MO: For example?

LP: When I was young intern at I learned how to make resections head and neck and of , and at the end of the six-month period, this intervention, practically only was made. The senior registrar was the angular stone of the services. We made large surgery. Truly as a chief, I practically made all the pathology of the hip which could be done at the time. There was little resumption of prostheses because it was the beginning of the arthroplasty. With the return of the military service, I discovered the total prosthesis of hip. made already a half-tone engraving total prosthesis of hip because it associated a prosthesis of Moore, with a cup of . But the genuine total prosthesis of hip, I discovered it in 1966. I was at . I remember that an extraordinary ritual surrounded the total prosthesis of hip of fear of the infection. One arrived very early the morning at 7:30 to operate, one put sterilized #FFFFFF behaviors, there was a wealth of precautions. I was too young intern to make such interventions, but the chiefs of made . The hip surgery I practiced it only at the end of the boarding school at at the time of my second half of the year. But the indications were not as thorough as currently. There was prohibition to make the before 70 years!

MO: You were senior registrar at ?

LP: I was senior registrar at in 1972 and 1973. I had been internal at his place in 1968. It is a great memory of my life because in May 68 I was obliged to cross Paris to return to me to the hospital and the situation was surprising and interesting…
When one arrived to , one knew that it was a serious service, where people worked well where environment was primarily made respect for the owner and of work. It came part-time, but was invested much in the service, besides it made there primarily spine surgery and cups of hips. He spoke little but one learned much from things to his contact.
He briefly answered us but he had a specific relation with his pupils: He operated downtown and he took us along! So that number among us assisted regularly. I remember that it made with me its first external fixer, and God knows if it did not like that! Alain assisted it and was interested much in the fractures of the , the low fractures of femur etc… It was an effective service where one worked well and where the results were analyzed with much serious.

MO: Which memory do you keep your passage at ?

LP: I started from to go to finish my boarding school at which had just arrived for 2 years I believe in .
One said many things of it at the time, in particular concerning the difficulties of the life within this service which was extremely demanding. I can say that was beneficial to me because at I had accumulated many knowledge but I needed to put a little command in all that and Mr. was “Mr.” of command. He adored the stages and the types, some time even he was muddled in the “stages and of the types” but at least he had concern of classifying pathology especially traumatology and of making it clearer.
And then we were with the starting of the and the . We had published with Mr. on the prostheses of , which was a knee prosthesis with hinge and one then made a communication on 300 very significant number for the time. My first contact with was rough. I had just arrived and made the inspection of hospitalized. I found a phlebitis. I believed myself authorized to discuss it. It proves that it was a patient of the owner, which I did not know and I had not reported. Ca was you can me believe, rapid in short, and instructive.
He told me how it wished that one work in his service. I understood and I must say that was advantageous to me because I always retained what I learned over there. One is not a pupil with impunity, of we are marked by a rigor and responsibilisation which can be I did not have sufficiently at the beginning.

MO: It is thus at that you learned the ?

LP: Yes primarily one put at the time of the prostheses metal/metal and then we put what we call of the couples “stove ”. The owner had noted that there was a risk of seizing in metal/metal and it had the idea to paper metal by polyethylene. We had major osteolyses. In spite of that, we learned how to put , to discuss the indications, and especially, to follow these patients. I had re-examined at the time 300 published in Holland for the days organized by . It had already shown us a certain number of troubles and we were in 1970. The owner wondered about the reactions of the bone with respect to cement or the implants, already at that time, which was premonitory.

MO: You arrived at Angers little time afterwards, you knew a little bit the area where you disembarked, he was necessary all to create I imagine?

LP: Yes whereas I was at in 1971, Jean who one of his friends was installed in private clinic was obliged to stop his activities during 3 weeks-a month.
It was necessary to replace Jean with the private clinic St with the raised foot. was addressed to its chiefs, I could release me for 3 weeks and went to replace . I must say that I found an organization almost perfect. I had been high only in the hospitals, I knew some favor and the disadvantages. There all bathed in oil all was easy, the anesthetists listened to us, one started at 8 a.m., the consultations rolled without tear. In short it was a very effective machine. This situation challenged me much. Thereafter, Jean and Jean-Claude , his associate, old from , called upon me very often and I went to replace them during 2 or 3 years. And when there was a place of released at the hospital, I had the possibility of postulating I must tell helped primarily by Mr. . When I arrived in this hospital, all was to be created.
At the time, there were 3 general surgery services and no department of csotcina.comaedics. All csotcina.comedy was done downtown. I enjoy to say that it was necessary to wait 2 years before making my first total prosthesis of hip. During all this time, it was necessary to make , to discuss the infections, the large case, all the fractures of , all that it was for us and I do not speak about the fractures of the rachis. One did a little all that at the beginning with the senior registrars of the time first was Jacques and second was which made general csotcina.comedy.

