Two North-American pupils of Emile , Joel and , directed the exchange rate on the surgery of the fractures of and the mining area organized by the last September to Paris. They report us the circumstances of their meeting with Emile and the teaching which they received from that they regard as their Master. Their account is more the nice homage which one can pay to Emile.

 

. : Mr and Mr , you knew each other before meeting Emile .

 

: Joel and myself were resident in California without us to know; we worked at the time in two hospitals different of Los Angeles.

. : At which time?

: It was in 1974 and I was internal. You know, at this time, the surgery of in the USA was almost non-existent but my owner had decided that, in its service, all the fractures of were to be operated and , and I can tell you that at the beginning it was “an adventure” and still the term is weak! It was a a little rigid bear in its way of thinking and it had not raised questions about the techniques too much to be used to arrive to its ends.

What was certain, it is that if one decided to operate a fracture of , one was sure that it was going to pass as an operating-room, but one never knew too when. And in general in the medium the most total confusion, it was pointed in your back and started to howl: “Then, what you are exactly making now! ”.

One thus operated a certain number of it. I am not really able to tell you what they became, but what I know it is that each time it was a difficult experiment. When I left the service at the end of the Seventies to settle in Nevada, as I had taken part in this “experiment” in Los Angeles, I continued with me to interest in it. I operated some cases. At the beginning of the simple cases, then increasingly complex and it is at this time which I understood that I needed to learn much more than what I knew already. I thus decided to go to see Emile who was, in my opinion, the only person who had understood something with the problem. I had met it when it had come to make a presentation in 1980. I remember the date very well because one had kept it after his conference to look at an American football game. It was the team of “Notre Dame” against another team, and it seemed to look at that with a certain attention. One had asked him: “And you Instructor, for whom are you? ” He had answered: “I am of Paris, I am for Notre Dame obviously! ” I had found the character enough sympathetic nerve, full with humor and that had encouraged me to send a letter to him by asking to him whether I could spend a few weeks in his service in order to improve me in this surgery. I disembarked in Paris in November 1981 when, as soon as I arrived in the service, he told me “, but you must know which is also of California, he left the service fifteen days ago. ” I answered him: “Not, I do not know this . ” You thus see that it is even thanks to Emile that I succeeded in knowing Joel .

. : And you, Joel , how did you come to the surgery from and the mining area?

Joel : I made me also, my boarding school in Los Angeles, the Martin Luther King hospital and, like , we were interested enough in the service by the lesions of and the mining area which arrived in large amount. We unfortunately had surgical protocols which were not truly at the point and there were many complications.

Our reductions were, it should well be recognized, rather bad.

In 1974, at the time, when you read the literature, there was really only the item of and in the of 1964.

It seemed that they were the only able ones to read radiographies of a fracture of . At the time, as soon as one did not understand any more, we speak about “ fracture”.

As much he was clear as much that for a fracture around the knee or of ankle the restoration of the anatomy was a requirement, the majority of the surgeons discussed in an csotcina.comedic way the fractures of . made me come in its hospital to Los Angeles, and it was accustomed to asking each one among we when we arrived on what we wanted to work and I answered him that the surgery of the moved fractures of interested me and it allowed me set up a protocol of assumption of responsibility. had even proposed to me to work with which was the owner of and which also was interested him in the surgery of .

I knew very well that if I worked with , that would not go because at the time it was “tea boss” and we were, no matter what one does, “tea servant boys”. I thus worked all alone in my corner.

With the end of the year 1980, had organized a great congress on the traumatology of the hip and had invited Emile to speak about the fractures of and more particularly of the x-ray reading of . Benefitting from his presence to the congress, I had approached it, very timidly as an intern can approach somebody who is known with the world plan.

I had asked to him whether he wanted to look at the cases which we had operated and especially if he could come with us to the laboratory from anatomy to show us channels initially and a little the way in which he began there to expose the lesions.

I had been surprised besides that it accepts so readily and it was really felt that it did it with pleasure and with much patience.

