The congress of the which was held in Nice in spring 1998 was a real success. We asked the organizers Philippe and Pierre to give a progress report to us on the main assets of the congress and to inform us of their vision of the knee surgery.

. What the ?

P. : It is off Sports , an association created now 14 years ago in Berlin. The idea was above all to make a European society of the knee and of then sports traumatology was added approximately four years ago. There are approximately embers today.

. : Who created this society?

P. : The was created on the initiative of Werner , of and of a Dutch surgeon, Van At the beginning, it was a society with rather Scandinavian predominance, but for a few years that has balanced. Initially, of the congresses were organized more in the south with de and Nice, then of Latin entered the office. In addition, the current chairman of the is an Italian: . Since the first meeting in Berlin 14 years ago, of the congresses were organized every two years.

. : Why to have created this European society?

P. : I believe really, to have assisted with first negotiations, that and Werner had a true feeling of frustration with respect to society which made the too beautiful share with the North-Americans, in particular the which was at that time “the” international society of the knee. Europeans did not have their place in North-American society, and he wanted to create a platform where they could express their ideas.

. : it so much There-had divergence coefficients between the European and American points of view?

P. : I believe that 15 years ago, “the leadership” was incontestably American: the European surgeons were turned more or less towards the States-Unis.Un certain number of them had of it enough of this situation of scientific monopoly, this dominant position and wanted to make a counterweight with the system: therefore the was created. I believe that today the position of the European surgeons compared to the United States is completely different from that which I knew 20 years ago. There is now a European counterweight which did not exist at the time: the only place where one could communicate, they was the United States!

PH. : I.e. to meet a German colleague… one was going to Washington!

. : However the “Lyons Days of the Knee” existed already 20 years ago! …

P. : Yes, but the Lyons Days interested primarily the French. We had many Italians, of Swiss, but we did not have Germans, nor Scandinavians.

PH. : It should well be seen that the is the first European csotcina.comedic society. One saw the movement developing thereafter with the shoulder, pediatry, the rachis, and then the EFFORT was born.

. : At did the beginning, the relate to only the knee surgery?

P. : It was knee and . There are 14 years the only which existed, they were the knee arthroscopies. There was practically no of the shoulder or ankle. Therefore, at the beginning, it was coherent: “Knee” that included the knee of the sportsman, the degenerative knee, and the which was a means to discuss various pathologies of the knee.

. : Why have added “ Sports”; which is the interest to rake so broad?

PH. : This decision was the fruit many debates. Actually, it was necessary to take into account the type of a little different formation according to the countries: in certain countries, in particular Scandinavian, the surgeons make either of the surgery, or of the degenerative surgery, but do not make both. In other countries, one deals overall with hinge by making at the same time the degenerative surgery and the surgery of the sport. There was a species of which makes that up to one recent period the degenerative one was a little put aside to the profit of all that was sports traumatology. The “S” of “ Sports” wanted to mark this preponderance. Now we try to rebalance the things.

P. : In what relate to me I think that the is a society which functions well and which organizes good congresses but which gives sometimes the impression “that it has fear of missing, fear of being made take market shares”. I have the impression that this “S” corresponds a little to that. Personally, I think that the should deal only of the sporting knee and the degenerative knee, in order to leave the remainder, in particular the shoulder degenerative and sporting, to people which have of it more an great experience… but it is not currently the option which was taken.

PH. : In the long term, it is essential that society which is interested in pathologies borders finds means of agreement and one is working in this direction while trying to make common congresses.

P. : Yes, but is this really necessary to make one day of the shoulder with the ?

PH. : It is necessary to make one day of the shoulder with the , because many participants are interested in the two hinges, but what is also necessary it is that this day on the shoulder is made by qualified people, i.e. in fact by the European Society of Shoulder surgery and the Elbow. It is what one did in Nice and I think that “this first” is a good thing.

. : From the bosom of the does a pretense of European consensus emerge on the conduits to hold?

PH. : If you want to say by there that one means all on the indications, it is obvious that the answer is not! But one can say that now, in Europe, the is a federator element for sports traumatology, the and the knee surgery ; for the degenerative knee it is more difficult. Like Pierre says it, maintaining the surgeons American come to the congresses from the . It is enough to see with the last congress the number of papers proposed by American. We received many compliments of American who told us that the did not have really anything to envy theirs.

