. : How did you make known yourselves as regards shoulder surgery?

I.K. : It is the question! I think that as for much among us it arrived incidentally. When I finished my boarding school, I was directed towards the articular rebuilding with certain leaning for the polyarthritis (PR). One of my superiors had specialized in Canada in the shoulder surgery and of PR and had developed this activity in Glasgow. When it set out again to settle definitively in Canada it left a strong demand on the spot. I then had small experience of the shoulder unstable and traumatic and I put myself at the shoulder prosthese.

 

. : At which period?

. : It was with beginning of the year 80. I then made hip surgery and knee, in particular of the knee , but as I was also interested in the shoulder all my colleagues asked me to deal with their problems of shoulder. At this point in time I realized that I did not know in fact not large thing there and that I started to reading. There were not many works on the subject and I often had to make very personal therapeutic decisions. I considered the anatomy and I believe that in 1984 I went to my first congress on the shoulder. I remember that by listening to the conferences of the rare tenors of this surgery I noted many true things but also things which contradicted my clinical experiment frankly. That encouraged me to make search. I learned much from my patients with whom I posed heaps of questions. I did not have any certainty and I quite simply tried to understand this pathology at one period when was not with the mode to be a surgeon of the shoulder. I think that I had chance to find me in a surgical discipline which was under development full.

 

. : You were the only specialist in the shoulder in Glasgow?

. : To tell the truth I was the only one of all Scotland. The problems with which I was confronted were rather complex besides. I started a consultation reserved at the difficult cases of shoulder where I saw only patients addressed by my colleagues and who often came from rather far. All that caused a reflection and a teaching. Today, the level of the shoulder surgery is completely satisfactory. There are now very many specialists in this surgery in Scotland.

 

. : Why this strong PR recruitment?

. : Because on the one hand, it is a frequent pathology in this area, and especially that on the other hand the organization of the rheumatology in Scotland concentrates all PR in Glasgow. Thus in the event of surgical indication it is rather a surgeon of Glasgow which is requested. I thus made my experiment of shoulder prosthesis on PR, but it quickly appeared to me that these patients had problems of shoulder for which the prosthesis was not the solution: pathology or subacromial. I thus started to make studies concerning the exact location of the pains.

 

. : How?

. : That started during one sabbatical year which I took in in Sweden. I examined a patient who complained about pains to the mobility of the shoulder with a radiographic destruction of the glenohumeral hinge. The indication of a prosthesis appeared logical. However its overall mobility was good and I infiltrated it into subacromial with and that improved it well. Thereafter, we cured it by a , but the striking fact was that its glenohumeral was reached. From this case, I examined the patients with much mistrust and I infiltrated them with l on the areas likely to be at the origin of their pains: the , the subacromial one or the glenohumeral one. It appeared at the end of this study which if a patient had about thirty degree of RE and a relatively spherical humeral head, the pain most certainly came from subacromial or the and thus that it did not need prosthesis.

 

. : How was the Society of Shoulder surgery and the Elbow organized?

. : During an international congress of the speciality, I believe that it was in 1986 in Japan, the British surgeons thought that they should gather in a Society and they submitted the project to me. The idea appeared good to me. I then organized a congress in March 1987 in Glasgow and it is there that off was created. I think that we were embers. This Society was strengthened at the point to become a structure of teaching and a partner of the governmental authorities on the therapeutic choices and the choices of implants in the speciality. Society is open not only to the surgeons but to the rheumatologists with the kinesitherapists with engineers etc… We have an annual convention.

 

. : Who were the influential members of the time?

. : , Mike Watson, , Angus Wallace. There was also de which worked on the shoulder for a long time and which had been among the first to develop a reversed prosthesis. Its model did not have success but it was especially a whose work is wrongfully ignored. Constant was there just as Souter

 

. : Which were your functions?

. : At the beginning I was the secretary of society and Souter the first chairman. I left the committee which I joined later as vice-president, then I became chairman in 1996. In 1987, was held in Paris the European Congress of the Shoulder and the Elbow. I was already implied since I carried out with Gilles the bilingual text of the platelet of the congress. Then I became a national delegate of European Society. The aforementioned plays a very important part for our speciality. At the beginning it had a little obsolete statutes and the things then improved. When the Newspaper off was created, I was the joint editor as a Europe chief with Mr. .

 

. : When did you become member of ?

. : I was invited to be member approximately 4 years ago. It is a small firm which communicates very actively. The has, it should be said, be creates thanks to American. Europeans had discussed much the interest of such a newspaper but the things were not done and they are American who contacted the Mosby editor and federated all society throughout the world.

 

. : There are few examples of a surgical newspaper which links all the specialists in the world!

. : It is probably because this speciality developed in the Eighties to one period when the international communication was excellent, the quickly disseminated ideas and where all the interested parties felt the need to create a newspaper at the same time.

 

. : Do you see great differences in approach between American and Europeans as regards shoulder?