MO: Parallel to traumatology you worked on the prostheses of ankle. Which is currently your feeling on the prostheses of ankle? It is said that you are perhaps one of the largest layers in France.

LP: You go a little too extremely. I put my first prosthesis of ankle in 1975, it was on a posttraumatic osteoarthritis, which is not the best indication but the patient refused completely with the arthrodesis and suffered much. I put a prosthesis , a very forced prosthesis to him which finally held 15 years. It held perfectly on the but the tibial part was inserted. This patient never again complained about its ankle and I re-examined it for the last time 15 years afterwards. One of my bosses of private clinic saw it at 20/21 years and did not have the presence of mind to require radios of him and to examine it, it saw it for a fracture of adhesives what made me lose the retreat at 21 years, which I regret. I had thus kept this idea of prosthesis of ankle, but I made some very little finally since in a score of years I have to make 15 or 20 of them.

MO: Thus about at the rate of 1 a year?

LP: I.e. very little. Not very many was the colleagues who believed in it, initially because it is difficult, the hinge is very tight, the hardware was very approximate and it is true that the arthrodesis goes well. But why be would ankle the only hinge which one is satisfied to lock? Why can't one seek a good mobility? The best of the indications especially remains the polyarthritis than these patients have an attack under , médio-tarsal and than if one can back up a mobility to them, they are very grateful. This the more so as the attack is often bilateral and that a bilateral arthrodesis must surely “function” but not very well. It is for that I was always interested in the prosthesis of ankle but I remained in stand-by until the moment when there was the New Jersey prosthesis then Buechel-Dads who introduces a concept which rose from the prostheses with mobile plate of the knee. The mobile polyethylene insert could decrease the stresses on the level them interfaces and less request the prosthetic components.

MO: Which were then your observations?

LP: I realized of a difficulty. These prostheses at least those which we had in France at the beginning were prostheses which the . However, in the large articular destruction, the is very reached, irregular, sometimes these cheeks are asymmetrical and to pose a prosthesis of patching perfectly positioned on a completely worn , it is a challenge to which I had the greatest difficulty in answer.
It is for that which by seeing what the others did, we took the party in the group to decapitate the dome , the more so as in its symposium on the fractures of the had shown us that the spans crossed under the dome in full body of the , thus one could decapitate it without too much problem to support our prosthesis without risking which it is not inserted.

MO: And then it was inserted?

LP: The future will tell us if the prosthesis conceived by at is inserted or not; for the moment that does not take the path of it.
Remain the problem of the tibial base plate. In the New Jersey prosthesis it is necessary to make a former window cortical to put it, which is unpleasant, weakens the tibia and returns the positioning of this difficult implant.
We directed ourselves towards another drawing by using a small pin which is easier to position and which should bring to us I hope for a retreat higher than those that we know.
But it is true that the prosthesis of ankle is not a solved problem and that the difficulties are incontestably in connection with the tibial component.

MO: Which is the greatest retreat which you have with this prosthesis?

LP: 2 years, i.e. unimportant; the retreat is more important for , that made at least 7 years now.

MO: You disadvise the prostheses in necrose dome ?

LP: Yes, if you are confronted with this problem it is necessary to make a MRI.
If necroses it is really very important, I think that it should be been able another although the therapeutic choice is not very easy. I show with everyone one necroses bilateral in a 22 year old young girl following a kidney transplant which I saw many years ago and which goes well in the absence of specific treatment.

MO: Which experiment did you fire from the processing of the fractures of ?