. : Would one feel, today, the same need to create such a society?

P. : The attitude of the North-Americans compared to Europeans completely changed during the last years. That is due partly to the and the exchanges of young surgeons between the United States and Europe, within the framework of the “dolly ”. That made that one understands oneself better. When I was internal that did not exist. There was which told us “he is necessary to travel”… but one did not know where to go!

. : Let us come in to the Congress from Nice; which were the main themes?

PH. : The main themes covered the large fields of investigation of the with a strong note of fundamental sciences: relatively little paper of search on the former cruciate but of many papers on the conservation , i.e. the meniscal suture, the , the replacements meniscals by collagen or other. There also were two important meetings on cartilaginous repair, one of fundamental science and the other private clinic because it is a subject of topicality and which deserves to be developed. We innovated by organizing (“with the Frenchwoman” and not “with American” where one places people the ones beside the others, each one coming to bring back its series) true European multicenter trials. The teams put their files together. It was a first for the knee in Europe. I think that was well appreciated. Four symposiums: the processing of the instability of ankle (more than 400 cases!), processing of luxations of the knee (more than 250 cases!), bone necroses after which was a “small subject” but which deserved to be thorough; the last symposium related to the patellar problems in the prostheses of the knee. Finally a day devoted to the shoulder was organized with the collaboration of the .

. : How much there At it have participants?

P. : 1300! It is a large congress if it is considered that it is not an csotcina.comedic congress general practitioner.

. : Then, that is it necessary to make in chronic instabilities of ankle?

PH. : Among about fifty described operative procedures, the techniques of stabilization can be schematically divided into anatomical techniques and techniques of . The great conclusion of this symposium was that on the functional level, in the long run (with more than 10 years), the anatomical rebuildings give better functional results, in particular in term of pain, that the gestures of .

. : What does one understand by anatomical rebuilding?

PH. : In fact the techniques seek to recreate the side collateral ligament starting from the remainders , or of the adjacent periosteum.

. : Finally, all these techniques of the type made failure?

PH. : That made failure because in the long term that gives pains by subtalar attack. The anatomical techniques, including a simple technique of of the capsule in front of the fibula are to be recommended.

. : Another concern of the csotcina.comedic surgeon approached during this congress: how to manage a luxation engraves knee in a young person?

PH. : It should be recalled that there are two great types of luxation of the knee: antéro-posterior direct luxations and luxations with considerable damage on a collateral level, whether it is side or . In addition to the organic diagnostic problems, and the tracking of the complications (in this respect the indication of arteriography must be very broad), these lesions pose in acute period a very difficult therapeutic problem. What was released from the symposium, it is that the processing csotcina.comedic or functional is exceptionally satisfactory and that best processing, it is the operative treatment which repairs all the lesions. It is not any more question of telling “I drop the posterior cruciate, I drop the postéro-intern plan, it is too difficult…”. I believe that maintaining the concept of repair of all the lesions is a basic concept.

P. : I do not know, I would not be also categorical. I am “of a prudence of Sioux” for Bi-crossed: it often sometimes happens to me to plaster one month and half and to discuss the after-effects. With the symposium, we did not have many files concerning the conservative treatment and the study was, in my opinion, skewed insofar as we primarily have files of surgeons who from the start operated everyone!

. : Then, csotcina.comedic processing or operative treatment in urgency?

PH. : One can forward the thing differently by saying that the secondary surgical treatment of a luxation, it is not the panacea, it is the least which one can say! The results as well in functional term as anatomical are disappointing.

P. : I am completely of agreement with you but it would be necessary to make an exploratory study comparing the surgical treatment in urgency, and the csotcina.comedic processing followed by the processing of the secondary after-effects. The problem it is that we do not have sufficient patients to do it and currently nobody is able to answer truly this question. We knew about what gives the emergency surgery which is not always glorious because we are a little aggressive,… I am sure in particular that with the surgery from the start we create necrose peripheral, on the level of the postéro-external point of angle. I am accustomed to saying it to the Interns, “the postéro-external point of angle,… you look at it… you damage it! …”

. : Of agreement, but a completely luxated knee can be plastered efficiently?

P. : We cannot tell “completely luxated”. In any event, if it does not have any position of stability, the operative treatment is compromised too.

