Derek is the uncontested promoter of the patching of the hip of 2nd generation. It is with him that returns the idea to have joined together two concepts which had failed separately in only one which functions. He tells here his beginnings, his failures and the lessons drawn from passed since the “prosthesis from ” in 1989 to “Birmingham ”. This player of Rugby, jovial fellow and not chewing his words was a time the troublemaker of British csotcina.comedy but it also devoted many energy and means to the training of his colleagues.

 

. : Where is one patching of hip?

: The patching knows a renewal of popularity after having crossed one difficult period in the years 70-80. New technologies made patching of hip a viable solution. Since its introduction, there were in the world 68 480 installations of Birmingham prosthesis in 24 countries. We have just obtained the adoption of the FDA in the USA which represent half of the worldwide market of the arthroplasties. Up to now, the results published in the medium term by multiple centers, seem good and of survival rates higher than 90% of source various are not exceptional. The problem of the patching is today the lack of training of the surgeons to this technique. Indeed few surgeons are confronted with the patching during their formation and much must all learn during the first installations, which is difficult.

. : How much are there models of patching of hip?

: There is at least ten systems of patching available in the world. They have a couple metal-metal and the differences are tiny seemingly. In particular, they have a whole a stem. But for the majority of the systems their results are not known because they have only small series and a weak retreat. We think, of course, that the differences between and the different systems in patching can be very important. But as regards results we have an advantage because we have medium-term results coming from very many centers. 140 contributed to the development of an independent database on Birmingham what enables us today to establish learning curve for these 140 surgeons: 96% of survival of the implant, they is rather good! The Australian Register of the hip shows that has the best results and two different systems of patching have a failure rate 4 times higher.

. : Is this a prosthesis which requires an initially specific channel?  

: I posed it by channel of , external channel , a traditional external , minicomputer posterior and even by . I thus used all the channels initially and whatever the channel used, one can obtain a good implantation perfectly.

. : Which your is preferred?

: It is it mini posterior which allows a fast recovery. It is easy to make but that has the disadvantage to disturb the vascularization of the femoral head and that could be important longer-term. Until now, within sight of my results and of those many other colleagues who practice Birmingham, there are no disadvantages, but you know, I am only 15 years old of retreat for all my various implants of patching. Who can tell what will arrive later on?

. : Why not a former channel?

: Time of the cups of Wagner we made channels of , it is easy to make but for the patient and recovery is slow; and I used it for some patients, in specific indications, for example in the event of traumatic lesions of the posterior soft parties. Thus I made of and some but I find that it is a difficult surgery. I saw Thierry making the former accesses perfectly. But for me it was each time a combat. Then I made external channels among thin patients with a good mobility. Many are those which with more than 15 years of retreat have very good performances and tell themselves very satisfied. But in the case of patient more corpulent and more muscular with a stiff hip, it one was crowned job and some of these patients preserved a permanent . And these are the cases of which pushed me to operate by posterior voting right while making pass vascularization to the plane second. Until now that does not seem to have of specific angle of attack but I recognize of course that we sacrifice the terminal section of circumflexe posterior.

. : How do you fix?

: In 15 years, we tested three different methods of fixing for the cups and the heads: cement, near-made it and the hydroxyapatite. And the results obtained are very interesting. The series of cups with hydroxyapatite gives the best results whereas for the femur it is the cemented series. Insofar as I very tested, I have patients with uncemented femoral heads which, at 15 years of retreat, are perfect radiologically and clinically. But those there, very had a bone of good quality and we know well that all the young patients for whom this operation is indicated do not have a femoral head of good quality. Therefore, I think that it is necessary to have a femoral option cemented for a bone of less good quality.

. : How do you cement the femur?

