Mr. strongly influenced in France, the development of the prosthetic surgery of hip. The therapeutic options that it knew to defend, the rigor of its surgical gesture combined with a considerable clinical experiment made of him a true chief of School. Meet with a Master.

 

. : Traditional question: why did you make surgery?
: I would tend to tell a little by chance. I surely made medicine by chance because at the beginning I did not intend myself at all for that. I was rather a math student and not knowing too what to make in my Brittany, I went to spend my holidays to Paris where I had of the family. I met in the landing gear a buddy who was same college as me and which was going to be registered in medicine. I did not decide anything in the immediate future but I thought of it and finally I went to register me in medicine.

. : You had not had any medical influence?
. : I remember that when I was small, around 10 years, I wanted to be a doctor because I had an uncle doctor and I found that it was well, but the idea had left me. When I decided to register me in medicine in Paris, one told me: “It is not possible, you do not have a residence in Paris, he is necessary that you turn over towards Rennes”. While turning over at home I was mistaken in landing gear and I went not to Rennes but to Angers. I am descended to Angers. It is a city which I did not know and who rained me. I spent two days to Angers, I saw that it was pleasant, that there was a medical school and I went to register me there.

. : You had perhaps the unavowed intention to move away you from your family?
. : Yes probably.

. : In which year you did make your studies in Angers?
. : In 1952. I did not have a difficulty with the because I had had a rather good formation of maths, physics, chemicals. I found myself in first year of medicine and soon vis-a-vis the contest of of Angers to which I forwarded myself. I was received without difficulty as besides the little of people who forwarded themselves. Attracted always a little by Paris, I started to prepare the day school of Paris.

. : There was this possibility?
. : Yes… One spent three months to Paris to the Halls of residence, and one was going to follow the conferences in a hospital or what one at that time called the House of the Student and who was this ship located in front of which had been built at the end of the war with the American money. I was appointed with the of Paris rather quickly and I left Angers the third year.

. : Had you, tasted there, already at this time with the surgery?
. : A priori I was not attracted at all by the surgery. I had made nths in Angers. In Paris because the started obligatorily with a year of surgery, I chose to come in in Merle from because it had been told me that it was a good service, that one learned there much things.

. : I suppose that this training course sealed your destiny?
. : A posteriori one can say that. In practice I spent one year in Merle of where I learned much. There are surely things which “were inculcated to me”, as said the Owner, and which remained in me in a more or less indelible way, but I did not can formulate them without reflecting. Actually I left the surgery at the end of one year, very happy to go to make medicine.

. : In was the service of Blackbird of , the external one to be the fourth wheel of fits with body?
. : Yes, even the fifth, because the service could function very well without external. We were solicited primarily for operational aid, but we were integrated immediately in the team. I.e. the external one had a certain number of patients in a room (these was always common rooms at that time) of which it was occupied, of which it made the observation and of which it supervised the operational continuations. It from time to time forwarded an observation Saturday morning to the Owner and to the whole of staff. Blackbird of was a character who, told one, started at the time improving but there remained still dreaded. One can even say that it terrorized a little everyone. But it had already created in this service a manner of working which immediately rained me, because all was organized perfectly, the morning and the afternoon, sometimes the evening, and the external one was integrated perfectly.

. : Then you find yourselves in medicine…
. : I found that medicine was a richer thing, more intelligent where the professional work was broader. The csotcina.comedic surgery had appeared to me like a kind of technique being connected a little with joinery or with mechanics but it was primarily of the technique. It is the aspect which the external one seized of a stay in a service like that there. Whereas medicine, would be this only if one compares the questions of medicine of boarding school with that of surgery it richer, was varied more, much more dubious also and it was as many things which attracted me.

. : Then you pass the boarding school…
. : It is that. I missed the first contest and I made a success of the second. Meanwhile I had been external in other departments of medicine including six month in pediatry. But I kept my stay of external in medicine an impression to lose much time and a certain therapeutic inefficiency, in particular in neurology and cardiology. In cardiology, every morning with 8:00 the first job of external was to go to recover with the mortuary the cores of the patients died in the night. One examined with the owner the lesions whose one had understood the auditive translation the day before. It was surely a good way of learning pathology and the cardiac anatomy. But I felt the need for a greater effectiveness and when I was appointed with the boarding school, I told myself that I would make surgery.

