It there has more than twenty years, the team of the Center of Traumatology of Strasbourg, directed at the time by , developed the technique with locking. Arsène Grosse was the essential actor of the development of this method which thereafter knew a worldwide dissemination and which deeply amended the assumption of responsibility of the diaphyseal fractures of the members. We met this impassioned at the time of one of the many meetings of teaching which it regularly organizes under the aegis of the International association for Dynamic Osteosynthesis.

. : Arsene Grosse, your name refers to at the same time the processing of the fractures and the spine surgery. Do you continue to carry on these two activities?

A.G.: As you know it, I exert the functions of surgeon departmental manager in the Center of Traumatology of , close to Strasbourg. My current activity is directed rather towards the degenerative rachis and the after-effects of fractures, emergency traumatology being made by young people. People that I are a little surprised of this change of orientation which in fact is explained easily. It is necessary to distinguish two quite different periods in my professional life. The first, where during more than ten years I occupied the post of head of the emergency service in the Center of Traumatology and csotcina.comedy, where I in the broad sense ensured traumatology term knowing the fractures of members, vascular and visceral traumatology, the , and the traumatology of the rachis. It is for this period that I could develop the technique locked femur and tibia, and a little later the gamma nail and its derivatives. I have thus, during many years, on the occasion to discuss all the fractures possible and conceivable and the moment had just left that to young people. I have in fact from time immemorial impassioned by the spine surgery, which explains why the second period of my career was devoted to this field. To take again your question, I would say that my activity is shared between the spine surgery degenerative, the hip surgery and after-effects of traumatology of the members, especially vicious nonunions and cal, which often leads me to make closed chamber osteotomies, but I think that it is a subject which later on we will reconsider.

. : In which circumstances you were attracted by the emergency traumatology and surgery?

. : I passed the first contest of national boarding school in 1967 and I had six months then before taking up duty. There was a post available to the Center of Traumatology and as I did not want to waste time, I jumped on the occasion and thus I was brought to discover the emergency surgery.

. : You have a reputation of great versatility, which is the ideal for a . How did you can acquire this versatility?

. : My formation proceeded in the following way. I spent my first year of boarding school in the Center of Traumatology, where I quickly could note the need for a general-purpose formation to discuss the multiple breakages of traumatology. I then carried out two years of my boarding school in the service of the Instructor Fontaine where the essence of the activity was directed towards the vascular surgery and digestive. Extremely from this two years experiment, I returned in the Center of Traumatology to finish my boarding school. As there was much , the Instructor suggested me supplementing my formation in the department of neurosurgery of Colmar where I remained for three months, at the sides of Doctor . I then was likely to work for three other months in the service of the Instructor at the Hospital in Paris. Thanks to this formation I was able to face in the majority of the situations in traumatology and it is well what it was necessary since we were and we are always on a site distinct from the REGIONAL HOSPITAL of Strasbourg. This concept of center of traumatology, inspired of the German and Austrian model, had allured us at the time because it allowed the processing of all the lesions in a surgical team and unity of place. The Germans continue to be faithful to this concept and train surgeons general-purpose, osseous and visceral, which is not any more the case in France, where osseous traumatology separates more and more from the visceral surgery.

. : Does the principle of a center of traumatology distant from a Regional Hospital appear to you of this fact adapted still well to the assumption of responsibility of ?

. : Unfortunately, I must say that it is not really any more the case, our senior registrars and assistants do not have currently any more the formation necessary to face visceral traumatology and we are brought to call upon digestive or vascular surgeons external. It occasionally sometimes happens to us to transfer from to the , for very specific problems, in particular of imagery. As for the problem of on-specialization of the interns I think that it is very a good thing but it should not be done with the detriment of a overall and more general training of traumatology, in particular in visceral surgery. Our fellow-members German and Austrians continue to profit from a mixed, osseous and visceral formation, and these surgeons remain complete and exclusive , without practice of regulated csotcina.comedy, for all the duration of their career.

. : You Co-signed a method of chamber treatment closed of the fractures of members. From where this passion for the came to you to closed chamber at one time when the anatomical open chamber reduction reigned as a Master.