: Various systems take again various philosophies. In England, we were very influenced by the group of Robin . We consider that cement simply implemented to a surface does not allow a durable fixing; there will be unsealing. On the other hand we think that the integration of cement to the cancellous bone offers a very durable fixing. Thus with our Birmingham system, we seek the perfect contact of the head with the femur. I.e. we perforate the spongy one, and that when that we place the femoral part, the aforementioned acts like a piston thus creating a good anchoring of cement in the bone. I never had unsealing of a cemented femoral component. I had fractures of the neck, I had necrose and of the hull slammings of the femoral head. I had examples of infection, but unsealings of the femoral component, I never yet saw some. But of different systems cement high viscosity, with Preserve use + for example, and leave a space between the bone and the implant because they seek to create a cement mantle under the cephalic cup. could not use cement low viscosity with its implant because it would run and could not ensure an effective fixing. Conversely, one could not use cement high viscosity with Birmingham because the implant would not have correctly sat on the bone.

. : You use a system of aspiration to drain the bone?

: I aspired initially to reduce the risk of lubricating embolization systemic and then to reduce the local embolization of the small vessels of the head and the coll When I started to cement, I quickly noticed that at the time when I introduced the implant, grease left the femoral neck. Therefore, by pressurizing cement in the bone I increased the pressure so much so that grease left the bone. I thus realized that the generated pressure was to be very high and that I owed not badly of small vessels. I wanted to avoid that not to generate one necroses bone and this is why, there is that well a long time, I decided set up an aspiration during cementing. And that caused forever of fracture.

. : You wrote that you changed your implant for tribological reasons and problems of manufacture. What did it occur?

: In fact the implant of Birmingham patching changed forever. It did not change since 1997 and this so far. The implant manufactured by another company and that I used six years before Birmingham , but with my knowledge. The history is the following one. I had been very favorably impressed by the durability of certain explants of and Boxing ring which were run implants, i.e. manufactured with the metal run in a mould. The characteristic of a chromium cast cobalt it is that it forwards an large amount of carbides and that these carbides are as hard as a ceramics and thus offer a great wear resistance. I had thus asked the society which manufactured my prostheses to make the same thing. The implants were manufactured by George who worked at but had also worked formerly for the largest manufacturers of Co cast Cr implants. Thus George had the knowledge to make and as long as it was in charge of manufacture there was no problem with the implants. However as the number of implants manufactured increased, other people intervened in manufacture. When took its retreat of others took the hand and the things changed.

. : I.e.?

: If you heat several times, i.e. that if you make him undergo a series of heat treatments, you can deteriorate his qualities by carbide deficit. Society was worried by the high rate of rejection to the factory. At the time of the machining of the implant one saw appearing holes and this porosity at a advanced stage of manufacture brought to put the implant at the rejection. Thus, with the purpose of eliminating this microporosity they decided to call upon the heat treatments. Thus you heat metal at a temperature close to the point melting and there metal is forwarded to an atmospheric pressure of 1000 bars which densified the structure and eliminates porosity. And well, indeed the rejection rate dropped. Always it is that the implant had changed quality, which I did not know because they had not told it to me.

. : If you had been warned, that could have made?

: I would have consulted the literature. When I discovered in 1996, that they had made undergo heat treatments I made Internet search and there were two items which explained why with the heat treatments there is an increase in wear. Here, it is as that which that occurred and this series of implants which underwent these heat treatments has today a rate of overhaul of 12% mainly related on the and osteolysis. It is that which caused my divorce with at the time. I had a good contract with them and I was very happy. But they refused to go into reverse and to stop the heat treatments. Thus I told them: “! if it is what you intend to do I do not want that my name is there associated” Thus we tightened itself the hand and we separated.

. : Where is one problems of metal salting out in blood?

: It should well be understood that the body is accustomed to assimilate cobalt and chromium. They are present in the fuel supply, champagne and the windfallen wood which we drink in this moment. There is an area of Australia, which suffers from a cobalt deficit and the sheep die there if a cobalt contribution is not ensured to them. We must introduce chromium and cobalt to remain in life, they are elements of the normal food supplies and the organism can assimilate them. If you receive some in excess, or that an implant salts out some more, all that will occur it is that you will find of them a more important rate in the urine. Consequently if one wants to measure the difference between an implant has and an implant B, in fact the blood analyzes will be more speaking. As for collecting the 24 hour old urines, you can note enormous variations of the metal rates of ions eliminated per day. We spent of the hundreds of thousands of dollars for studies on the metal ions. It there currently 21 ongoing studies! It is a true industry in Birmingham which the product engineering of ions metal! I think that the consequences of the salting out of the ions are far from being as destroying as the sidetone effects as are the osteolysis and the unsealing of the cups.

