. : From where are you?

D.: From Toronto Canada

 

. : How did you integrate Mayo ?

D.: I came initially a year like to work with and in 1989, because I was very interested by the shoulder surgery and of the elbow, and that I wanted to benefit from their great experience. And also because I had the possibility of making search in the laboratory of biomechanics with Doctor An and . Then I am turned over to work in Toronto.

 

. : How did your return to Canada occur?

D.: At the end of my in Mayo, I am turned over to the university of Toronto as surgeon of the shoulder and the elbow. I had also to face an intense activity of traumatology because I worked in a hospital who drained many urgencies. I also installed a new laboratory intended for search on the cartilage.

 

. : Toronto is a big city. Why didn't you remain over there?

D.: I wanted to remain in Toronto and it was what I had at the head. I had been able to make me a good recruitment of shoulder and of elbow and our research laboratory on the cartilage went very well. However the circumstances decided some differently. Mr wished that I join the staff of the surgeons of the shoulder and the elbow in Mayo and that I transfer my search to the laboratory from Rochester. Because of my commitments I had first of all told him that I could not release me. But my hospital abruptly was in a difficult financial position because of embezzlements of the Director. That involved severe restrictions for all the surgeons with in practice for me, impossibility of having new hardware, the closing of my laboratory and the reference of the affected biochemist to search. In this context, it became illusory to carry out face a surgical practice and a search. In any case to arrive there I should have worked at the point to compromise my family life. Thus the possibility of working in Mayo became to me gravitational, although that was not my preliminary draft. The great ways of Mayo as well in the field of the private clinic as of search enabled me to plan to contribute my share to progress of medicine.

 

. : With was all the American which pass at his place, why interested in you?

D.: Why me? But it is with him that should be asked. We had a very close relation as of the beginning. And this privileged relation is based on a mutual capacity to understand themselves, work together, to stimulate one the other and to teach themselves. I was not afraid to announce something to him when I felt that could enrich it. He formed me during months and months and I think that it discussed me like a potential colleague not just like a simple student.

 

. : Thus because of the deterioration of the work conditions in Canada you considered a transfer to the United States…

D.: It is not completely that because I did not wish to leave Canada and I was not interested by the many proposals of post in the USA. It was really to work in the Mayo which attracted me. And I had the feeling that there was an opportunity for me and that I could better contribute my share to medicine while going to Mayo than if I remained in Toronto. After having turned over all the arguments for or against, I contacted and simply “I told him had told you that I was not available but now I am not also any more sure”.

 

. : Do you regard Mayo as very different from the other American hospitals?

D.: We are likely to work in a medical structure all over the world celebrates with like consequence the fact that the patients and the colleagues come to see us whole world.

 

. : Summers you paid?

D.: Yes but we work each one at our rate/rhythm. For example, last week, I operated patients programmed up to 1 hour 30 of the morning. I could have entrusted them to a colleague but they were personally recommended to me. On the other hand I made myself available during the two following weeks.

 

. : If one of you stops working, is he recalled to the command?

D.: Obviously, we pass all by phases or our output drops, but it appears not very probable to me that one of us is nonproductive in a permanent way.

 

. : Y have-you it an evaluation of your activity?

D.: It is evaluated each year.

 

. : Which is your current field of predilection?

D.: What impassions me more is to discover new things on the assumption of responsibility of the patients. I focused myself as well in the field of the private clinic as of search on the shoulder and the elbow although the essence of my intellectual energy is devoted to the elbow.

 

. : Where is the prosthesis of elbow?

D.: The prosthesis of the elbow evolved/moved well during the last decades. But the progress most important to come relates to in my opinion the instrumentation. For knee prostheses, the improvement of the made it possible to make the intervention more reproducible and more reliable even by somebody who is not explicitly specialized in this field. For the elbow, we do not have yet this kind of instrumentation with the result that the installation of the prosthesis will be very different according to the surgeon. And this difference can have consequences on the biomechanical properties of the prosthesis and its survival. Thus it is necessary for all to develop the instrumentation of the prosthesis what should decrease the evil positioning; then it is necessary to imagine a new drawing which avoids the main complications. I want to speak about the instability and the osteolysis which contribute to decrease the durability of these prostheses.

 

. : And of the elbow?

D.: It is for me a true passion. The is currently the technique which contributed the most to the surgery of the elbow. That evolved/moved quickly and maintaining the indications extend in an incredible way. She is still regarded as technically very difficult, even dangerous. In fact it is a field which is not familiar, which is not taught yet and one can thus understand the reserves of the colleagues. But I am convinced that as for the knee and the shoulder, it will be the surgery of the future for much of young csotcina.comedists.

 

. : How did you make to develop with this point this technique?

D.: Part of progress which I have fact comes from the development from instruments. The way of using them is more important than their number. But I think that the largest projection in the of the elbow was the use of a spreader. While judiciously slipping this spreader into the elbow, you can pass from an almost impossible operation to a technically possible operation while increasing the security of the surgical act.

 

. : But where you found the patients?

D.: The indications of the of the elbow are rather broad: idiopathic osteoarthritis, post-traumatic osteoarthritis and the polyarthritis . These pathologies are usually seen by the csotcina.comedists, but the majority of them do not know that there is, of true good indications of . A relatively frequent situation is the stiffness of the elbow. The elbow is superbly improved by the of the elbow, but it is also the subject currently more discussed. The is indeed very effective but with the reputation to be dangerous. And I fear that this controversy does not last several years. This is why the of the elbow must become a regulated intervention. Then, that will become an operation divided into sequences and reproducible stages and not an operation only reserved for some very experienced surgeons. The injury risk nervous is real in the capsulectomies. The use of spreaders makes it possible to have more a large volume of work and in more one good knowledge of the position of the nerves avoids the complications. I am accustomed to telling “When you know where is the nerve, you know where it is not” and you thus can the tissues in full safety. I have now experience of more than 150 under without permanent neurologic complication. At all events those among us who practice much this surgery have the impression which the results are better than those of the with open sky.