. : The answer to your question requires a historical small reminder. I lived the time when the central-medullary and osteosynthesis by plate had shown the limits of their possibilities. The simple with closed chamber was an excellent method for the processing of the localized simple diaphyseal fractures to the average third party. On the other hand, this method was badly adapted to the distal fractures and, and especially to the unstable fractures with third fragment or . The complications and after-effects were frequent, in particular the pseudarthroses and vicious cal in , valgus, rotation with shortenings by telescoping of the chamber. To compensate for these insufficiencies, we had at one practiced time of the with open chamber with complementary osteosyntheses by anti-rotatory plate or hooping. In spite of that, the complications remained frightening, in particular the delays of consolidation, the nonunions and especially the . The processing of the comminuted fractures with crash was done in a different way in the two Strasbourgeois departments of traumatology. In the Instructor Eugene the of alignment was recommended, which consisted with set up a nail and to leave the patient in extension during a certain time until obtaining the cal. On our premises, the Instructor had imagined a protocol with deferred osteosynthesis, the fracture being put in extension initially during three to four weeks to obtain a beginning of consolidation, after which the fracture . Despite everything these artifices, the central-medullary of the fractures , distal or often gave poor outcome and the method was not very appraisal in the remainder of France, in particular by the team of and which had to face many complications of the pseudarthrosis type aseptic or infected with this method. It is as at this time as the Swiss ones of proposed osteosynthesis with open chamber with screwed plates allowing an anatomical reduction of all the fragments. That appeared indeed very tempting and much of surgeons launched out in this method. There too, after initial enthusiasm, one needed in front of the fast appearance of many specific complications for rigid osteosynthesis for open chamber: delays of consolidation, pseudarthroses and after ablation of the hardware, consequences of the stress , or pseudarthroses infected and with sequestration, secondaries with the of the chamber. Osteosynthesis with open chamber it had also shown its limits. In the service one discussed great diaphyseal size reductions by continuous extension during six weeks, but that also involved important difficulties, in particular complications of of the type and phlebites, people responsible for functional after-effects, without speaking about the vicious cal and the very frequent pseudarthroses in this complexes fracture type. It is at this time there that Pr was brought to meet Doctor and of Frankfurt which forwarded at the time of a congress the technique of the locked . This technique appeared tempting to him and I could go to Frankfurt to attend an intervention. It was in May 74 and as of my return to Strasbourg I introduced the method in the Center of Traumatology where I posed the first nail locked in June 74. We improved thereafter the hardware, the instrumentation and developed the system of sighting, which enabled me to pose the first locked nail of Gross and two years later, in June 76.

. : After this period of confrontation between the partisans of the open chamber and the defenders of the closed chamber, can one today reach a consensus on the mechanical and biological conditions ideal for the consolidation of the fractures?

. : On the mechanical level, the ideal situation to support the consolidation is I believe a good stabilization by an elastic, i.e. nonrigid assembly of the chamber of fracture. Biologically, vascularization, so important for the formation of the cal, must be adhered to the best possible one and the hematoma must be preserved. It is for me the biological and mechanical conditions ideal for the consolidation. The central-medullary nail with closed chamber answers these requirements perfectly.

. : Is there for you more no place for osteosynthesis by plate screwed in the fractures of members?

. : Of course there remains a place for osteosynthesis by plate screwed in the metaphyseal or epiphyseal fractures, where the does not manage either to reduce the fracture or to stabilize it sufficiently. We have in our Center pushed back very far the limits from the method to make it usable for the very distal fractures of the femur and the tibia. For that, we used nails with lower end sawn to be able to lock possible. In these borderline cases, the requirement to use the locked is of being able set up two screws with good capture in the distal fragment. There thus remains incontestably a place for the plate screwed in the metaphyseal or epiphyseal fractures not allowing this double locking. As for the diaphyseal fractures, I think that the is much higher and in my opinion there is no more no place for the plate, except typical cases. The plate has for me far too many disadvantages already referred to above and even the various “astutenesss” recently suggested as biological osteosynthesis are not able to bring the same gains that the nail and I regard that as rearguard actions. For me the osteosynthesis of the diaphyseal fracture is an osteosynthesis with chamber closed by locked nail.

