Gilbert is one of the French figures of osteosynthesis. Its multidisciplinary training in traumatology naturally led it towards the central-medullary and it was heavily invested in the multiple developments of this technique. Its implication in this surgical discipline made it possible the csotcina.comedic school of Strasbourg to maintain very high its torch. We met it at the time of the Annual Days of the in Strasbourg in September 2007.

. : Where do you work?

. : I have worked for one year at the hospital of which is one of the university hospitals of Strasbourg. It is located in the western suburbs of the city, , and   thus carries     its   name. Recently, Traumatology was gathered on this site it is there that are the large surgical reanimations as well as the Unities of Imagery necessary to the assumption of responsibility of traumatized heavy.

. : Which was the reason of the regrouping of traumatology with ?

. : Previously, traumatology existed in Strasbourg on two sites, the site of where I had worked for 30 years, and the site of . For reasons of reorganization, the Agency   Régionale   of the Hospitalization decided that all traumatology would be gathered on a single site. The site of had a very specific specificity because it was not a hospital pertaining to the , it was a hospital managed by the regional Case of Health insurance and officially agreed with the . This situation goes back to the opening of site in the middle of the Seventies. Then, for the reasons which I have just referred to, it was decided to gather Traumatology on only one site  : . Whereas the old department of csotcina.comaedics located in and directed by Jean-François has transferred him to . Isn't this a little intricate?

. : Not, but that does it mean that the assumption of responsibility of in was not powerful enough?

. : It very powerful in the assumption of responsibility of large was traumatized in particular, and that was due to the training of the surgeons in place. Historically, the center of traumatology was created in Strasbourg in 1892 pennies because Alsace was then Prussian. In 1900, had been inaugurated a new ship, currently center of functional rehabilitation, but which was then the true center of traumatology. In the popular dialect it was the “house of the accidents.” There were Prussian owners whose celebrates it. After the Treaty of Versailles, returned from the French surgeons, then during the second world war return of the Germans. Then, after the Release, Charles de Gaulle creates the Social security into 47 and the system surviving of the Prussian Social Security, becomes integral part of Secu. One appoints with the head of the whereas Rene , great figure of the French surgery,   is   appointed   at the Hospitals   Universitaires   of Strasbourg coming from Lyon. As of the beginning, this center of traumatology functioned by still doing a little general surgery, but the surgeons were trained to make traumatology with i.e. they was general surgeons trained with the ostéo-articular surgery.

. : I.e. did they discuss the lesions of all the parts?

. : Yes, beside the osseous lesions and abdominal they made the neuroone and the vascular . The Instructor which was my owner and then Arsène Grosse, forwarded this torch to me and I was trained to do all that. Of course with specialization, and the , this type of surgeon almost became one out the law, even if it is still allowed in situation of extreme urgency to nona neurosurgeon to discuss an acute extra-dural hematoma. Whereas we, we operated the extraones, under-duraux acute, and that we establish the probes of intracranial pressure. We practiced without problem of the splenectomies when a fast gesture of hemostasis was essential. But one worked in good intelligence with our colleagues visceral surgeons of the which came to give us a knack punctually.

. : Therefore, in the Center of Traumatology, the famous of , you did all that?

. : Yes, I did all that. What was well, it is that the initial assumption of responsibility was done by a binomial anesthetist and surgeon , immediately supported by a specialist in the imagery. The capture charge it was not a pack of 18 specialists which dances around the patient. In addition, in these situations, that which carries the piece, they is often oldest in the grade more raised, which is not inevitably logical. We, we took overall charges the patient with it and then, if necessary we called upon our specialized colleagues. The colleague was able to make, for example, a resection of hail, but all was ready, the casualty , it was as an operating room, the imagery was complete and the colleague came to make a precise gesture.

. : This model is not that of ?

