The 30ème meeting of the Society of csotcina.comedy and Traumatology of 0uest (.) was held last June in Pont-l'Abbé. With this occasion, we met his enthusiastic Chairman, Alain .

 

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. You are originating in the West?

: In fact I am Lillois. I settled in Quimper into 76, i.e. 21 years ago and at once I became member of the . This society had existed then for 9 years and I was a young whole, all small member. I thus do not have well-known the heroic period of the beginnings of the .

. : To elect a former Inhabitant of Lille as Chairman, it is surely a very accessible Society…

: I was the first astonished by this election. It should be said that during 5 years of continuation my proposals for a communication were refused at the Society of csotcina.comedy of the West whereas they were accepted with the and the Society of csotcina.comedy of East . I finished by me asking whether it were not a a little closed club. And then, two years ago, without I not doing anything for that, they asked me to be Vice-Président. In fact, one of the rules of the is to make alternate with the Chair an academic and nonan academic.

. : Why to have left North for Brittany?

: I always told myself that the day when I will settle I will choose our framework of life. I like much North but I wanted to live in an area more smiling. My wife being , we found like point of agreement Brittany. I had thus found an installation in private clinic in Lorient. It was in September 76. Eight days before I settle, the surgeons of the private clinic called to me while telling: “one went bankrupt”. I had already resigned of my post of head of private clinic and our three children were very small, it was thus necessary well that I find a solution fast. Extremely fortunately I immediately found a post at the hospital of Quimper. I was there completely well. It is a marvellous country where it makes good things in life.

. : The Breton ones are very different from the Inhabitants of Lille?

: Yes, very different from the Inhabitants of Lille. The Inhabitants of Lille are very cordial and live in an area where there was much mixing of population. There is not too many roots there. Here, at the end of Brittany, it is really very different. One feels the people very fixed on their country and their folklore. They have perhaps less love of life than in north, but they are nice, very serious, very hard-working. I liked much to work with them. In addition to the beauty of the country, it should be said that when I arrived at Quimper there was no exclusive csotcina.comedic surgeon and an enormous pathology since Quimper drains 301 080 inhabitants.

. : Why did you leave the hospital?

: I left the hospital into 82 because there had just been a change and that one wanted to abolish us the private one. I considered that it was a breach of contract.

. : They abolished deprived at the hospital?

: Not they finally did not abolish it. But there had been at this time there two things. On the one hand it had settled a climate tended a little to the hospital and on the other hand a new private clinic and equipped perfectly well sought an csotcina.comedic surgeon. I made my decision and I went in private clinic. In fact I was well at the hospital. When I arrived into 76, it was almost an old people's home, then that developed and it became a modern hospital equipped very well with an good atmosphere. One made really a team work and one liked to develop this hospital. Currently the hospital of Quimper is a very large hospital which drains all the area.

. : You express a little nostalgia?

: I do not have nostalgia but I did not find same environment with the private clinic. In private clinic one is more individualistic. In the hospital of Quimper I really took part in a team work.

. : Which were your poles of interest?

: When I arrived, one especially awaited me for traumatology. I had been well trained in this discipline because I came from the service of Pierre where there was enormously traumatology. This competence enabled me to be made known in the area. Previously traumatology was made by not-csotcina.comedists and when I implemented the techniques that one had taught me in Lille that went definitely better. I developed very quickly customers and I reported myself that there was much pathology of the hip in the area. The latter finally occupied a very large party of my activity.

. : You easily gave up the remainder?

: At the beginning I did all. Very quickly I reported myself that I did not can make the hand surgery very well nor the pediatric surgery. My wish always was as the majority of the surgeons to do only what I know well. I asked Doctor to make the hand surgery, with Doctor Louppe to make the pediatric surgery. I did a little rachis but without more. When I settled with the private clinic I asked Bernard , who was senior registrar in Brest and which had been formed at , to join us. In addition, I had not been trained with the and I put myself there idly because I did not like that too much. I sought a surgeon who makes and I did not know with which to address to me. The of told me that it would be enough to ask Jean Yves Dupont, secretary of the Society of , and that it knows surely a candidate. I thus wrote to him and 48 H after it called to me while telling me: “I have somebody indeed: me”. That astonished me because it had a rather considerable reputation. He came, attracted by the area which is very beautiful and by the fact that the private clinic in which one works is a beautiful tool. There are really conditions of exercise which are excellent.

