. : How did you come to Mayo ?

: I made my boarding school in Mayo because this institution had the reputation to be a great research and teaching and surgery center also. I wanted to make my boarding school in a university environment and which would give me the best possibilities of remaining there at the end of my boarding school.

. : From where are you originating?

: I am of Texas.

. : Is it enough to want it to be registered in Mayo ?

: Not of course. In the United States when we finish the Medical school, we postulate for various programs. We have a system called the “Match” by which we draw up a list preferably our various choices and the institutions make in the same way with all our proposals. It thus acts a mutual insurance company selection. You choose an institution and it possibly selects you.

. : Why did they choose you?

: My situation was a little specific because I was soldier and I was going to be sent in a high level institution. I made my own arrangement to go to Mayo . They had my file directly sent by my school and accepted my request. I thus did not pass by the “Match”. To tell the truth I was engineer with NASA and I worked more precisely on the program.

. : Why didn't you remain in this enthralling field?

: I thought that medicine would be more interesting.

. : Really?

: I also thought of the future. I was 25 years old when we went on the moon and I did not know what was going to occur afterwards. I did not see what I could become at 40 years while remaining on the spot.

. : You knew that after the moon one long period ago of waiting?

: Yes and I wanted to make more my life that “to be gone on the moon”. In fact with NASA I had developed a programme of cancellation of mission i.e. a program which relates to the procedures of rescue when launching turns badly.

. : It is your very specific which interested Mayo?

: Perhaps, but I was also good at the Medical school. At the end of my boarding school, one asked me to remain in Mayo , but I could it only after having fulfilled my obligations towards the Air Force. I joined thus the Air Force during two years and returned here then. It was in 1978.

. : Why did they ask you to remain?

: Here there are specific qualities which one requests from somebody that one wants to keep and I probably had some of the necessary criteria.

. : And at this time, you were general surgeon?

: I was a general csotcina.comedic surgeon. I made surgical rebuilding of hip, knee, ankle and foot and a little rachis, but not the hand, pediatry nor of tumor.

. : How were you implied in the surgery of the elbow?

: My search was done on the elbow. My initial aim was to try to contribute to advanced of medicine. This is why I had come to Mayo. One of my owners advised me to launch me in a little explored field. And thus instead of me to make work on the hip or the knee it directed me towards the elbow.

. : Which was your first research task?

: The kinetics in 3D of the elbow, it was in 1973 during my boarding school. The kinetics of the elbow was not known at the time. I made use of the scientific computations which we use for the space programs. I thus benefitted from my experiment to NASA to make this first study on the elbow.

. : You had already the idea to develop a prosthesis of the elbow?

: Not, I had in the spirit to improve the surgery of the elbow which was then not very current. My aim was to improve the reproducibility and the continuations of this surgery. One of my first work was to follow the development of the implants of elbow, and the results were poor as well with regard to the performances as survival. And this, whatever the drawing and technique of implantation. Then we supplemented this clinical study by biomechanical studies at the laboratory. By basing us on these studies, we amended an implant to make it more appropriate to biomechanics of the elbow. At the time, there were already some prosthetic models. There was a prosthesis coming from England, . This implant had a failure rate of almost 100%, but nonearly, rather after 2 or 3 years. Then there was a latest thing in Europe and in the USA aiming at reproducing the anatomy. But the problem with this kind of implant it was stability and thus that was luxated. Following our work, we found two characteristics allowing to make more powerful the existing models. We integrated these two characteristics and that gave rise to the implant which we have used for 20 years, .

. : Who is ?

: It is a surgeon of . He worked into private and he drew a prosthesis of elbow in 1973. I saw this implant for the first time in 1976 when I was internal, and we started to make search on the question in 1978. We made a first amendment based on my study of the mobility of the elbow, by adding a few degrees of freedom to it. And then, based on the study of the stresses in 1981, we made the second amendment by putting a pin which resists the forces.

. : How did this idea come to you from very original pin?

: As I told it to you, I had re-examined the files of Mayo on the prosthesis of elbow, and I analyzed hundreds of radios in particular the failures of the prosthesis. The latter ended up failing whatever the quality of cementing and the size of the stem. The stem of this implant did not resist the forces which were implemented to him. Obviously, the problems were at the level of cortical posterior of the lower end of the humerus whereas the cortical former one was always adhered to. We thus deduced that it was necessary to rest on the cortical former one from where the idea of this former hook. Moreover while placing a bone graft between this hook and the cortical former one we hoped that it would be requested in compression and that the Clerc's Office would take.

. : Good idea, but there were other possibilities…

: I think that we were very lucky and also very careful.

. : With or without cement?