. : How be you come with the patching whereas there is a great number of good hip prosthese in England?

: I was specialized in the resumptions of hip and I was struck by the excessively high rate of overhauls among young and active patients.  The active men loosened their implants. In Birmingham, we posed much , it was the standard but there were big problems of unsealing among young patients and we discussed much case of overhaul for unsealing with 7 years.

. : But you could have changed for a prosthesis for example, why the patching?

: Because it was not only about . There was a heap of other implants which posed the same problems. We revised a whole series of it. I was with the head of a regional service of “recoveries” and the colleagues often called upon me for the difficult cases such as for example the fractures with important osteolysis of the femur. It is funny besides that these accidents there always arrive Friday after midday, you see what I want to say… Thus I decided to cure it. In Birmingham, my predecessors had posed Wagner implants. They were 7 or 8 surgeons. They had posed them and I revised them. And I understood that famous persons on insert EP did not function. These same colleagues, when they were younger had posed total hip prosthese with couple metal metal. Implants , and Ring. And I thus could follow the development of their patients. They came to see me very happy at 20 years of retreat, without osteolysis, in general claiming a prosthesis for the other side. And it is from there that the idea came to me. I told myself: “if all these prostheses with famous persons function well, why not implement the concept famous person metal-metal to the patching? ” And here! it came from my clinical experiment and my observations.

. : What did you conclude from the failures and explants of the cups from Wagner?

: With each time one carried out a recovery for rocker of the implant of Wagner, the histologic review showed a large destruction of the head due to remains of EP. And in a certain number of cases of overhauls for unsealing of the cup and osteolysis with a well fixed femoral part we nevertheless made cuts on the level of the head. And even when the femoral part was not loosened we could observe the presence of enormous granulomas destroying the underlying bone. And thus I do not think that there was a problem of fixing. When I was younger, I thought naively that there were two major problems with the Wagner: the first being the problem of rocker of the head at the time of the installation; at the last time the implant tilted! Thus there I told myself that should be able to be regulated with a small stem. The other problem had occurred, from time to time, of fractures of the neck and that was an additional argument for a stem. Thus therefore I added a small stem to the head: initially for a good control of alignment, to avoid the rocker, and secondly to limit the risks of fracture of the coll.

. : At that time there was the plate , a kind of screw plates with prosthetic head, why not have used it?

: I did not like it because the neck was larger than the head of 28 than one used at the time. I did not like at all the idea of an inversion of the ratio neck /t . And I had observed many cases where that had lengthened the lower extremity. At that time there, it was not regarded as an medical error, but today that is on our premises. If you lengthen the lower limb of a patient, you pay. If you made the two hips, not of problem, but for only one side it is really not well. It is that which displeased to me.

. : Which is the percentage of joint replacement of patching compared to the conventional arthroplasty in England?

: That turns around 5 and 10% and it is stable. We more or less reached the threshold of saturation in England. I formed with this technique more than 200 surgeons only in England, they put all there and can do it all alone. Thus, in all the country, almost each big city recovered some surgeons trained with the patching. Thus any patient who wishes it, if it is young and active and that its osseous quality allows it will find in its area a surgeon who will be able his hip.

. : Which are the advantages of the patching?

: It there with peace of mind with respect to luxations.  There is not the difficult risk of recovery of a fracture. Everyone is focused on the fractures of the neck on patching, and they is indeed very tedious for the patient and the surgeon but are serious, it is an intervention very easy to realize: it is enough to the head and the neck, to put a stem and a modular head adapted to . It is one hour of regulated surgery. The angle of attack of the fractures reported on total prostheses of hip is higher than that of the fractures of the neck after a patching.