. : You thus made a boarding school of surgery, but had you already chosen csotcina.comedy?
. : When I began the surgery not. I begin with obstetrics because it was difficult in intramural Paris in first half of the year to have another thing that obstetrics, ENT SPECIALIST or urology. I chose obstetrics because the mechanics of the labor interested me a little, and there was nevertheless contiguous to obstetrics, gynecology with its medical share. It was a little a transition between the medicine which I left for the surgery. Actually I did not do much obstetrics because I had to stop me nths to make me operate. I had indeed had for a few years a bilateral pneumothorax repeating, fortunately nonsimultaneous, which had been discussed two years front per intrapleural injection of . These injections which have an irritating negotiable instrument had caused some flanges and at the time of a later repetition one of it, which contained a small artery, broke. This involved an hemothorax of 2 liters in a few hours and I was operated in urgency by Claude .

. : Where did you go afterwards?
. : I went afterwards to which held the great general surgery service of , and I discovered in an extraordinary man, of an extremely pleasant and pleasant personality. He was full with humor and he had an impressive general education, which in any case impressed me. I also met there.

. : And did the visceral surgery rain you?
. : Yes, the surgery of rained me well. It operated many colonists and all seemed simple with him.

. : Perhaps because it selected its patients carefully?
. : Not it was not at all the kind. It had can be some patients who were simple but the majority of its operated were not with their first intervention. I was always sensitive to elegance, the sobriety and especially to the effectiveness of the gesture. I found at this control of the gesture, but also a thing which I had already learned like external in Merle from . It is that an intervention, it is necessary to think of it a long time in advance to have less possible surprises, or in any case to have considered all the possibilities, to know how to face there. It was a thing which I kept of my in csotcina.comedic surgery and which I found there.

. : You find yourselves where, the next six-month period?
. : At . But at the end of two months I have to stop because I continued to make pneumothoraxes on the side not operated. I was operated again by Claude .

. : Did these adventures stop your boarding school?
. : Yes that obliged me to stop it 2 times nths. In fact, I stopped only 2 times nths and I passed half of my convalescence to make operational aid at which had also an impressive leg surgical and which I admired much. It was an assistant of which worked in a private clinic. It made at the same time infantile surgery and visceral surgery. I learned much by helping it three or four times per week. Then I took again my course of boarding school at because I was interested by the vascular surgery of . The vascular surgery at the time was full with risks but interesting. In the laboratory of I tried to do some experimental work of vascular surgery in the dog. There was in particular a problem which was not solved at this time there, it was the arterial spasm which one could not raise. At present I suppose that one has drugs likely to do it. I never succeeded in creating the same arterial spasm in the dogs. After this first work, this failure complete, I had acquired a certain experiment in vascular surgery all the same and I had undertaken a comparative study between the venous transplants to replace the arteries and the prostheses in Dacron. This experimental study which occupied me during more than one year and for which I sacrificed many dogs, did nothing but confirm data already perfectly known. I forgave myself to have sacrificed so many dogs for nothing.

. : Did this possibility of repairing the arteries have all the same to interest you?
. : Yes. Completely. Afterwards, I went to which was in Trousseau and which had an immense service with at the same time rooms of visceral surgery, of csotcina.comedic surgery, , and various malformations, a sector of flarings. There was also an infantile small room of urologic surgery which was held by which interested me also much and I learned much from things in urology to his contact. All impassioned me. I continued at this time to work there with which made primarily neonatal surgery and in particular esophageal .

. : You operated?
. : Very little, but I helped much.

. : You operated a little perhaps keeps some?
. : A little. In guard at the visceral surgery urgently, apart from appendicitis, was made by the chief. Traumatology was generally left with the intern. Many fractures were discussed , even the cervico-trochanteric fractures. At on the other hand the guards were very charged, and the rather busy intern.

. : After ?
. : I went in Merle of , in third year of boarding school.

. : Which impression gave you this return?
. : had just opened and it was “Versailles”. All was new, impressive with fantastic dimensions. Subsoil to the 5th stage there was very at disposal: the radio, laboratories, rehabilitation, a splendid sector of teaching; it was really the flagship which was sufficed for itself “able to take the sea” according to the expression of Blackbird of . All functioned with even more rigor because the organization which it had instituted and the buildings it had lent to it better. It started nevertheless to delegate some powers to its assistants who were , , , and . But he saw every saturday mornings the patients who were to be operated the following week. All these patients who had re-entered Thursday or Friday, were examined by the intern, the chief, the assistant, and finally forwarded to the owner Saturday morning, to be operated the following week. Those which were operated Monday that still went, but those which were operated Friday, spent eight days to the hospital before the intervention.