. : Precisely these are the situations which worry us…

P. : Currently, nobody with the capacity to say that a knee which does not have any position of stability (antéro-posterior, posterior, internal, or external) can have a good performance by a surgical treatment.

. : It is necessary well that it is discussed…

P. : Of course! … I plaster much… I have shame… It is not major surgery!

. : Now so really, some is the plaster, the knee relocates itself, how to make?

P. : I will leave “to the adventure” to operate it.

. : It is what “the adventure”?

P. : The adventure it is the adventure.

. : And why not a pin of of the ball joint?

PH. : Not, initially, because it was shown that does not make it possible to stabilize the knee perfectly, and then, because they is bad for thepatellar one. Fixing by external fixer has our preference, provided that the knee is fixed in “position zero”, i.e. without former or posterior drawer, without in or valgus and with a bending with 30°.

. : In is urgency, necessary to make repairs or plastic surgeons from the start?

PH. : on the crusaders, I make readily plastic surgeons from the start and on the side levels, the attitude is function of the type of injury: one rather often observes wrenchings periosteums of the collateral plans which one can allow to rest; if not, it is necessary to make joinings with plastic surgeons of reinforcement.

. : Concretely, a great name of football luxates the knee and is made a , which do you make?

PH. : Nothing, because it will see directly!

P. : Me, I tell him to go to see , especially if it is a player of the .!

PH. : More seriously, I tell him that it with the , no matter what one makes him. Then, I would operate it in the neighborhoods of the tenth day because one will then have freed oneself from the possible arterial problems and that the tissues start to be less inflammatory. But one is still during a time when one can consider that the lesions are fresh, therefore under the best conditions of cicatrization.

. : Would use ligaments of reinforcement?

PH. : Not, I use plastic surgeons of rebuilding . From the moment when one is surgical from the start, it is with the rebuilding by transplant that it is necessary to appeal not to the joinings, in any case for the central pivot.

. : You think that the posterior crusader cannot be sutured?

PH. : Not, that will not hold! I would rather make a plastic surgeon using a patellar tendon for the ; and for the if there are theleg ones of quality, I take one or two tendons. If there are no ischio-leg, I use a tendon , or a transplant taken on the other knee.

. : It is difficult situations with which the of the general hospitals are confronted…

PH. : It is a very specialized surgery. It is a major surgery, with septic great risk, great risk of stiffness, great risk of malalignment of the transplants and it is necessary to have an unquestionable knowledge of the surgery for launching out inside.

. : Is wisdom to plaster and direct?

PH. . : Yes, if it is estimated that there is a surgical indication and that one does not have sufficient surgical experience. Still it is necessary to have checked the absence of vascular injury.

. : How were held the European symposiums?

PH . : They were very well perceived and by the listeners by the members of each symposium who said all that they had fired a great personal benefit from it. It is a strong way to federate the different csotcina.comedic crops, rather than to announce that the Germans proposed 40 specific communications, French 40, Spaniards 40, Italians 40, etc… There they worked together. It is truly the aim of a European society. And people who worked together, will continue to work together.

. : This type of symposium can also skew the studies…

PH. : In the field of the scientific validity, it is possible. As Pierre said previously, it is true that there was only very little functional processing in luxations of the knee. But this “scientific” disadvantage is composed of the major advantages: either as for luxations of the knee, to put together different technical approaches for the same pathology, or as for the bone necroses after , which are extremely rare, gathering a sufficient number of patients to be able to draw the conclusions on a subject of which everyone intended to speak but of which nobody can affirm to have experience.

P. : It is true that we thus could gather about fifty case of osteonecrosis proven after internal . I specify that it was really necrose condylar occurred after since we knew, thanks to the preoperative MRI who was normal, that he did not have there necroses at the time of the . Therefore, they were not errors of diagnosis initial.

. : Is it necessary to make a MRI before a at the subjects of more than 55 years?

