Like each year, a broad place was made with the knee surgery and the American surgeons, proximity helping, were with go. We could maintain us with Peter who contributed to the development of the prostheses with mobile plate and which particularly studied the external access in the deviations in valgus of the knee the multiple homages paid throughout the congress to their founder, late the Raymond , however did not can make forget his absence.

 

. : Mr , where were you born?

Km No: I was born in Pennsylvania, some share between New York and Philadelphia and finally I did not move away too much since my birthplace is with approximately iles of my current residence.

 

 

. : Why did you become surgeon?

Km No: I always liked to carry out things of my hands and when I was child, joinery interested me much. Later when I went to the university was to be a dentist, because I had good friends dentists and that this trade implied to work with its hands. And then I realized that I wanted to be rather a doctor. I was very interested by the human contact, and the idea to look after people. Then, when I decided to become doctor, it appeared obvious to me that I was to be a surgeon. My very first idea was to become neurosurgeon or plastics technician or csotcina.comedic surgeon. For multiple reasons, I chose csotcina.comedy.

 

 

. : At which time you did choose?

Km No: With beginning of the year 60. It was initially necessary to make a year of general surgery. It was the time of the war of Vietnam and I was built-in after this year of general surgery. Fortunately, I could continue my education and my csotcina.comedic training in the military university hospitals.

 

. : In which structure?

Km No: US in Texas, William General .

 

. : Were you implied in the war of Vietnam?

Km No: Yes, immediately after the end of my boarding school in 1968. My arrival was at the time of the offensive of the Small fireclay cup. There were intense bombardments and I had to wait 3 days before being disembarked in hostile ground. It was very testing. Then, I was appointed responsible with the 91st Evacuation in , located between and at the south of the China Sea.

 

. : Which were the usual lesions which you discuss?

Km No: One discussed many wounds by ball on various body parts. But the civilians were also looked after. One dealt with all the wounds of the civil populations of the area, which did not require an csotcina.comedic care badly.

 

. : Did you use external fixers?

Km No: In fact, it was necessary to arrange. Pins embedded in a plaster were used to us as external fixer; sometimes tutors out of wooden were used. And that went rather well. We also looked after children amputees partially on the level of the feet, because of the mines.

 

. : In this context of rescue, did you progress much in csotcina.comedy?

Km No: yes, and I am in fact become a specialist in the amputation. Three years after my return, I became chief of the department amputation in Forge in Pennsylvania, one of the largest military hospitals. I had the responsibility for 150 patients amputees.

 

. : Is thirty years afterwards, which your feeling on this war?

Km No: It was a war which had not been very quite considered. We succeeded French without learning the lessons from their failure. Most of the time, one bombarded the night without seeing the enemy. When you are army medical officer, you have a commitment and you must look after people costs whom costs. On a philosophical level I did not like this war but I had a mission to fill.

 

. : How do you evolve/move on the professional level after the army?

Km No: I sought to work in hospitals which had university fasteners. I chose to remain in the East because I liked the area, near to New York, Philadelphia. Of course, we were at the beginnings of the arthroplasty, modern traumatology and sports medicine. The majority of the surgeons did many things and did not have there specialization. I was interested in the prosthetic joint replacement, because that represented for me the processing of truths problems.

 

. : Did you have Masters in the field of the arthroplasty?

Km No: Yes, Dr. in Cleveland in Ohio. It was one of the first layers of in the United States and also Dr. Charles , a very known surgeon at that time. There was in my university of Philadelphia of the surgeons who were interested particularly in the polyarthritis (PR) and who had developed their implant such as for example a prosthesis metal-metal. I had acquired myself a good experiment of PR in Texas. And as there were many patients with a strong demand, we could propose the prosthetic arthroplasty of the knee to them as soon as the technique improved.

 

. : At which time you did start to pose knee prostheses for rheumatoid arthritides?

Km No: In 1972. We then used or , ; then in the middle of the Seventies arrived, then the Total of John

 

. : What do you think about it?

Km No: It was the beginning of a development very exciting, and we learned much on the knee. We had started with models of the hinge type. I made my first total prosthesis of the knee during my boarding school in 1964 with the Scandinavian prosthesis and then it was .

