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THE PREPARATIONS

INITIAL TESTS
A series of 20 tests, including blood samples for anaemia, sugar, infection, chest X-ray and ECG.

Though Vajpayee's general condition is believed to be stable, these preliminary tests will be conducted to ensure he is physiologically fit for the knee surgery and to prevent possible complications.

ANAESTHESIA
Vajpayee is given a spinal epidural treatment to numb him waist downwards. A balloon-like container with liquid painkillers is also inserted so that the body is free from pain for at least 48 hours after the surgery.

STERILISATION
The left knee is shaved and cleaned twice with antiseptic. The entire leg is then draped in sterile sheets and placed in a stocking set. It is kept elevated and a net coated with antiseptic placed on top. A tourniquet is fixed to prevent blood flow to the knee which is now ready for the operation.

THE THREE-HOUR OPERATION

Step 1
An incision is made through the stocking to open up the knee. Blood vessels are doubly checked to ensure there is no blood flow. Layers of fat and the surrounding soft tissue are pushed aside so that the bones- tibia and femur-within are revealed.

Step 2
Using sharp instruments, the debris of the cartilage is removed. The roughened portions from the tibia and the femur are nibbled off. A thin section of the tibia bone surface is sliced off to accurately level the surface so that the artificial plate can easily sit on it.

Step 3
Cuts are made into the femur bone to allow the artificial knee frame to fit. A hole is drilled into the tibia so that the plate can be fixed to it. Another hole is made in the femur to reduce bone pressure. The idea is to minimise eventual strain on the artificial knee.

Step 4
Bone cement-polymethymethyacrylate-is mixed into a thick liquid consistency. This is filled into the drilled holes and behind the two frames that make up the knee joint. The plate is finally placed on the tibia and femoral implant is fitted in the femur.

Step 5
The implants are firmly pressed and hammered into position. The plastic plate which pushes the joint is attached over the tibia plate. A plastic implant is also fixed to the knee cap. Any remaining gaps are plugged with the cement which hardens in about 10 minutes.

Step 6
Once the artificial knee parts are in place, a little tube is inserted to suck away any blood for the next two days to prevent infection. The main incision is then closed carefully using vicryl-a suturing material which dissolves after 90 days.

THE TOOLS

Alignment Rod
An alignment rod is attached to the lower leg to accurately align the tibia so that the roughened portion of the surface can be cut at the correct angle. The right view shows how it is fixed to the tibia.

Keel Punch
The bottom half is the keel punch attached to the tibia. The slap hammer on top has a moveable portion. The instrument is used to make a hole in the tibia for the plate to be fitted.

Femur Cutter
The femur cutting block with notch guides, to give this instrument its formal name, is used to shape the femur for the implant. It has grooves through which blades are placed.

IM Rod
The intra-medullary rod with a femoral cutting jig, as doctors know it, drills a hole in the femur to reduce bone pressure.

Implant Inserter
As the name implies this is used to place the implants into the bone structure.The slap hammer (right) thrusts the implants into place.

Old Knee, New Knee
On the left is a natural human knee and to the right the human-crafted metal and plastic knee that Vajpayee will use in the days following his operation.

Bone Saw
It is used to slice off a thin piece of tibia to level it so that the artificial plate can sit on it. The femoral bone is similarly cut three to four times to fit the implant.

THE MEDICAL TEAM

Dr Chitranjan S. Ranawat
NRI orthopaedic surgeon who grew up in Indore and now practises in New York.

Dr Nandu Lad
Well-known Mumbai-based surgeon who will assist Ranawat during the operation.

In the 50 years it has been around, Mumbai's Breach Candy Hospital has rarely invited the sort of scrutiny it does now. Old-timers suggest Vajpayee will be the most important patient since Amitabh Bachchan entered Breach Candy in 1982, battling for his life. For Ranawat too it is a test as much as a vindication. Once refused a job at AIIMS, Delhi, he returns to his native land to operate on the prime minister. The doctor, who admires Lincoln and Einstein, finds his place in the sun.

POST OPERATION

Physiotherapy
Will begin the same evening and continue for six weeks. This is the crucial recovery period.

Walker
After four days Vajpayee will use a walker. After three weeks he'll use a cane. After three months, he'll be normal.

COMPLICATIONS

Infection: micro-organisms could sneak in during the surgery process.

Blood seepage: This too could cause a major infection.

Blood clot: A remote possibility but when it occurs, circulation is affected.

Bad fit: Artificial knee may not be fixed properly, resulting in pain.

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