Report 2 Saket Tibrewal - Indian Orthopeadic Society (UK)

The BOTA/IOSUK Travelling Fellowship 2011-12
Saket Tibrewal
The Fellowship
The BOTA-IOSUK travelling fellowship to India has now been running for a
couple of years and I was fortunate enough to be awarded the fellowship for
2011. The fellowship is open to any post-FRCS trainee and the hospital
placement offered is dependent upon your sub-specialty interest, although any
specific requests are considered. My sub-specialty interests are lower limb
arthroplasty and trauma and I was able to organize a two-week fellowship,
spending one week with Dr Arun Mullaji in Mumbai (navigated arthroplasty)
followed by a week at the Ganga Hospital in Coimbatore (Trauma).
Pre-travel checklist
There are several things that need to be organized before any travelling
fellowship, but even more so when travelling to the Indian sub-continent.
Visa’s, immunizations and anti-malarials need to be considered along with
organizing cash and travel arrangements both in the UK and in India.
Most important is a camera and a notebook in order to document the fellowship
and important learning points.
My visit
I organized my fellowship to run for two weeks in February 2012, splitting it into
a week in Mumbai followed by a week in Coimbatore. Swapping a cold, wet and
windy London for a hot, sunny and dry Mumbai was a welcome change. The
overnight flight was comfortable enough and by the time I arrived into my hotel
it was mid-afternoon giving me just enough time for some relaxation time prior
to organising myself for the week ahead.
Mumbai – Breach Candy Hospital
Mumbai is a sprawling metropolis in southwest India with a population of
approximately 20 million. It is commonly considered the heartbeat of India and
home to the Indian film industry, Bollywood. As depicted in a recent Oscaraward
winning film, this is a city of extremes – extreme wealth and extreme
poverty co-existing in close proximity. I was able to experience both sides
during my week in Mumbai.
The majority of my week was spent with Dr Arun Mullaji at the Breach Candy
Hospital (BCH) in affluent South Mumbai. BCH is a private hospital with 212
beds and it is arguably the most famous hospital in the whole of India with
patients ranging from wealthy industrialists to politicians and A-list movie stars.
Dr Mullaji has been practicing in Mumbai for the last 15 years, prior to which he
spent a fair amount of time training overseas including time in Colchester and
Liverpool as well as in the USA. An invited fellow of the prestigious Knee
Society, Dr. Mullaji is also a reviewer for several journals and has published
extensively. His practice runs Monday to Saturday with operating each day
followed by evening outpatient clinics. His team includes an associate surgeon
(Gautam Shetty), 2 fellows and his surgical assistant (Deepak) and each of these
has specific roles within a well functioning unit. Dr Mullaji’s practice is mainly

lower limb arthroplasty with his particular niche being navigated knee
arthroplasty. He is recognized as an expert in this field and has been an invited
speaker around the world, including the current concepts meeting in the USA.
His patients come from all over India and neighbouring countries, the vast
majority by recommendation and word of mouth.
I coordinated my visit with Gautam, his associate surgeon, and arrived at 8am on
the first day ready for action and I was not disappointed! On the first day alone I
scrubbed in for 3 sequential bilateral navigated total knee replacements - each in
patients with significant deformities – the standout case being a gentleman in his
70’s with bilateral fixed flexion of @ 45 degrees and varus deformities of @ 35
degrees (pre and post-op pics). This theme continued throughout the week with
the majority of surgical cases being bilateral navigated total knee arthroplasties.
Combined deformities were common and significant, something which seemed
common to the population on the sub-continent, and the “average” deformity
that I saw was a combination of approximately 20 degrees fixed flexion with a
similar varus or valgus component. It was fantastic to be able to discuss
management strategies and philosophies for these difficult cases with Dr Mullaji
intra-operatively and unfortunately pictures alone do not do justice to the
corrections achieved nor to the progress his patients made in a very short postoperative
rehabilitation period.
In addition to the time I spent with Dr Mullaji, I had one free day that I used to
see the less privileged side of Mumbai. I visited the grandfather of Orthopaedics
in Mumbai (and India) – Prof. N S Laud. Prof Laud, who turns 75 this year, has
been practicing Orthopaedics longer than I have been alive and this was reason
enough to spend some time with him! I visited him at the cooperative hospital
that he founded in the working class suburb of Dadar – Shushruth Hospital. It
was a humbling experience to see the Prof at work in his busy and cramped
outpatient clinic – he is still full of boundless energy and drive with the patient’s
interests being put well before his own despite the financial restrictions placed
upon them.
On my last evening Dr and Mrs Mullaji were kind enough to take Gautam and I
out for dinner at one of their favourite restaurants. We had a fantastic evening in
a more relaxed environment and it was a lovely way to end the week.
Overall Mumbai was a tremendous experience and certainly an eye-opener for
me in terms of the pathology that I was exposed to. Unfortunately the week
passed very quickly but having made some new friends I departed for my next
stop…
Coimbatore – Ganga Hospital
Coimbatore is the second largest city in the state of Tamil Nadu in Southern India
(the largest being Chennai/Madras which is about 100 mils away). It is a major
textile hub and is known as the Manchester of India. Over the last few years
there has been an exponential growth in the city and it now has a metropolitan
population reported at being over 2 million in addition to an international
airport. This has made medical tourism much easier and many patients travel