. : Did pathology relate to already especially the hip?
. : Not it was a pathology more varied than that of my service currently. There were nevertheless many hips, much congenital malformations, much primitive hip osteoarthritises also, and especially what one sees less nowadays, much after-effects of traumatisms.

. : For was an intern the service attractive?
. : Yes. I liked much the rigor of the reasoning, search for each patient of the best indication in order to obtain the best possible result. It should be said that at that time the results of the articular surgery were far from being as brilliant as they are it currently.

. : How was the indication posed?
. : The intern, the chief and possibly the assistant had the duty to propose an indication, to defend it, quote the other possibilities and finally Merle of chose one of them. Staff was primarily a exercise of teaching. But it was a teaching which although very profitable was not always pleasant because one .

. : Were there already total prostheses of hip?
. : Not, but there were prostheses of Moore. The acrylic prostheses that I had known external, had disappeared. A fracture IV of the neck at an old woman had her prosthesis, but a III was fixed by a nail of .

. : As an intern, whom did you have the right to make?
. : We were 7 or 8 interns in this service. We were thus of guard once per week, with a chief, external and an anesthetist. We received in guard the Parisian current traumatology which did not change much since, plus a certain number of victims of the route who at that time were not dealt with by the peripheral hospitals which did not exist. It was thus rare that it occurs a guard without one receiving large . had cranial lesions but also frequently abdominal lesions and the team of surgery of guard dealt at the same time of the osseous lesions and the visceral lesions, particularly of those of spleen. The team of Leger had it also her quota of fractures of the neck with which it posed prostheses. The things were however changing, but true separation, I knew it a little later when I returned as chief in .

. : Which type of equipment did have you for the fractures?
. : One had of all, in particular all the possible and conceivable nails of : humerus, of tibia, femur, clavicle, ulna. We did many .

. : With open chamber?
. : Yes, except the tibia. The tibia without boring; the femur with open chamber with boring. We had the obligation to show the morning with the Owner all the operated patient records keeps some at the same time as one showed radiographies of the cold operated patients the day before, and one was made a little abuse if the reduction or osteosynthesis were not perfect.

. : At the end of this year, had you made your choice of speciality?
. : Not yet. I went to make my last nths at where I took taste with the thoracic surgery so much so that I remained nths after the end of my boarding school as attache.

. : You thus had at the end of the boarding school an excellent training of general surgeon, and incidentally of csotcina.comedist.
. : Yes, it was the usual course of the interns at that time. I had actually made in 4 years only 1 year 1/2 of csotcina.comedy. 1 year of adult and nths of infantile. I hesitated at that time between the infantile surgery and csotcina.comedy. Finally, I chose csotcina.comedy and I returned in Merle of as senior registrar.

. : Why?
. : Because I liked that of advantage. I liked the work method and the way of reasoning. In addition, there was no yet separation within the infantile surgery between csotcina.comedy, urology and the remainder. There started to be a small specialization but made of all. Small at the time made also whole and I did not see myself in this situation.

. : Thus you are Senior registrar in ; how does one make about 1960 to discuss a fracture of the neck III?
. : One reduces it on csotcina.comedic table by putting it in light traction and internal rotation. Then one makes two angles of attack radios to control the reduction. Exceptionally one reduced by a maneuvre of which is a reduction in bending of hip. The patient is lying on the back, one puts the thigh in bending at 90°, and one exerts a traction in bending followed by an extension in internal rotation. This maneuvre was often effective, in the IV.

. : Once the reduction obtained, how did you ?
. : With a nail of , but screws were appearing.

. : Why not use a large screw?
. : The large screws of m one had were not perforated. It was simpler and surer to place a pin in the center of the head and neck and to thread a nail.

. : When it was about IV, you put a prosthesis of Moore?
. : Yes, when it was about an old subject. Moore itself had come besides to earlier show us 2 to 3 years how his prosthesis was used.

. : Who was Moore?
. : Austin Moore was American. “No ” was a concept which was rather foreign for him and its way of operating had shocked us a little.

. : And total prostheses of hip?
. : The total prostheses of hip arrived at the same time as I began my in Merle of , i.e. in September 65. It is Watson who came to pose the first: one , metal-metal.