. : Thus you direct yourselves towards the hip; is this a legend or it really much of dysplasias?

: There are enormously hip dysplasias in the area. It is not a legend it is an established fact. The instructor Masse of Rennes has, on this subject, writes an edifying item on the area with a card of the congenital dislocation which shows that it is really concentrated in the country . Quimper is not the country , it is the country , one should not confuse. One is astonished by the multiples small borders which divide the area with different folklores, different traditions and different pathologies. For example, there is a difference marked between North and South-Finistere. In the South-finistère, it is in the country , the area of Bridge the Abbot more precisely, than there are really many dysplasias.

. : Why?

: There would be a genetic factor. Obviously the fact that there was much consanguinity could select a defect. There is a second mailman, they are that the children with the rectilinear lower extremities and even, appears he, with the cross lower limbs…

. : Can that be explained at the beginning of the century, but today?

: When I arrived there was still much case of congenital dislocations of the adult, and maintaining that did not change much. People whom one operates of an adult congenital dislocation, they have generally at least 40 to 50 years. There are 40 or 50 years, tracking was not yet well made; progress made thereafter will bear their fruits.

. : A little : action to be taken vis-a-vis an hip dislocation in the adult?

: Firstly, it should be known if it is quite necessary to operate it. There is of it much which is luxated on the two sides, and not painful. They should not be operated, it is the best thing than one has to make. If they are luxated only one side and that they are painful, one can propose an intervention. The prosthesis on congenital dislocation of hip it is an intervention which is not very difficult on the technical plan but which poses specific problems of guideline. Personally, I find that the installation of is relatively simple. It is enough to find , one digs on the level of right to the top of the obturating hole. The installation of a prosthesis in a femur it is not difficult either insofar as there are prostheses which are made for that. The difficulty is to regulate lengthening and to regulate the guideline. It is there that is the difficulty because there are large defects of rotation of the lower limb with very often an internal rotation in the femur, an external rotation in the leg skeleton with risks of luxation and risks of functioning knee in inside, etc… It is a surgery which I practiced much and I am always admiring when I intend Marcel to say that when it puts prostheses on congenital dislocations the patients do not limp afterwards any more. I do not have this claim, I note simply that they are better….

. : How do you regulate the problems length?

: I start readily with a in “”. I.e. I leave the great trochanter in continuity with the average gluteus in top and the vast external one in bottom, which facilitates the rebuilding. The descent of the hip is not simple and I remain perplexed in front of publications where one tells: “one lengthens of 5 cm without problem”, me I had sciatic paralyzes, and patients who were not inevitably well with too tended muscles, etc… I try to avoid making very great lengthenings more especially as they are people who are accustomed to go with a difference in length and one should not certainly give them the same length on the two sides.

. : How do you regulate the guidelines?

: Primarily in the course of intervention. On a patient installed in side, when the knee is bent and the leg with the vertical, one obtains plan 0 of the femur and in theory, I place at this time there my prosthesis in the horizontal plane. But mobilities should well be tested because the risks of luxation in the two directions are great.

. : What do you think of the prostheses to measure?

: I was really impassioned by the prostheses to measure because I thought that it was the future and that it was necessary to have prostheses which marry the femoral cavity exactly. But on the one hand there were the budgetary restrictions which limited the installations and on the other hand I reported myself that the problem it was not so much the amendment of the prosthesis to the femur. One manages to have very good primary stabilities without cement with prostheses standards; the problem it is especially the tuning of the . It is true that with a prosthesis to measure, thanks to scanning it preoperative one sees and one corrects the excess of , but one can arrive at the same result with a prosthesis to directional neck. I think that is very well to have prostheses in three parties i.e. a stem, a neck and a head, as there is currently on the market. That allows, after having placed the stem, to direct the neck with the request.

. : There are nevertheless disadvantages…

: It is true that American insisted much on the risks of the modularity with risks of corrosion, possible problems of rupture or long-term degradation. This seems to me more theoretical than practical. That made more than 20 years that one uses heads on Morse tapers and one does not have a problem. It is true that there is a Swedish publication with the photograph of a Morse taper very eroded; that can arrive in certain cases but it is really something of marginal. I believe that it is the same thing for the directional necks. used this type of prosthesis for a long time. I am not agreement with his concept of prosthesis screwed in the femur, but I do not believe that one announced much rupture of the attachment unit of the neck on the stem. It had problems of pains and extraction of the stem, but not of problems of modularity. It should be said that there are sometimes enormous differences between what is published in the American press and our European experiment. I think that it is very useful in this surgery of the dysplasias to have modular prostheses; under these conditions the prostheses to measure lose of their interest.