. : The reports are often forwarded in term of competition but in fact, and that is very comforting, there are many North Americans present in the meetings of European Society. Of course the cultural way of life and practices are at the origin of differences in the therapeutic indications but I do not think that there is a different approach in pathology.

 

. : Do you have contacts with French surgeons of the shoulder?

. : My main agent is Michel and this on several levels. Initially on the level of European Society and then on shoulder prostheses. We worked both on the prosthesis and the project of the modular prosthesis about at the same time. We knew each other thus and we share moreover one passion for Rugby. Then a little later when the is appeared I was joint editor for Europe what further increased our contacts. I went on several occasions to Toulouse and I took at home one of the interns of . Through Society, I also corresponded with Gilles .

 

. : Or did you make your studies of medicine?

. : I made my studies of medicine in Edinburgh. In fact, I had started by making psychology before deciding to me to make medicine. One of my first training courses was in a small hospital with in which worked, celebrates for its , and I decided to make csotcina.comedy. Then I am gone back to Edinburgh to make my boarding school in csotcina.comedy. I worked with the Princess #DBFFFF and Royal with the Instructor James and well of others. Then before making my , I was to make general surgery and I did not find from post in Edinburgh but in Liverpool for 2 years. Then I was to go back to Edinburgh but there was no yet post and one advised me to take a post in Glasgow where I arrived in 1977 with the intention to go back to Edinburgh and here, I am always in Glasgow.

 

. : There is a great difference between these two cities?

. : There is very old and very strong competition between these two cities. People of Edinburgh are supposed being more reserved and less accessible than those of Glasgow. A traditional anecdote said that if you arrive in end of the afternoon among people to Glasgow one will propose you to take your “” whereas if you are received per same hour in Edinburgh one will say you that you already took your tea. There is also a difference in climate; Glasgow is very wet because of its situation in the west. Before coming to Glasgow, I had not carried the impermeable one for a long time. Edinburgh is in the east where the weather is colder but much less wet. The two cities are separate only of iles but they are very different. They is probably the longest miles of the country!

 

. : You were born in Edinburgh?

. : Not in Liverpool where I grew.

 

. : If you grew in Liverpool in the Sixties, how do you have escaped with the pop ?

. : I was not good enough! I was completely there when made their beginnings in “” and it is true that it was one period very exciting and that this music had something of revolutionist. That known as I did a little nevertheless.

 

. : Why did you leave Liverpool?

. : The strong family Celtic influences gave me desire for going to study in Scotland. I wanted to study psychology. The medical studies in England last 5 years at the end which you are qualified in medicine but it is necessary to make then a year of , entitled Junior House in England and resident in Scotland, to become doctor of medicine . This year understands nths of functions in medicine and six months in surgery. Then, the majority take a post of Senior House for two years what today can constitute the beginning of a surgical formation. There is no entrance exam and one learns during these two years the bases from the surgical formation. At the end of these two years, it is necessary to off pass an examination to the Royal College Suckers.

The success of this examination gives the bond of ( off Royal College off ). Then you can begin the higher surgical formation which in csotcina.comedy lasts 6 years. However, there there is a strong demand and there can be waiting to be able to reach the higher surgical formation. There are thus also called intermediate posts Senior House which people take while waiting and which they use to make of search or to publish in order to improve their chances to integrate the higher formation. This 6 years formation is done by nths training courses during which all the csotcina.comedic specialities are practiced. For 4 years one with the possibility of taking a in csotcina.comedy and traumatology but he is necessary to pass an important, essential examination if one wants to be a specialist in csotcina.comedy. That understands a written test and several oral examinations. For the two years of , it is of use to seek a post abroad and to direct themselves towards its field of predilection. At the end of the 6 years, one can postulate for a post of Consultant.

 

. : Which choice did you make at the end of your formation?

. : At the end of my formation, I was particularly interested by search on biomechanics of the movement and I obtained a purse of voyage which enabled me to visit the centers North Americans which then were very implied in the analysis of the functioning. I could spend a few times to Mayo and I had planned to work in their laboratory of . But of the financial considerations did not allow me to concretize this project and I finally worked at the University of in Sweden where there is a very great center on PR and with which I tied many contacts.

 

. : During these ten last years how did you evolve/move compared to the dominant pathological concepts of years 80/90?

. : I have the largest respect for which I had the chance to visit during a study trip. Its contribution in pathology of the shoulder is immense but of course I am not agreement with all his opinions. I for example never accepted his classification on the subacromial conflicts. Why the osteophytes would be formed in first? I think that the origin of the disorders is rather in the cap of the rotators and that the fixing is only secondary. Moreover my experiment on instability makes me think that there are a fundamental dynamic aspect and an interaction between the pain and the muscular control of the shoulder which contributes to the conflict under . I am of course not the only one with being in contradiction with on these subjects.

 

. : How do you think of having contributed to the shoulder surgery?

. : I hope a little to have contributed to a better comprehension of the shoulder . I feel well far from to have very understood. I have several research projects and now I need researchers in molecular biology to advance. As in much of field, when one dives oneself in-depth in a subject, it becomes increasingly attractive. And I was particularly impassioned by the various manifestations of PR on the level of the shoulder and his implications in the surgical therapeutic options.

