Professor Nguyen Van Nhan is one of the pioneers and leader in Vietnamese Orthopedic and Trauma Surgery. He was a witness to the last conflicts in his country and devoted his life to treating war and civilian victims. He kindly and humbly evokes his life and career.

 

MO: Monsieur Nguyen Van Nhan, how was your medical training?

NVN: My medical training, as that of all my colleagues of the same generation, was quite unusual. When I was in my second year of medical school, the war started, so I all the rest of my training was in war conditions in the North Vietnam forests, especially in Dien-Bien-Phu, where I very soon became a surgeon inside an Army Surgical Unit. Our teachers were then Ho Dac Di, Ton That Tung, Hoang Dinh Cau, Nguyen Huu... all well known by French surgeons. This war lasted nine years, and as early as during my fourth year of medical study, we used to work alone, without any supervisor or teacher in the Army Medical Units. We learned by field experience, in all medical specialty, especially in surgery, as in War days, every physician is a surgeon. Only after the war ended could internists really start their specialization.
My favorite textbook of surgery was « Exercices Chirurgicaux » by J Sarroste and R Carillon, which I had « looted » from the library of our medical school during Hanoi evacuation, during the first days of the French Vietnamese war.


MO: How did you become an orthopedic surgeon, and why in the army? Why didn’t you get into civilian practice?

NVN: During the War days, there was no difference: everybody was a military surgeon. Only when peace was restored could you tell military from civilian surgeons. For me, I had no choice, so I remained a surgeon within the army. Why orthopedic surgery ? During the war, everybody in my generation was doing war surgery and we all were operating « from the head to the toes ». My favorites were then vascular and abdominal surgery. But after the war in 1955, the Nation wanted to create a « Academie de Medecine » so we had to specialize. Again, I had no choice, and I was send in the USSR with two colleagues in order to train in orthopedics and trauma surgery. So I spent four years in Moscow, two years for specialization, and two more years during which I was a so called « Candidate Es Science » which is the first step in scientific research study, before the Doctorate Es Science.

MO: Then you came back to Vietnam?

NVN: Yes. In 1960, I came back with my title of « Candidate Es Science » and my acquired specialty. I became the Chief Surgeon in the Orthopedics Department of the Army Central Hospital in Hanoi.

MO: What have been your first works?

NVN: My first work was about nonunion and bone loss in the two bones of the leg. I treated 150 cases between 1958 and 1960. In the majority of cases, they were War injuries with infected nonunions.
The usual technique was then free bone grafting, autologous or heterologous, associated with internal fixation (intramedullary nail or plate and screws), after osteitis had resolved, which was sometimes quite difficult and time consuming to obtain. This same technique was still used during the American war. It yielded good results in case of tight nonunions, not too badly infected, and with a long period of calm. But, in case of large bone loss with important soft tissues defects, we often had problems, like sequestration of the bone grafts and loosening of the osteosynthesis. Sequelaes, joint stiffness and limb major shortening, were almost constant, even if bone union was obtained.
I must say immediately that these are the problems that lead us to our actual use of the Ilizarof method.
In that time,I was Associate Chief Surgeon in the Specialized Hospital for the Disabled of War, 85 kilometers north of Hanoi.
The wounded came on stretchers or by car from the south. After months or even years spent in a succession of field-infirmary, extending on almost a thousand kilometers in the Annamitic Chain from South to North. There usually were 1200 - 1600 patients, and we were about 30 surgeons.

MO: How did you manage your osteosynthesis?

NVN: We used our own devices, except for a very few plates and screws that came from USSR. Fortunately, I had a passionate interest in osteosynthesis and, as soon as 1960, I did compression plate osteosynthesis, using the Danis technique. I had to create a modified plate for we had no metal to make a compression unit. I must say that, in these days, plates were made out of large intramedullary nails, which we opened and hammered flat, and then cut to make plates in all lengths we could need. This way I created five different types of plates with a compressive effect, which gave us quite satisfactory results, at least compared to the plaster cast method we used before.

MO: Were you able to sell these devices in Vietnam or in Asia ?

NVN : No. I had sent a number of my plates to my university in Moscow, but I had no response from them. When, five years later, I came back to visit them in the Institute for Orthopedics, I was quite surprised to see how much the Sivach plates resembled mine. I asked what was the difference, but the only answer I got was a smile.

MO: You had also a large experience in pollicization.

NVN: Yes, before 1972, thumb reconstruction was only done using the Nicoladoni procedure.
I wasn’t satisfied with either cosmetic or functional results. So, starting with cadaver study, I used the Hilgenfeldt technique. I’d like, during this interview, to express my gratitude to the works of Marc Iselin, to his « Traité and Atlas de Chirurgie de la Main », which guided me during my first steps in hand surgery.
From 1972 to 1983 I did 55 pollicizations. One half of these were transfer of complete second to fifth digit, and the other half transfer of partially mutilated digits, finger stumps or metacarpals. I have done pollicizations not only in case of thumb amputation preserving the first metacarpal, but also for complete avulsion of the entire first column. For this, I suggested a personal technique of translocation of a third or fourth digit with reconstruction of the trapezo-metacarpal joint using a « home made » spring shaped metallic prosthesis. After 2 to 3 years, the spring broke, but the neo thumb function had created a new joint that allowed some pain free motion. I showed this work in Leningrad in 1990 when I graduated for my Thesis in Science. I was able to follow up some patients for 15 to 20 years. I like to see again patients I have operated, for instance, I see occasionally patients that I operated on 30 to 35 years ago, for giant cell tumor of the hip, using homologous articular femoral head grafts.