. : Do you still have indications of osteotomies?

: I made my thesis on the osteotomies of femoral . At the time we had good performances in not very advanced hip osteoarthritises but in the other cases the indications were thorough too far with poor outcome. It is a surgery which became very rare; I make sometimes osteotomies of when I on a young subject (- 50 years) which has an hip dysplasia with a and a not very advanced hip osteoarthritis. It is not necessary that there is a pinching of the line space of more than 50%. As soon as it appears a severe osteoarthritis, the risk of failure is of 50%.

. : And stops?

A.D.: I make more stops than of osteotomies because it is about a more benign intervention. The osteotomy of they is nths and half in discharge, at least six months of rehabilitation and a year of . Whereas the stop they is three weeks with two canes and then two or three months of rehabilitation. The dysplasia, must be with prevalence with an external and especially former unroofing. It is nevertheless the defect on the false profile of which is most important and this dysplasia should not be accompanied by an important osteoarthritis. I think that it is not reasonable to consider it among patients of more than 60 years.

. : At were the time of your installation which your designs as regards prosthesis?

A.D.: I made like the majority of the surgeons, I posed the prosthesis that one learned how to me to pose. I put prostheses of tail banana, with heads 32 and of course cemented. Then in 79, I discovered that allowed some surgeons “elected” to use its prosthesis . I was among the first with being able to pose it and I found that marvellous to be able to fix the prosthesis in the femur. But at the time had told me that did not appear very good to him because there was an inhomogenous distribution of cement with a direct contact of the prosthesis on the bone in inside and outwards, and much of cement in front of and behind. Wrongly, I did not believe it much and during ten years, I considered that what had been decided and created by our elder it was the truth and I did not seek to dispute this truth. For me, by putting a prosthesis of , I made the ideal and I rendered the best service to my patient. Then with a little time and retreat I reported myself that the prostheses started to be loosened. I told myself that perhaps one could better do. At the time one said that cement was responsible for all, and I thus wanted to put to me at “without cement”. They was the femoral prostheses of then of Harris i.e. prostheses with diaphyseal fixing; there were troubles, pains of thigh and early mobilizations. It was with beginning of the year 80. One believed to better do and one made less better. But that taught us what one did not have to do: one did not have to put a long stem which is locked in the diaphysis and which can turn. Thus in 85 I decided to direct me towards prostheses with metaphyseal fixing.

. : Why to have chosen “without cement”?

: It is true that at the beginning we thought that it was cement which was the person in charge of unsealings. One reported oneself thereafter that the problem was dominated by the reactions to the polyethylene remains. Always it is that after a long routing to control the technique of without cement reached that point we and the technique became ripe in 1990. On the one hand we had acquired a control of the technique which made that this operational act became very simple and that if one decided at this time there to add cement the things unnecessarily were complicated, on the other hand, we think that the prostheses with metaphyseal fixing with coating hydroxyapatite have multiple advantages which are not limited to the simple fact of avoiding cement: transmission of the stresses to the metaphysis, obstacle with the migration of the microparticles, easy ablation and not dilapidating, advantages which we will reconsider.

. : How did you arrive to this concept of metaphyseal fixing?

: My original idea which appeared too difficult to control, it was to make a prosthesis with cervical fixing. When one looks at a neck of the femur divided by the top one reports oneself that the cortical ones form “U” with rounded, cortical former and cortical posterior relatively rectilinear. I thus designed a prosthesis which adapted exactly to the form of the neck of the femur thanks to various sizes and various thicknesses. I.e. there were flattened metaphyses and broad metaphyses. These prostheses were technically difficult with posing well and they did not allure many surgeons. I thus evolved to a metaphyseal fixing. I adopted modular prostheses, i.e. they are in two parties a diaphyseal stem which under-are inevitably dimensioned compared to the diaphysis and a metaphyseal party which, it, is stabilized obligatorily in the metaphysis. Beside the drawing of the prosthesis and technique of installation, it is a crucial question it is that of the surface treatment. Even with a very good primary stability, we have durable results only if there is a secondary stability by ostéo-adherence. During 4 years I used prostheses with metaphyseal fixing out of sanded titanium. I had rather good results with 92% of survival at 10 years but there was nevertheless 8% of early failures. The problem with without cement, it is that it is a race against the clock between the speed of ostéo-adherence and the solicitations mechanical. If the bone is of quality poor and if the of the surface treatment is poor, one is likely to have a mobilization of the prosthesis before to have been able to obtain an ostéo-adherence. It is all the interest of the surface treatments bio-assets. With the hydroxyapatite, in one month one thus obtains an ostéo-adherence one gains the race against the clock. Therefore I put myself in 1989 to use the coating in hydroxyapatite and I did not have any more a problem of early mobilization as from this moment.