LP: I believe that there is a question of age. If one is in front of an young individual and that one knows well the procedure of these fractures, I believe that it is necessary to try to reduce to the maximum the intra-articular fragments. It is a surgery which when it is well made, makes it possible to obtain good performances with important passing. I come from last week a patient whom we operated 20 years ago following a complex fracture of , it was a fracture in Y with posterior size reduction.  We delayed the hour of the thus much. On the other hand in the vicinity of 60/65 years, my tendency would be to follow what indicated to us: if congruence is relatively preserved, I put the patient in traction, with the need make a “wild reduction” to try to so improve a little the things after consolidation the patient complains, I can position a prosthesis under good conditions and with a less neuro or septic risk. Here are our current indications.
But we keep rather broad indications of osteosynthesis on the fractures of at subjects of Middle Age.

MO: You belonged to the group, apart from the prosthesis of, which development do you make with this group ankle?

LP: Vast subject. The group is a group of friends, and a group which works. Unfortunately our publications are not sufficient and we are not made enough any more know what is damage because we have an absolutely extraordinary sum of files which should be exploited. We worked, on all the hinges safe on the hip because the interests are too divergent. Our studies related especially to the knee, the most known implant was the prosthesis with hinge, then about years 75 the prosthesis Kali, it was one of the first prostheses with conservation of the posterior crusader. At the end of ten years we developed more evolved/moved prosthesis, the prosthesis. This prosthesis now understands 4 types of implants, with conservation of posterior crusader, without conservation of posterior crusader and overhaul.
Knee prosthesis is the hobby horse of this group. It with the prosthesis of ankle there about which we spoke, and the prostheses of the upper limb: shoulder prosthese always under development, it did not leave yet but it is a question of month. There are the prostheses of the elbow and trapézo-metacarpal. We gave up the radiocarpal prostheses unfortunately because we are saw of a certain number of deteriorations with time. Here is, the group continues to work and what is interesting it is the mixture of old and of young people. The young people push us to develop modern technologies (navigation for example), introduce new ideas, the group continues with good outward journey and will develop still implants these next years.

MO: Where is the changing?

LP: We hope that it is assured, the old ones of which I form part now will be compensated by younger surgeons but of quality, I quote for example Bernard , Denis , pH. , R. , I forget certainly some. Others young people re-entered in the group, they will bring there their knowledge and their experiments and also their criticisms. I believe that it is that which is interesting: to take part in a group of study, to swap ideas. I like the concept of group I think that the young csotcina.comedists do not take part sufficiently in such groups. For my part, I form part in addition to one group of voyage: for 27 years each year, we have left with ten colleagues through all Europe or in France to see such surgeon in his structure to question it, see it working, to see its results, it is very enriching.

MO: With the passing on the prosthesis, currently do you privilege the conservation of the posterior crusader?

LP: We were holding them of the conservation of the posterior crusader, it is true that the Kali prostheses behaved remarkably because we removed very little of it. We on the other hand saw appearing secondary ruptures of the posterior crusader. These ruptures probably recognize several causes. Perhaps we put our too tended prostheses and can be which have is done of the too low cuts on the tibia and weakened the posterior crusader or then what is more alarming, the broke because of an insufficient drawing of the prosthesis. At all events, each time I currently re-examine the patients, and we have much chance, in Angers, because our patients are faithful, I am struck by the frequency which I cannot quantify of these posterior subluxations translating the bankruptcy of the correctly.

MO: Did you amend your approach on the conservation of the ?

LP: Consequently the question arises, is truly necessary he to preserve the or not. It is true that the when it is left improves the mobility of the knee and the proprioception. It is true also that the conservation of the makes more difficult certain corrections for example a large valgus or large a . I believe that it is necessary to have the 2 prosthetic models at disposal, my personal tendency currently can be by facility, is to preserve it less and less. Perhaps because we lay out in addition to one congruent ultra prosthesis, or because we use a new prosthesis with mobile plate without conservation of the ; but it is true that gradually I start to separate me from the conservation of the . It is necessary to also tell that in university center it is easier to show with our interns and our chiefs, prostheses without conservation of the whose realization is easier.

MO: Which type of prosthesis with mobile plate do you use?

LP: Mobile and slightly rotatory since the prosthesis that we use is the prosthesis still a little confidential. It is manufactured by , it is a prosthesis which allows rotation with advanced and retreat of the tibial plateau of m, which decreases the forces of shearing. Because of a broad surface of contact until 100°, wear will be decreased by it. It is a little early to provide for the behavior of these prostheses, but incontestably the insert moves and turns under the control of a tibial retentive stud.