. : Unfortunately not, since the assumption of responsibility of the urgencies is done in an emergency service where the management is bicephalous  : anesthetist and hospital practitioner A&E doctor. There are appeal processes which have just been reactualized to explain why it is necessary to call upon the seniors , neurosurgeons, thoracic, vascular, etc… I think that one loses in effectiveness. Our old system, of Germanic inspiration, avoided dispersion and facilitated diagnostic and therapeutic decision making. I think that it will serve again us of model in the development of our future Department of traumatology and csotcina.comedy which will be born with in four years.

. : You are you forwarded to the next of service of ?

. : Not, although one me made the proposal of it. But I preferred not to take the of service. I want to still be on the ground. I directed the emergency department of traumatology in during 20 years and I noted that became increasingly heavy. One is obliged to disconnect itself from the surgical practice and like I continue to badly develop not thing in the medium of osteosynthesis, I have to be still on the ground. A choice should be made, and I made this choice. It is thus François , which is currently pH with which will take the , to replace Patrick Simon who leaves the academic world and Strasbourg for Lyon.

. : How much operating room suites do have you?

. : For our speciality, there are 5 blocks. We make there traumatology emergency and secondary and there is a also little csotcina.comedy, but one tries to limit because the csotcina.comedy of the is done in theory in now. It should be also said that there is a third pole which is in the center town (at the central hospital) where Jean-Henri does much knee and sporting traumatology. And then there is Jean-Paul who makes the spine surgery, apart from the spinal surgery urgently in particular of which is done on our premises, always for the same reasons of imagery and heavy reanimation. Thus rachidian traumatology comes on our premises.

. : Who discusses it?  csotcina.comedists or neurosurgeons?

. : There exists a system of obligation per week for rachidian traumatology. In this pool of obligation there is a majority of csotcina.comedists. It is thus rather our speciality which discusses the traumatic rachis, because historically the neurosurgery in Strasbourg was rather directed towards pathologies cerebral and medullary.

. : How did you disembark in the ?

. : As external I was rather inclined to make reanimation. I always liked the activities of ground and the environment of the urgencies. I passed in medical and that had rained me much. The service was directed by a very dynamic owner who was Jean Marie and I wanted to continue in his service. Then randomly of the training courses, I arrived at the Center of Traumatology which had just opened in . Thus I could admire his operation which was enough revolutionist for France of the middle of the Seventies. I was impressed by the rigor of and the surgical leg of Arsene Grosse and therefore I decided to turn me towards this speciality.

. : How old were you?

. : I was 25 years old and at the time I. pulpit was titular, and Arsene Grosse directed the unity of emergency traumatology. I worked much with Arsène on a post of since under the articles the hospital was managed by the Health insurance. Then I left for nths to Fort-de-France into 80-81 as a volunteer for the technical assistance. I worked with Henri , Yves and , West-Indian neurosurgeon of formation . I did much neurosurgery there, because Fort-de-France was the center referent of neurosurgery for all the French West Indies, the close Guyana and islands which had just acquired their independence like Co.-Lucie and the Dominique.

. : And with your return?

. : When I return to Strasbourg, at the end of 81, I turn over to the . I took much guard to see a maximum of things, and I passed in all the unities. There was of course the unity of the hip which I. directed. Its senior registrar of the time Jean-Henri was interested already in the knee and I was likely to be able to form me at his sides. I also passed in the septic unity of surgery directed by Guy Jenny, I made my thesis besides there on   the cement balls to the . It was a German idea of the school of Frankfurt and we had much relation with Frankfurt at this time.  To finish my specialization, proposes to me to be sent to Frankfurt at Prof , because as Alsatian we are perfectly bilingual. But finally he proposes to me to go to Brussels at André Vincent, whom he knew very well, because they needed a . I thus leave three years to the Catholic University Leuwen.

. : How that does it occur to Brussels?

. : Very well, I have a large activity of but also of csotcina.comedy. I do much prosthetic surgery in the service of Andre Vincent, and not badly of rachis. But also I meet my wife who worked in the service   of   .   . I had the possibility of remaining in Belgium, but I wanted to return to Alsace because it is an area to which I am very attached.

. : What does it occur on your return to the ?