. : How is made this osseous adherence?

: Immediate ionic exchanges make that the bone comes in the month which follows in contact with the hydroxyapatite, and adheres to it closely. That brings three advantages mechanics, biological and during ablation. The mechanical advantage it is the transmission of the stresses in metaphysis. The radiological observation in the medium term of the prostheses whose surface treatment limits osseous adherence in the first centimetres of the femur shows a condensation of spongy the metaphyseal reflection of the transmission of the stresses on this level in agreement with the law of Wolf. The observations which go back to more than 7 years of retreat for the oldest cases confirm the absence of stress with such prostheses. The thinning cortical metaphyseal and diaphyseal high observed with all the prostheses with diaphyseal fixing that they are cemented or not cemented is not usually at the origin of unsealings, however it takes part in the osseous deterioration which will lead to great osteolyses. It is thus not useless to prevent this mailman of degradation. The biological advantage, it is the obstacle with the migration of the polyethylene microparticles. The surface treatment ensures an osseous adherence intimates without interposition of the fibrous membrane systematically observed between cement and bone. This fibrous membrane allows the migration of the microparticles of wear all around the implant, in particular in the diaphysis (Effective gasket of and Harris). The circumferential treatment the hydroxyapatite in metaphysis constitutes an obstacle with the migration of these microparticles what explains the constant absence of diaphyseal femoral even after retreats higher than 7 years. The last advantage, it is that ablation is easy and not dilapidating and we on the occasion to check it with three recoveries. The limitation of the surface treatment to the first centimetres of the prosthesis makes its extraction easy. It is enough, by using a thin and flexible blade to take off the prosthesis of the adherent bone. Ablation is of as much less dilapidating that it acts, not of a penetration of the bone in prosthetic anfractuosities (maid ), but of an adherence of surface (right ). The ablation of the prosthesis which was the major issue of the prostheses without cement with diaphyseal fixing and the ablation of cement which leaves a weakened and devitalized bone are thus avoided.

. : But doesn't the hydroxyapatite reabsorb?

: The hydroxyapatite reabsorbs but in a very slow way, over years, with a variable time according to the thickness and of the chemical and physical characteristics of the coating. What was proven by , and , it is that as the hydroxyapatite reabsorbs it is replaced by bone. I.e. when there is no more hydroxyapatite the bone is in contact with the implant. Intimate adherence can thus last after resorption of the hydroxyapatite in the condition that there is a surface treatment under the hydroxyapatite.

. : Does your drawing give you a good metaphyseal filling?

: I think that it is as a concept as it would be necessary to revise. It is not essential to fill the metaphysis. It is necessary to obtain a primary stability in metaphysis which can be done on three something to lean on.

. : That causes very localized stresses…

: Without any consequence if the implant is perfectly stabilized and quickly ostéo-member. which is the designer of the , prosthesis that I use now, understood well that one should not put the largest possible prosthesis but which should be put the first prosthesis which is stabilized. Essence in this surgery as in any surgery without cement they are the per-operational tests of stability. It is necessary to test stability in the three front-end processor plans, sagittal and axial. If primary stability is ensured and if the prosthesis is fixed in metaphysis, one does not observe the pains of thigh characteristic of the prostheses with diaphyseal fixing, pains which were with semi-thigh former or external irradiating towards the knee in charge. These pains, one sees them never again with prostheses with metaphyseal fixing, and it is something which was established perfectly not only by me but by all the surgeons who use the prostheses of this type.

. : And on the level of , how did you evolve/move?