PH. : The MRI is the examination which makes it possible to make the share between meniscal lesion and possible necroses condylar. But even in the absence of preoperative osseous image, that does not prevent that the patient can do one necroses after because the in itself to start one necroses. But at least one is sure that there was not necroses . Therefore, to answer the question precisely, yes, it is necessary to make a MRI before making a at a patient of more than 55 years. “What raised hare” of the bone necrosis after , it is the laser! Following the introduction of the to the laser, one saw appearing some publications of bone necroses. At the beginning one very put on the account of the laser. The laser probably increased the frequency of these bone necroses of the condyle but one realized by taking again the files older than there were authentic condylar bone necroses on mechanical conventional , and they were not initial errors of diagnosis!

. : By which mechanism the laser can it to induce necroses condyle femoral?

PH. : It is not a heating effect because the laser used in is a laser of which the heating effect is extremely limited outdistances some compared to the point of implementation of fiber. That is probably due for a purpose of shock wave since they are pulsated lasers, it is what one appeal the photo-acoustics negotiable instrument. But there is not the absolute proof and the responsibility for the laser is discussed. Nevertheless Philippe and myself published in the the results of the after laser and that they are less good than those of the conventional . Even if we did not observe necroses, we noted an important rate of visualized on radios at one year.

. : At all events, these necrose femoral condyle exist even after conventional ?

PH. : That always exists. Those which say that necrose them after are in fact initial of the errors of are mistaken! Some time it is authentic necroses which did not exist before the and which appears These patients secondarily never go well after their with persistence of pains and . If one makes a scintiscanning or a , one will have early amendments; if it is not made that radios one will see appearing the radiological amendments only 6 or nths later… Advanced etiology, but it is only one assumption, is that it would occur a brutal increase in the stresses at the condylar level because of disappearance of the shock absorber meniscal.

. : But does that start with a or is this true necroses?

: It is one necroses histologically proven.

. : Wouldn't it be a consequence of the garrotte?

: One cannot answer this question.

. : The problem of ball joints on knee prostheses was tackled…

: Indeed, within the framework of a symposium such as American understand it: they were not a collective work but experts who came to speak: Peter Walker, John , , , Werner . Each one brought back its experiment and delivered its opinion on the subject.

. : There did it have a discussion on the need or not for the ball joint during the prostheses of the knee?

: Yes, with an absence of conclusion: ones being for, others against. At present, nobody can tell what is better. For of London, the decision of the patellar patching depends on the preoperative patellar height. When the preoperative ball joint is low, the results are better with a patching than without patching; it is for him an element important forecast.

P. : Me I always. I knew the first prostheses of which were not anatomical and did not have a patellar button… it appeared these rails in the ball joints at the end of two or three years! … The surgery, it is often a beam: that leaves in a direction then that returns in another! It is similar for the sealing of the prostheses: one seals all… then one does not seal more nothing. When we have “a business which turns”, we do not may find it beneficial to always set out again in new adventures. It is necessary to let an small group occupy itself some. I find that in surgery, it is dangerous that everyone leaves in all the directions. It is necessary that a serious team tells itself “I believe that it is what it would be necessary to do, I will evaluate it ” and should then adopt his position to us.

. : However do the American tenors seem not to have problems with their prosthesis of the knee?

P. : You know, they announce amazing results on much thing! But it is necessary to say the truth and there is in enough the set language: the prostheses of the knee always do not go very well. I always tell to my patients before a knee prosthesis: “It is not an hip prosthese, you will never forget your knee. ”. But even when we prevent them, some return while saying “Doctor, I have badly there! … ”; I answer them “It anything, that is not made always badly there! … but that passes with time! ”. They return six months afterwards: “Doctor, I have badly there! … ”; “But the radio is well, I promise to you, that will pass! ”. One year and half afterwards: “I have still badly there! … ”. You do not know any more what to tell them, you tell them: “I do not have a solution, it is not serious”. I very tested: I took again patients, I made …. Before I fought when they told me “I have badly there! … ”. I was going to seek why they had badly, I often did not find anything. Not, me the prostheses of the knee, I find that it is not as the American tenors claim it. One “rows” sometimes and there is in 3 to 5% of the cases of the unexplained residual pains.!

. : Then on is the ball joint, the section of the external aileron systematic or not?

P. : Especially not of section of the systematic external aileron! After having tested the prosthetic parts, to say “Ca does not go, the ball joint is not well, I cut the aileron! ” is an error. It is the positioning of the prosthetic parts which determines the stability of the prosthesis.