. : Are the fractures rare, you could propose the advantage of preserving the natural offset?

: Except that it is not exact. On this point it is not as perfect as what one had hoped with the whole beginning of the experiment patching. The promotional literature gives like arguments: “You replace joint surfaces but you preserve the , you preserve the offset, the same size of head, the rate of luxation is very low”. Well, but the offset is not perfect.

. : And why?

: Because with the majority of the total prostheses of hip modern, you can vary the offset. Many a proposes various offset presses but actually the majority of them involve a of the socket. If you measure the center of the into pre and post-operative you will see that whatever the type of joint replacement, you the socket. If you want to restore the offset one the femur will need you. And well with the patching, you cannot as you can do it with a conventional total prosthesis. The only patients for whom the patching is better for the conservation of the offset, are the strapping fellows for whom it is almost impossible to reach that point without implant to measure whereas it is very easy to obtain with the patching.

. : What do you have like good argument in favor of the patching?

: Failure rate!

. : You think that it is a parameter which will be really visible in the years to come?

: It is already visible! If one compares our series of patients of less than 55 years with those of of less than 55 years of the Swedish register, whether the prostheses are cemented, without cement or hybrids, we beat them! We make significantly better. Of course, some will say “! these Swedes, they cement all! ”. And well separately left me the results the prostheses cemented, uncemented and hybrid and there is no difference at 11 years in retreat, none! And I do not think that Swedish manages badly. Thanks to the compilation of all the data in a national register, the person responsible for a Swedish surgical center which would have results except standards would receive a mail telling him: “Your rate of overhaul of last year exceeds the national average! What would you tell of an additional training? ” I want to say that they have a very severe quality control and that the rate of overhaul in Sweden did not cease decreasing with the passing of years. In same time, in the United Kingdom, that is T it passed? that did not cease increasing. And in the United States that exploded! And certainly not for lucrative reasons. The hospitals have the obsession of the overhauls because they lose money in the recoveries.

. : If the main argument of the patching is the reduction in unsealings, then why not to also advise it for the old patients?

: Not, not at the old patients. In fact, There are two reasons with that. Initially, the total prostheses of hip conventional function marvelously well among old patients. Then, we know well that the four things that one fears when one operates an old patient of a are firstly, the death, secondly the fracture, thirdly luxation and fourthly the infection. Unsealing is not a . The other problem is that among many old patients, in particular women, the bone is of poor quality what constitutes a risk of fracture of the femoral neck after the patching.

. : It was said that the fact of preserving the natural neck involves an clear improvement of the functional result?

: I would not say any more that today. I often receive patients who claim a patching but for which that is not indicated. Particularly women of more than 60 years, for which more the top-level of physical-activity consists in eating chocolate. They are in general very large and do not have a bone of great quality. But they know a 45 year old guy to the street corner which was made operate and which now plays squash. Then they tell me: “It is that which I need”. I explain to them that yes can be, but that within sight of the radios, I do not think that the quality of the bone allows it; but that however, if I note in that the bone is of good quality, I will make them a patching. But I add: “In any event, Madam, in all the cases, without the radios, you would not see the difference”. And that I believe in it firmly today. The only notable difference, the only great difference it is that my patients with conventional do not practice any more any sport of impact.

. : Don't you think that the training is much longer for the patching than for the arthroplasty of conventional hip?

: So completely. This is why we specifically followed the learning curve of 140 using Birmingham. We wanted to make sure that they did not cause a damage! We all formed them. We spent of fortunes to make them come to Birmingham, we sent trainers of Birmingham to the corners of the world; and I speak to you about Australia, South Korea, Japan, all kinds of places not always simple of access!

. : Which are the obstacles which you had to cross these 20 last years, to develop your implant?