. : What said Merle of of it?
. : It had chosen after being gone, if I dare to tell, to make its market in England. It is a country which he attended very regularly, he was besides very anglophile. The history of the total prosthesis of hip was in the air since one moment. We did not have any, but we knew that it existed. We knew in particular that there were two English who worked there above since years. Blackbird of and went to make the turn and to see a little how the things went. At that time, was perfect, without major trouble. At John it was the catastrophe because it took again the every day his out of Teflon. It had tried out for 2 years polyethylene , but had not authorized its marketing.

. : What did you think of the intervention of ?
. : used an antéro-external channel of Watson Jones, the patient installed on the back. I did not like the intervention much because one badly saw and one controlled the preparation of the femur badly. To see well, it was necessary to cross a little too much of neck and there one found oneself with a a little short member and a mechanically defective hip. Then very quickly, at the third total prosthesis, Merle of put the patient on the side and makes to an external channel of which was the common pathway of the service. It is a channel external, with section of the tendon of the means and musculus gluteus minimus with one centimetre of their trochanteric insertion but conservation of the .

. : Why did you give up this channel?
. : One continued during two years. One day in 1967, I helped to put a total prosthesis on a woman who had already a prosthesis of Moore and whereas it was on the point of cutting the glutei, I pointed out to him that there was a hole behind and that one could try to pass by there. It did it, and I believe that this day there was established the first total prosthesis of hip by channel of Moore.

. : Had nobody done it before?
. : I do not believe, but that remains to be checked. The following day I put a total prosthesis by channel of Moore on a primitive hip osteoarthritis. Very quickly all the operators of the service put themselves there.

. : No complications?
. : We inaugurated with this channel initially a series of thromboembolic complications because we told ourselves perhaps that since one raised operated as of the following day, one could not give them an anticoagulant. In one week we had three phlebites. One gave the patients under anticoagulants then one went to seek an explanation by carrying out channels of Moore on fresh corpses with injection of the femoral vessels. One realized that those were completely wedged when one associated with an internal rotation 90°, a certain adduction and a certain bending. While one was there it was checked that another position, i.e. former luxation through the external channel, left free the arterial and venous axis.

. : But which were your continuations when you divide the glutei?
. : When one cut the glutei one left the patients in traction 15 days, as the joint replacements with cup which one often left with the bed three weeks. One operated little at that time. The intermediate duration of a hospitalization for a hip was one month.

. : Did your cadaveric studies make you reconsider the channel of Moore?
. : Not, one did not give up for as much the channel of Moore because it is extremely convenient, and one carried out face during one moment the channel of and the channel of Moore. At one given moment one did by channel of Moore all, including the recoveries. I believe that it is into 68, that one told oneself that it would be interesting to compare the channels initially; and to make the study more interesting, the channel was introduced. There was a large series of channel of and of channel of Moore, one added 200 channels there.

. : You published this study?
. : In 1969 one took stock at the time of my first item on the total prostheses. I had made beside the usual study results, a study of the results according to the channel initially but Merle of forever desired only one speaks about technique in the Medical Press which published this item and thus this aspect of the problem published forever. We had nevertheless learned that at six weeks the patients operated by channel of Moore were clearly in advance on the others, but in six months they were caught up with and exceeded by the channel .

. : Why?
. : There are with that several reasons. The patients operated by channel had better directed prosthetic parts. They had as a whole a better balanced mobility, less venous and sciatic complications. In addition, they had less ossifications. One frequently found a small ossification on the level of the external section of the trochanter but elsewhere very little. On the other hand those which had had a muscular section, either of the glutei, or of the external rotators had readily ossifications: in top, when the glutei were cut, and those operated by posterior channel behind and especially in bottom. That involved which sometimes were done in vicious attitude. But with the famous persons ms in diameter there was not luxation. Thus it is rather less the good quality of the function in six months which made us stop into 69 the channel of Moore and since we did everything by channel .

. : You think that the thrombogenic risk of the posterior channel is so important that?
. : With the systematic setting of the patients under calcic heparin the accidents became rare. But this risk appeared higher than that of the external channel in various multicenter trials made at the time of the experiments on heparins with low molecular weight.

. : The duration of the intervention should be taken into account; how long one put in 1968 to put a total prosthesis of hip?
. : Not very a long time, a little less than 2 a.m. often.