This day, it made a great enlarged channel initially which one all looked with much curiosity but finally one among us had dared to raise the question: “You made this kind of dissection only to show to anatomy or you to us made that also on alive subjects? ”

He had answered us while smiling that he did that among patients who had fractures of and whom they recovered a very good function. It should be known that at the time to the maximum one made channels initially of and boldest divided the great trochanter to note part of the gluteus range in order to reach the former column.

Then imagine when one read in his book the extended initially ilio-femoral channels or !

A little later I showed him some cases which I had operated who, he should well be recognized with the passing were not extraordinary.

: You showed him some of the cases that you had made at the time?

Joel : And yes, I did that.

: I find always extraordinary way whose young people surgeons, when they meet somebody which could have experience like Emile , pass more times to try to show their case than to try to learn. Emile could make use very well of that. By congratulating them, then in their explaining the errors which they had made, it gently attracted them towards the way in which this surgery made him.

Joel : It is at the time of this passage to Los Angeles which I am allowed to ask to him whether I could come to see it in France. There is another history in connection with this inspection in Los Angeles at the end of the Eighties. One had asked him to operate a case. It was a police officer who had had an motorbike accident and which had been made a fracture of the two columns of . It had been asked to him whether it could come to help us and show us a little its techniques, this more especially as it had come with all its forceps, its plates and its screws.

That was not very simple, because, you know, the laws in the USA are very strict and no matter who cannot enter in operational room, even less to practice one surgical gesture. Finally, one succeeds in obtaining the authorization and the intervention begins. It makes all its channel initially , and it is at this time that supervising it of the enters the room while : “It is impossible that continuous, Doctor does not have the right to operate here, it is necessary that it leaves the immediately. ”

And Emile had answered him in his English: “Madam, I am absolutely sorry but the aircraft is in the air and I am the only pilot able to currently pose it. ”

He had all the same asked us before the end of the intervention if the font awaited it outside to take it along in prison but finally the things were finished very simply and our patient had perfect continuations and very a good performance.

It is where it had started to surprise us with its procedures. For example, it took the fuse, bored in the mining area, it left the fuse and it asked for the instrumentalist a screw of m and us very set on the principles of the , asked him: “But you do not take a measurement-screw? ”

He had answered us: “And well do not hesitate, take in one” and indeed they was m!

. : Then finally in which year did you come to Paris?

Joel : in 1981, a little before .

: I also came in 1981 and that had been a little difficult with my wife. I had had some difficulties of explaining to him that I left to make surgery in Paris. For it, France was almost a country under developed, fallen into the claws from Communism. She imagined me well near the “small women of Paris” and at all near one of the most known surgeons in this field. The stay in Paris was absolutely fantastic only with cause of exchange rate at the time. In 1981, for a dollar, there were ten francs. I had been a small hotel very sympathetic nerve not very far from the gate of and I spent only 35 dollars per week to place me.

I had thus gone to the Private clinic of the Gate of where I had arrived near the hostesses of the greeting and I had asked to them whether I could see the Instructor . These charming ladies had told me that they did not know, that was not inevitably possible but only if I wanted to wait well they should see what they could do.

At the end of 5 a.m., as I saw that the things did not progress absolutely, I am turned over to see the “ladies” which finally made an effort and I could meet it rather quickly afterwards.

The first meeting was relatively short. He simply asked to me whether I had read the first two chapters of the book.

He made me re-enter in his office by showing me a cupboard. All the cases of the book are there! When you study them in library return to see me…

After this a little icy departure, the things improved well and I spent a few extraordinary weeks to operate with him.

. : How long did you remain in Paris?

: About three months. That was really a very pleasant period. I immediately had much attachment for this sympathetic nerve troublemaker! It was a baited, untiring worker but who could also have fun the festival very well and I discovered France under one day particularly favorable thanks to him. The atmosphere with was truly exciting. One launched out in excessively difficult surgical cases. One worked a whole day in an absolutely incredible way, and the evening, whereas one had that an idea, to return to rest with the hotel. But he explained us still various procedures until undue hours. And it was not finished! It was still able to trail us into bars with oysters or restaurants where it was accommodated in an extraordinary way. And that did not prevent it absolutely from starting again the next morning with the dawns!