. : It was at the end of 86, I had my diploma for the occupation of csotcina.comedist-traumatologue and I recover to work with Arsène Grosse. He started to be a little wearied traumatology and had been a passion for the spine surgery. There was thus a good passage appropriateness of relay. I had profited from his teaching and I adored this work then I succeeded to him very naturally in the Unity of traumatology.

. : You had worked together on modern osteosyntheses?

. : If you think of the locked , it is an old history  ! That started in the middle of years 75. Always because of the privileged relations that had with the center of traumatology of Frankfurt. It was one day returned while telling to Grosse  : I saw a nail set up in indications of septic surgery, but they put screws to avoid rotation, you should go to see that. Arsene leaves to Frankfurt and it returns from there while adapting the technique to the processing of the fractures, as of years 74. But the hardware which was manufactured by a German small firm was not very powerful, the of and the sights were not very good, it was necessary to roast the hands under the amplifier… In short, he told himself that one could better do. He takes his small bag and his ideas and will see Benoît who tells him  : we have just been bought up by an american company which is called and which has a factory in Kiel with which collaborated. As in Lorraine good it was also perfectly bilingual, it there goes and discusses with the engineers. It is as that which the history of the nails began. It was, one will tell, into 76. Practically as of the beginning, we organized run because people started to be interested in it, and as me I was his small hand, as of 77, I helped it to make teaching. That made now 30 years  ! We proceeded in a rather original way the team of guard put the nail and locked in , but it was a well defined team which made distal locking not to miss it. Three people constituted the special team which   guaranteed the quality of locking: Arsene, an assistant who was and me.

. : From the start distal locking appeared difficult!

. : Yes but rather quickly thanks to Denis , unfortunately deceased too early, and an old radio operator manipulator, which was called Eugene has emerges the idea of the sight fixed on the image intensifier. Thanks to this sight, one did not take any more a department and that endured until there is little. This sight is not adaptable any more on the amplifiers of brightness of last generation, which are too large, and this technique is falling into the lapse of memory.

. : How do you proceed today to lock?

. : Today, one locks like practically everyone, i.e. with freehand. But one works on one generation of external sights. With Arsène we tested all kinds of sometimes incredible prototypes. Currently we especially test external sights on long Gamma, which seems to go well. And then one works on new technologies whose navigation which I think will bring to us interesting things in distal locking if the price decreases, and if the startup of the system takes less time. Because it is the mailman limiting in the operating-rooms nowadays.

. : At which Arsène moment it was interested in the upper end of the femur?

. : It was the obvious result of the things since one made for the diaphysis and the proximal part of the femur. There was also the influence of the privileged relations which had , with   in Vienna. We thus did many of in the Seventies and with beginning of the year 80 because we wanted to remain in the philosophy of the closed chamber and the respect of the hematoma .

. : Were you satisfied of the nails of in the fractures ?

. : One was not always very content with , but it should be said that one made of it so much that learning curve had been fast and that thus one controlled the tricks and the astutenesss of them. One   also laid out     of good food of operation what facilitated the reduction largely. And then had the idea to lock the nails of on the level of their condylar penetration.   I.e.   that after amendment of the pallet distal, more and larger, one could in end of operation bring closer the three distal ends to the nails and to fix them using a screw. Thus, one of the complications, which were the projection of the nails of on the level of the skin, was controlled, just as external rotation. But there were of course other problems, and one of the major complications they was the partitions on the level of the entrance point. That points out an anecdote to me: when the interns showed the radio operators with the “Soviet”, they always hung radio operator knee in bottom on the right and they were put in front of dissimulating the entrance point of the nail, sits of the partitions to the Owner,   since   with   the time Mr supervised all the “Soviets”…

. : “Soviets”?

. : Yes, it is the name which one gave and which one always gives to staff in Strasbourg, survival of times of large the which were then Fontaine later.

. : How did you arrive from there at the gamma nail?