great distances to be treated in Coimbatore, which has recently been given the
nickname “Medicity”!
I spent my week at the Ganga hospital – this is a private and tertiary Orthoplastics
unit, which is owned and run by Prof. S Rajasekaran (Orthopaedic
surgeon) and his brother Dr. S Rajasabapathy (Plastic surgeon). The history of
the unit is quite amazing and testament to the drive of the brothers to produce a
world class institute. What started off as a 17-bedded unit has over the last 20
years expanded into what is currently a 440 bedded hospital. There are 18
operating rooms of which 10 are orthopaedic (5 trauma, 5 elective), 6 are
plastics, 1 general and 1 neurosurgical. Additionally there is an ITU along with
an A&E department for acute admissions. The volume of work carried out here
was phenomenal with approximately 40-50 Orthopaedic procedures a day and in
2011 alone they managed over 400 open lower limb fractures. Although the unit
is best known for its trauma and spine units, they are expanding the other
elective disciplines with an arthroplasty unit, a sports surgery team and plans to
expand further still.
Prof. Rajasekaran ensured my stay was as comfortable and easy as possible, from
organizing a car to pick me up from the airport to providing a room in the
hospital. On my first day I was asked to attend elective theatres at 7am and
arrived to find that Prof. had started his list at 6. This, I discovered was common
to all the elective theatres and they generally ran until 7pm. I spent the day
assisting the Prof in his elective work, which consisted of a morning performing
arthroplasty work and moving onto spinal surgeries in the afternoon. I found the
Prof to be extremely engaging, very humble, and a fantastic surgeon. I
thoroughly enjoyed the day – even the spinal surgery! A man of many sayings,
the one that sticks in my head is one that encapsulates his whole philosophy and
explains how the Ganga unit is what it is today – “if you want to walk fast, walk
alone. However if you want to walk far, then walk together”. The entire
department works as one, with the same philosophy and it is an inspiring place.
I spent the rest of my trip with Dr Dheendhayalan (or DD as he is affectionately
know), the senior trauma surgeon, and his team, most notably Dr Devendra, the
senior fellow. They were both fantastic trauma surgeons and I picked up lots of
little tips and tricks along the way. The amount of trauma, both high and low
energy that I was exposed to was phenomenal. During my week, an average day
would have 5 or 6 tibial nails and a couple of tibial plateaus, along with the usual
low energy fractures. I was able to scrub in and out as I pleased and also move
between theatres to see whichever cases I was interested in. All of the surgeons
were very accommodating and enjoyed having me there to discuss cases. The
opportunity to see, be involved in and discuss complex high-energy trauma in
such a high volume was invaluable and something that would not be logistically
possible anywhere in the UK.
At the end of the week I spent an entire day with DD in his outpatient clinic
where the team saw 300 patients in a day. Again I was lucky enough to see some
excellent cases, mainly post-operative, and DD spent time discussing the more
interesting ones.

On a social side I had a busy week! There were several overseas fellows in both
the Orthopaedic and Plastic units, including surgeons from the UK, Nigeria,
Russia and Europe. The consultants were all very hospitable and I was lucky
enough to be treated to dinner by them on several nights, including one evening
where we went for a traditional South Indian meal served on a Banana leaf.
Overall Coimbatore was a great experience and again I made some new friends
who I would hope to see again in the future.
Final thoughts
Overall this was a fantastic opportunity and one that I would highly recommend
to others. A travelling fellowship allows you to see how other units in other
countries run their practice and this can help you to improve your own.
Additionally, the opportunity to be exposed to complex cases, both elective and
trauma, in such a high volume is not something that is easily achievable back in
the UK, purely down to the difference in population size. I was able to make
some new friends and would hope to stay in touch with them and see them again
in the future. I would like to thank BOTA and the IOSUK for running such a
worthwhile programme and for giving me the opportunity to take part.