Joel : In fact, I came in with a sight a little different from that of . At this time, as I already told it to you, in the USA the surgery was far from being accepted and when one started in the congresses to forward the cases which one had operated, one was made a little discuss the insane furious one. The colleagues asked us what one could promise well with our patients. Because of the almost inescapable complications, there was especially a good luck not improve them, to even worsen them. Then of course, there was this French surgeon, Emile , who seemed to have well understood radiography, seemed well to analyze the cases, but one really wondered if the follow-up of its patients were correct, if it really did not have too much complication, if… In fact, I will say almost that I came to France to check myself all that.

Thus, when I returned in a with him, I was intrigued enough by what he understood by “perfect reduction”. I wondered whether it were not a word which only the French use and which we do not dare to employ. For us, reduction is a word which is then enough itself to add the item to it “perfect” left me a little dubitative! The first case, on which I helped it was a transverse fracture of and I entered in room by asking me how it could obtain these famous 75% of perfect reduction well.

It was a transverse fracture. One made a channel of . It installed the two small screws of reduction, then it placed forceps of and it asked me what I thought. I looked at the feature, which seemed to me indeed perfectly reduced, and I answered him quite simply: “That me with the perfect air! ” It looked at me and told me: “At all, you are mistaken, it is not a perfect reduction. There, under our eyes, that with the perfect air but your finger in the large sciatic notch and a little the quadrilateral blade, you palpate pass will feel a small aliasing. It still persists a small error of rotation which should at all costs be corrected! ”.

It very removed, it very began again then it again reduced the fracture. It again turned towards me while telling: “Now, it is perfect. ” I must recognize that it is one of the things which it me really taught; to know to recognize the small imperfections, and to correct them. The correction of these small imperfections makes the difference and involves large benefit for the patient.

Joel : And you, , you were not a little skeptic when you arrived at ?

: In fact, not, because I had just spent one year to Switzerland to quoted of Maurice and I was probably readier to accept the various techniques of internal osteosynthesis than a surgeon trained in the USA. In fact, osteosynthesis had some difficulties of being made accept in the USA. At the beginning of the century, when one launched out in osteosynthesis, there were nevertheless many problems of metallurgy, procedure, infection, problems of anesthesia. The English school dominated csotcina.comedy between the two wars and after the war because of that. One had shown the catastrophes which could involve of bad osteosyntheses and one had become very pointed and very extremely in all that was csotcina.comedic processing. It is really thanks to the work isolated from some like and the school Suisse that one could judge interest of internal osteosynthesis.

During my passage in Switzerland, I had been able to appreciate these techniques which were relatively new in the USA and I was already persuaded that a surgery well done could bring to a completely unquestionable benefit for the patient.

In fact, when I arrived to , I was already persuaded that a good osteosynthesis was better than an csotcina.comedic ill treatment and I was rather excited with the idea that one can also now attack the fractures of which were one of the last bastions of the csotcina.comedic processing.

. : Was Joel , which man for you Emile ?

Joel : It was somebody of very intelligent, very hard-working, with a savage will to succeed. He was really very cordial with me; it was enough that I forward myself to him as somebody of interested in his work so that it devotes me much of his time. At the time, I did not have almost any experience on the matter and I was always very grateful to him to have taken such an amount of time to train us.

: As I said it, when I arrived at his place, I almost had just spent one year to Switzerland. I had thus attended much Maurice of which all the techniques were very rigorous; environment was far from being jovial and I was almost persuaded that everywhere in Europe in the services this very studious and a little cold environment reigned. That was really a large surprise for me to meet this overflowing man of energy. He was not very different from Swiss in his will to achieve a very neat work and very precis but he went simply much more quickly with an extraordinary energy.

. : Did he speak English well?

: One suspected well that it was not its natural language but it used expressions which were so convincing that they invited us to change our way of using the words.

. : For example?

: Instead of telling as one said it: the fracture line goes from the pubis until the , it preferred to tell: “The feature of this fracture of the pubis interests the ”. It is much more subtle!

It did not have a problem to speak English: it was made perfectly understand and it was always very clear.

Joel : In more since one knows it, its English improved well. He started to attend more and more the American community starting from beginning of the year 80 and with fine its English was truly excellent. At the beginning, all its exchange rates were written in English but towards the end, it did not need more that and spoke in a completely natural way.

