. : Mr , how is your name pronounced?

. : How the French GUI! I am csotcina.comedic surgeon with where I took the succession of Robin to his retreat. I was engaged to primarily make hip surgery and knee. 20 years ago, we did all of the general csotcina.comedic surgery but now I am in a unity specialized in hip surgery which rests on four surgeons. I am with the head of this unity but let us take we the management of it in turn every three years. We currently have in the Department 13 surgeons specialized in each surgical discipline csotcina.comedic.

. : How did you arrive at this post?

. : I am originating in South Africa. I come from a very old African Southern family. As regards my mother, the origins are English with an immigration in 1820, and as regards my father it was of French which had left France for the Netherlands at the 17th century then which settled in South Africa. I on the spot made my medical studies and practically all my surgical course. It is during my last year of training course of csotcina.comedy that I decided to leave for England for one year before returning to exert in South Africa, in spite of the big political problems which I saw coming. In fact, this last year in England was essential to acquire a good surgical experiment. I really went to England to enlarge my experiment apart from South Africa but as to throw an eye outside and to tie contacts because I was really worried by the political situation and felt as it could become necessary to leave one day.

. : I was also attracted by the USA, but it was with England that the university networks were organized. In addition I had two friends who had been in and which had spoken to me about it like extraordinary training course. A post of one year old resident was opened to the foreign trainees and was reserved in turn for Canadian, Australian and African of the south. When I made my request, the place was already taken by Australian. My course in South Africa being finished, I was to leave to make my last year in England and I finally found a place with in Victoria . Little time after my arrival, I had a appeal of telling me that the Australian colleague had withdrawn himself and that its place was free if I wanted it. My superiors with strongly encouraged me to accept this opportunity and released me from my contract one year old and I thus could find me in in June 1985. 

. : Which was your first impression?

. : In fact, on my arrival with I told to my wife who it was a very good post but that there were unfortunately far too many total prostheses of hip to make and, because of what I had seen with the country, I did not like much that. Indeed, on the first 6 interventions which I had been able to observe in South Africa four were intricate of 2 luxations, 1 complete sciatic paralysis and an infection… But after three months with , I had completely changed opinion and I said to my wife that did not disturb me any more to make and that I could do only that for the remainder of my days. I had been able to see operating an expert, a perfectionist.

. : Was that a revelation?

. : Absolutely. is an extraordinary character. It is a remarkable department head, a perfectionist, a surgeon meticulous person, an eminent researcher and at the same time it is so simple, if humble. In spite of the success of its prosthesis, he in forever made an aggressive promotion. Even after 15 years of retreat and the exceptional performances he concluded his presentations by saying that if this prosthesis were liked one could pose it if not so much worse. Surgically it was a large technician who carried a great care to the exhibition, with the perfect preparation of bone surfaces and it is him which, without any doubt, invented modern technologies of cementing. And even today the visitors tell us that they never saw a technique of so perfect cementing.

. : You did not have the evil of the country?

. : At the beginning if, of course! I had been born over there and had spent there the first 33 years of my life. L `South Africa is an extraordinary country in term of natural wealths, landscapes and of climate. There are mountain splendid even if one cannot there ski because he there made not cold enough, beaches superb, reserves, golf courses etc… We were numerous in my generation has to be completely hostile with apartheid, but we knew that despite everything the changes of these last years the political situation remained very delicate. In spite of all these uncertainties as for a professional future in South Africa, I never really made the decision to remain in England. I had been in for nths when there were riots in South Africa and Robin asked to me whether I wanted to go back in June 1986 really there. I answered him that I was not sure, then it proposed to me a “” one year, that I accepted.

. : Why did he ask you to remain?

. : I do not know. As his wife is Southern African, it is possible that there was a sympathy… It is a fact that he liked me but I worked much and I was very implemented in my surgery and very devoted. I think that he saw me as of the beginning as one of his potential successors but I understood it only nths before his retreat. 