: To avoid the problems of patellar instability during the , it is necessary well to position the femoral part in particular in external rotation and to avoid an internal rotation of the tibial part at all costs. One should not especially regard the patellar cut as a small gesture only one makes quickly in end of operation. The implantation of the patellar button owes a great number of very precise criteria (rotation of the parts femoral and tibial, patellar height, overall dimension sagittal overall, thickness of the prosthesis, positioning of the button on the osseous ball joint). If one satisfies all these criteria correctly, the section of aileron becomes exceptional.

. : But what to make if one were mistaken in rotation in the femoral component?

P. : But, one should not be mistaken, it is a . There is not with my direction of section of the external patellar aileron justified during the installation of a total prosthesis of the knee. The only indication that we could have, it is the genu valgum with a subluxation of ball joint or patellar luxation but I discuss them by external channel and the channel initially generally solves the problem.

. : Do the prostheses with mobile plates, you think what of it?

P. : There is for and against. That recovers completely different concepts. There are “the prostheses which slip and which turn”. For me, it is a negation of the total prostheses of the knee, because they thus do not roll do not have retreat of the femur in bending. There are “the prostheses which advance and which turn” and there you must keep the posterior crusader if not that does not have a direction. Now we see appearing prostheses with “rotation-translation” which have a postéro-stabilized system and there I do not understand any more.!

. : Why the prostheses with mobile plates in rotation-translation must absolutely keep the posterior crusader?

P. : Because if there is a system at the time when the femoral condyle comes to take support on the tibia the retreat of the condyle is not done because the tibial plateau flees ahead.

. : Isn't the problem the indications? If there were of them one which goes to which would it have to be put?

P. : not! These prostheses are addressed to knees which are not destroyed too much on the plan of the collateral ligaments. Currently, these prostheses with mobile plates, it is all and the opposite of all! For the moment, it is a business of market demand and mode.

. : What was told on the cartilages?

PH. : All and opposite of all. There initially was a whole meeting of fundamental science showing the pathological amendments of the cartilage during ageing, the incapacity to reproduce cartilage spontaneously, and then a meeting showing the basic possibilities of rebuilding of a cartilage. Several possibilities are offered to the surgeons: the Clerc's Office, the cell culture (chondrocytes) and graft it or “ plastic surgeon”. What is sure in practice clinical, I believe that it is the most important message, it is that these cartilaginous rebuildings at present address only to the losses focal substance with an entourage of healthy cartilage. I.e., in practice, the fractures , , but to in no case cartilaginous decays. One starts to be solicited to make gristly Clerc's Offices on cartilaginous decays because one understood with the radio…

. : Let us take the example of a osteoarthritis on after-effect of total : is a cartilaginous Clerc's Office indicated?

P. : Not it is not the indication. An after-effect of per definition, it is a cartilaginous wear, it is a osteoarthritis.

. : What is it crops of chondrocytes? Who practice them?

PH. : In Europe, it is primarily the team of in Sweden which practices this type of cell culture. Their studies showed that was effective with the condyles and not with the ball joint. In France, a prospective multicenter study under the aegis of the will start.

P. : I know that in Lyon the Old people's homes were of agreement a study but by controlling it perfectly It should well be said that in France one has all the sorrows of the world to tally the study and to make it re-enter within the precise framework of the law . Moreover, the cost of a processing, 75 405 , remains prohibitory.

. : Therefore, the Clerc's Office remains the surest means and most economic?

P. : According to the publications the “” is indeed a reliable intervention. Ca goes with the proviso of tallying well the indications. As we go progressed we will better know to determine the indications. It is necessary for my opinion that still remains in hands. That is not used for nothing to do one or two of them a year. If you have somebody beside you sympathetic nerve and who with the experiment, he is necessary to send the patients to him to be operated. Nowadays, it is necessary to work like that. Personally I do not have any experience of this intervention and I entrust the few indications to somebody moreover tested.

. : But is the technique so difficult that?

PH. : Not, but still is needed, to be able to draw some the conclusions, that it is concentrated in France on some teams. If the cases are dispersed too much, the results could not be evaluated.

P. : The plastic surgeon, it is not a technical exploit but currently it would be important to concentrate the patients on some teams so that they can quickly tell us #FFFFFF or black. Then this technique will be able to fall into the common field. Who in with the experiment today in France? made 10 - 15 of them. I believe that one will be really adult in csotcina.comedy the day when one will tell: “Me I know somebody who practices this technique, see it”.