It as should be known as the fifteen last years, it did not publish almost any more in French language and very wrote in English.

: You know, French is an extraordinary language for csotcina.comedy. To describe the lesions, French is much more precise than English and Emile had known to keep this precision of French when he wrote in English.

. : What did it occur when you returned to the USA? Did you have the impression that something had truly changed in your practice?

: For me, it was absolutely undeniable. It is obvious that I could make things which I did not can make front.

Joel : It is true that I learned in a few weeks near him than in a few years before. It is extraordinary to be close to a Master like that. As soon as you have a question, you can pose it, you have the answer immediately, which is not inevitably the case in your everyday practice. I had immediately realized of that because it had come to make us, as I told it to you, at the end of 1980 an exchange rate on the hip fractures and it had made us a lesson of one hour teaching on the normal radiography of the mining area.

That had been extraordinary, because the audience was only made up csotcina.comedic surgeons, specialized in the hip, who had thus seen passing a few thousands of radiographies of the mining area before this conference. We have this radiograph. One had them under the eyes and one never had seen them well!

The chapter on normal radiographies in its book is a pure wonder. Any person who is interested a little in the hip and not inevitably with the fractures of must have read it. One apprehends really the standard radiography of the hip in a completely different way afterwards.

Joel : I put myself in contact with and we since remained always very close one to the other. We do not work together. At the time, was in in Nevada and me I was in Los Angeles. is currently in Détroit after having been in in California and I am always in Los Angeles. We see ourselves several times a year and we compare our cases. That was very productive especially at the beginning.

And then, one was likely to be a little the pioneers of this surgery in the USA, to drain, each one among us, of broad mining area of population, which enabled us to acquire a fast and extraordinary experiment.

: And then, one formed also part of the what was an essential thing to be listened in the USA as regards osteosynthesis. We were likely to become quickly within this authority the two leaders as regards fracture of . That enabled us to disseminate these ideas much more quickly than if we had worked in our corner by publishing our cases simply.

That was also interesting for Emile . When we are turned over to Switzerland to speak about our first cases and the interest of the osteosynthesis of well done, they are then the Swiss ones which was interested in this small French who did not form part of the and which used a little personal techniques.

They are finally the Swiss ones which came to seek Emile to belong to the .

Joel : In fact, the things did not occur also simply. When Emile went to see Maurice to develop implants specific to the surgery of with curved plates, screws much longer, it were opposed to a categorical refusal of Maurice who explained well to him that with the plates and the screws of the , one could do everything.

In fact, the relationship between Maurice and Emile were never extraordinary even if later Emile belonged to the and gave consultings for the creation of a set of implants.

At the time he worked with a Swiss society which was , and it is them which have truly carried out the implants which are closest to the philosophy of Emile .

Joel : When I returned to the USA, I tried of course to use the principles acquired during my stay in France: that was not always possible. For example, we did not have a true table of and one tried to make with the means of the edge. One tested on ordinary tables, but I must recognize well that it is as from the moment when I had a true table of which the things improved well.

When we, American, we started to interest us in the surgery of , that made him more than 25 years that it was interested in it and in fact, it invented almost all the basic principles of this surgery. Each time one tried to make small amendments one realized that one really did not go in the good sense and one more or less always returned so that he had taught us. For example, you know that I worked much on screwings of the fractures and luxations of the sacroiliac ones. It had developed the technique with open sky and I a little amended the technique by using the image intensifier and while trying to pose my screws in a cutaneous way . He had advised me to withdraw the screws with five or six months and I did not do it for a long time. And then finally I started to do it and I actually saw that my results were better.

. : Do , you remove the screws?

: Until now I did not do it but I probably will put to me at it!

. : How long did you put to sit your position as a surgeon of and the mining area?

Joel : In fact, that was simple. When I returned and that I started to explain that I wanted to operate all the fractures of the mining area and moved , all my colleagues hastened to entrust them to me. I believe that did not interest anybody except some enlightened our species. One even discussed us the insane ones with the beginning, as I already told it to you. It is when people started to see that the results were far from being bad, even much better than than they could obtain with simple tractions than the things gradually started to change. But our positions had sat already well and we had already become of the “references”.