: The first difficulty came owing to the fact that I had chosen with metal-metal. All the manufacturers whom I contacted told me approximately: “The couple of friction metal-metal was a failure and the coupled cups were a failure. And you, you think that while associating two failures that will be a success?  Very happy to have made your knowledge, goodbye! ”. And that was the message which I received from all large society which however today sells themselves of the patching metal-metal. And a day, in the Eighties, with the at the Orleans News, whereas I made the turn of the stands, I fell on a young Mr , at the time where and worked together, and I asked him what he thought of the concept. He answered me that he had worked with and that he had manufactured all his implants to him. As he told me: “It is necessary to see! We have George well, at which in the past made metal-metal. One could organize a meeting”. And thus, after having wiped the refusal of the majority of large society, it is thanks to the fortunate coincidence of a conversation, that three people finally decided that it was feasible! had already a appointed a little odd with a stem and two ailerons which were inserted in the . It was asked to me whether I were ready to use this and although I would have told myself that one ran to the disaster, I accepted not to break the dynamics of the project. They had already the mussels of the cup and thus they was expenses in less for them. It was only one small firm at the time and they even tried to persuade me which only one size of patching would be sufficient. There, nevertheless, I told them that it and that I was madness needed 3 sizes. George manufactured three moulds of different-sized heads to adapt to the sizes of of . And thus in February 1991 first implantation of
the prosthesis of patching metal-metal took place.

. : And then?

: I must tell you that at that time, I had already started to pose hybrid total prostheses. I used a stem and a without cement. And with share of luxations, of the occasional fractures and some examples of infection, I was satisfied. I started to use my patching close made without surface coating. Because, had had this marvellous sentence: “To obtain good pushes back osseous, you need a good stability”, but if you have already the stability who needs pushes back osseous? ” Overpowering! It is of typical : a dazzling formulation, but an false idea.

. : Not completely…

: , not completely. In short, I found myself with a rate of unsealing of 10%! I.e. 9 patients out of 10 were satisfied of the result. Except notable for the strapping fellows at which by the external access I injured the nerve higher gluteus almost systematically and who limped. But if the majority of the patients were satisfied, there was of them one on ten which came to see me for an overhaul. After one year like that, I decided that could not last any more. And at a meeting in Toronto I see and I tell him: “ I began Super patching” the “! ” says me he and me I answer him: “It is not super , I have 10% of unsealing as of the first year!” And it very seriously releases “Not chance, mets a little cement, son! ” I recalled it to him at a meeting to Zurich and it retorted: “I never said that! I said that for the femur but I never cemented a of my life and I would never have advised you to cement a ! ” And yes, here what arrives when one has a discussion with somebody at the time of a conference. In short, I persuaded to change the drawing of ; in other words we owed of the studs and the ailerons of and to add some amendments. All that their took several months.

. : What did you make while waiting?

: I had some patients who posed problem, therefore while waiting for that the final amendments are made to , we used a layer of hydroxyapatite temporarily. It was the fastest solution. Thus during 3 or nths, I posed a series of ha while waiting for the final implants to cement. Then I started to cement at the same time the cephalic and cups what had two contradictory negotiable instruments. On a side I had unsealing of the femoral component never again but of the other that was the catastrophe on with nearly 50% of unsealing of cemented . They were early unsealings and the implants divided cement mantle. I spoke about it in Laurent who had tried itself to cement his ceramic in the past and which had had the same troubles.

. : How did you react?

: I told myself: “, which is what I made! ” The balance-sheet of the analysis of the results was the following. Near-made: 10% of unsealing and overhaul; Ha: not an overhaul, all the patients are well and the radios are perfect; Cemented: catastrophe for , perfect for the femurs.  I thus made as for my conventional , a hybrid couple: cemented femoral cup and near-made hydroxyapatite for . Thus the implant was used during three years with excellent results. And it is then that in 1996 the changes in the manufacture intervened of which I already spoke you and who very wasted!

. : For all this trial period, which did say your colleagues?