. : You remained senior registrar how long?
. : Two years. At the end of 2 years I had had at one given moment a small hope to be able to profit from one of the last batches of aggregation but that was not done. Very stopped during 4 years. I thus settled downtown while remaining attached to quasi full-time with .

. : In did you act as assistant?
. : In 1968 Blackbird of divided its great service into two. It kept of them one and Michel took the second. I found myself at his place. I thus worked primarily with him. Besides I continued to regularly help it downtown because it was still part-time job with .

. : When did you stop posing prostheses ?
. : In 1969. At that time one any much but I had been unpleasantly surprised to see that good number of enters had, as from the second year, a complete edging of face and profile with some pains and a small . We had allotted these unsealings , realities or potentials, with a too important friction. The measurements which we had made on the removed parts had confirmed besides that the moment of the couple of friction was very high. The “low-friction” started to make speak about it and the early troubles did not seem to exist with polyethylene. Therefore, in 1969, when authorized the marketing of its prosthesis, one used it, but we could obtain only two or three from them. Then Michel decided to make it manufacture in France.

. : There were difficulties of provisioning of the prostheses?
. : Yes. There had been of it also in 1965 with and it is one of the reasons which pushed Merle of to do his. The other reason was that he/she did not like the femoral stem.

. : What allured you in the prosthesis of ?
. : Its extremely low friction metal-polyethylene. When one put it on our machine to compare it with Merle of it was the day and the night.

. : From which did this machine leave?
. : It was an aircraft which one had made build and who was in a laboratory with the subsoil. There was at that time a mechanic, extremely skilful, who could do everything. All our surgical instruments were repaired, and some even conceived, on the spot.

. : Doesn't that pose a problem to remake a “”?
. : One had asked , since one could not obtain his prostheses easily, the authorization to make it manufacture in France. It had given its agreement to the condition which the French prosthesis is called of “ type”. One did it with identical after some gropings and some small errors which one hastened to correct.

. : You kept at the beginning the same characteristics, the same …
. : Absolutely, so much for the standard than for the prosthesis known as of “overhaul”. But the latter, instead of using it like to take again the failures of the osteotomies of internal translation, we reserved it for congenital dislocations and their after-effects, i.e. with the femurs .

. : Thereafter you amended the stem of . Why?
. : In 1971, one saw appearing with , not side where all was perfect, but femoral side a certain number of worrying images. It was primarily a clear edging with the back of the convexity of the prosthesis, frequently associated with a transverse fracture with cement compared to the end with the stem. The prosthesis was inserted a little, a strand and more or less. , with which we had announced our concern, had answered us “yes, it is current, it is not serious, In addition the patients do not complain”. These abnormal images, which were not however always asymptomatic, were often visible as of the sixth month. I tried to take stock and I joined together 200 files. I found that at 2 years I had almost as many femoral problems with than of problems with . I told myself that one could not continue like that because these unsealings, even if much were not very symptomatic, were going badly to evolve/move and that something had to be done. My first idea was to make a hybrid prosthesis containing the cup of , the head and the neck of and the stem of Merle of , since the fixing cemented of the aforementioned had proven highly reliable. This prosthesis that I had drawn in 1971 remained finally in a drawer because I found that it was not very pleasant to see. I then started a certain number of reflections and studies. I interpreted unsealings intra-cement of the stem of in the following way. This prosthesis with thin stem, strong arm of external lever and closed cervico-diaphyseal angle forwarded cement, in the area , with high stresses in pressure which it could not withstand. It resulted from it a vertical fracture interns, simple or double, which enlarged the upper part of the cement sleeve. The prosthesis, being fixed in its higher third party, strongly pressed on the final cement base which broke transversely. To improve the behavior of the prosthesis in its cement sleeve, my first idea was to increase cohesion prosthesis-cement by giving to the prosthesis a rough surface. I quickly gave up it because the overload of the interface cement-bone which would result from it seemed to me too risked. I thus decided to keep a smooth surface, but to amend the form of the stem. This amendment related primarily to two things. Its cervico-diaphyseal angle and its section. To decrease the on cement, I reduced his overhang and rectified to 130° his cervico-diaphyseal angle. While thickening and by enlarging his metaphyseal party I had a more decreasing section and I hoped that shear stresses along the stem would be transformed into their horizontal components of pressure, sufficiently to reduce the residual vertical force on the final section of the cement case, and to avoid his fracture.