. : You made only hips?

. : Yes, when I started as a consultant I made hip surgery and so busy knee but I soothsayers that after a few years I ceased the activity of surgery knee. Again, when I soothsayers even busier I ceased, 5 years ago to make arthroplasties of knee. Naturally while I carried out my training course I made all the types of surgery. In England at that time the trainees operated in a room with the “boss” in the close room which came to see, between its own interventions, how the things occurred.

. : Did you have the impression to use an exceptional prosthesis?

. : In 1985, we did not understand very well how functioned and we had not realized that it was going to become an exceptional prosthesis. We still had the stem on matt surface which generated some problems and we returned on the polite surface only in 1986. As the results of the first prostheses on polite surface had been excellent, returned to the initial model. It is only in years 1990 that we started with understanding well how functioned the prosthesis and that the conical stem engaged in the sleeve of cement by putting the proximal femur in unconstrained charge of shearing at the interface cement-bone. Then we knew that we held an exceptional prosthesis.

. : Why to have drawn this model and not be remained with the stem of ?

. : It is necessary to go back to years 65 to answer your question. When it started in in 1965, used the prosthesis of . A great number of clinical failures since 1969 brought it, him and his/her colleagues, with having to change implant. All used the posterior channel. raised the question of the prosthesis then but his/her colleagues refused because it was necessary, to be able to lay out, go to be formed in and to use the of it. They were very satisfied with the posterior channel and like only the other prosthesis available at this time was the Boxing ring metal/metal (like was Mac ) they were thus brought to make their own prosthesis of which first was posed in 1970. Why to have chosen a prosthesis on polite surface? Quite simply because the regulation in England specified that all the stainless steel implants were to be polite. It is for this same reason that original was polite. Why a doubly conical stem? Because already thought of the problems of cementing and that this drawing with a narrow stem contributed so that the prosthesis drives out all cement towards the content of the diaphysis. It made enter in force cement in the cancellous bone. And why not of flange? because it had observed bone resorptions under the flange of . Thus reasons which had little to do with our knowledge today.

. : Why to have changed surface a few times afterwards?

. : With this first model, there were few sizes of implants and metals were of low quality. In 1975, there were ruptures of stems. One thus needed larger stems, more solid and thus a new range and at this time the legislation on the implants had changed. New steels 316 L did not need more to have a polite surface. The manufacturers thus proposed stems with matt surface because much less expensive to manufacture. But, with these surfaces, phenomena of osseous lysis appeared which imposed a return to polite surfaces.

. : With which diameter of head?

. : The prosthesis of had a head of 22, that of of 40 and thus chose 30, halfway between the two. Nobody knew what would be the good size. The modular heads for were introduced only in 1988.  

. : When do you decide to remain in England?

. : After spendhaving spent 2 years there. did not have medical faculty. There were two hospitals in England which ensured of the formations without being attached at a medical faculty: and . But African southern csotcina.comedic Association did not accept like validating training course. My six-month period with was validating but not my formation with . I was either to thus turn over to spend nths to South Africa and to finish my training course there low or to make nths more in England in a validating hospital. In addition a new legislation had just left, which imposed on very new resident coming from abroad to turn over in his country after its formation. That was not implemented to my case, except if I turned over to Africa. I thus decided to remain and I sought a post in the area. I found in to a hundred miles, in the south-west of England. I left there for nths and I left my wife and my children with because my children had already integrated the school. There but then I had to remain a year more with the result that I finally spent nths far from at home. I made general csotcina.comedy like a resident, with stays in the various unities. However whatever was the unity where I was, each time there was an intricate hip one entrusted it to me because I was regarded as an expert in the field since I had already spent a year to quoted of . Thus in all, during my formation, I posed 500 hip prosthese: 420 primary elections and 80 recoveries.

. : How were made the recoveries then?