. : But if one left to remake a former crusader under and that one discovers lesions with the punch on the internal condyle, what one does make?

PH. : Personally I do not make a Clerc's Office because I find that in these cases there one cannot appreciate the result of it.

. : What to make in the grosses where one does not manage to stabilize the fragment and where one finds oneself with a ?

P. : I believe that it should nevertheless be said that the that we regarded a long time as a benign disease can be a catastrophe, with an early osteoarthritis. It enough is not said. Or it should very early be discussed by preserving the fragment or that can be serious.

. : Let us speak about future; is it necessary to accept in the cell cultures or the hormones?

PH. : For the moment, one still reasons as a mechanist: it misses cartilage, one brings cartilage to fill a in order to answer the stresses in pressure. But in the future, it is clear that one will reason more as a biologist. One feels a strong pressure biological in the fields, cartilaginous, meniscal, with the growth factors, of cicatrization.
P. : Ca will be true societies' problems. One touches here with ageing. There was in Nice a conference on the gene therapy and one feels well that our trade in the 10-15 years to come will be less a mechanist and more biological.

. : If one slipped towards the joinings and Clerc's Offices ?

PH. : What is sure, and it was a communication of Philippe spokesman of a study of the French company of , it is that the long-term outcomes of the even under are not excellent. Partial , and this term can be debatable, does not put safe from cartilaginous wear, in particular with the external meniscus. From where the idea, largely defended for a long time but not yet last in manners, of what is called the economy , i.e. to preserve the meniscus each time possible, to even remake it. To keep the meniscus that wants to tell to propose joinings, repairs each time it is possible. About knee one knows that the joining associated with repair with the former crusader has good performances. It was as shown as one could leave it in place without no gesture on the condition of repairing the ligament On the other hand on stable knee i.e. with an intact former crusader, success rate is much less important. This told, I believe that at the young subject which has a really reparable lesion, in vascularized area of the meniscus, it should be done everything to preserve its meniscus and to propose a joining to him even if the continuations are much longer than a and even if anatomical failure rate, i.e. the absence of real cicatrization of the meniscus borders 30-50%.

. : Is the rate of after meniscal suture on stable knee, nevertheless important?

PH. : A meniscal suture on stable knee it is 10% of assured clinical failure, and according to series 30 to 50% of incomplete cicatrization (many anatomical failures are indeed ). The discussion is posed in front of a 20 year old young person: isn't it to better tell him than one takes the risk to suture the meniscus to him and than there are two chances out of three only one rather fires it from business than to make a systematic .

P. : I believe that there are people who have “a disease ” to 35-40 years, then there is a negligible percentage of it which has diseases at 20 years. I want to say a defect of fixing of the meniscus which is a little .

. : In one year you made how much meniscal suture?

PH. : On stable knee, a meniscal suture for thirty . I make 250 , that made six or eight joinings a year, not more. But one should not pass beside these cases, in particular on the level of the external meniscus.

. : The number of meniscal sutures T it does not have not decreased during the last years?

P. : Of course, the largest series of meniscal sutures, it was in the Eighties. because very advanced chronic laxities were operated. On the former crusader there is a thing which completely changed, it is that people are made operate earlier. The diagnoses are made earlier. As soon as they start “to uncouple” the knee, people consult a surgeon. It is easy to convince them to be made operate. They are careful, from the moment or they are uncoupled they are worried and they go to the surgery more quickly than front. The great difference in my opinion it is that. The other difference it is that if there is a posterior lesion limited with a stable meniscus, it is possible after having remade the to abstain from suturing the meniscus.

. : Would the knee surgery have become easier?

P. : More one is specialized less we see advanced laxities; or then one sees the failures of the others. I always say that it is easier to be in the knee because sees the people concerned with their pathology. The senior registrar in a department of csotcina.comaedics not specialized in the knee, sees patients less implied in the sport, less “worried” by their knee. These people wait a long time before consulting and often have of this fact more important laxities.

. : What to make when one removed the meniscus and which the patient forwards a syndrome ? Does the Clerc's Office of meniscus, it go?