. : It was a sophisticated reasoning and you would have simply wished to have a larger stem…
. : Sophisticated not, elementary rather. The only interest to have a larger stem, therefore more rigid it is than she requests less cement than a finer and more deformable stem, but a large stem is not enough to put cement at the shelter of the stresses which it cannot support. In fact, I made large stems and averages and the small ones, a whole range of prostheses in 5 lengths of neck and 4 degrees of lateralization to face all the morphological possibilities and to be able in all the cases to give again with the artificial hip an architecture close to the normal. All these stems had the same mechanical characteristics, i.e. they reduced tensile and bending stresses of cement to the profit of the stresses of pressure that cement supports much better. But so that it supports them well, is needed that the osseous support is smooth and rigid, i.e. cortical and nonspongy, from where need for abolishing the spongy intramedullary one. Not only in the areas and inféro-side, where the form of the prosthesis forwards cement directly to stresses in pressure, but also on all the height of the stem because of the horizontal transformation of shear stresses and because of the forces of axial torsion that the stem receives and which transmits them to the bone in the form of stresses pressure.

. : You were not far from the theory of without cement.
. : I even failed to give up cement in 1971 when we had troubles with and . I even drew at the time a range of prostheses intended to be used without cement and which would not strip too much among the current models.

. : Why didn't you cross the pitch?
. : Because I believed and that I still believe to have found a good solution by keeping cement, which has an indisputable interest all the same.
. : What do you fear for a stem without cement?
. : That it is not fixed or that I donot can remove it without osseous damage, in the event of need.

. : How do you explain the failures of the prostheses very filling with little cement?
. : It is a complex question, and to try to answer you, I will appeal at the same time with my experiment and some mechanical considerations. I had noted in 1971, by using the standard prostheses of which they had a more solid and more durable fixing when they were used in a small femur, therefore with little cement, that when they were embedded in a large cement mass inside a very broad medullary canal. I had also noted that the fractures of the cement sheath never appeared in congenital dislocations whose medullary canal had had to be reamed to be able to establish a right stem. The layer of cement under these conditions was thus inevitably thin and in addition the medullary canal was completely removed from its spongy. These observations were thus in favor of a fitting of the femoral part to dimensions of the medullary canal and it was one of the aims of the series born in 1972. This series disappointed forever and it showed an extraordinary reliability in the long run, since the survival of its fixing at 20 years, oscillates between 97 and 99%. This prosthesis had in addition 3 important characteristics; a brilliant polite surface, a rectangular section and an important angle of decrease of the section. Of this fact it did not adhere to cement, forwarded only stresses in pressure to him and its rectangular section, throughout the stem, avoided any concentration of the torsional stresses. The fact of returning surface subdues makes microscopically it irregular, even if with the finger it remains still smooth, and one thus increases the adherence of cement to the prosthesis. This results in an overload into shear stresses of the interface cement-bone which is thus likely to yield by fatigue. In addition, if the section of the prosthesis is oval in its metaphyseal segment, cylindrical in its diaphyseal portion, its behavior in rotation in cement is poor. It is even null in its diaphyseal segment and all the torsional stresses thus will concentrate in the third party and will impose on cement forces which it cannot resist. I did myself this double error under the combined influence of the mode and the engineers with the and the . Their fixing cemented in the long run is far from being as good as that of the . I thus believe that the failures of the prostheses very filling are not due to the fact that they are adjusted with dimensions of the medullary canal, but on their matt surface and an inadequate morphology.

. : You think that one could have enlarged the stems without disadvantage if they had been kept at the same time smooth and more angular?
. : Yes. The which remained smooth and of rectangular section seem to prove it. The survival of their fixing cemented at 10 years is about identical to that of the . However, whatever the dimension of the prosthesis, the aforementioned must preserve an angle of decrease of its section sufficiently high so that shear stresses, throughout the stem, become exhausted gradually while being transformed into their horizontal component of pressure. Lastly, one should not in any way of reaming the cortical femoral ones to put the largest possible prosthesis. It only should be removed the spongy one so that the stresses in pressure which cement forwards are supported by a rigid osseous base.

. : This amendment of had much success.
. : It was undoubtedly awaited per many csotcina.comedists who, like me, found that standard was badly adapted to the large femurs. Its success was progressive because had the reputation, and it always has it, to be a very good prosthesis. This amendment was worth me besides a severe argumentation by itself.

. : On which arguments?
. : That I had not understood anything and when one could use his prostheses, one made very well with his 2 sizes. It had been invited in 1974 by the and had made a one hour conference and half on the technique of use of its prosthesis in all the morphological possibilities.