. : When I arrived at , the recovery consisted simply with a new stem. In 1987, on a case of iterative recovery with a femur of poor quality, I proposed to the senior to pack bone in the diaphysis before sealing the prosthesis what had never been done. did that on but not on the femur. We used which was stored by the colleagues who made rachis. I showed the radios with at the sixth week and it was very satisfied. In fact had already grafted femurs of recovery before but without using cement, because everyone thought whereas cement would penetrate in the grafts. Thus since this experiment we always grafted the femurs in the recoveries.  

. : What think of the stems without cement?

. : In 1987, the results of the recoveries without cement were very bad. The stems used had only one surface coating . The results improved significantly in the years 1990 when the stems were entirely covered. In certain situations, it is a good solution.

. : Let us return to your course; how does your return to occur?

. : On my return asked me what I had the intention to make in the long run. I told him that I would like to devote me to the prosthetic surgery, in particular hip. Then he told me that if I wished to ensure my professional future and to obtain a good post, I was to postulate for the John . That would enable me to be financed for one year of training “elsewhere”. I answered him that I returned nths of formation “elsewhere” and that it was perhaps time for me to pose to me. He then said me that if I wanted to make career, it was necessary that I occupy myself some and that I put myself in a position academically unattackable. I thus postulated and I obtained the purse. I went to the Netherlands at for one year.

. : What did you see?

. : Especially the resumption of by impacted grafts. Then I finally returned in 1990. Robin then asked me precisely when I would have completely finished my formation and I told him: June 1991. He then answered me: “very well, I will thus take my retreat in May 1991! ” It is at this time that I realized abruptly that it had lengthily planned my career so that I can succeed to him.

. : During all these years of training, did you have a family financial support?

. : Not. I had to make loans on my arrival to be able to install me in . Then in during two years and half I lived with woman and children in a housing of the hospital which cost us 60 books per month. I believe that it is the record of stay in the hospital for a doctor. Then when I left in I could buy a housing for my family with at one favorable period and when the prices went up a few years later, I could profit from a bowl of financial air. But if I had not had the post of consultant in June 1991, I would have practically been in bankruptcy because my 3 children were in “public ”. But thanks to this post very arranged itself as well as possible.

. : How was held the succession of ?

. : There were forty candidatures, but it was necessary that it is somebody who has an great experience in hip surgery and which knows the prosthesis perfectly and it was my case. I was thus impossible to circumvent. Then I had much chance in my liberal activity. When one settles and that one wants to develop a liberal activity, it takes a few years before reaching that point. But me, I had already posed 300 , which represents many patients and families of patients. I was thus known. Moreover, during his last consultations, Robin had office registered his patients on my program. He offered his private customers to me.

. : It was rich?

. : Not, not really. For a long time, all the royalties of its prosthesis were versed with an association which financed equipment for the hospital: data processing, secretariat etc… It is only later that it could garner the benefit of its prosthesis.

. : And then?

. : Thus I made hip and knee of 1991 to 1998 then I was overflowed by the hips and I ceased making knee.

. : Despite everything the changes which had occurred in the field of the hip prosthese, you kept your initial principles?

. : Yes, because we did not have any problem on the stems and there is always no problem. We cement all the stems whatever the age. The problems on the other cemented stems came from nonjudicious choice, as for example that of Harris which tried to fix cement at the stem. As it was a thought leader in the United States, after these failures, when it passed to the stems without cement, everyone followed it. But if it had used a polite stem like many Europeans, it would never have had troubles with cement. On the other hand, we had some small concern with . But if you analyze the literature carefully, the rates of overhaul and of the cups without cement were always and are increasingly higher than those of the cemented cups. If you stick to the rates of recovery to 10 and 20 years failures, even in the young people, are more frequent with without cement. But today in the USA, the same teachers them are for the cups without cement. About 1995, I thought that if a cup without cement did not have a hole, it should not occur osteolysis and I started to put some cups without cement in the young people, to see… But I was disappointed. Fixing is good but lyses and the wear of polyethylene were major. I did not understand why. Probably a problem of excessive stresses. The cup without cement is well too rigid.