. : Central-medullary boring was often criticized because of its potential negotiable instrument of ischaemia by vascular destruction. What do you think about it in particular for the processing of the open fractures?

. : Boring actually was the criticism purpose multiple during these last years and one in particular reproached him for supporting the infections, for increasing the pressures in the cabins and especially for causing fat embolisms. In fact the various studies which compared the with or without boring indeed showed that this was false and that there were not more complications in the teams which practiced boring. Quite to the contrary, when boring is not practiced, the nail and thus the screws are necessarily of smaller diameter, which causes complications dependant on the hardware, type of ruptures of screw or even of nails, and prohibits the early weight-bearing. We thus remain of enthusiastic followers of a reasonable boring, without excess, and we go never again up to 16 or 17 for a femur, contrary to what was practiced at the beginning. The usual diameters are currently from 11 to 13 for the femur and 10 or 11 for the tibia. We remain very faithful to this technique because for us the problem is not related on the concept even of boring but rather to the of the borer. The very sharp borers currently available, used at low rotational speed, do not cause any more necroses it by heating which the preceding models with end involved foams. As for the indications for the open fractures, our attitude evolved/moved much. At the beginning of our experiment we recommended the in the open fractures of the femur and of the tibia at the stages I and II even sometimes at the stage III and we observed frequent complications, especially on the level of the tibia. Thanks to the development of the techniques of plastic surgeon and repairing, we know today that these complications were not related to the or with boring but much more with management of the lesions of the soft parties. Currently we know to discuss in same time the fracture and the damage of the soft parties and the complications are quite less than before. Currently in the Center of Traumatology our attitude is the following one: on the level of the femur we all the open fractures, some is the stage. On the level of the tibia, we the open fractures at the stages I, II, III has and we have resort to the techniques of complementary plastic surgeon for these situations. For us the external fixer is reserved for the open fractures stage III B and C and for the fractures where there is urgency for the vitality of the member, in particular total ischaemias where it is necessary to go quickly and stabilize the skeleton as soon as possible to allow vascular repair.

. : The method that you developed in Strasbourg knew a very fast dissemination and there is currently practically more no country in the world which is unaware of the existence of the nail of Gross and …

. : As of its development, locked has known rapid success, probably because this technique made it possible to answer the insufficiencies of the csotcina.comedic processing or the methods of osteosynthesis by simple plates or nails, which caused too many complications, especially for the complex fractures. Initially, extremely three years of experiment with the locked we organized in Strasbourg in April 77, a first symposium where already 250 surgeons were present to learn the technique and to take note of the first results of this new method. After this symposium we set up since 1978 a cycle of theoretical exchange rates and practices which proceeded initially in the Center of Traumatology, with the means of the edge. Quickly the need was felt to add to the French exchange rates of the English and German meetings. In addition, of many colleagues of various countries started to be interested in the method and to organize congresses on their premises, and it is while travelling, while visiting and by exposing the results of the locked nail and especially by teaching the technique which we succeeded in advancing the ideas and to establish the method in many countries. It is primarily this regular teaching carried out in France and abroad which contributed to make known the locked on the five continents. Our results were the subject of many French and international publications, in particular the princeps item of the Newspaper off Good Joint , giving a report on the first ten years experiment. We finally created in Strasbourg the International association for the Dynamic Osteosynthesis which aims to promote the methods of dynamic fixing of the fractures of members and in particular the locked . This generated other subsidiaries in many countries, and there to date exists ten national which make it possible to relay the teaching of the method.

. : Was this teaching thus done apart from any university structure?

. : Unfortunately yes.

. : Which are thus your links with faculty?

. : Currently none.

. : Finally do you regret not having been teaching hospital?