. : He openly argued you?
. : Not in public, rather severely all the same but without spite. Two years after it amended its stems.

. : Did it make amend?
. : Not. It did not have to do it besides because the amendments which it made did not have the same mechanical bases as mine. It strengthens the stem as a whole, rounds its angles, gives him a matt surface and two higher expansions which one makes call Cobra. It preserved an important overhang and a closed cervico-diaphyseal angle. It held better in cement but overloaded the interface cement-bone, which was worth with those which used it a rather consequent number of unsealings cement-bone.

. : It put ears at its to put cement under pressure. You never put you. Why?
. : Because I think that it is not useful for several reasons. If the flange stops the opening hermetically (what is impossible to carry out in practice) one cannot insert the part in cement, and if it with the least escape the pressure falls there immediately. In fact these “” had been created for the reinterventions with damage . As of 1974 we preferred to rebuild this osseous damage with bone to return to a cavity of size and form normals, whereas exempted him Clerc's Offices and filled the loss of bone substance with cement.

. : How was ?
. : Sympathetic nerve, funny even when he had drunk a little, serious, impassioned by all that he made and I believe of a great intellectual rigor.
. : It had the direction of humor?
. : Undoubtedly, but I did not report myself well from there because the mediocrity of my English undoubtedly did not enable me to appreciate it.

. : During did these years your situation university change?
. : It changed in 1971 when Mazas left to Clamart. It was time because I had been on the short list for 3 years when this place appeared.

. : It is which decided.
. : Surely since the place was in its service.

. : When one has an great experience of the hip surgery why continue to make ?
. : For several reasons. I do not like to cut the muscles transversely, nor the of the bone because I think that this manner of making weaken the musculature and create a weak point which can cause instability. The second reason is that this channel initially is much higher than the others in high congenital dislocations and the reinterventions with osseous rebuilding. The third reason is that if it is not well made (as well the section as fixing) it can give place to many vexations. The best way of making it well and especially to teach it is to make it in all the cases and if it is well made its disadvantages are very rare.

. : The debate 20 years ago was concentrated on the diameter of the prosthetic head; does that have importance today?
. : I think that remains important for polyethylene because the quantity of released remains is proportional to the surface swept by the head thus all the more reduced as the head is small.

. : But with the new couples of friction…
. : If you have a couple ceramics-ceramics, or metal-metal, you can obviously use a famous person. The main issue in these couples of comparable nature and with extremely rigid materials is not any more with friction. It is in my opinion with the durability of the very rigid work-holding in a deformable and elastic cavity. I think that there is a considerable risk of progressive mechanical divorce.

. : Does a patient have a very elastic mining area?
. : Very elastic not, but in the lower part of it is it indisputably. It is a risk. I do not say that it is a very important risk.

. : Did you pose without cement?
. : Not and I do not plan to do it for two reasons. A polyethylene articulated with a head of 22,m is not loosened, if the technique of implantation were correct, that if polyethylene wears, by osteolysis due to the remains of wear. This late unsealing by osteolysis will also occur with polyethylene without cement. I thus do not think who the survival of their fixing is higher than that of cemented than we use. In addition, the implantation of a without cement in a cavity ovalized by osteoarthritis results in increasing this cavity at the expense of the wall higher than one weakens a little, especially at the expense of the walls former and posterior which one thins. This worsens the mechanical between a very rigid prosthetic and an osseous cavity returned more deformable in its lower part and the risk to see one separating from the other does not appear negligible to me. Besides one starts to see some impacted perfectly fixed during 8 to 9 years, to very yield blow it tenth year.

. : What becomes a cemented at the end of 20 years?
. : A of established in years 70-75 is likely all to be still intact or hardly worn afterwards and fixed 20 years perfectly. The polyethylene of this time obviously had an excellent wear resistance, quite higher than that the fifteen last years.

. : But the quality of the bone changes with the years…
. : Undoubtedly, but it seems that the progressive osteoporosis of old age is not sufficient to loosen a prosthetic part or femoral.

. : What did you think of the efflorescence of the French prostheses between the Seventies and 90?
. : I think that they testified to an extremely sharp and fertile imagination of the French csotcina.comedists, unfortunately not always allied of a direction of articular mechanics.