MO: Is what with the prosthesis that you use of routine you noticed that in the event of sacrifice of the there was a “excess stress” of the aircraft bungee cord?

LP: With the prostheses with mobile plate for the moment I did not note that. But our experiment is not enormous. We put some in group 80 and in the house a fortnight our retreat is still insufficient, but I did not note a patellar problem in particular. One of my first patients, that which has the longest retreat announces a small pain former to the level of its patellar tendon, bilateral besides. This translated a conflict of the insert with the patellar tendon? I cannot tell it to you.

MO: Which is the philosophy of your prosthesis of resumption of knee?

LP: The prosthesis III is a very beautiful prosthesis of recovery. It rests primarily on an intramedullary sighting, carried out thanks to guides borers which will be locked very far in the medullary canal to be on to some extent finding the mechanical axis of the tibia then femur. From there, we make orthogonal cuts, it does not matter the levels to which will be made these cuts since we will have possibilities of correction by blocks out of cement and not metal which are blocks punts, nontriangular what makes the cuts easier since one is always orthogonal. We have 2 systems of blocks, 4 and isters.
One can thus have on the tibia, of the shifted cuts which we catch up with by these fix, the whole is to find a base plane, perpendicular to the mechanical axis of the tibia to support the metal base plate there on which set right stems of size, length and diameter variables.

MO: And on the level of the femur?

LP: On the level of the femur it is the same thing, we make an intramedullary sighting with gradually increasing borers with the purpose of one blocking inside the medullary canal. From there we let us deduce our plan from it from cut with like always in the resumptions of the difficulties of evaluating adequate rotation. That is to say the first prosthesis installation was well positioned on the rotational level, that of which one ensured oneself the need by a preoperative scanner, we can refer to the former cut which will give us rotation, in other cases, if it can we will refer to the line of . Not being able to take account of the posterior condyles force is thus if there is not one or the other of these reference marks to be based on the epicondyles from where advantage of the scanner .
After positionhaving correctly positioned the guides in the rotatory plan we will determine the bending stress. Thanks to an adapted femoral template and inserts various thicknesses in order to obtain stability in bending. We carry the knee in extension. In extension we have the possibility of lowering the femoral template to obtain stability in extension, one thus will restore the balance , initially in bending then in extension. From there all is done very simply. One very easily puts our implants with keels of which there exist various sizes and for the femur, the possibility of having 3,5 and 7 of valgus.

MO: Which was your development concerning the ?

LP: When I arrived at Angers I told to Mr. , I want to continue well to pose your prosthesis in the condition which you have a polyethylene , he told me “that is not necessary, remain with metal metal!”. But in the area it was not possible for me to pass to metal-metal, everyone made metal polyethylene, and I was to melt me in the mould. We thus could obtain a plastic couple metal/. I put of 1 then of 2. Very quickly by analyzing my patients, I realized that cement did not solve all the problems in particular on the level of . I was informed of work of Gallant and Harris. I have Galante overdraft with a congress in Copenhagen and I was very interested by this man who became a friend, who speaks perfectly French, and American that I understand. It forwarded its studies on the monkey to us, the cuts that it had shown us authenticated the osseous . In France at the time, one was not favorable to without cement following the failures of the metal of the school. Lord continued but the majority of the surgeons did not believe in it. I told myself that being in a small town of faculty as mine if I wanted to make it was necessary that I try to make another thing that what the colleagues make, therefore I ventured in the experiment of without cement. I put much without cement of Harris Galante.

MO: When did you begin with without cement?

LP: We began our experiment in June 1985. I waited nths to see how behaved the first 2 patients and awaited the end of the year 1985 to start to make without cement regularly. We made some enormously, and will publish besides in the the 191 patients having more than 10 years of retreat. The patients are well, certainly we noted pains of thigh to the amount of 17%. Only one imposed an overhaul because the pain was important, all the others decreased. With an anatomical prosthesis, one of my bosses of private clinic noted 6,3% of pains of thigh to the longest retreat, but 36% of the patients had had at one given moment a pain of thigh.
When you carefully question the patients they tell you to have a small pain, but I realized that this phenomenon could also be found with the cemented prostheses. With regard to , we were likely to pose many large , therefore, of large polyethylene insert this explains why we took again for the moment few patients. With the retreat from 10 to 15 years the reliability curve is to 97% with an IC far from important because on 191, all the patients were re-examined except 2.