PH. : At present the , the implants collagenous meniscals, are completely experimental techniques. The appreciation of the results of the , for example, is extremely difficult because they are generally associated with an osteotomy or a rebuilding and that one does not know any more very well “who does what” in the result. The biomechanical capacity in vivo of the grafted meniscus is not evaluated yet. At most, one can affirm by the biopsies at distances which the meniscus is and viable.

. : Precisely, is the grafted meniscus viable?

PH. : One can appreciate by biopsies the possible of the meniscus. The freeze-dried Clerc's Offices are dedicated to the failure. For the frozen Clerc's Offices, Rene showed that to become to it airframes, once the made implantation, is extremely variable; the meniscus was viable, i.e. that there are airframes inside. Sometimes in fact the airframes of the donor persist; Sometimes the is colonized completely by the receiver and sometimes it was a mixture. This told, that does not show the biomechanical properties of the .

. : How does one put places and fixes one these Clerc's Offices from there?

P. : The engineering problems are a little additional. There are people who make osseous studs and there are people who make simply joinings. I believe that simply made a joining. There is especially a big problem of size between the meniscus of the donor and the receiver.

PH. : Because of this problem of size, some (as D. ) use autografts of patellar tendon. Just as an autograft “”, it “” and there one frees oneself from the problem of the size. This technique is obviously very experimental There are also collagen matrices , about which one starts to speak, which would be likely to be by collagenous tissue of the receiver.

. : A word on the development of the plastic surgeons of ; which place do you keep for the mixed plastic surgeons, and extra-articular?

P. : The mixed are to be held for advanced laxities which we see less and less, as I said previously. In the event of former laxity with an important differential, we can add an antéro-external plastic surgeon, although there are people who discuss it. In the event of postéro-external laxity, I am a little reticent to make possible associated postéro-external gestures, because I repeat it: “the postéro-external point of angle, as soon as you look at it, you damage it! ”. In the event of postéro-external lesions, the processing passes by the osteotomies of normo-correction more than by postéro-external gestures whose we do not know the result well. As an postéro-intern all that is of the capsule showed his limits. In Lyon, Henri made capsular: that did not give fabulous results. I think that the only indication on the level interns it is possibly the repair of the side ligament interns if there is a laxity in valgus. With my opinion, all that is peripheral plastic surgeon must be done by free Clerc's Offices and one should not any more make after ., For the side ligament interns, for example I use the patellar tendon or the tendon with a bone fragment. The bone fragment is positioned in a one-eyed tunnel at the upper part of LI and the party doubles defective LI.

PH. : To return from there to association external rebuilding former-ténodèse cruciate, it is felt that it is probably necessary for certain knees but one does not know yet which is the limit between the knees which need a simple intra-articular reconstruction and those which need in addition to one extra-articular plastic surgeon. Nobody at present can tell exactly for which laxity it is necessary to propose this association. exploratory studies are in hand.

P. : Me, if I have one centimetre of differential to the or a of more than 30°, I make an external return, but I recognize that it is completely arbitrary!

. : What think of the current development of the plastic surgeons of of ischio-leg ?

PH. : In addition to a certain thrust, two elements justified the development of the plastic surgeons to theleg ones: one is true, the other is false. Truth it is that there are nevertheless some tendinites of ball joint, some former pains after ; the forgery it is the weakness of the quadriceps after taking away of the aircraft bungee cord since it is known that it finds 93% to 1 year and 95% of its value at 2 years. This type of plastic surgeon is nevertheless a channel to be explored.

. : Is fixing it as solid as with the patellar tendon?

PH. : The experimental studies on the animal showed that fixing appeared as of the third week. But at the man, the histological studies are exceptional: they show the cicatrization of the tendon in the tunnel with the appearance of the fibers of which are these fibers which make the bridges between collagen and the bone.

P. : What is sure it is that it is an operation technically enough sympathetic nerve, but which one does not know which the result at 10 years. In the sportsmen, thing, I had more with this technique than with the rachidian tendon. I believe that it is a technique which is very good but which did not completely supplant the patellar tendon except proof brought by the retreat. Currently, there is always a place for the patellar tendon. Another problem is the strain of the transplant under cyclic pressures When we forward the transplant to a cyclic charge, it seems that there is a more important strain in the case of a bone-tendon incorporation i.e. semitendinosus musculus that in the case of a bone-bone incorporation i.e. patellar tendon.