. : If you must draw a prosthesis today, that would you make?
. : I drew in 1972 a prosthesis, derived from the original model of , which proved practically perfect. While wanting to better do I redrew two others of them since and I was mistaken twice. Thus at present I returned to the initial model and as it does not appear reasonable to me to preserve a prosthesis which gives 10 to 12% potential unsealings at 10 years, I transformed the matt prostheses of section oval or cylindrical ( and ) to make them brilliant polite and of rectangular section like was the which remains the reference.

. : You preserve the couple of friction metal-polyethylene?
. : Yes in the very large majority of the cases by seeking all
time to decrease the wear of polyethylene by improvement of its mechanical qualities. I use a zirconia head of 22,m since a little more than 2 years in the quite precise cases, but it will undoubtedly be necessary to wait 10 years and to know more if it is a real improvement.

. : When one has 50 years and small hip dysplasia, hip osteoarthritis beginner and that one knows that one can hope for 20 years of happiness with a , can one still accept the stop or the osteotomy?
. : The CR Michel formula “20 years of happiness with a total prosthesis” is excellent, but I fear unfortunately that it is not always exact. To come to the conservative therapy from a painful dysplasia at 50 years, it is surely a difficult problem. Although the indication of a stop associated with an osteotomy with in a mixed dysplasia is excellent and that the chances of success are large, the length of the operational continuations and thus of the stop of activity, generally push the patients to refuse this intervention, and to come to seek their prosthesis later a few years when the deteriorated hip imposes a total arthroplasty. There exist however still some patients who make a point of keeping their hip more the possible for a long time and who have the possibility of stopping one year.

. : You see such patients?
. : From time to time, but more and more seldom. I see well, a year, about fifteen hip dysplasias which would justify a preserving intervention but I operate only 2 or 3 of them.

. : Didn't that cost you throughout your surgical life to give up very to make hip?
. : First of all, I do not have all my life operated only hips. When I was young surgeon I were, like many others, general-purpose. Then gradually the hands, the elbows, the shoulders, the feet, the rachis disappeared and I practically more saw only hips and knees. They is finally the patients who oblige you with you . It would be undoubtedly monotonous to be limited to only one hinge if I operated only primitive hip osteoarthritises, but I devote much more half of my activity to the reinterventions, and there there are not really two identical.

. : Summers you opened with the exception?
. : I have my ideas, my convictions that I believe sitted on strong foundations due to the reflection and my experiment. I do not like the exception of principle without serious arguments, because I find it sterile, but I am completely open to the discussion which I cause or cause readily. You doubted it?

. : At all; I wanted to ask to you whether you find yourselves in the interns who come on your premise?
. : Yes sometimes completely, but as a whole there is an indisputable difference between the interns of there are 40 years and those of today. This difference is undoubtedly due with a different formation but more probably to the fact that the men, mentalities changed, as well the oldest young people as. The atmosphere of the service is relaxed currently much than it was it 40 years ago and it is undoubtedly much better thus. On the whole, at the end of the boarding school I find that intern current are as valid as those of my generation.

. : And work method?
. : That of the intern changed only little. The intern of 40 years ago, just like that today was primarily busy to examine the patients, to hold up to date the files, to take the guard, to help as an operating room. The intern of my generation operated less than that of today. The operational activity of the services was much less important besides than currently and it remained with the intern not badly of time to re-examine the files.

. : One with the impression which the things are discussed more freely nowadays.
. : It is certain that the environment of the services is currently much user-friendly, the less heavy hierarchy and the relations much simpler. It is surely a good thing, but it is not necessary that this freedom turns to anarchy because then the service loses any unity of thought and share.

. : Don't you have the feeling that , gradually, was contained in its shell?
. : Undoubtedly one can have this feeling, especially if one compares of 1999 with that of 1960. At that time there were in Paris 2 schools of csotcina.comedy and . Currently, and are nothing any more but 2 csotcina.comedic departments among a dozen others which emanate from it for the majority and which have their own identity. That is due also undoubtedly to the fact that we do not publish enough, although we continue to work much. But I so much saw one year old panaceas which had disappeared the following year, that it appears preferable to me to speak only when one has something of reliable to say. That led us to communicate little. I think that the things will change need because of the obligation to make a hospital career have a long list of publications. The aforementioned can be often established only with the detriment of the training of our trade. This type of selection where the clinical value and technique of the candidate are less and less taken into account seems me unrealistic and rather perverse. It is likely to lead to a completely opposite result with the sought-after goal.