MO: On ?

LP: On . Concerning we did not re-examine the files but the thicker metal hull worries me. Being been useful by the experiment of the , our tendency is not to put a head 2ms in diameter when we have a thickness of polyethylene lower than m, the ideal being isters.

MO: American described these last years of important osteolyses due to the holes in , but, it would seem that this phenomenon is retrogressing. Which experiment do you have osteolyses by knowing that one of “is the most perforated”?

LP: With my direction what was said by American is not to take into account, and this for 2 reasons. On the one hand we put in the past multitudes of screw, I continue to currently put 1 even 2 screws but in our first series put of them we 4 or 5 because we were very afraid that this is mobilized. On the 191 patients whom we re-examined 12 osteolyses are noted. But the definition of osteolysis is difficult, so that I will convoke again the patients, will make them make radios and scanners to see whether what we regarded as osteolyses is truly but the definition is very difficult.
One noted very few edgings, I believe that only one patient has a complete edging lower than m out of the 191 cases. The is really very surprising. My son, csotcina.comedic surgeon was at Galante during one year and half and made his report on the influence of the screws and the osseous . On these studies , it showed that the best of was made on the level of the screws, it is there that the osseous capture was the best certainly there were metal remains around the screws but without pejorative character. It is true that I noted by taking again a of Harris, an important , but that was very rare in our experiment. This phenomenon appears when we had wears such of the polyethylene which we find a contact metal/metal, if not our behave well in the condition of putting a sufficiently large and a sufficient thickness of polyethylene.

MO: You confirm well that you continue to put at screw?

LP: Yes completely.

MO: Is what currently you use of the prostheses covered with hydroxyapatite?

LP: The only prostheses covered with hydroxyapatite which we used are the . The we let us follow 132 from there, who have a retreat higher than 7 years and whom we will re-examine the next year. Personally, I do not have the impression that the hydroxyapatite is the panacea, I am struck in particular by the importance of the osseous reactions the femur, in particular the proximal femur. It is about stress , or of osteolyses, I do not know it. One will analyze the radios, after having convoked again all the patients and them to re-examine but there is on this prosthesis with my direction something which challenges me. Is this drawing of the prosthesis? Is this hydroxyapatite? I do not know anything of it, in any case they are the only prostheses with hydroxyapatite which we put.

MO: In which area you did have problems?

LP: In area 1,2 and area 7, only in the bearing areas. The appears completely satisfactory to me on the level of areas 2 and 6, we have very little depression but once again, this deserves a finer analysis of our results.

MO: What do you think of the modern couples of friction?

LP: I am with interest friction metal/metal. I am not recipient in this business although I know that the old prostheses in particular the prostheses of which we put at the time are some contained times very a long time perfectly well, without wear nor without manifest damage. But the few cases which I followed were really too rare to be able to draw a conclusion from it. Personally I am anxious presence of metal remains chromium plates cobalt. I do not know which is to become to it remote of this chromium/cobalt. I was surprised by the communications of on the concentration of cobalt and chromium in plasma and by these metal remains which one finds on the level of the ganglia so that personally I leave this couple on side. On the other hand, I am very interested by ceramics/ceramic.
I did not put any yet. I put often on the other hand, the ceramic couple/polyethylene but my boss of block knows that the next young subject that we will have to operate will have a ceramic/ceramic couple, I believe that it is a channel which is interesting. Here where I am today.

MO: You very specific studies on the femoral neck fractures in , can you made tell some to us more?

