The csotcina.comedic Days of Fort de France were organized in February 2006 by Jean Louis . We met there Philippe , who chaired a meeting on the topic “hip prosthese and necroses”. Philippe is departmental manager at the hospital Henri in Creteil and its publications on the surgical assumption of responsibility of the femoral head necroses refer. It gives a progress report to us on the procedures of the prosthetic arthroplasty in this indication. We give also an account of the interactive roundtable on the balance-sheet at 20 years of the “ hydroxyapatite” animated by Jean Alain Epinette.

 

. : Why did you choose csotcina.comedy?

PH H.: I discovered the surgery csotcina.comedy during my co-operation. I made my military service in Tunisia and I had asked to make digestive surgery. I was directed in csotcina.comedic surgery in Tunis, by chance, and it is there that I made my “first weapons”. It was the service of the Instructor who did much traumatology.

. : What marked you in your Parisien boarding school?

PH H.: It was the variety of the schools and their clear opposition. It is a situation which tends to disappear because of the development in the technologies and the ideas. The teams tend to specialize.  I was likely to pass in services as various as those of to , of with , Raymond to Pity or with . All these schools were extremely rich.

. : You passed most of your professional life to the hospital Henri ?

PH H.: I passed most of my life to . I was one of the last interns of Mr then Senior registrar in 1981 and since I never left this hospital. I passed a great number of years with Daniel before taking his succession. This unity of place for one long period represents for an csotcina.comedist an advantage insofar as it can follow the development of pathologies and the survival of the implants. During a quarter century one can develop several research projects, and follow a certain number of it for a long time

. : How is the hospital Henri structured?

PH H.: It is a hospital which has a vertical structure and which has many medical specialties and surgical. It is an indisputable advantage to join together all these specialities in the same structure. The association of a large structure of csotcina.comedic surgery and research units makes it possible to develop search topics which would undoubtedly be more difficult to lead in other places.

. : It is the explanation of your research tasks?

PH H.: Yes, the juxtaposition of the various teams is inevitably one of the supporting mailmen. The typical example it is my collaboration with Frederic on the sickle cell anemia. I started to work with Frederic in years 81. Today with 25 years of experience of this pathology, there is no team in France and undoubtedly in the world, which have this seniority in this practice and this recruitment. There is also the co-operation with the cell therapy on bone marrow transplantations which made it possible to launch in 1990 the cell therapy in the pseudarthroses or in the processing of necrose.

. : Was there a specific university encouragement to your hospital where you had made a personal step?

PH H.: There is forcing a university encouragement. But it is especially a personal step. I.e. if one does not make the effort develop research programs one passes beside the proximity laboratories of fundamental science.

. : In connection with necrose: when to establish a prosthesis in the event of hip necroses?

PH H.: When one does not have other solutions. When the femoral head is broken down and that the patient is developing a osteoarthritis, there are not other solutions and this, whatever the age of the patient. One can thus have to establish a prosthesis among some 30 year old patients!

. : It is the best processing, even at this age?

PH H.: Certainly when necroses it is beyond the conservative treatments and that the hinge is very damaged. The prosthesis brings an indisputable comfort of life to the patient.

. : Maybe, but which prosthesis?

PH H.: There are various types of prostheses but also various practices according to the countries. In certain countries, necrose them are still discussed by the simple cephalic prostheses while leaving places the cartilage from there. It is not any more the case of France where the prostheses are total, which they are conventional with an anchoring for the femoral part or which they are coupled cups. Generally, in France, the two slopes of the hinge “”.

. : Why not a bipolar femoral prosthesis?

PH H.: Generally the cartilage is not intact. One is not completely in the situation of the femoral neck fractures where the accident occurs one day “J” with an intact cartilage . In necroses, the history of the disease makes that the head became deformed, that the patient went a certain time with a deformed head and damaged the cartilage . Even if it appears intact on the radio, the cartilage is not intact any more when the patient is operated. And to pose a bipolar femoral prosthesis against a cartilage which is not intact exposes to a discomfort of the patient or a recovery.

. : Which is the current surgical consensus?

PH H.: It adopts two attitudes there. Those which privilege the conventional prostheses with a femoral anchoring because they were the proof of their effectiveness on important series. For example 30-35 years of retreat for and 25 years for . That poses the problem of the inescapable recovery all the same when the patient is operated very young person. The other attitude is to propose cups to avoid the femoral recovery but necroses it is not the best indication for the patching. In a youthful hip osteoarthritis one can imagine that the anchoring of the femoral cup on the head will be of a correct quality. In necroses, one will be embarrassed because the subsoil is not perfect and that the anchoring of the femoral cup is random. The experiments published are variable with the results which for some are good, for the other poor ones insofar as there are sometimes rockers of the femoral cup, even of the fractures of the coll.