I continued to use the prostheses hinges with beginning of the year 70 for very severe deformations, then I started to use the prostheses more developed more than I already mentioned like , the Total etc. perhaps I used inds of prostheses in the Seventies. Then, in 1980, one asked me to study the concept of the knee with mobile plate and thus I worked on this very special design, with the possibility of carrying out , of preserving the two cross ones or the or of sacrificing them and all that with a system which had a very specific drawing and a moving part.

 

. : Who asked you?

Km No: Designers; Doctor and Pappas. Dr. Pappas was the engineer designer. I was thus implied in the development of this concept of joint replacement of the knee and we started a multicenter trial. The first clinical studies for the FDA ( Administration) were carried out in 26 different centers, in order to obtain sufficient case. Because the concept of the mobile plate was so worrying at the time, that required 4 analyzes FDA.

“Until there, a prosthesis of the knee was a prosthesis of the knee and it was the first time that an evaluation was required. The rigor of the FDA obliged us to show that the concept was valid and viable.”

 

. : What did you think the first time that you saw this prosthesis?

Km No: I was immediately impressed because at that time I believed that the conservation of the always involved problems. The concept of mobility by keeping stability was very attractive. The fact also that the femur and the prosthetic tibia were always well articulated together, in spite of the disproportion of sizes, represented an enormous pitch ahead. Indeed, the different systems with stationary star could not carry out that, and often, you had smaller femurs and larger tibiae.

 

. : At that time, there were 2 “meniscuses” or only one mobile plate?

Km No: Not, we had the complete system as of the beginning. We had linked the mobile, we had the model with conservation of both crossed or only of the , and also the rotary shelf for the serious cases. We did not have all the sizes, but all the ideas were already there.

This new system was very exciting. One also asked me to begin the development of hardware , and to consider the best approach to carry out correct implantations. I had reserves on the replacement of the ball joint but the evaluation of the ball joint was not included in the studies FDA. I could thus choose “to surface” or not “to surface” the ball joint what was very interesting. At that time, we hardly had just realized that the knee was not a hinge, that its dynamics was complex and that the basic element was rotation.

 

. : How long this study on the knee lasted?

Km No: The first study was made in 1980. The fixing of the knees without cement had just been proposed and thus of 1980 to 1984, all the implants were cemented. The 1st study finished in June 84 and with 3 or 4 surgeons brought we it back in front of the FDA in Washington.

 

. : On how much case?

Km No: On 600 cases approximately. I probably had myself 80 to 90 cases and I had even carried out some checks in order to ensure me of the movement of the moving part.

 

. : You started the at this time there?

Km No: I began the makes some in 1975. started to manufacture in 1975; I remember it because our new hospital had just opened, and we had the permission to buy one of them.

 

. : What did you see in ?

Km No: When the installation was correct, the “meniscuses” moved normally before behind as we had noted in radioscopy and that there was no conflict with the .

 

. : Which are your conclusions on this study?

Km No: Very good. On the whole of the cases, we had 2% of luxation and some technical minor problems. We had a very primitive hardware . Sometimes the tensor was not very precise, but as a whole it was better than than we hope, because we start a very new concept. I had not had of large complication and in particular not luxation. Of course, later the problems involved in wear appeared.

Therefore, as a whole we were extremely content with these first studies. In 1984 when we finished the study with cemented fixing, fixing without cement started has to be accepted. Thus, immediately after having stopped the first study, we began of them another with all the components without cement. In 93, practically all the new cementless implants were accepted by the FDA. And all that because at that time we thought that cement posed a problem. But, as you know it, the problem is probably not cement, but rather polyethylene. At all events, during 9 years, I believe that I cemented only one or two knee for very specific cases and I thus acquired a very good experiment of without
cement.

 

. : Which were the models which you use more, total or unilateral?

Km No: Only 5 to 10% of . For the total ones, I made initially more conservation of the posterior crusader with a ratio 6/4.

 

. : However, you thought that it was to better get rid of the posterior ligament?