LP: Yes indeed with Gerard we were responsible for one roundtable at the Society of csotcina.comedy of the west in 1990 on the femoral neck fractures in . I had re-examined on this occasion 100 patients of Angers reached of this type fractures and I had been surprised by the fact that we had a rate of necroses absolutely amazing, since we had 33% of necroses in the service for a fracture considered benign. We learned from our Masters that the fracture in was the fracture without risk. It always consolidated and did not pose a large problem but it is true that time with others one saw necrose… Here where we were when I fell on an item published in the in 1985. At the time of a not moved fissure of at a subject without any antecedent the author had seen appearing in the year or in the 2 years one necroses massive femoral head, and he had wondered about the problem of the “tamponade”. Then I acknowledge that was a revelation for me the more so as in the 2 years which followed I had exactly the same case of a patient who after a fissure of put in traction (this is not pain-killer perhaps besides) forwarded one necroses. It was a mason, I questioned it, he did not drink. We also wondered if the tamponade could not be the cause of its necroses and no specific antecedent forwarded.
We had then made about the Nineties, an exploratory study relating to 26 or 28 fractures in with for mission of taking the pressure by a pointer put in the hinge and we are saw that in many cases it was high. Certain papers had shown that a pressure higher than illimeters of mercury could be harmful and we found that about half of these patients had a higher pressure, to 30 to illimeters of mercury. It remained to check so in all the the capsule was intact, we made arthrographies and the capsule always has was regarded as intact. We have splendid arthrographies. Consequently we brought closer these elements: tamponade and intact capsule and mission were given to the chiefs and to the interns to make a puncture systematically.

MO: How?

LP: One tried to develop a hardware unfortunately, us did not meet much interest on behalf of the manufacturers. We were inspired a little by the system of tap pressure in the muscular cabins but that did not go very well, we met many difficulties, this method depends on the anesthetists, that depends on the hour, of the intern, in short on the methodological level there is something which does not go. What is certain it is that since we systematically make a to evacuate a which we do not find constantly besides but very frequently.

MO: How do you proceed?

LP: When one makes the access for osteosynthesis as long as one is there, one makes a small in the capsule and one evacuates blood. It is enough to put a spreader under the average gluteus and to go to give a small blow of bistoury per former channel in the capsule or more simply to puncture the hinge with a large pointer. Since we saw our rate necroses to disappear, finally to decrease in a very important way since one of my bosses of private clinic re-examined 33 patients into 96 when we received the society of the west here and were we to 6% I believe.

MO: Thus you always made an osteosynthesis of these fractures?

LP: Yes, it is true that we always discuss these fractures in by osteosynthesis. Previously we made a screwing, by percutaneous channel, it was easy, one made a very small on the skin. Maintaining everyone put, in the condition that there is not too much retroversion of the coll I believe that does not pose a problem, but what important it is that the 2 necrose that we had in the series re-examined by my boss of private clinic occurred among patients who were unpacked tardily. As well and so that I consider as these fractures are an urgency and that it is necessary in the 6 or 12 hours to unpack these hips to see the rate necroses to decrease, I would in any case like that others can confirm this…, here are one of the options of the service.

MO: Is one of your sons makes csotcina.comedic surgery, to say that you are trustful in the future of the profession?

LP: In addition to one son who makes csotcina.comedy, I have a girl who makes hand surgery. It is installed in Jerusalem. I am trustful in the csotcina.comedic surgery I am even persuaded that it is the only surgery which will keep a curve of progression.

MO: Here is a beautiful optimism!

LP: Why? The lifespan of our compatriots is increasingly long, the progression of the fractures of the neck testifies to it if it of it were need. People will be less and less satisfied small miseries of the life (small , small malformation, a foot which is not beautiful etc…) and will be made operate. People will want to always make sport more and more, to go more and more far, more and more high, more and more quickly, all this will continue to bring patients enormously to us. What worries to me it is the disaffection of the young people for the surgery in general and the in particular because it is a difficult speciality, difficult and badly paid. Many children of colleagues do not move any more towards the surgery what is nevertheless a sign. Finally, I am optimistic because the development of csotcina.comedy these 30 last years returns to me optimistic. Take for example, the problem of the infection: to reimplant a prosthesis… you report yourselves! I remember which came to expose us to the recoveries under these conditions it was extra terrestrial, maintaining this surgery became banal. Look at all that we do as regards prosthetic surgery where even current surgery! They are reasons for satisfaction, more especially as all this development is European! American simply applied our principles, but it is well in Europe, (I am a convinced European), that the principles of modern csotcina.comedy were found, the balance , the total prosthesis of hip, osteosynthesis, and I pass from there.
N MO: What is what attracted you in the teaching hospital career?
LP: What interested me in the hospital and university career, it is the contact, the contact with the young people, different view of optimism besides. What makes our force they are the young people, they push you and hustle you in your ideas and your certainty: Mr you told us that, and they show you the reverse of what you said…

MO: You are thus a happy university ?

LP: Yes still.