. : On the basis of the ideas of , of course, but also while being confronted with a little specific cases with the nail of Gross & . Thus, we had had the idea to take nails which we reversed to very discuss of the fractures . A nail right put in a left femur allowed the installation of the screw of locking in the axis of the neck 130°. But the diameter of this screw and the presence of the departure of the posterior slit of the nail made that this type of assembly was not very satisfactory on the mechanical level. On the basis of this Arsène idea told itself that it was necessary to make a more powerful nail and better drawn. It is as that which it drew the current nails but while being also helped of the ideas of . had already had the idea to draw a nail with a key which it had called It the nail in Y. was not very easy to pose because at the time it did not have very good amplifiers. The key was not always easy with set up, and then it was necessary to thread the nail in the key what is often difficult. On the whole it took many departments, and moreover the nail was not locked what explained telescopings. At all events, the first gamma nail born of all its reflections and experiments were posed in December 86. December 86, it is also the creation date of the . The first nail was a prototype, which had defects. One posed 27 of them. They did not have médio-side curvature  ,   they were very large, they were very long. Then, there were reworks which made that the experiment really started in 1987.

. : The first in particular Anglo-Saxon communications of beginning of the year 90 concluded that it was a technique which gave many complications…

. : That comes in particular from an item in the . The authors had not followed the technique and had systematically used nails of very large diameter introduced with the hammer. When the item is read again, one reports oneself that there were only technical faults. The authors regretted of the fractures but also of the early postoperative fractures which were in fact of the unperceived last fractures . To put the distal screws, the cortical one was prepared using a punch and of a hammer and that also weakened the diaphyseal area. The gamma nail is not a nail of osteosynthesis like a nail of for a diaphysis. It is more one support for a cervical screw which will maintain the fracture that another thing. But people had not understood that, and learning curve was very long particularly in the United States. The first time that one forwarded the nail to the United States it was in 1989 in New-Orleans but very quickly they completely “destroyed” the method. American returned to the Gamma 4 or 5 years later starting from long Gamma. Opposite pathological fractures, thediaphyseal ones or organic associations     certain teams said  : why not take again this concept there  ? One then did much exchange rate, one explained the concept much, one often went to the United States to show the technique, and American often came to Strasbourg to see how we made. Finally indicator which long Gamma went in often difficult cases, they retrogressed and told: the court must go too. That was then a restarting in North America.

. : One remembers that at the beginnings of the locked , you had been very attacked by the “platers”?

. : Yes, I lived the violent period. Even in certain services   of   German-speaking countries  , which a priori were to know the ideas of well, it was “criminal” to especially make a in the open fractures. This time, fully lived it. It was made attack because people said that it destroyed bone marrow and that bone marrow was the “core” of the bone. Finally, people saw that the first results were convincing and that in the crashes, one managed to maintain the length and the axis by making small incisions and that the cal was formed in an abundant way. The ideas then started to change. But there were many platers especially in Switzerland and in Germany and the attacks were virulent  !

. : The basic problem remains, the medullary it is not very physiological…

. : With regard to the cal, there do not seem to be problems, the osseous consolidation being done by the periosteum. On the mechanical level, it is true that a hollow tube is more powerful than a full cylinder because of its elastic properties but all osteosyntheses amend the elasticity of the bone.

. : And what do you think of boring?

. : I believe that boring has its interest. It was supposed a little empirically that the product of boring stimulated the osteoblasts but much people thought that it was not true  ! There is a thesis which was made in 2001 in Amsterdam which showed that the product of boring swarmed with osteoblasts and thus there are good arguments for the cellular role of the product of boring. Now, one goes even further, because one reports oneself that the product of boring contains mailmen ostéo-inductors. Not badly of teams worked on top, in particular in Germany. I am convinced of that, but one does not need more to ream in to put nails of very large gauge. feared at its time the ruptures of hardware because the metallurgy was not what it is nowadays and one put of the large nails so that there is no rupture of nail. When the manufactoring processes became better, one used less important nails of diameter, but one continued to ream because boring always brings something.

. : Did you have fat embolisms with boring?