Km No: Yes and I did it in 40% of the cases of my first study. Each time the did not appear normal to me I withdrew it. I changed a little opinion in the light of new studies kinematics. The kinematic analysis of the knee is always delicate to realize, but the results are better in the absence of the . I am implied in 2 studies with , Dennis and . It seems that there is more foreseeability in the results when you remove the cruciate. However, I always use the model of prosthesis with “meniscuses” but with a better polyethylene and in the absence of large deformation and for people who have normal cruciates. The majority of our failures were related to polyethylene. The rotatory mobile plate and maintaining version Glide have of a thicker polyethylene and a better congruence, however I think that the problems of the conservation of the will always exist.

 

. : Which was the thickness of polyethylene at the beginning?

Km No: The minimal thickness of polyethylene proposed was approximately 4,m thickness, and we were enough careful to pose only 6,m thickness. But as showed, if you have a good congruence, the thickness is only part of the equation. Congruence and the thickness are two different problems.

 

. : Which are the brakes of the “polyethylene meniscuses”?

Km No: The “polyethylene meniscuses” have a base plate in the form of dovetail which engages in the antéro-posterior furrow of the metal plate; this furrow has out of cut the form of dovetail. Thus the “meniscuses” can move freely risk-free side luxation or . They can go only from before behind in the furrow and they are then stopped by the soft parties. The suitable tuning of the voltage of the soft parties is a subject on which we insisted always much and who is one of the keys of the good performance.

 

. : How did wears occur?

Km No: In fact, the first failures of the prostheses with “meniscuses” were related to a too fine edge of polyethylene and on an action leverage which was exerted towards the back at the time of the bending whenever the realization of spaces were not suitable. Posterior and central wear ended up fissuring the “meniscus”. That did not occur with the rotary table, because it has a large stem, and an important thickness of polyethylene.

 

. : Which was the development?

Km No: In the beginning Doctor and Pappas were the main concerned ones. Then during the years, there was a whole movement in the search of various models. There is 10 years the concept of Glide (antéro-posterior update of a shelf) developed, to avoid the disadvantages of the component “meniscus” of small size and to benefit from the advantages of the large plate. More recently, because of the success of the postéro-stabilized knee, a group of American surgeons evaluated a rotatory model postéro-stabilized to combine rotation with the passing of the condyle at the time of the bending i.e. the “”. This development comes from the comprehension of the importance of the rotation, which is the key of the mobile plate. Is the question to know if the “” is so important? Perhaps our clinical studies show that not, but at the laboratory or in the studies in fluoroscopy it appears that gets a better amplitude of bending.

 

. : And on the ball joint?

Km No: The ball joint is 20 years old of retreat and knew to resist the time proof. It represents what the has of better. I must say that the , in its drawing, is the only one which started with the fémoro-patellar hinge. All the other prosthetic knees were designed initially by thetibial one. I think that the reason for which the patellar race is so good in the is that this prosthesis was designed around the fémoro-patellar hinge.

 

. : You never thought of demolishing you this arthroplasty of the ball joint?

Km No: Yes of course, very early I started to analyze the prostheses with ball joints not “surfaced” which I posed because at that time the patellar complications were severe. The patellar prosthesis of the is a mobile ball joint, but it seems that the results are good with or without the “”.

 

. : Did you take part in the amendments of this prosthesis?

Km No: I was indirectly implied in the changes. My main contribution during these years was to initially optimize the channels and the instrumentations and to contribute to small variations around the concept of origin. Dr. Pappas was a mechanical engineer and not an bio-engineer, and in 1976, when he spoke to us about minimal stresses, nobody was interested in it. It really introduced this important concept, by thinking that what did not go for an aircraft, could not go in the human body. This concept of low stresses constitutes the engineering of this knee. Consequently, our later amendments were completely minor.

 

. : Why don't you use sees it initially antéro-intern like everyone?

Km No: I did it much. It is as that which I operated the genu valgum, in the years 1970, but I was never really satisfied because I did not have a correct exhibition. Until the day when I began an external that I was obliged to add up… That goes back to 1980 and since I decided to approach by external channel the for better exposing me.

The only disadvantage it is that it is an access a little more difficult to learn. But one encounters problems which can be solved and I could appreciate during the years, the advantages of this channel. I gradually improved the problems of hedging with which one can be confronted but it should be said that by this channel, the race of the ball joint and overall stability are guaranteed. In addition, there are many cases where the surgeons after a conventional access interns are obliged to make major “” into side what is source of complications. I see still regularly in my catastrophic area of the results of operated by using the internal access. Lastly, the external channel is interesting because it gives an unusual point of view on the knee joint.