MO: Have you published your works?

NVN:I’ve published 65 articles in Vietnamese and Russian. I never was published in English or French. This would be quite difficult for me now, because, even if I spoke and wrote fluently French in my youth, I’ve actually not spoken or written it for almost half a century now.

MO: Since when have you been a member of the SOFCOT?

NVN: Since November 1992, after the second French-Vietnamese meeting of orthopedic and trauma surgery in Ho Chi Minh Ville. Before this, we had very little knowledge of French orthopedics, except through a very difficult to obtain literature. Fortunately now, I get my personal copy of the Revue de Chirurgie Orthopédique, and I must say it is helping us a lot.

MO: Do you have any contacts with other foreign orthopedic surgeons?

NVN: Until 1991, before the « Fall of the Soviet Empire » we had contacts with Russian surgeons. Now we are building relations with our neighbors Chinese and Thai surgeons. Quite a few Laotian surgeons come to train in our country. Actually, it is through American, Australian, German and French surgical missions that we have the most frequent contacts with the International orthopedic and reconstructive surgical community.

MO: You are the Vietnamese vice president for the Smile Operation. What is it?

NVN: Yes, but just for the Smile Operation in Vietnam (OSV). It is a Society that groups orthopedic surgeons, plastic surgeons and maxillo-facial surgeons. Our society was founded under the authority of the International Smile Operation (OSI) with which we keep a very friendly relationship.
Every year, we organize missions in our distant cities and operate hundred of children with facial dysmorphy such as hare lip or cleft pallate. Every year, surgeon from OSI come to our hospital to perform great microsurgical facial or orthopedic reconstructive procedures. Every time, they come with all their staff and equipment. They’re very well equipped and operate just as if they were in Washington or San Francisco.

MO: What about French missions?

NVN: The only French organization we work with (la Chaine de l’Espoir) has been organizing mission in hand surgery for five years. I like the way these missions are organized because their operations are performed using our nurses and our equipment, and this is the best way for us to learn how to do ourselves the procedures they teach us, which concern hand malformations, burns sequelaes and hand traumas.
Thanks to grants and helped by OSI, we know have a few operating microscope, and we have learned some microsurgical procedures. Recently we performed successfully a few toe transplantations.
For large bone and soft tissue defect, we can now use free flaps with osseous, muscular and skin transfer. We have performed over 20 free vascularized fibula transfers.

MO: Do you still take care of War traumas ?

NVN: No, war ended in 1975, it took us only 5 years to treat all sequellaes. In 1954, after the French-Vietnamese war, we had a 15 - 20 years delay before everybody was taken care for. Before this time, there were hardly no orthopedic or trauma surgeon. Now, in our big cities, most of the trauma are vehicle related accidents. The number of motorcycle accidents has tremendously increased, and they account for most of the infected nonunions we take care of.
We now treat them with improved techniques: microsurgical free flaps and compression distraction osteosynthesis. I have invented a bilateral external fixator which allows a well controlled distraction and compression.

MO: Don’t you use the Ilizarof device?

NVN: I used it in USSR and here, but we gradually came to limit it’s use only in large bone defects of the femur. In tibial fractures, I prefer my fixator, especially since it is 15 times less expensive than the Ilizarof device, which we have to pay for in roubles. I was very interested by an article by the ASAMIF group I read in Maitrise Orthopédique about the Ilizarof method ten years after it’s been introduced in France. They came to use circular external fixator only in indications close to ours.

MO: How do you treat osteitis?

NVN: By radical resection followed by a muscular flap, usually local flaps in the leg, sometimes we use free flaps. Then we use a bifocal osteosynthesis as suggested by Ilizarof: compression at the resection site, and lengthening distraction osteotomy. Results are far superior to those obtained by classical bone grafting techniques.
We have had very good results in limb lengthening, especially in the leg, using my external fixator and the Ilizarof method. We now have over one hundred cases operated with a follow up from one to five years.

MO: Do you do total hip or total knee arthroplasties in your premises?

NVN: We have been doing prosthetic surgery for the past four or five years, but we only use Moore prosthesis, for we cannot afford a total hip prosthesis. We only started using total hip prosthesis a couple of years ago, with German surgeons. In the knee, we do only osteotomies. We see very little knee primary arthritis, our civilian surgeons treat more of them.

MO: How do you see evolution of orthopedic and trauma surgery in Vietnam ?

NVN:We are now better organized with a National Society of Orthopedic Surgeons and an Annual Meeting were we meet civilian surgeons. I was vice president of the Society when my civilian friend Professor Dang Kim Chau was president. We are now constantly improving our knowledge at the contact of more and more foreign surgeons and we take tremendous benefit from all surgical missions in Hanoi. Our working conditions are still somthing difficult for you to imagine and you have seen us work almost bare handed. It is much better then what it used to be and my motto is: « Don’t stay passive in front of difficulty: invent something to override it! » It helped me a lot during the war days when our hospitals were either in mountains or underground. In Dien-Bien-Phu for instance, I had a very nice operating room just a few kilometers away from the French positions, and during the American-Vietnamese war, three meters below the ground, we could resist bombing and operate night and days.

MO: A last question, how old are you?

NVN: 72 years old.

MO: What about retirement?

NVN: Being professor and chief expert, only when my health will not allow me to continue. I must take care of my department were ten surgeons work, among them is my son. Most of all, I love to teach, and all my energy is devoted to training young surgeons and to have them master new techniques, microsurgery for instance. Of course, just as much as we can afford.