: At the beginning, there was in the USA an hot trend avoid cement. Therefore, the implants were carried out with a surface compatible with an implantation without cement. But we have some to want to cement systematically for several reasons. On the one hand, the experiment of the hip prosthese showed us that only the young people tolerated prostheses without cement and still, in the event of PR cementing was systematic. Therefore, by analogy, the only patients for whom we could propose an uncemented prosthesis of elbow would have been post-traumatic osteoarthritides. But that did not form part of our indications. The prosthesis of elbow was indicated either in the elderly persons or in the event of PR and in these cases there are many reasons to cement. In addition, I could note at the beginning of the experiment of the bone graftings under the pin that there was a good capture of those. There was thus a solid and fast fixing with cement and a longer-term fixing with the pin and the bone grafting.

. : What do you think of the prosthesis in traumatology?

: In the literature, there is very little item on the subject. The majority of the models of prosthesis of patching arise like not indicated in a traumatic context. In what relates to us, the third party of our patients has a traumatic etiology and we published 5 items on our experiment in this context. That represents 150 cases, primarily posttraumatic osteoarthritis, with an average passing of 5 years and a rate of satisfaction of 90%. The results are not as good as for PR but are better than in the other options in post-traumatic osteoarthritis. However, we propose a prosthesis only for the patients beyond 65 years.

. : In these 150 cases, how much do you have recent traumatisms?

: There is 22 case of recent traumatisms on more than 10 years.

. : Why if little?

: Let do a little history to me. Of the beginning the majority of people thought that the prosthesis of the elbow did not work. That if it were to go, it would thus go for the PR. before proposing it for traumatology, it was necessary for us well to document our option in order to have guarantees on what one did. Therefore, we selected the comminuted fractures of the elbow beyond 65 or 70 which one thought of not being able well . They are fractures of the humeral pallet, very low, very and at the patients of more than 65 years osteoporotic. With these three characteristics, we think today that the good processing is the prosthesis. We prudently documented these 22 patients who have after 6 years of retreat, 93% of good performances; it is better than after osteosynthesis. Thus today, I have the clinical data to say that it is the processing of choice, but I arrived there very gradually. We are currently re-examining a complementary series with 45 cases in all.

. : In which other field of the elbow you worked?

: I spent much time to try to understand the anatomy of the elbow. I worked on the of the elbow and the manner simple and reproducible to carry it out. I was very interested by the methods allowing to stabilize the elbow all while mobilizing it and I developed an external fixer.

. : How did you proceed?

: Once again, on the basis of the laboratory of biomechanics to understand where was the axis of rotation. I then took account of the Russian experiment of , and a small circular fixer Européen. We wanted to make simple. But for the first version, we left the pin in the axis of rotation with the around turning . The problem with this option it is that an infection of the card causes an infection of the hinge. Thus we developed a model with a temporary card with the level of the center of rotation which one withdraws once the fixer in place. And now, we seek which are the precise clinical situations which require a unilateral fixer and those which impose a fixer on the two sides. We use this fixer when we want to obtain an immediate maximum mobility while protecting the ligaments or joint surface. It is the case for example among patients among whom we made an osteosynthesis of the , or a joint replacement of interposition.

. : With which propose you an arthroplasty of interposition?

: Still young patients forwarding post-traumatic after-effects. We use a tendon of Achilles taken on corpse. That avoids making another incision, and one has tissue to cover the bone and also to rebuild the ligaments.

. : And does it go?

: Ca goes well to 80%. The graft is not vascularized and thus the organism does not attack it much. Ca gives in fact a cicatricial tissue which ensures indolence.

. : But if you clean simply and that you put your fixer, it should create a cicatricial tissue?

: Perhaps yes, you are right and it is perhaps not necessary to put a tissue of interposition. It is possible that the cicatricial tissue resulting from the post-operative hematoma is as dense and stable as a tissue of interposition, but I did not do it yet. However if there are no more ligaments after , one needs something well to rebuild them.

. : How do you choose your axis of rotation?

: We identify ourselves outwards on the external condylar tuber, and in inside on the point antéro-inferior of the epicondyle. But we have a sight a little as for the . It is not obvious without guide.

. : How do you see the future?

: Sincerely my objective is to try to better understand the elbow joint and to propose effective therapeutic solutions and if possible solutions with the range of any csotcina.comedist. I think that there will be more and more surgeons who will pose prostheses of elbow, and which will do it well. There will be more and more csotcina.comedists who will be interested in the new techniques like the . But attention with the risk of increase in the complications.

. : Many colleagues will tell you that there is not as well problem as that on the level of the elbow…

: It is true that the surgery of the elbow will not reach the frequency of that of the hip or of the knee but the elbow is a really specific hinge. It can be implied in an unusual way in traumatology or in various pathologies. It is probably the most unforeseeable hinge on the evolutionary level and she shows a great percentage of complications. I have work so that a group of surgeon is devoted to it to content.