. : How much fractures of did you operate?

Joel : I must have approximately 750 fractures with a complete iconography and I am not any more very far from the thousand of operated cases.

: I have a clinical follow-up which is less brilliant than that of Joel because I worked in 3 different places but I had to operate between 600 and 700 patients.

. : you operate them yourself or entrust them to you with your senior registrars?

Joel : Not, I operate them myself. I always have a “” which helps me but I am too anxious to entrust the instruments to him. It is a difficult surgery and the majority of the patients whom I operate are addressed personally. If there were a problem and that a avocado excavated in the file to discover that another operated it… I do not prefer to imagine the continuation.

. : How Emile has you you it perceived as from the moment when you became credible in the USA.

: It was very proud us. He regarded us a little as his spiritual sons and always helped us. Ca it really passed very well; one opened to him the gates of glory in the USA and it returned it well to us…

. : , which have is done after your installation in Nevada?

: I settled in in Florida where one proposed to me to work at the University of Florida. I could install a department of traumatology during a few years. There was much case and it is there that I specialized in the complex problems and surgery of .

I could operate during years between 5 and 8 cases per month. The experiment comes quickly!

. : Is what you operated all the fractures of and you do not think that you were too aggressive?

: I believe very extremely in the surgery of . Of course sometimes the lesions exceed our therapeutic potentials completely. When there exists large muscular disrepair, nerve injuries, lesions of the small mining area, it is necessary to be satisfied with a compromise!

. : Do you think that the surgery of is a difficult surgery reserved for some initiates?

. It is a difficult surgery, it is obvious, but it is not an impossible surgery. She asks simply a little more drive than the remainder of traumatology. If one with the chance to learn it near a specialist it is still better. One saves time and especially one saves some with the patient.

. : After one period when one did not operate the fractures of , don't you think that one operates some too currently?

: It is not that one operates too much of it, it is especially that the patients are operated per too many different surgeons. There is probably too much “” with surgeons not trained completely enough for this surgery.

. : You think that with progress of the prosthetic surgery, there is an age where one should not any more operate. For example beyond is 50 years, he still logical to propose a surgical gesture?

: You speak about the age of the surgeon or the age of the patient?

. : Age of the patient, of course!

: One should not too much be interested in the age of the patients, he is necessary to concentrate on the level of activity which your patient had before the accident. Our patients will live more and more a long time, they want to remake sport, to have an excellent quality of life and an aggressive processing even at a 65,70 year old patient will be often at the origin of a much better result than a simple csotcina.comedic processing.

. : But you know well that the muscle tissues, the cartilage will react less better to 60 years than at 20 years. Shouldn't one better discuss these patients and put an hip prosthese thereafter to them?

: To an active patient, the age does not enter for me in account!

Joel : If the statistics are looked at, the surgery of among old patients does not give results as good as at the younger subjects. We lose about 10 to 15% of excellent and very good performances and that is explained by less the good quality of the reductions which we obtain after 40 years. But if the reduction is good, the results are also satisfactory!

This fall of the quality of my reductions after 40 years is explained by several mailmen: the quality of the bone will obstruct handling, and will decrease the behavior of the assemblies. Impactions are also more frequent.

I tend also to amend my channels initially if the patient is old. I thus avoid practicing wide channels . If I must operate a 35 years old patient, I would not hesitate to make this great channel initially to obtain a perfect reduction. At a 55 year old patient, I would use more readily a channel even if I must make a compromise on the quality of the reduction. One accepts more easily a traumatic osteoarthritis at an old subject!

In the event of posterior wall fracture of associated with a permanent subluxation, the csotcina.comedic processing gives catastrophic results and I prefer in these cases, to operate the patients. Most of the time one is able at all to repair but when there exist important impactions with lesions of the head, one can also pose a prosthesis from the start with immediate Clerc's Office.