. : What gains a young person to have a coupled cup?

PH H.: It gains at the beginning the advantage of a femoral head of large diameter. The mobility of the hip is more important than with a conventional prosthesis. A better amplitude and a better stability are the two advantages related to the large diameter of the femoral part. In addition some pose “famous persons” on conventional stems for the same reasons.  The disadvantage which results from it is an increase in wear and stresses on the part .

. : And if one decides to put a conventional prosthesis in a young person, which couple of friction?

PH H.: All the couples of frictions have advantages and disadvantages. The oldest couple and most conventional is the couple metal-polyéthyène. When the series objectively are looked at it remains of topicality since there are series of necrose with 25-30 years of retreat which ensure young patients a survival of the implant which approaches 60 70% what is not negligible. It is known that the limit it is the wear of polyethylene and that this wear occurs because polyethylene and metal lose during time their initial qualities. For metal, the roughness of surface accelerates with the yarn of time and increases the wear of prosthetic . From where the idea to improve polyethylene and to replace metal by other materials like ceramics. The couple alumina polyethylene, which has a long retreat now, showed that it produced only little remains, and the alumina head does not become deformed and does not amend its roughness with the yarn of time. It remains intact and even “new” after 15-20 years. One used some much in Henri . This couple gives completely correct results to 20 years. It has a wear nevertheless, but there is very little osteolysis undoubtedly because the number of particles does not increase with time. To abolish any wear, a couple alumina-alumina should be used.

. : Where are the fractures of alumina head?

PH H.: They are serious but rare. It is difficult to know the frequency of it. There are two information sources. On the one hand surgeons, and on the other hand manufacturers. The manufacturers give figures which are brought back to them and which by definition are not globality. The risks given by the manufacturers are certainly undervalued whatever their rigor. The figures given by the surgeons surely more important but are scattered. Does the angle of attack decrease? Certainly because the quality of alumina improved during the last years.

It does not remain about it less than they are not fractures with the accidental direction of the term but of the fatigue fractures. It is enough to an error of initial position of the head on the cone or to a fall of the patient to start the stress fracture. The risk “0” does not exist with a head out of alumina and whatever the improvement of material this risk will be never null. From where the idea of some to benefit in fact from the advantages from metal and the to pose other couples of friction like . It is a new alloy, which is out of metal. There is thus no risk of fracture. The is obtained simply with oxidation and the heat surfaces some which gives in practice a surface as perfect and as inalterable as alumina.

. : To return from there to alumina, does the risk of fracture defer according to the couple, i.e. alumina polyethylene or alumina alumina?

PH H.: Yes, there is more risk of fracture with couple alumina-alumina, the fracture of the head and the fracture of the cup are risked. Alumina is more rigid and one finds in the literature a risk of fracture more important than with polyethylene what is logical. The alumina fractures are serious because alumina is extremely hard and that the pieces of alumina will attack the Morse taper. In addition, in the presence of polyethylene, the particles will remain anchored in polyethylene and thus the change of prosthesis which follows is problematic. Should be given such a hard couple. One cannot put metal because metal “would be eaten” by the alumina particles which remain in the hinge. Even if a synovectomy as perfect were made as one hopes, it will remain always small remains which will make to some extent “grater” and will use metal. One is obliged if there were a polyethylene cup to remove it because the alumina remains remain enchased in polyethylene. In short, a couple alumina/alumina thus should be given, which is a paradox, because if the patient broke a first head, he can break a second of it. Especially one cannot give a new head alumina on an old Morse taper. Thus should moreover be changed the femoral part. What brings to propose a relatively heavy intervention if the patient is old. The experiment showed that the alumina fractures when they have a very high rate of reoperation since more half in the 5 years which follow.  It does not remain about it less than the couple alumina-alumina has many advantages nevertheless.

. : And if one immediately after the fracture of head?

PH H.: It is what it is necessary to do by removing the maximum of remains but certain patients, in spite of their fracture, can go during a few days while being embarrassed but without reporting fracture and seriousness which it involves because if they go thus, the pieces of alumina will use the Morse taper and will make more difficult the intervention which follows.