. : Which was your development on the couples of friction?

. : And well, we have just re-examined patients at 30 years of retreat. With initial polyethylene, wear proved very weak. On the other hand, with the cups posed towards end of the year 80 there is definitely more wear. But we changed diameter of head to pass from 30 to 26 during this period and can be that explains the higher rate of wear. I was very worried by the attrition rates of polyethylene especially in the operated young people, but our results in these young people nevertheless show 98.2% of survival at 10 years. However one does not observe badly edgings in area 2 or 3 of and this is why I put myself at ceramic in the young people.

. : And what do you think about it?

. : For the moment, at 4 years of retreat, I do not have problems. Among patients of more than 60 years I cement completely and between 50 and 60 I decide according to the and on the activity of the patient. When there are not a and a good quality of cancellous bone, I know that the cemented will hold more than 20 years. Conversely, so on radios he there has much of and that one supposes whereas that will bleed and weaken the interface bone-cement, it is preferable to use a without cement. We re-examined 150 files of 1986 to 1997 when we had classified, on the cards, the bleeding in: “negligible, average and important” and in: “not of , some and much of ”. Among 5 cases where the bleeding was abundant 3 required a recovery, whereas in all the series there were only 5 recoveries. In addition, it is among the any cases of “” that the 5 recoveries took place. Thus the failures related to the cases with multiples and abundant bleeding.

. : But you do not know if, in these cases, the cups without cement would not have also failed?

. : Of course. But we at least identified the possible cases of failure of the cups cemented to continue on the couples of friction, much of my colleagues continue to use the couple metal-polyethylene. With regard to the stems and as regards aseptic unsealing we have reliability curves at 15 years giving a report on 100% of survival. In the young people it is about 99%. We cannot thus improve the results any more on the stems. And I wonder why we would not make in the same way on the cups whose successes are only of 90%. This is why I passed to ceramics and as one cannot seal the ceramics cups I am obliged to use it without cement.

. : Did your colleagues who use polyethylene pass to modern polyethylenes?

. : Not, it is always the same one since 1995. Vacuum irradiation. We do not use highly polyethylene and in England we were warned officially against the dangers to use new materials without clinical retreat.

. : How do you make your recoveries?

. : For 70% they come besides. The majority of our personal recoveries are justified by repeating luxations or for unsealing . Femoral unsealings, even apart from , are done rare. 90% of our femoral recoveries are done by impacted and in some cases with strong bone losses in elderly persons, we resort to long stems without cement with distal fixing. Therefore, for , it is necessary to be old to deserve a stem without cement!

. : What do you think of the vogue of the mini access?

. : If you made a wound of 3 cm, will it be more painful than a wound of 1 cm? I do not believe. The length of skin incision does not cause more pain. Most important with regard to the mini access, it is that obliges us to reflect, to discuss with the physios on the mobilization postoperative, to call in question some of our sections or capsular. It is a new mentality rather than a new technique. We put ourselves there and we brought back our incisions to 8 or 10 cm. It was stimulative for surgeons who had practiced the same access for 20 years. We encouraged the patients to leave the hospital earlier. But we then saw stems in , in poor posture and we wondered whether that were worth the sorrow to fight during the intervention to obtain a less satisfactory mechanical result. We thus returned to an incision of a dozen cm. But we are more preserving with respect to the soft parties because, thanks to this experiment, we developed instruments which improve the exhibition. Our patients leave to the third or fourth day and I think that it is very satisfactory. If it were me, I would not like to leave the following day an intervention of this importance. I think that all this strategy of hospitalization of day and channel initially by two mini incisions will not be spread because it is too intricate and that can relate to only some in search of private customers.

. : In what are you more preserving on the soft parties?