. : Now. You know, I am very often invited by many instructors and universities of the whole world. I take part regularly as teacher in exchange rates of traumatology organized by famous hospitals or faculties, in particular in the United States, in the United Kingdom, Germany, Austria, Hong Kong and in much of other countries. In Strasbourg we organize every year several exchange rates in which thousands of surgeons of the whole world already took part. But that was unfortunately always done apart from the university framework. That also shows that one can be known in the whole world without being an instructor and we are some in France with being in the same situation. I then to prevent me from deploring only the exchange rates which we organize in Strasbourg obtained without problem the accreditation for postgraduate teaching in Belgium whereas for France it is not for the moment not yet the case.

. : The with chamber closed with locking is a relatively difficult technique for which each detail has its importance since the installation until the sighting of the openings of locking. One of criticisms is that the technique is easy only on your premise where you have an trained personnel. You who in many foreign countries, that do you answer your detractors?

. : It is true that the central-medullary with closed chamber is a relatively difficult method and that even in a Center of Traumatology like ours, or the practice is daily, there are still from time to time technical difficulties. Like any closed chamber method, the central-medullary requires a patient training and a rigorous technique, adhered to in its least details. A minimum technical plate is essential, in particular a good food of extension allowing the reduction of the fracture, an image intensifier which one must be able to handle in all the directions without being obliged to change anything on the level of the installation and especially of the actuated manipulators. But here as for other methods, I think of being able to say that all can be learned on the condition of following the recommendations stage by stage, without seeking to innovate not to reinvent the errors. It is especially necessary to learn how to know the many small tricks and astutenesss specific to this technique which are regularly recalled at the time of the exchange rates and the meetings of teaching that we take again every year. It sometimes happened to me to carry out in many countries, I even think of being able to say that I operated on the five continents. I thus of the modern blocks, equipped well as in HongKong, Singapore, in Canada, or the United States. In other countries, the conditions were sometimes more difficult, but I always succeeded in finishing my osteosynthesis and I believe that with the help of a little technical astuteness, a locked is realizable anywhere, even without ultramodern equipment.

. : What do you think of the various techniques of distal sighting which were developed with the idea to reduce the irradiation of the surgeon?

. : We were always very sensitive to the problem of the irradiation and we developed our method of distal locking with framework of sighting with the purpose of moving away the surgeon from the field of the departments at the time of the installation of the screws. At the time of the sighting of the openings, the surgeon moves away from the field, whereas during screwing itself, there is no radiation. If the surgeon does not have the framework of sighting fixed at the amplifier, it can use the sight with freehand , technique which I often used during my displacements abroad, which with the disadvantage of exposing more the hands of the surgeon to the radiation, reason for which we prefer the conventional framework. In fact, for me, the protection of the irradiation is solved and is not any more one current problem.

. : The locked central-medullary gradually extended to the humerus, then more recently with the trochanteric fractures by the gamma nail, in short and long version. This gamma nail was the subject of some criticisms in the recent literature. What do you tell some?

. : As soon as the techniques of of the tibia and the femur proved to be reliable, we got busy to extend the technique to other diaphyses. On the level of the humerus, it is Doctor in Hamburg which developed the method of humeral, whereas the of the ulna was developed by the Instructor of Brest which currently continues the development of a nail for the radius. When the problem of the trochanteric fractures which are complex fractures, difficult to discuss because of the osteoporosis and a requirement of raising early in complete support, no method used in the past, which they are the screw-plates, the blade-plates or even the nail of which was very much used on our premises, made it possible to bring the ideal solution. We have of this fact developed and used since 1987 the gamma nail, derived from an original idea of which for this kind of fracture used the nail in Y. This nail in Y never had been very much used, because of technical difficulties to the introduction. There was indeed no system of sighting for the cervical screw and this implant was not addressed finally that to simple and stable fractures . The idea of the gamma nail came to us from the of the fractures of the femur. We were accustomed to using for these localizations a reversed nail, for example a left nail for a fracture on the right, which made it possible to mount the screw of locking in the neck and the head. In fact, the reversed locked nail was not really adapted to this fracture type and we had many complications, in particular pseudarthroses with rupture of the nail. We thus imagined a new implant, while remaining persuaded that the aforementioned was to be central-medullary, that it was to be set up with closed chamber, that it was to recreate the anatomy of the proximal part of the femur and thus was born the gamma nail which answered perfectly these specifications and which allowed in addition the complete and immediate weight-bearing fracture. From the standard gamma nail was imagined a long version to answer the problem of the trochantéro-diaphyseal, associations of fractures of the neck or per-trochanteric fractures with diaphyseal fractures, or fractures metastatic. This long gamma nail makes it possible to bridge perfectly all the épiphyso-diaphyseal segment fractured with an anchoring by a cervico-cephalic screw and a distal locking by two lower screws. The Y connection carried out by the crossing between the nail and the cervical screw, relieves mechanically all the fractured area, whatever its extent, which allows the immediate weight-bearing of any kind of fracture. The consolidation is often very fast, since the method adheres to the principle of the closed chamber. In spite of some criticisms, in particular in an item which was appeared in the Newspaper off Good Joint stressing many complications inherent in the technique, the standard and long gamma nails will be essential like implants of reference in the processing of the trochanteric fractures in the elderly person and trochantéro-diaphyseal of the young subject because they mechanically and are biologically adapted perfectly to these fracture types.