: With my beginnings, when a colleague surgeon asked me what I posed and which I told him that I posed a patching metal-metal, it undoubtedly laughed and thought: “it is a nutcase! that he has fun all alone”, and that did not go further. But during the three years which followed, more and more of surgeons put themselves there and then there, I was made attack of any share. I was violently made criticize by colleagues that I knew years since! I was secretary of the British Society of the hip and chairs, we worked together. At the beginning when I had announced to him that I made patching it had been encouraging: “And well! If you started, you must continue and make so that functions! ” it had says me. But then, the project took too much magnitude. Other society started to look us of an evil eye and they influenced their surgeons in the incentive to criticize me like all my work. During 10 years I was vilified by the csotcina.comedic companies of implants and good number of influential surgeons. did not speak to me any more. I was unaware of them because the implant functioned well, we progressed well, but that was not a very pleasant period, you know.

. : Money problems?

: I do not know if it were a money history… When one starts to shake the boat of csotcina.comedy a little too much, people react! If you made a technique which, in their opinion will fail, they make fun about it, but when he became obvious that I had made patching a viable technique, many were the colleagues who reacted very badly. But my large troubles really started at the era of the Birmingham implant. Because I contributed actively to the creation of Medical in which I was implied financially and other surgeons knew it. my god! you know, the money stories, it is terrible!

. : You created Medical ?

: Not exactly! We founded it to three. But I am one of the creators. Let us say that I financed the project with 60%. There is another surgeon and the Director of the society which, is not to him surgeon.

. : Perhaps does that raise legal obstacles?

: There is no problem, neither legal, nor financial! It is a question of perception, the colleagues do not like that. Then if I thought well of being trailed in mud before, it were nothing beside what I had to undergo at this time there…

. : You worked at the hospital or in private clinic?

: Both, at the hospital and in private clinic.

. : Speak us about your course and Birmingham…

: It should be known that Royal in Birmingham is the oldest csotcina.comedic hospital of the United Kingdom. In London there is the Royal National , it is , and its equivalent in Birmingham it is Royal off Birmingham. And Birmingham proves to be oldest. But the government of the time had decided to close the hospital because of its geographical location. It was a hospital specialized in the tuberculosis treatment in the beginning, therefore isolated. Tuberculosis having disappeared with the arrival from the , the hospital then specialized in csotcina.comedy. We were the only specialized center in the total joint replacement, in particular in the years the Sixties, the first, and we were quickly very busy. We made our first in 1966 in Birmingham and came besides to assist us. That went very well. Later the government decided to close the old hospital and to build a new csotcina.comedic hospital on the same site with an independent ship, modern buildings, etc… Evidemment, for lack of money, the project was abandoned and the replacement solution was all to separate and scatter the services in the various regional hospitals. It was in 1992, the Minister for health signed the final document of fence. Then there, my furious colleagues thus decided to rebel. Two days after the signature, they appointed me chairman of the committee of the medical personnel. “Derek! We elected you chairman. Your duty is to save the hospital! ”

. : How did you make?

: That was relatively easy! Among our patients, there were influential people. And well I called those which worked for a channel of TV, or for a newspaper and I used my relations, with the result that one day out of two, we were in the newspapers, and once by week we pass to the TV.  We arranged ourselves to make alternate the promotion of our services and the criticism of those which claimed our fence. Moreover, to close a hospital which has a history unresolved replacement causes a shock in the opinion. And that lasted 2 years and that because a hay of the devil! There were resignations in mass on all the levels of the local managers of the department of health and to finish we obtained win. The hospital could remain, from the funds were going to be freed to modernize it, and it would be self-managed to prevent that anyone of outside does not interfere, which did not change since. However, following the combat that I had carried out to save this damned person hospital, I had been made so much enemies whom it was better that I leave. I thus put an end to my contract, left the hospital in 1994 and I devoted myself to my private activity.

. : Without damage?