. : We preserve the former capsule, opening only the posterior capsule and repairing it in end of operation. Its section is carried out by only one right incision of 6:00 to Plus 12:00 recently we tried to preserve the tendon of the pyriforme one, which is not always possible but can be obtained in the majority of the cases. We had the practice of the tendon of the , which is not made any more and the tendon any more.

. : Do you have problems of luxation?

. : If 2,35% of luxations for the whole of the operators constitute a problem, then yes we have a problem. My colleagues of North who make side accesses in dorsal have a rate of luxation close to zero. Their patients do not have any post-operative restriction absolutely. This is why, in very specific cases, I entrust my patients to these colleagues. I already did it for a young patient reached of a severe form of trisomy and suffering of hip osteoarthritis. Into postoperative immediate, I went to see this patient, to whom one could nothing explain and which tried to place its bead behind its neck! 

. : Why don't you use this access?

. : The exhibition is not terrible. In any case, in what relates to me, I obtain a perfect exhibition by posterior access. And all our visitors with are impressed by the exhibition which we obtain by posterior channel. If I must face a repeating luxation, I can do something but in the event of pains or of after an external channel I am disarmed. There is practically no pain or of postoperative with the posterior access.

. : With are the passing, which the parameters which contributed to the success of the stem?

. : There are 3 significant items: the polite stem, the absence of flange and the doubly conical drawing. With regard to polite surface it is the absence of abrasion with cement and thus the very small quantity of metal and cement remains. Concerning the conical form without flange, it is able to engage in cement. When cement polymerizes it retracts, therefore: either it moves away from the bone, or it moves away from metal; there is inevitably an interstice some share. With a flange, the stem cannot be mobilized to fill this interstice. Thus this association of the drawing in the form of corner and the absence of flange is very important. It makes it possible to close the interstice and to prevent the cement remains migration possible. Moreover, as the stem is not fixed at cement, at the time of its “descent”, cement is not driven back into distal but is not plated against the osseous walls. It is the latter element which is probably the key to success: the radial compression of cement against the bone. This comes to be opposed to the negotiable instruments of shear stresses to the interface.

. : From which does the idea come from the stopper centring pin?

. : Robin had the idea of it since 1970. It was at the beginning a kind of spider metal but it appeared it is that prevented the stem from going down; when the stems went down, the branches of the metal centring pin broke. And this is why in 1986, amended the centring pin so that it is integrated into the cement sleeve. It is now in LDC. It is not only one method which centers the stem, but especially which makes it possible the stem to engage in the sleeve of cement. The point of the stem is not supported against cement but is suspended in the vacuum of the hollow centring pin, which authorizes a certain descent. If the clinical scores are observed, the stems which went down the most have scores a little better than those which did not move. I speak, of course, of migrations of 1 or isters.

. : How do you discuss the fractures on prosthesis?

. : With a long stem, hoopings, impacted and cement. And the impacted prevents cement from being put in the fracture line. With the need we use netting because that allows a better vascularization than a massive . A study published of showed that cortical bone was formed under netting. But makes of it stability on the level of the femurs is so good that the osseous formation is not essential. It is not at all similar on the level of where if the bone is not formed in a few months, the is loosened.

. : Finally what remains to be improved?

. : On the femoral slope large pitch thing. Our long-term outcomes with the cemented stems are nearly perfect and for without cement the results of the stems of the type or are also excellent, although on very the long run there is a resorption of the bone . With regard to the cups, for the moment there is metal-metal and ceramics. Metal-metal worries me a little because of the chromium cobalt remains which could prove to be problematic very with long run. For the moment ceramics goes well, but in the long term I believe that they will be surfaces less rigid as the which could be essential as couples friction ideal because they would absorb the shocks best. 

. : And how do you see the development of your practice?

. : Listen, I really collapse under the hips and I dream to specialize me on only one side. I am left-handed and I make the right hips more quickly and in more the visitors have the much better seen when I operate a right-sided. Surgeon of the right hip, that do you think about it?