. : Even if they are rare, these complications encourage the couple metal/metal…

PH H.: They could, because it is also a hard couple and theoretically with little osteolysis. But there are all the same some disadvantages and interrogations on the couple metal-metal. The retreat of the current couples is not very large. Of course that it is an old idea since she had been proposed, there is more than 70 years, by Philippe in England and there is a whole series of couple metal-metal which already were tested and stopped. The couple metal-metal in its recent history goes back to approximately a decade and it is little. For the moment there are no catastrophes. But one can fear in certain cases “of” prosthetic which can lead to patients because of the metal high rate in blood. In the particular case of necrose it should be known that one cannot use this couple when it is about insufficient renal, of one grafted or one dialyzed renal. The remains created by the couple metal/metal are not negligible since a pitch generates a million particles. With each pitch, it is a million small particles all which are eliminated by the kidney. If the patient is in impaired renal function, they accumulate in the organism. It is thus a counter-indication at a patient who has an impaired renal function. In addition in the event of osteolysis by the are difficult to detect.

. : I.e.?

PH H.: Osteolysis with polyethylene is seen well because polyethylene is radiolucent. In osteolyses by there is a bony destruction in which a fibrosis with metal particles accumulates to which the is close to that of the bone and which one thus does not see on radiography. This osteolysis by is particularly misleading in knee prostheses but that can also be observed on the total prostheses of hip.

. : With regard to is the femoral stems, necessary to seal?

PH H.: Fixing perhaps a problem because of etiology of necroses. Corticoids, kidney failure and all pathologies which decrease the quality of the bone will cause a difficulty of implant fixation without cement. Cement solves these problems, at least in the first years of surgical operation. Conversely, is there against indications with cement? At the grafted renal ones, or the insufficient renal ones, it was not observed of counter-indication to the use of cement.

. : Before the stage of the prosthesis which propose?

PH H.: There are several types of operation which one can propose. For the early stages they are drillings, the drillings improved with bone marrow or with the spongy one even with a vascularized fibula but the principle remains the same one. The voting right initially on necroses remainder the cylindrical drilling improved by more modern techniques which aim at facilitating the osseous rehabilitation either with airframes osteogenic or with growth factors. At more advanced stages of necroses, there is still a place for the osteotomies but the indications become rarer. Complex osteotomies such as one could do them 20 years ago have difficult continuations because in fact articular osteotomies engage the patient over several months, and which moreover lead later on to imperfect prostheses. The preference currently goes to simpler extra-articular osteotomies (type #D1FFFF ) which give identical results. Thus the osteotomy is possible at a very young patient, 17-18 years, deformed head. This result will be average what brings 50% of the patients towards a surgery in the 10 years which follow; but there are some patients who went up to 20 years. But the prostheses do not give always better at the very young subjects. It should not be forgotten finally that the advantage of the osteotomy is to be practicable whatever the country.

. : Is there really a difference between simple drilling and improved drilling?

PH H.: Yes, it is obvious. On the private clinic, simple drilling improves the pain. But simple drilling does not make it possible to prevent the development of the osteonecrosis and does not allow either to obtain the cure of the bone necrosis, contrary to the processing by autograft of bone marrow or not contribution of .

. : of cementing?

PH H.: The it is a little the same result as an osteotomy. That gave a little imperfect results, with a mean survival about equivalent to 50% to 10 years. Currently, on the hip that lost a little its interest initially because with progress of the imagery one sees the patients is at a stage earlier and accessible to a processing by autograft from bone marrow. There are thus less indications. With the shoulder, one continues of to make because that makes it possible to lock the sequestration and the shoulder is more tolerant. But currently, rather than to use acrylic cement, one directs oneself towards a rebuilding using substitute of solid or injectable hydroxyapatite with growth factor.

. : Why do they necrose them are painful?

PH H.: There are undoubtedly several mailmen in question. One realized for example that the patients who received corticoids with high amounts developed hip pains the very same day . I noted that on three or four of my patients. Then, there are pains which appear in necrose well before the loss of sphericity. There are symptomatic hips approximately around nths after the corticosteroid treatment. Certain hips rather quickly become symptomatic, others remain asymptomatic during two years. The experiment shows that they all become symptomatic at one time.  Generally before the loss of sphericity which it involves pains brutal and invalidating.

. : What do you think of “navigation” of the hip?

PH H.: It is still at its beginnings. It will be able to surely bring data on the prevention of luxations and the inequalities length in the future.

. : Did you work on the knee?

PH H.: Yes, one worked much on the total prostheses, the prostheses and the fémoro-patellar prostheses.

. : One with the impression that every two years the prosthesis is rediscovered and that this technique does not manage to take a quite clear place in the therapeutic arsenal…

PH H.: It is a little true, but the indications are restricted. The difficulties of the prosthesis it is that in my opinion, it is more one problem of surgical indication which a problem of operative procedure. Of course the technique must be correct but the selection of the patient is extremely important to have a good performance. That represents to more 20 % of the prostheses for those which push far this indication.