 

. : How much do you make per month?

D.: About 10 per month…

 

. : And which is the percentage of each pathology?

D.: A half is for osteoarthritis and PR, and the other for the stiffness of the elbow.

 

. : Thus should the solve a good part of the problems of elbow?

D.: There is not sufficient retreat yet but for the court and medium term, that gives extraordinary results. When one started to discuss PR by synovectomy and complete capsulectomy under , one obtained excellent results and thus now for the PR of less than 65 years, we make a complete synovectomy and a capsulectomy safe in the very advanced stages with a complete destruction of the elbow.

 

. : Why the of the elbow be would more powerful than a chemical ?

D.: I do not have really comparative data, but the rheumatologists here prefer to entrust PR for a to us.

 

. : And tennis ?

D.: It is which promoted the processing of tennis . It releases insertion of the . We checked with the scope in our tennis and we found that the lesions resembled well so that described with 1/3 of visible rupture , 1/3 of rehandling of tissues but without rupture. We thus put ourselves at the percutaneous release of the insertion of the common bungee cords under control . It is a minor intervention.

 

. : But it is about a surface operation by a short incision; which is the advantage?

D.: By the painful period is very short and the fast renewal of activity. The continuations by shorter are compared with the open sky.

 

. : You referred to a search on the cartilage…

D.: Yes, I had started in Canada in 1981, in the service of Mr . That of the classification of epiphyseal separations, the osteotomy of the mining area…

 

. : Which kind of man was it?

D.: Extraordinary. It was Canadian of Toronto. A man with an enormous intellectual potential and which contributed much to the advance of csotcina.comedy. It is the largest teacher whom I never had. I made a “” with him on cartilaginous repair and we developed several models to try to understand how the cartilage is repaired. Beside the growing problems of the cartilage there is that of the support of the airframes, of the frame. We think that the periosteum is a good support because it has qualified airframes and regulatory elements of the growth.

 

. : How do you proceed?

D.: The periosteum is fixed at the banks of the with the surface layer of the periosteum against the bone and the deep layer like joint surface. It thus different from the methods is already used clinically injection of airframes but which do not have a matrix to retain them. The future of the repair of the cartilage rests on obtaining a matrix.

 

. : What do you think of the traumatology of the elbow?

D.: The traumatology of the elbow benefitted much from the techniques of fixing which allow an immediate mobilization of the elbow. Because, if you do not mobilize the elbow in the days which follow the synthesis, the risk of is major. I work much with the improvement of the synthesis of the fractures of the elbow. For example, in the distal fractures of the humerus the problem often is fixing unsuited between the distal fragment and the diaphysis. Thus it two elements to be improved there: first is to maximize fixing in the distal fragment, second is to maximize the force of fixing between the distal fragment and the diaphysis. That involves practical consequences. Initially, it is necessary to use a plate on each side and then to adhere to five principles. One, each screw must pass through the plate, so that the fixing of the distal fragment is most interdependent possible party condylar. Thus not of screw which is not pressed on the plate and if you must stabilize a reduction before putting a plate it is necessary to use pins. Two, as much as possible of screw must take the distal fragment. Three, the screws must be longest possible and that it is simple biomechanics. Four, the screws must take possible fragment as much, which makes it possible to maximize the fixing of the small fragments. Five, and this point is really very important, each screw crossing each plate must cross in a fragment its counterpart of the opposite side, which increases the stabilization of the assembly. In addition the plates must be rather strong and rigid to prevent that they break.

 

. : What do you think of the screws which are locked on the plate?

D.: It is an very good idea, but which forwards limits on the level bends. Indeed these screws have only one possible guideline, and that wants to say that if the plate is not absolutely anatomical the screws will be at the wrong place.

 

. : What to make in the event of osseous ?

D.: You can shorten up to 1 cm, even 2 cm so necessary.

 

. : In is the distal and very fragmented forms of the old subject, sells by auction to consider the prosthesis?

D.: The indications are not as frequent as I thought it. The last time that I made some, it was there are one year and half.

 

. : And on the other pouring of the hinge?

D.: Another thing that we noted in traumatology it is which the radial head is not as essential as thought we it. And these last years ago of excesses in the conservation of the radial head. Concerning the stability of the elbow, it is not a primary, but secondary stabilizer. An important component of stability in the traumatisms is the apophysis . Until now these fractures drew the attention little. We learned that the is a primary stabilizer of the elbow, and in a fracture luxation, the fractured must be in the majority of the cases. In addition the fracture of the is in oneself the witness of an important traumatism. Thus a small fracture of the apparently isolated can correspond to an instability . During the traumatic mechanism, the side ligament is injured, the ulna is put in internal rotation and the party of the trochlea is moved before coming against the and causing a fracture of its party and intern. And thus without stabilization of the , it endures an instability of the elbow in stress with a tiny subluxation which involves a contact between the seat of the fracture and the party of the trochlea, supporting the appearance of a osteoarthritis. It is thus a fracture which threatens the function of the elbow.

 

. : How to fix it?

D.: We were accustomed to using techniques of joining, but those often allow m displacement and it is enough to support the development of osteoarthritis. I thus gave up this kind of fixing and we developed a specific hardware. The fragment is fixed by direct reduction at open sky, is maintained by thread spindles and a small circumvented pre plate. The cutaneous access is posterior with then passage right in front of the ulnar nerve, under the group of the flexors.