After treatment, patients with bone fractures can not only walk but also run and do push-ups.

Surgery for complicated bone fractures relies on orthopedic trauma specialists, as well as full complements of instruments and a team of medical staff

Around 50% - 60% of orthopedic patients are not joint replacement patients nor those with spinal disorders; they are bone fracture patients. Although every orthopedic surgeon can perform fracture fixation, treating complicated cases requires the expertise of an orthopedic trauma specialist in utilizing special tools and performing more delicate surgical techniques.

In this issue of MedPark Stories, we speak with Dr. Pongsakorn Bupparenoo, an orthopedic surgeon at MedPark Hospital. He is one of Thailand's pioneering orthopedic trauma specialists and a contributing author to the MIPO (minimally invasive plate osteosynthesis) textbook of the AO Foundation on sale worldwide. In addition, he is the first Thai physician who successfully performed pelvic surgery with the pararectus approach.

Treating complicated bone fractures, helping the patient resume running

After graduating with second-class honors from the Faculty of Medicine, Siriraj Hospital, Dr. Pongsakorn undertook a residency in orthopedics at Rajavithi Hospital. During years 3 and 4, he treated patients in an outpatient clinic. Most of the patients came with complicated fractures due to accidents.

“There was a patient whose bones broke in four places at the upper and lower leg bones of both sides. I, the team, and the attending doctor performed an 8-hour-long surgery; it was exhausting, but the patient could start walking after two days. Seeing the legs for the first time, he thought he would never walk again. Afterward, he sent me a video of him jogging, making me a happy man. The surgery not only enables him to walk but also run again. Some patients with broken arms were able to do push-ups after treatment. That inspired me to pursue a career in this specialty.”

While most of his fellow residents chose a fellowship in popular subspecialties such as foot and ankle, hand and microsurgery, spine, and sports medicine, Dr. Pongsakorn was passionate about orthopedic trauma. At the time, not many institutes offer a fellowship program for this subspecialty. Because of this, he decided to go abroad for fellowship training in the US, Germany, and Switzerland.

“I did a fellowship at  Denver Health Medical Center in the US and in Berlin, Germany, a bona fide trauma center. German laws and regulations were open to hands-on surgery for me. My professor allowed me an immersive surgical experience from the first day. We operated on 3 - 4 cases every day; all were fascinating. I learned various surgical techniques; the German medical technology was far advanced.”

Minimally invasive surgery: higher precision and easy to perform

During his training in Germany, Dr. Pongsakorn was particularly interested in pelvic surgery through the Pararectus approach. It is a complex, complicated surgical technique, requiring him 4-5 months of practicing before performing an actual procedure, which he later popularized once he returned to Thailand. 

“Treating complicated bone fractures requires orthopedic trauma specialists, as well as full complements of instruments and a team of medical staff. For example, pelvic surgery involves making a large incision, but the German Pararectus approach entails a more intricate skin incision, reducing its length by nearly half. It also allows for the insertion of longer screws, enhancing stability and facilitating faster recovery. This approach is usually appropriate for patients injured from falling from a height or road traffic accidents. This surgery has never been conducted in Thailand. When my professor handed me a scalpel and said he would be my assistant surgeon, I was flabbergasted but tried to stay calm. The surgery was a success.”

Currently, only a few large hospitals - mostly medical schools and leading private hospitals – have the means and resources for the Pararectus approach, MedPark Hospital being one of these hospitals. In addition to incision techniques, the indispensable equipment is a C-arm fluoroscopy unit capable of generating intraoperative 3D imaging.

“During surgery, we make an incision above the end of the fractured bone and insert a metal plate for fixation. C-arm enables us to see clearly where a metal plate is, how well the bone alignment is, or how secure are the screws' fixation of the metal plate. Intraoperative 3D imaging can be helpful. Plus, the C-arm technology has advanced considerably. The machine can rotate, creating intraoperative images similar to those from a CT scan.”

Another surgical technique Dr. Pongsakorn mentioned is suprapatellar tibial nailing. It involves inserting an intramedullary nail through a small incision above the knee without requiring a patient to bend the knee. He is the first orthopedic trauma specialist to perform this technique in Thailand.

“When the knee is bent, the muscles are stretched. This position introduces difficulty as it forces us to make an incision through the anterior ligament of the knee. A straightened knee, like when you sleep, the bone will assume a configuration optimal for the surgeon, surgical assistant, medical staff team, and patient. The incision will be small, with no postoperative pain. This technique is available at MedPark Hospital as well.”

Orthopedic trauma specialist and the treatment of a challenging, complex case

When asked about the most challenging case, Dr. Pongsakorn said it was a case involving a big bike rider hitting a road barrier and sustaining four long bone fractures. The patient moved to MedPark from the first hospital. After multiple surgeries and conscientiously following a postoperative physical therapy program, he can now do push-ups and weight training again. Another severe case is the one in which a patient was hit by a car, exposing the knee bone of one leg and breaking the knee bone of the opposite leg as well. 

“The patient crossing a road was hit by a taxi running a red light. He thought it would be impossible for him to run the marathon again. After five months of treatment, he resumed walking and exercising like before and is about to take up jogging again. This feat is quite an achievement and the pride of the orthopedic trauma team because intraarticular fractures normally take more than six months of healing before a patient can resume running. This case recovered rapidly.”

Prompt treatment provides benefits for patients. Well-prepared hospitals, doctors, medical staff, and medical equipment are crucial.

“Once a broken bone happens, it needs to be stabilized. If possible, leave it alone. Then, call for an ambulance immediately. As for this case, the patient arrived at MedPark around 3 a.m. We thoroughly checked and were sure that there were no torn blood vessels, so we started surgery at 5 a.m. The patient's leg quickly stabilized with no postoperative infection. This outcome was due to the state-of-art medical instruments. The operating room is also spacious, almost the length of a futsal field. Orthopedic surgeons prefer a large operating room to accommodate numerous tools we need to employ.”

Witnessing bone-fractured patients return to their favorite activities filled me with pride and invaluable joy, especially a return to running, one of Dr. Pongsakorn's favorite activities. 

“I participated in last year's Berlin Marathon, a 42-kilometer run. It felt like revisiting my Berlin fellowship program. The weather was balmy, and I didn't feel tired at all. I usually prefer to run in Benchakitti Park as I can see a patient if there is one after finishing running. I like to play music in my free time. I was a band member at Saint Dominic School, playing a saxophone.”