 

. : When the indication is a prosthesis, does it have to be total?

. : The answer is complex. When I began the surgery of the , the common procedure was to approach the shoulder, of the head, to establish a and to put the humeral prosthesis which one could make enter. That gave very tight shoulders. Thereafter, I realized that it was necessary to take account of the tissue retractions in the same way that we did it for the knees. I thus amended my technique and I began the operation with a . Then the difficulty of the selection criteria of the size of the implants arose. At the end of the Eighties, there were two studies on mobility necessary to be able to carry out the epic of the daily life. I thus decided to obtain in end of operation, at least 30° of external rotation, 90° of internal rotation and 90° of abduction. And it appeared at the end of the time of that space surgically created always did not make it possible to place a head and a . In these cases, I made only one hemiarthroplasty. But because of work published which highlighted a better clinical result with the total prosthesis, I made an effort, each time possible to put a total prosthesis. The review of the medium-term results of the two techniques, i.e. systematic and choice according to space did not show significant differences between the two techniques. I have the impression to make as well as possible but in term of mobility and patient satisfaction there does not seem to be difference. For this reason I cannot give you a simple answer. However what has an importance it is the clinical form of the PR. the hemiarthroplasty on an erosive form gives more probability of having an evolutionary wear of in 6 years and in addition in this form the ruptures of the cap are more frequent. Context of PR between also in account in my therapeutic choice. But this knowledge is incomplete and cannot be used with precision yet.

 

. : And what do you think of the prosthesis bipolar?

. : I never used some. But some of my colleagues of it are satisfied. Insofar as much PR has nonfunctional caps, there is a certain logic with these models. But the problems it is that they are often used for anything.

 

. : What do you make when he does not have there more cap?

. : Many things. At the 70 years subjects and beyond I put a forced prosthesis of type though I have put only 3 of them for 2 years. The problem with these implants which go well in the short run is to become to it fixing which can only fail and this is why I reserve this implant with the elderly with a functional slack demand and weak life expectancy.

An hemiarthroplasty can be also considered and when the subscapular is absent I transpose the 2/3 superior of large pectoral under the coraco-biceps and on the small tuberosity and sometimes on the former party of the large tuberosity and that goes well. But that requires the existence of a little under thorn-bush. When there is neither under scapular nor infraspinator the situation is critical. I do not have experience of the transfers of large dorsal. I carried out some tests of transfers of large round to try to stabilize a prosthesis. I also made osteotomies of the Benjamin type which consists in making an incomplete section of the surgical neck by keeping the cortical posterior one. This intervention is with purely antalgic sighting and would act by venous decompression. That always does not go but it is sometimes very effective and it is a preserving method. One could make only osseous perforations.

 

. : But why a prosthesis?

. : It is here not about head bald person, i.e. of broad rupture of cap but well of “ joint disease”. Some of these old patients answer the infiltrations well. In any event though one makes them these patients never find a good function. But I think that the prosthesis in their giving a good joint surface facilitates remaining mobility notably. Simple the of the shoulder would not give to my opinion also a good performance.

 

. : And in front of a PR with thin cap?

. : The process progresses in the cap and the prostheses put in these cases evolved for a great proportion to higher luxation. This development of the lesions is the cause of the mobilities limited to 90°/100° of the in the PR.

The synovectomy is used in certain countries; it is probably interesting in the erosive forms. It should be done though I do not have experience of it, but in the synovectomies with open sky one is struck by the brittleness of under scapular. The synovectomy is surely preferable.

 

. : How do you discuss constitutional instabilities?

. : Most of the time by specialized rehabilitation. My experiment of this pathology is that it is very often ignored. I am likely to work with a very pointed team of physios on the subject and we see many swimmers among whom the problem arises and for which we developed various programs. The main issue is to convince the interested parties to yield with this rehabilitation for a long time but that goes well. To tell the truth those which are forwarded with a symptomatology of conflict under to the foreground leave there well with physiotherapy whereas the result is less good with those which have repeating luxations. For those, there I use an alternative of of the lower capsule.

 

. : Which alternative?

. : There were many versions of this operation and I use of them one which approaches much that original of . I make capsular joinings and I do not use an anchor.

 

. : And methods?

. : With regard to the “” I consider that it is about a method still in evaluation. I am interested much in the but I have, to tell the truth, only 4 or 5 patients a year among whom such an intervention could be considered. And in these cases I address them to which makes a study on the subject. In this manner I contribute to his series and I entrust my patients to somebody who controls much better than me the technique.

 

. : You feel Ecossais particularly?

. : Although I would not have been born in Scotland, I grew under Scottish influence and I have lived for 35 years in Scotland. I feel there well. I had been interested much in the Scottish dances before even of living in shells. In addition, for the pleasure, I initiated myself with the musical instruments from here like the bagpipe. Quality of life is excellent for my family and I can continue my personal work professionally. I can also devote myself to my preferred: Rugby and fisheries with the fly.