. : Which is the good indication?

PH H.: The good indication, it is of course an isolated osteoarthritis, therefore not of fémoro-patellar attack, not of attack of the opposed compartment, a functional former cruciate. Then, a knee which does not have too much angular deviation. The angular deviation partially is corrected, but it is necessary to leave the knee in and it is not necessary that the residual is too important. That eliminates the very great deviations, and it is necessary to be wary of the knees which at the beginning normal are centered. That as well as possible does not represent more than one knee out of five.

. : And if there is no instability but what the former crusader isn't present?

PH H.: It is not desirable at “young” subject but it is possible in somebody of old. The prostheses give forgotten knees. The operative procedure is of a low morbidity, there is little bleeding and a simple functional recovery. Thus not of former crusader, one knows that it is not well and that decreases the durability of the prosthesis, but it is also known that if a perfectly horizontal cut is made, it is tolerated a certain number of years and that among old patients the lifespan of the prosthesis will be equal to the patient's life expectancy.

. : Are the techniques of installation reliable?

PH H.: Yes, they are reliable whatever the types of prosthesis currently used. Each prosthesis has a more or less sophisticated hardware , but I would tell sufficient, for a correct installation. The greatest difficulty, it is the choice of the indication and especially the sufficient practice. Indeed, if it is admitted that the indication represents only one knee out of five, to make ten prostheses a year, one needs at least nee prostheses. The colleagues who do not have this recruitment hesitate to launch out in this surgery…

. : And the fémoro-patellar prosthesis?

PH H.: The indications of fémoro-patellar prosthesis are even rarer since it is necessary to have an isolated fémoro-patellar osteoarthritis i.e. the two normal fémoro-tibial compartments.  In fact thus knees re-enter in osteoarthritis by thepatellar one. If there is an initial etiology which can explain this isolated degradation, the decision is simple.  But if it is a knee which does not have a dysplasia and whose osteoarthritis starts with thepatellar one one is confronted with an unknown factor. Will osteoarthritis remain fémoro-patellar for a long time in which case it is completely logical to propose a fémoro-patellar prosthesis, or in the short run osteoarthritis will become overall and in which case one goes towards the failure of the fémoro-patellar prosthesis. It is a little there that is the difficulty. Thus the indication most logical it is undoubtedly the ball joint which becomes . But it is also the technical situation most difficult since there are a patellar dysplasia, a dysplasia , and thus a potential risk of instability. The other indication relates to the patient with an isolated fémoro-patellar osteoarthritis but on perfectly centered knee and without fémoro-tibial pinching and for which one can think that one has in front of oneself a good decade before the extension of osteoarthritis.

. : How much do you pose some a year?

PH H.: About between 5 to 10 a year. To make 80 of them it takes one decade.

. : In addition, apart from the prosthesis, how do you see the surgery of fémoro-patellar young subject?

PH H.: In the fémoro-patellar instability of the young person, one will practice the section of the patellar ailerons or the transposition of former tibial tuberosity, by knowing that if there is a frank fault on radiographies, the section of the patellar aileron is not usually sufficient to prevent the repetition of luxations. The transposition of the former tibial tuberosity prevents the repetition of luxations best but inevitably does not give constant results on the pain. There are also other techniques as the but there too the results are a little random. This exceptional technique has complications which are not completely negligible. The surgery of the soft parties of the ball joint beat a retreat and one does not do of it any more much. Perhaps that the pediatrists continue to use it because one cannot touch with the tibial tuberosity because of the cartilage of growth. In the adult, one can consider that generally the transposition of the former tibial tuberosity is practiced and that she cures instabilities well.

. : How you see the development of the hospital practice?

PH H.: I think that one a little difficult period ago for the interns, there are 4 or 5 years. Currently, there is a new attraction for the surgery. The interns return towards the surgery. It should be hoped that this movement will remain because the prospects for trade that one offers to them with the young people are not as simple as that whom one offered to us when we were intern.

. : I.e.?

PH H.: They have like us it choice of a hospital career or to settle in the private one. In both cases, the stresses are and will be more important than in the past but they do not have a very large visibility on what will be their to become in both cases. Therefore some hesitate to be invested in the surgery, and choose medical, less heavy and less heavy disciplines. What frightens them a little, it is that they see very well the stresses of the profession during their boarding school and that they less better undoubtedly see the advantages of the long-term profession.