. : That was not a problem because one had of it but very little. One worked much on top. One of our owners of faculty of pharmacy the Instructor was impassioned by the subject and made systematic blood dosages while one reamed and finally it proved to us that did not have many repercussions. One had even made a controlled study with the service of of the time, to compare our series  : even standard of patients, even geographical surface. They had more fat embolisms than us and the only difference between our series it was the time between the accident and boring-enclouage. In the Eighties, on our premises, it was of about a one half-day and on their premises it was on average three days. The difference was statistically significant: we had less than 0,5% of fat embolism and they had 3% of them.

. : How is Arsene Grosse?

. : It took its retreat and it made the choice stop completely. It remade its personal life and it a little cut all the bridges around him and especially with its trade. It was a remarkable surgeon who had “a leg” like one tells. It was a glutton for work, able to operate day and night, to have fun the festival and after starting again. It was a jovial fellow, a temperament  !

.  : And didn't a life of x-ray exposure, that leave him after-effects?

. : Not, because it was always well protected. In addition, he very quickly said to the beginning of distal locking  : “me I do not continue like that, to put the hands close to the radiation source, it is necessary that another thing is found if not one stops, they is too dangerous”. Therefore the sight was developed. We always carried our dashboards of lead and always paid attention to the radio protection. Since 1975, there were manipulators of electroradiology dedicated to the , that represented a guarantee for the quality of the per-operational imagery. One was already advances some on top too.

. : How you managed your open fractures?

. : One immediately discussed them while being probably with our beginnings on the .  But one controlled the techniques of external fixing well too. Therefore, on the level of the leg, one used external fixing, sometimes but one dared to go until the open fractures   3B with the .  Thereafter one rather used the external fixer initially followed in the second time.

. : With which chronology?

. : That depends on the general context. I think that it is necessary to go there relatively quickly, i.e. rather before the fifteenth day. In practice, one initially followed . One removes the fixer and one sets up an immobilization i.e. either a continuous skeletal traction, or an immobilization foundation of concrete with possibility of supervising the openings of cards: and then one takes over by the when the local situation appears good. When one started to proportion the CRP, one had a more reliable argument for the choice of the moment of the . Roughly speaking if the CRP standardized in lower part of   15   ,   one     went there. Now, a little as for the total prostheses of hip infected one does all in a time. One removes the fixer then one carries out the in the same meeting by making a bacteriological analysis of the product of boring followed by . If that passes it is well, if it occurs an infection, one discusses it by an adapted .

. : How do you see the development of traumatology in France?

. : The tendency is with the reduction and the regrouping in the great centers. It is seen that the hospitals of medium size   have   tendency   to send the towards the great centers. It is the logic of the centers referents and I am convinced that for the surgery of for example, it is for the benefit of the patients. But even for rather banal traumatology, the tendency is with the transfer because they privilege csotcina.comedy more and more. I will throw the thick piece in the pond! I think that people ignore traumatology more and more to turn towards csotcina.comedy much more lucrative. The young senior registrars do not regard any more traumatology as being an necessary evil with their formation.

. : That holds with the prospects that one offers to them for their professional exercise…

. : Yes but then how will   be made? If one makes “centers of ” to attract young colleagues it is necessary at least that their wages are correct. One cannot accumulate the guards, to have the stress to make only , not to know what one will do in the two hours which follow and to note only the colleagues who make regulated surgery earn their living better. What will it occur? We are already living it! One will engage of people who come from other countries (and it is a recommendation of OECD besides) to make this surgery. We then arrive at two-speed medicine that some feared. “Banal” traumatology concerning a still young population, that of the fractures of ankle and of the traumatology of the knee, will be discussed in private structures for-profit. The , the will be they managed in the Public service with personnel whose formation will become increasingly random, considering the mode of recruitment.

. : What do you think of osteosyntheses of minima with plates?