. : Which are the future developments under consideration for the method?

A.G.: I think that the indications of the of the diaphyses were well codified and that all that is . Our development efforts are dedicated especially on the techniques of osteotomies to closed chamber. A new very powerful endo-medullary saw has just been clarification; it makes it possible to carry out osseous sections without opening of the chamber, with the purpose of adhering to vascularization and of thus accelerating the times of consolidation. These osteotomies can be used for the processing of the angular vicious cal in valgus or and of the rotatory shifts. We also use it for the osteotomies of closed chamber shortening and lengthening for which we usually limit ourselves to 2,5 cm of gain length. Lastly, our interest goes of course also on the nails of progressive lengthening.

. : Does your technique in the osteotomies of diaphyseal shortening remain always realizable with closed chamber?

. : It is very a good question. Two features of osteotomy are necessary to delimit the sector of resection. If one is in full diaphysis one easily manages to practice these two features with the endo-medullary saw. It is then necessary to eliminate the intermediate fragment either while cutting it into two and drawing aside the fragments at the time from the introduction of the nail, or while grinding it to the strawberry. In certain cases, a complete cut osseous is not realizable by endo-medullary channel, which then requires to carry out a small distorsion with the principle of the chamber closed to finish the osteotomy. I regard this distorsion as very tiny since one makes an small incision of one to two centimetres to introduce a torque link well edge, which makes it possible to supplement the osseous cut.

. : Let us come in to the spine surgery. In which circumstances you did pass from surgeon to surgeon of the vertebral column?

A.G.: To the beginning of my boarding school the processing of the fractures of the rachis was generally limited to reductions and applications foundations of concrete, with frequent cutaneous complications, or with the instrumentation by hardware of on the level of the dorso-lumbar rachis. This hardware of did not manage to stabilize all the lesions and imposed a complementary application. With the arrival of pedicular screwing, vertebral osteosyntheses by plates allowed assemblies much more stable and it was not necessary any more of set up an immobilization foundation of concrete. I always had leaning for the spine surgery, and I did not hesitate to reduce my activity of traumatology to more fully devote me to the vertebral surgery. I initially was interested in the traumatic spine surgery, then I continued in the degenerative field. In addition I was likely to be very at ease for the former accesses since my formation of visceral surgery had familiarized me with these techniques.

. : Many controversies persist as for the respective place of csotcina.comedy and the surgery for certain kinds of fracture in particular the ones without neurologic disorder. How do you discuss them with Strasbourg?

. : Generally, I would say that there is incontestably still a place for the csotcina.comedic processing of the fractures of the rachis and the choice between a surgical or preserving attitude requires an enormous experiment. As for the specific problem of the “” fractures I think that the indications are currently well codified. One intervenes when half of the channel is sealed by a fragment, or when there is a kyphosis of more than 30° or of course when there are neurological signs. In urgency, we are accustomed to reducing and stabilizing these fractures by posterior channel, this access allowing if necessary a laminectomy with driving back of the fragment forwards. If decompression is not complete, or in the event of loss of former substance , we carry out a secondary former access then to graft into . L different is the decompression from the start per former channel with Clerc's Office and screwed plate.