 

. : Summers you for cement?

Km No: With the total prostheses we thought a long time that cement could be the answer to all the problems; one could all fill with cement without being concerned with biology. Then we learned that cement, for various reasons always did not go, and we then put ourselves questions and in particular we considered the possibility of fixing biological of the implants. There was in particular to solve a problem of osseous insufficiency among patients for whom I proposed the method of impaction of graft. It was a question, in the large , of making cortico-spongy Clerc's Offices in stay under the prosthesis. But, in the event of osseous insufficiency, even when I cement, I use the impaction of graft to strengthen the bone and to improve the biological answer. It is particularly true for the patient at whom the finger of the operator can be literally inserted in the bone.

 

: How do you discuss the overhauls of the ?

Km No: I quasi all the time use the safe in the cases of great instability. That makes it possible to avoid a diaphyseal fixing. The problem it is especially the voltage of the party soft in bending/extension. Most of the time one can leave oneself there with component standards but in case of doubt it is necessary to resort to the tibial stem of overhaul.

 

. : What do you think of the metal corners?

Km No: I think that they are largely used. I was very focused on the grafts before the arrival of the corners, and I did not have badly reserves to use them. But now I make use of it readily and when I am confronted with broad , I combine sometimes both: graft and metal corner. But these corners cannot be enough to only ensure the stability of the prosthesis, one also needs a stem and a good procedure.

 

. : Are the prostheses with “meniscuses” still marketed?

Km No: Two models, i.e. that with single mobile plate and that with “meniscuses” always exist. The model with “meniscuses” is sophisticated much more because it gives movements independent of each plate. It is more precise, more natural. On a clinical level, we observed many good performances. After 15 years, the always functions. The problem in the long term was the increase in the failures related to wear. The “meniscuses” are smaller and among heaviest patients, there was an real issue of wear of polyethylene, and this the more so as the quality of polyethylene was not always irreproachable.

 

. : What do you think of the surgery computer-assisted?

Km No: It is necessary to make the difference between robotics and navigation.

There is truly a place for the tools for surgical navigation. However, for the implant fixation one can put questions about the benefit obtained because of the cost and of last time but I think that there will be true
more for creation of the gaps in bending-extension. They should give us
the few degrees of accuracy which we still miss with the conventional .

 

. : The control stability in bending and extension, but what does it occur to 45°?

Km No: I think that it is a good remark, but how the navigation systems be able will to help us with 45°? It is where we think that the mobile plate has all its value. With a mobile plate congruence is constant and stability with semi-bending remains. In the great deformations, it is enough to have small inaccuracies on the tibial slope and also on the femoral slope so that the troubles start. That which we need in fact prostheses forgive the small faults. And the prostheses with mobile plate forgive!

 

. : In do a situation of recovery, with a stiff knee, how you expose?

Km No: I start by increasing my incision in and in the event of difficulty I make precut osseous. If that is not enough I make an osteotomy of the former tibial tuberosity then. I prefer this option with the section of the tendon .

 

. : Once you did you make your osteotomy of the how fix it?

Km No: I usually fix it with oblique screws. I did not have good experience with the joinings.

 

. : When do you begin the rehabilitation of your knees after prosthesis?

Km No: In the recovery room. My percentage of mobilization under AG is of less than 5%.

 

. : And which is the best moment for a mobilization?

Km No: I think that the best moment is between 6 and 12 weeks, but in certain cases, I was brought to mobilize in the 6th month and curiously that went well…

 

. : You travel much?

Km No: Yes and I came to France very often. For a long time the French surgeons are interested by the mobile plates. In fact, I made the knowledge of more than 200 French surgeons who came to visit me in the United States, and I met some at least as much in France. Thus I knew Yves . We approached thanks to my work on the initially external channel.

 

. : What do you think of Martinique?

Km No: It is single. The congress is splendid and milking of many subjects. I think that it is necessary to congratulate Yves for this organization. By the variety of the covered subjects and the will of teaching these is a congress which refers to that of .