the results with a unilateral frame system are equal to those with Ilizarov fixators but has the added benefit of less discomfort to the patient. He said that you would have to do external only with monorails because the thick pins required for them would be blocked by the intramedullary rod with LON. However, if you are adamant about getting LON done, then he would use the ring fixators. He said that they haven't encountered any problems with stability using monorails because they use very thick pins.

2) When I asked what he would do if any malalignment started to happen during lengthening, he said that they would be monitor me through follow up visits. He stated that if you put the pins parallel to each other on the monorails then you shouldn't have problems with malalignment, but if you aren't careful and put the pins at an angle then that's when you start to have angulation/malalignment problems. Apparently if you put the pins parallel then that will help ensure the bone grows straight. 

3) I asked what nails the team would use if the patient decided to get LON and he said that they would use Zimmer nails.

4) When I asked why he prefers externals to LON, he said it's because he doesn't believe LON is good way to lengthen. An example he gave is that in the case of infection with external monorails, he could just remove the infected pin and replace it. But if you get LON and the infection goes into your bone, then it's difficult to replace the nail and your regenerate can also become infected. He recognizes the advantage of shorter fixation time and doesn't think LON is that much more difficult than externals, but he'd rather avoid the infection risk.

5) I told him that I was concerned about the possibility of chronic knee pain with LON due to having to split the patellar tendon to put the nail in and asked him what his take on that was. He said that it's one of the complications with nailing, but if you do it right then you shouldn't have any future incidence of knee pain because you wouldn't affect the patellar tendon too much.

6) He would not do bilateral plate fixation. He said that plating adds stability but there are no distracting plates and he would not want to do plating after the lengthening is done. He said it's because the regenerate at fist is immature "baby bone" and shouldn't be mishandled. Because of this he would not do LATN either because the bone is too soft for the nail to be put in right after lengthening.

7) I asked how long I would have to wear the monorails for external only if I were to hypothetically go for 6 cm. He said that after 10 - 14 days I would start distraction, depending on the results of the first x-ray. From there I would lengthen 1 mm per day for 60 days, making it 70 - 74 days for the distraction phase. After that I would keep the frame on for approximately 140 days, or double the time it took to lengthen, so I should expect to wear the monorails for around 210 days.

8 ) When I asked how knee flexion contracture and equinous contracture are treated or prevented, he said that his patients hardly get knee flexion contracture because they start mobilizing the knee from the day after surgery, and the chance of knee flexion contracture is even smaller with tibia lengthening. For equinous contracture he said that I shouldn't start to develop it for the first 4 or 5 cm, but they put the sandals strapped to the frame and have you stretch constantly. He said if that problem still continues then they would do a tendon release, but that it was rare and needed in maybe one or two out of every 100 cases. He also said that when you lengthen your tibia bone from one part you're not lengthening the tendon or the muscle fibers, which are located in various parts of the leg and don't lengthen while you distract, which is why you need to constantly stretch them to prevent equinous. Interestingly, he said that with my bulk I likely wouldn't have a chance of equinous for the first 5 cm.

9) For the first ten days he would make you walk with the monorails on, but after 10 days when you start distracting you will not be allowed to. Once distraction is completed and he sees good consolidation then he will decide when you can bear weight again.

10) Patients are required to wash their pins each day with saline and warm water. Once the osteotomy site is closed you can then bathe safely.

11) I told him about Dr Paley writing that you need to fixate the fibula at an angle both proximally and distally. He responded that they do not do any fibula fixation. They will just do the osteotomy and the fibula will distract itself. He said that they sometimes take out the middle of the fibula for bone grafts, starting around 4 inches from top and bottom joints, and that the fibula's main role is ankle stability, which is why they leave the bony part around the joints. I told him I had seen instances where the fibula doesn't consolidate after the osteotomy whereas the tibia does and he said it will not alter the way you walk, the mechanics of your foot, or affect you at all.

12) Regarding follow ups, they will see you in the hospital every day and may discharge you on the 3rd or 4th day depending on your pain level. After discharge they will see you after one week and make you start distraction on the 10th. On the 14th day they take out the sutures from where they did the osteotomy. One week after the start of distraction they will do an x-ray and follow up every week until the end of distraction. If they detect any problems they will do another x-ray. At the end of your lengthening they will check to see that both legs have lengthened the same amount by measuring with a radiograph.

13) They will check for valgus (x legs) during each follow up. At that point the regenerate is still malleable so if they see valgus they will correct it.

14) For pain they would give you painkillers for the last few cm of distraction. He said that you should have pain for the first two days after surgery and then not much pain again until the start of distraction, which according to him wouldn't be significant for the first 4 or 5 cm.

15) They would prefer you to have a calcium-rich diet so the quality of regenerate is better. They give their lengthening patients two pills a day of a drug (forgot what it was but I think it started with cisco) that is supposed to promote bone formation. If you have calcium and a normal diet then he said you shouldn't need to take any multivitamins.

16) The complications that can come up are knee flexion contracture, equinous contracture, pinsite infection, non-union at the osteotomy site, or implant failure (if internals are done). After surgery they give antibiotics to decrease the chance of infection and sometimes they may have to change one of the pins or wires. 