. : On the level of the cervical rachis you were one of the pioneers of the screwing of the flank profile. Can you inform us of this experiment?

. : We have indeed important experience of the screwing of the flank profile. I was brought to use this technique adjustment by in Vienna when one day I was confronted with a moved fracture of the flank profile with a of practically a centimetre, therefore a very important instability, in a patient who in addition forwarded neurological signs of type. In this case of figure, a posterior assembly of type lacing first or second manner according to , very in vogue at the time, would not have made it possible to stabilize the lesion and it would have been necessary to make a occipito-cervical arthrodesis from the start. As it was about a young woman I launched out in a synthesis by former channel and I installed a screw in the axis of the flank profile. The development was very favorable and the patient practically very recovered from the neurological point of view, since it went simply with a small cane a few months after the intervention. We carried out 84 screwings of the flank profile to date, with very satisfactory results. I specify that it is indeed of an osteosynthesis and not an arthrodesis, from where the advantage of this technique. We primarily recommend it in the fractures to posterior displacement with medullary threat, in the very unstable transverse fractures and especially in the fractures of the type “cocked hat Londonien”. There of course remains a place for the csotcina.comedic processing but all the very unstable fractures, especially the transversals with alternative instability and in addition the fractures with posterior displacement are for us indications of screwing. This technique is interesting at any age since it allows the consolidation of a fracture without arthrodesis, therefore without functional repercussion, but it is especially useful at the old patient who badly tolerates the prolonged port of a foundation of concrete.

. : By which you were particularly influenced as regards spine surgery?

. : In France we are particularly spoiled in the surgical discipline rachidian. All the large Masters and in particular the Instructors , Louis or make authority not only in France, but also in Europe and in the whole world. I thus remained at the three. Initially I mainly followed the lesson of Raymond for the spine surgery cervical and of Louis for the thoracic and lumbar rachis. Thereafter my indications evolved/moved, in particular on the level of the cervical rachis, where I have me also followed the movement of progressive abandonment of the posterior channels and we do not make currently practically more but former accesses, according to the techniques of . To the level of the we also brought on foot of the exchange rates of spinal surgery which we organize every two years, where are represented the French and European universities.

. : A finally little you, your origin is Lorraine, how you speak were accommodated by your Alsaciens neighbors?

. : Allow me a small increase in time. Indeed, I was born close to Sarrebourg and I made my secondary studies in this small town of Lorraine which is on a linguistic border since on a side of Sarrebourg one speaks French, and other side one speaks the Alsatian dialect. I am thus well placed to confirm that there exists indeed a certain competition between the Alsatian ones and the Lorraine ones, the Alsatian ones being always caught for “higher beings”, which of course they are not. This competition of good quality is not in fact not recent and rests on historical facts. The destiny directed me towards Alsace since at the time the Moselle was connected to the university of Strasbourg, which led me to pass my two vats to Alsace. I was immediately allured by Strasbourg and I immediately liked Alsace, for this reason I remained there.

. : All the participants in the exchange rates which you organize in Alsace are unanimous as for the quality of your greeting. You reconcile the transmission of a surgical knowledge and the gastronomical and oenological discovery of your area!

. : For me the greeting of the participants in the exchange rate which we organize is something of essence and unfortunately I must say that in France one doesnot can always accommodate very well, if I refer to my experiment abroad. Alsace is a very rich area from the point of view tourist, gastronomical, oenological and cultural and I thus have much matter and the embarrassment of the choice to sensitize the various participants in these aspects of our area. I believe that belonged to the life and one can assiduous wellbeing with the exchange rates very and to pass one evening pleasant around a good meal and of a good wine of Alsace.

. : In teaching that you ensure throughout the world you contribute to the radiation of csotcina.comedy French traumatology. According to you how are we perceived abroad?

. : It should unfortunately be recognized that much French abroad is not met and that our the defect not to be rather mobile. In addition they handle the foreign languages often badly, including English, which explains why our work is little known abroad. I believe that for the young people there is an important challenge to take up.