: I had started by making large errors by putting large screwed rings which at the time were smooth. On approximately 250 screwed I had to take again 150 of them. They was of . There are of them some which still hold but I do not know why. In 1984 or 85, I discovered of Harris. To the beginning, I told myself that it was a little gadget this with these small screws. In fact it was a brilliant idea. It was necessary to put a hemispherical in a hemispherical cavity what appeared logical but that nobody made before and one needed especially a surface treatment allowing a durable stability by osseous adherence.

. : Did screws have to be put?

: At the time one put some. One put as the same size of as the cavity. Once the of Harris placed, one made our holes but, time to take the screw, the moved a little and the holes of screw were not opposite any more. At the time I had told myself that it was necessary to have a with points which one impacts in good position, and after there would be no more problems to place the screws. It is as that which I had the idea of the Atlas. I also thought that had to be carried out a lower slit, because since the horns were elastic, it was logical to insert a cup which is elastic. I used this prosthesis since 1987, 10 years ago, with excellent results. In fact what helped me much in the continuation of the development of this prosthesis, it is the fact that other surgeons started to pose it. They gave me heaps of suggestions, in particular Jean Louis Doré of Turns who posed more than 1000 Atlas, practically as much as me. In 1989 he told me: “You know if one puts a of a size higher than milling that will lock oneself all alone and you will not need to put screw”.

. : Because at the beginning there were screws of anchoring on the Atlas?

: Yes I screwed systematically as for of Harris. Then I found that went very well without and I stopped putting screws. In same time, one reported oneself during work completed to the University of Technology of Compiegne that, when one placed the polyethylene core in the elastic cup, the unit was not any more very elastic. It is there that the chance intervened. The elasticity of the cup which had only one relative interest, core in place, made it possible to obtain an excellent primary stability with impaction. If one wants to avoid the screws which are tiresome to pose and which has multiple disadvantages of which that to support the migration of the microparticles, he is necessary to impact a cup of a size higher than milling, what is called “Near-made it”. The impaction of a rigid cup in a smaller cavity produces peripheral stresses which are opposed to the penetration of the cup in the cavity and are likely to cause microcomputer-fractures as that was shown by and . On the contrary, with an oversize cup split compared to milling, the slit is closed with impaction, which allows the penetration the content of the cavity, then the cup exerts a force of expansion and ensuring an excellent primary stability easy to check in operational since even by exerting a strong traction one cannot extract the cup. In the success of something it is necessary to have chance, I had had an idea and involuntarily my idea was very useful for something which I had not imagined at the beginning.

. : One could have feared that precisely this permanent pressure of does not involve one necroses osseous…

: There are many not checked theoretical ideas. If there is a very specific support on bone one can have one necroses but there it is about a pressure which is distributed on all the surface of and on one bone very quite vascularized. There is no reason that there is one necroses and besides the experiment proves it since more
03 000 of these have been posed for 10 years with excellent results and no necroses osseous.

. : Thus you found a little before everyone this history of with expansion.

: There was somebody who had done it before me. It was . They was a few years before me but its cup had six slits. It was perhaps not essential to have six to them, only one was enough. Indeed I was the first to design a with only one slit. After much developed in the tread.

. : In the light of do your results, you think of having regulated the problem of the prosthesis without cement?

: Not. One cannot be sure that the problem is definitively regulated, say that holds the route at 10 years; it will be necessary to wait re years before having certainty.

. : Which are the areas of uncertainties?

: There is the problem of the long-term anchoring of the prosthesis. Secondary stability depends on the surface treatment under the hydroxyapatite. The technicians say that under the hydroxyapatite one needs a sanding of titanium with a RA around icrons, it east appears he the ideal so that lasts a long time. But only the future will say it. The results are good at 10 years of retreat, if that holds the route at the end of 20 years one will be able to say that the question of anchoring is settled. There is also the problem of the couple of friction and the release of the microparticles. There too, although there are many hopes on the side of the metal or ceramics couples, one cannot know if that will hold the route at the end of 20 years. Certain surgeons are persuaded to hold the truth, and I think that it is often a means of defense against the extraordinary difficulty of our trade. In front of the crushing responsibilities which are ours, it happens that one reassures oneself while convincing oneself that the truth is held. But I believe that it is necessary always to be conscious that there are several possible truths and that to achieve a goal one can use various paths. I find completely stupid to consider that the options which one chose are the only valid ones. In religion as in medicine the integrist ones are wrong.