17) When I asked about the risk of embolism with LON or internals he said the chance is very low. He stated that embolism is a higher risk with fractures because they have to put in a larger diameter nail and ream more, whereas for cosmetic cases they would put in a smaller nail and the reaming would be less. 

18) I asked about the possibility of amputation and he said that he would never admit me for surgery if he thought there was even a 1% chance of it, as amputation is his least favorite surgery to perform. He also said that amputations have a higher risk of being necessary if the surgery is on someone who had gotten in an accident and messed up their limb and they had to perform surgery to try and save it.

19) When I told him I was worried that my bulk would affect my lengthening he said that it would not affect it significantly. His main concern was how the person taking care of me would manage. He also said they'd probably have a slightly more difficult time operating on me.

20) During each x-ray they will measure the amount of distraction in case of pin loss, and if I were to have a goal of 6 cm they may recommend lengthening to 62 or 63 mm, or even 70 mm if my body can take it because he thinks 172 cm would be a good height.

21) Their team does not have a height limit on who they accept as a candidate. They will generally accept a cosmetic patient less than 165 cm with no problems, but they may try and convince you not do do it if you're taller than that by stressing all that cosmetic lengthening requires of you. But, if the person agrees to all that then they think they shouldn't have a problem agreeing to do it. Dr Verma personally doesn't like lengthening people who have an average starting height, though he would do it if you don't show any signs that you wouldn't be a suitable candidate.

22) People who they will NOT accept for lengthening are those with bone disorders that prevent good bone formation, heavy smokers, drug addicts, people who don't seem to understand what will be required of them during the post-op, people who will seem to have a hard time following doctor instructions, or people who have HIV.

23) They do not do any psychological evaluations on prospective patients, but they will require a consultation before surgery and make you write a consent form stating that you came to them to get the procedure done. Up to now they've never had a patient who has turned out to be psychotic.

24) Their team has apparently done a lot of cosmetic procedures together, though I didn't get an exact number. Dr Verma did say that they don't get too many people coming for cosmetic lengthening, though. Maybe 2 or 3 a month at the very maximum, but often times they can go months without a single inquiry about it.

25) I asked if there's a real difference between lengthening for cosmetic cases and lengthening for discrepancy or deformity. Dr Verma responded that when you do cosmetic lengthening you have to be really precise about things, such as the corticotomy being the same level on both sides so you can easily estimate the length you're getting. Cosmetic lengthening also requires much more careful monitoring because if they lengthen for a discrepancy of 7 cm, for example, and it's brought down to a 1 cm discrepancy, the person can still make up for it with a shoe raise and they can consider it a success. But with cosmetic lengthening if there's even a 1 cm discrepancy at the end of it all, it would be considered a failure on his part as a surgeon.

26) Dr Verma prefers a clean cut osteotomy to a fragmented osteotomy.

27) They can lengthen with Precice but he stressed that the problem with internals is the chance of implant failure which would require replacement of the whole device and additional surgeries to remove the failed implant and reinsert the new one.

28) He was sent an e-mail a few days before the consultation from the makers of ISKD stating it's now approved in India. He was not sure if they sent just a trial assembly or a whole set but he e-mailed them back to find out more info.

29) I showed him a picture of the infected screw that was popping out of Russianblues's leg and asked him how something like that would happen. He said that something like that can happen with any implant you put in the body and the rejection of the implant is an individual reaction that you cannot determine beforehand. He said another possibility for that happening is if your body is too thin and has little muscle cover. Apparently he's seen cases of fracture fixation, spine fixation, and hip fixation where that sort of thing has happened. He said the chance of something like that happening is extremely minimal, though, less than a 0.00001% chance. He then went on to say that medical science is "not a dot" which I took to mean that unexpected things happen all the time. He said they could operate on someone who has a lot of complications and they think won't make it past a week but then they see walking fine later. Or they could do a very simple surgery on someone who ends up with a lot of complications.

30) Because of my bulk and nutrition he doesn't think I'm a high risk or even a medium risk patient but they'll investigate all that with blood tests, x-rays, and a pre-surgery checkup done before surgery.

31) I asked if my size would make lengthening harder and he said that bulk is always a good thing. He said that they could operate on two patients, one who is very thin and one who is very bulky. Due to the amount of muscle covering the bone, the bulky patient would have a better source of blood supply to the area of the corticotomy as well as more stability to his limbs. He said the thin patient would have less stability and have "very cheap" blood supply in the area, which could make healing take longer.

32) Dr Verma, Dr Ratra, Dr Talwar, consultants, and junior residents will make up the lengthening team. Dr Talwar is the Senior Director but Dr Verma and Dr Ratra will be the primary surgeons.

33) The cost of surgery is about the same as is shown on Dr Talwar's page, but there are things not covered. The first two follow up consultations are free. You have to pay for your x-rays though, which are $10 USD to $15 USD. Follow up checkups after the first two are also between $5 USD to $7 USD. The doctors at Rockland don't actually monitor the prices themselves, basically whatever you go there for is put into a computer and the computer calculates the price they will give you.


I'll post the other consultations next.

Very good information KiloKAHN,
I am doing my surgery in september with doctor Salameh, but this information is really interesting.
Cheers, paco