. : What can one propose with a laxity former to 50 years?

P. : 10 years ago I would never have operated somebody of more than 40 years. I operated 52 year old recently somebody. It is necessary to operate if people make the proof that they have a functional embarrassment. In this case, it is necessary to make a semitendinosus musculus. If it is a laxity which goes back to 15 years and which it breaks a meniscus, we are not any more in the same problems. It is initially necessary to discuss the meniscus and to see whether that is enough.

. : Why not a patellar tendon?

P. : Because it is much more serious and that there are risks of pains .

. : At 50 years, why not make an extra-articular plastic surgeon of Lemaire?

P. : It is in my opinion an operation of veterans! A Lemaire it is heavier than a under . The incision is more important, the risks of hematoma are more important.

. : What justifies this aggressiveness with respect to the former crusader?

PH. : For two reasons: less old laxities are operated, therefore small laxities with integrity and one has a surgery which is minicomputer-invasive. The results thus overall much better even if the knee is seldom perfect, “are forgotten”.

. : Why does one operate more former crusader today?

P. : Because one is much better! You did not live the surgery of the former crusader in the Sixties. It was an adventure! I saw Albert making internal transpositions of the former tuberosity, type, in the ruptures of the former crusader! … And most extremely, it is that from time to time it went! After, in years 73-75, in Lyon, one remade former crusaders with the patellar tendon but by leaving it attached at the tibial level, like the original technique of Kenneth-Jones recommended it. It was a “working”. The patients if they folded the knee in post-COp… one was content! We secured ourselves the continuations: “it was the war! ”. After in 1978 we started to make free transplants of patellar tendon: I was then chief at and I found that the prostheses were easier than a former crusader. You thought of the operation three days front, and three days afterwards. We had so much concern in the Eighties, that the patients went in rehabilitation three months. Now, if they do not leave at the 2nd day, the patients !

. : Which is moment to operate a serious distorsion in a sportsman?

P. : In the event of rupture of the former crusader isolated without any blood escape apart from the capsule, we can operate quickly because the risk is tiny. From the moment or there is an hematoma with an escape of blood in the peripheral slip surfaces, I believe that it is necessary to wait under penalty of having long and difficult continuations.

. : How to make this diagnosis?

P. : The existence of edema, subcutaneous hematoma, of peripheral painful points, make thus suspect capsular lesions must make defer the intervention.

. : When you deal with high level sportsmen, you can make them wait?

P. : Yes, that depends on your credibility and your impact in the sporting medium…

. : What made you for a 45 year old mother who breaks her crusader former to the ski?

P. : I do not operate it but I deal some with A to Z.I am it up to nths with a protocol of rehabilitation strictly identical to the protocol of rehabilitation of people whom I operate.

. : This 45 year old woman returns to the charge nths after because it does not go well…

P. : If you made well rehabilitation, there is little chance that it totals nths. If you known as with the patients: “I do not want to operate you, clear up! ”, they start again to move immediately and have indeed instabilities. It is necessary really to deal with them and to follow them a long time. One should not make them take again the sport too quickly, he is necessary to keep a , not to work the quadriceps. If we put a former crusader who comes to break at two weeks in physical therapy program of the quadriceps in opened channel, it is as if one made it play !

. : Do you think that your low level of secondary surgical recovery after functional processing is due to your selection of the patients or your physical therapy program?

P. : Both. I am re-examining them, I am astonished by the number of patients who do not have any more laxity: there is a patient on 4 who does not have any more laxity! In year 94, I saw in one year of ski 105 broken former crusaders. I operated 65 of them, I did not operate 40 of them, and in the 40 which had a conservative therapy I only two of them. I have the example of a boy out of world cup of ski which has a discussed former crusader in a preserving way and which does not have any more laxity. I think that there are many athletes who have a rupture of the former crusader and who could take again the sport without problem after a functional processing, perhaps not all sports but in any case it. The problem it is that we do not have courage not to operate them because we are afraid which the functional processing fails while one is sure to 95% of our operative procedure! I say that too much is operated!

. : With when the next congress of the ?

PH. : In London, in the year 2000, from September 15th to 20th, under the patronage of David Dandy; with, I am sure a success at least equivalent to that of Nice!