: Before this episode, my private customers were not very consequent and I devoted myself mainly to the regional service of resumption of the hospital. There is illion inhabitants in our area, therefore there was what to make as regards recoveries. I made 150 revised a year on average. So that when I left the hospital in 1994, to earn my living, I increased my private activity and that functioned rather well.  And then finally, all people with whom I had entered in conflict, all the administrators left the hospital little by little… As said it the Mao quartermaster: “If you remain sitted sufficiently a long time at the edge of water, you will see passing the body of your enemies floating in the current”. If you remain well off a hospital team sufficiently a long time, the team members who do not appreciate you go from there. And thus a few years after, all my enemies having left, my friends and colleague clinicians invited me to return and I began again part-time. We have a very good arrangement: I am paid only when I am there. Thus if I disappear for three months, they make fun about it. I have very accommodating colleagues.

. : You made medicine in Birmingham?

: Not. I was born in Ireland and I lived in the north of Ireland. When I finished the college, the disorders in Northern Ireland had just started. The situation was very difficult and I decided to leave. Thus I postulated for the medical college in London. I was a good player of Rugby, I had been the captain of the school and I also played for the regional team of Ulster. Therefore, the faculty of St Thomas whose team of Rugby was weak and required reinforcement, offered a place to me! I joined thus the faculty of St Thomas and became captain of their team, etc… It is as that which I found myself in London. I am thus graduate of St Thomas, I even obtained the price of surgery.

. : And where you made your boarding school in csotcina.comedy?

: One cannot make his boarding school in csotcina.comedy. One must make nths in general surgery and nths in general medicine. Thus I made the first nths with St Thomas and the 6 others just at side, in . And after I heard of a certain Peter who was a famous and who directed the single department of traumatology level 1 to the United Kingdom, at the hospital of the urgencies of Birmingham. I thus postulated to join it and I was accepted. It is there that I met the girl of the instructor in surgery of Birmingham which became my wife. Everyone undoubtedly thought: “He marries it only because she is the girl of the instructor of surgery” I make a point of saying that they is false. Finally in short, having married local, I was wedged a little and I remained in Birmingham.

. : It is how Birmingham?

: The life is pleasant there. It is in the center of an area of illion inhabitants. One does not know so much any more where the town of Birmingham stops because by increasing all the cities around were attached little by little there to form an urban unit. At the economic level, Birmingham was the core of the industrial revolution, the area is called, the “” because of the carbon and pollution. My beautiful father often told me that when he was young doctor, he had had, on several occasions, to give up his small car on the roadside and to return to foot of work because the “” was so thick that he did not distinguish any more the route. We have ' S, Peugeot, Land Rover, Jaguar, There are many automobile manufacturers installed in the Midlands. Of course, much of industries did not survive. The years where the firm was to provide for its needs without any state aid were particularly difficult. Many industries disappeared and it was necessary to reinvent the city and to rebuild. It is not the most beautiful city of the world but I am accustomed to living there. For a few years I have lived a farm of 61 hectares to ilometers outside Birmingham. It is a nonconstructible protected area and my wife raises sheep in addition to her work of radiologist.

. : Finally, you made your speciality in Birmingham?

: Yes, but I arrived as intern “senior”, and I postulated with the programme of specialization in surgery. Thus I followed the training courses of general, urology and csotcina.comedy. Among the names of memorable csotcina.comedists, there was max Harrison which badly did not publish on femoral vascularization. There were Simon and who them also, much published on the vascularization of the femoral head and which also wrote a book on the fat embolism. Thus there were some large sizes of the hip. One could also quote specialist in the tumors which held the world records of the greatest number of rebuildings practiced on primary tumor. There was also in spine surgery. You know that the first scoliosis was made in Birmingham?. Mr. in Birmingham had a kind of small jack which it placed between the iliac crest and the column and which enabled him to make lever. And then us have received some trainees American which came to be formed in Royal , including one certain Doctor , who could, him also, to observe this technique. is not known but , is very known for him.

. : How did the purchase do without the Midlands Medical by & ?

: There were 7 purchasers on the blow, of which majority of those which had told me that I wasted my time to develop a system of patching. There are of it even one which made an offer more raised to us than that of & to which we however gave the preference because we knew that they would discuss the personnel well.

. : And you have same freedom to do what you want?

: I do not have a freedom similar to that which I had at MT, but I start to make me the made-to-order to work of a great multinational.