Finally in the event of transverse fracture very moved at the old subject, it is essential to give again a normal anatomy with the bone . If it is not done, one is likely to be vis-a-vis a pseudarthrosis where with one cal vicious of making almost impossible the correct installation of a prosthesis total of hip. In the event of fall at the old subject, the pressure of the head on is very often at the origin of a fracture of the former column or the 2 columns of . One can then consider an csotcina.comedic processing and the installation of an hip prosthese because the even amended anatomy did not generate that modestly the installation of a . There will not have to be forgotten only if you consider this type of treatment, the patient must remain confined to bed a long time with all the risks that represents. This is why personally when the case arises well I do not hesitate to propose a surgical gesture of osteosynthesis to them. That will enable them to find a good range quickly. That would not come to the idea from anybody to let organize one cal vicious of the end of the femur to be able set up then a femoral prosthesis.

: Joel at a rate of specifying that much fracture of discussed does not allow a set up a good hip prosthese. If one discusses a fracture of in order to be able set up a prosthesis, it should be done with much understanding.

. : Which is the oldest patient of your series?

Joel : 90 years!

: I beat you, I have one 93 years of them… He lived at his place, he had a fracture of the former column with a beautiful intrapelvic luxation. What is what one could do of other? To leave in a bed?

Joel : If there exists an intrapelvic luxation, in any event, the patient should be operated quickly. Either set up a prosthesis and in 17 years I had to carry out a score of time this gesture, or to practice an osteosynthesis after reduction. If you leave your hip in the state “to see”, you go obligatorily to the functional catastrophe! There is a category of patient whom I operated and who can want me. In fact the 3% of patient had into postoperative an infection articular. It is always a catastrophe because the possibilities of secondary rebuilding are difficult even impossible. In my series I have 15% of poor outcome. There are of course the 3% of infection. There are also patients who forwarded lesions above any therapeutic resource but also the patients that I do not should have operated.

There is probably 15% of the patients who have a fracture of the which one currently knows that they will be well if they are not operated. I operated patients who are very well and who would have perhaps had a good performance without intervention. In the doubt, I do not hesitate to practice a gesture because I do not want to await a poor performance of the csotcina.comedic processing. It is then too late! At a 20 year old patient, I do not want to take this risk…

: The surgery of the vicious cal and the late cases is really of a great difficulty and the results are far from being also good.

. : Do you think that the future of the surgery of passes by a better comprehension of the indications?

Joel : Absolutely. One will not improve a little the operative procedures but it is absolutely necessary to continue to study our cases to specify our indications.

. : , 17 years after, with the technical plan, can one note significant improvements?

: It is difficult to tell! The plates are probably better in any case they are available… There are also better forceps… In fact not large-thing… To each time I came to see Emile with new forceps which seemed me to solve problems, it looked at it and released one: “I made some manufacture like that, it sleeps at the bottom of the wall cupboard”.

In the channels initially there is what we call “tea ”. One associates with the channel of a rising into of the great trochanter. That improves the day on the former column without compromising the stability of the glutei. The Swiss ones and worked much there above. Ca can be useful…

Joel : For me the main change as regards fracture of it is that the number of surgeons who operate these fractures increased considerably. Much of them has only one limited experiment and again will leave the poor series. Worse, some, in front of their poor outcome try to invent novel methods.

It is a little like the hip prosthese. One developed these 20 last years a heap of new prostheses to answer many questions but nobody still could leave the statistics better than that of . In fact it is probably necessary to be solved to accept that very few surgeons are able to invent truly new things. The majority among us must be solved to learn and try to make as well. It is not easy to accept, but it is like that.

For example, certain surgeons had concern with the enlarged channel initially . They thus tested other things: sections of the iliac crest, , accesses less invasive, double channels, the percutaneous one. They also perhaps forgot a thing: the reduction of the fracture. The good performances come from there, not of the channel initially, do not forget it!

The techniques which has clarifications Emile have the merit to exist, to be powerful but also to be constant by an extraordinary clinical follow-up. All what Emile advances is supported by very thorough statistics. These results were confirmed by , Mayo, Eric by myself and much of surgeons.

It would be a shame that the surgery of the fractures of is inserted in a stagnation creates per too many false innovations, without true interest. It is a thing to develop novel methods, it is another to prove that they are valid and better than what exists.

: Ca points out to me where two csotcina.comedists are seen, one operating and the other looking at it making.

That which looks at exclaims “Which marvellous technique, it is of you? "". Yes known as the other: ” It is an amendment! “