. : I badly did not joke about it with Robin Peter of Geneva while telling him:   “still make an effort and instead of putting the plate along cortical side femur you put it in the channel and you will have very understood  ! ” More seriously, in the service, one also has good experience of it. It is sure that for the articular fractures, the locking of the screw to the plate that brings something in the field of the stability of the assembly. Now, starts to pose the problem of the ablation of this type of hardware. There are well 20 to 25% of difficulties of ablation of the screws of locked plate. The majority are out of titanium and that poses also the problem of the osseointegration on the level of the end of the screw in the cortical one. In practice ablation often ends with the torque link to strike and in a long incision. Of an invasive mini implantation one arrives at an invasive maximum explantation. Then is titanium ideal metal  ? Does one have inevitably to give up other alloys  ? Is locking with a system net-net, it what there is best  ? Isn't it worth to better take a more traditional screw and to lock it by an additional system  ? There are all sorts of thing which already exist and which are under development.  The ablation of the hardware was certainly minimized. You will tell me that one always does not need to remove the hardware, but they are often young patients and the plates are often cumbersome. But what will it occur if this type of hardware in place is left? I think of the colleague who will want to put an hip prosthese or of knee and which will be found confronted with the ablation of this type of equipment set up 30 years before.

. : Currently, which are the subjects which impassion you?

. : It there with the navigation which is, amongst other things, a true means of solving distal locking. I tested a prototype there is a few weeks in Strasbourg it is quite advanced. One does not even need to have a round image     distal openings   since the computer program will correct the error of rotundity of the holes. There is no more that to navigate on the screen, and it is very pretty to see. The mailman limiting of course it will be the price, but there is no reason that does not decrease. One saw well the development of the navigators GPS in the cars  ! The other limiting mailman, it is that to start the navigator that takes time. It is still too long. When one has systems which will start more quickly with installations of locator very fast, this obstacle will be raised. Then, I work on an younger generation of boltable epiphyseal plates which do not have any more the defects of the first generations and from which the first clinical trials soon will begin. The new guidelines of the organization of our speciality in Strasbourg within the University hospitals make that in 2012 a new ship will open its gates. This ship will gather all the Unities of Traumatology and of csotcina.comedy and to take part in the development of this project is of course enthralling. We will have opportunity of bringing our experience gained during thirty years to the to give on the way of the circuits of assumption of responsibility of the urgency and the consultations! What could be more enthralling than to re-examine a true Center of Traumatology and csotcina.comedy in Strasbourg!

. : Summers you very implied in the ?

. : Yes, I was a long time chairman of this Association in the international   plan.   Mr and Mr Grosse founded the in 1986 and I belonged to the cofounders. The things quickly evolved/moved since this , which was very of Strasbourg, became international with subsidiaries in Germany, then in Italy and Asia, and now there is of it more than one score. The structure . The structure of the clearly evolved/moved during the last months since it became a foundation with Swiss statutes!

. : Why not France?

. : To create a foundation in France it is very intricate. Like creating a society in France that lasts of the months whereas in England, it is done in 48 h. the historically lived royalties. The patents having fallen into the public domain these royalties disappeared, and the main sponsor allocates a sum with this foundation. But it is the foundation which manages, which organizes teaching, which allocates research grants and which really works in all independence.

. : Like is made the teaching of the ?

. : Teaching is done thanks to exchange rates which are intended either for young surgeons, or with personnel of surgical unit. There is now a permanent training center in Nice in a very beautiful ship. There are made basic or fundamental exchange rates rather, but much of exchange rate are still done in Strasbourg. One has a few hundreds of surgeons who come each year to see the “” surgery. They come to discuss very freely and it is not directed solely on the surgical hardware used but also on the problems of installation of the patients and towards the post-operative follow-up. There are other exchange rates in France which are organized for the as in Brest and Nimes. In all the other countries where the foundation exists, this type of exchange rate continuous to being organized and a very dynamic way in Germany, in Italy, in Spain, in Asia, in Japan, in HongKong and the USA. But teaching is not the only sphere of activity, of the research grants are also allocated each year with researchers of all the continents. Publications are also done under the aegis of the national , and very recently the Italian colleagues have just left a work operative technique which refers already in the transalpine universities!