The Lyons Days of Knee surgery of October 2004 were devoted to “Choice of Knee prosthesis” and in this number, we propose some extracts of forwarded work to you. These days were marked by an opening on Europe and among the invited speakers, one noticed the presence of . is the main figure of the knee surgery in Tuscany and it very pleasantly recalled for us the stages of his career.

 

. : Where did you make your medical studies?

: I made my studies of medicine in Florence. After my diploma, I wanted to do something of surgical, but I did not know which surgery exactly. In fact, I wanted to have concrete results. I liked the scientific side of medicine, but I saw in the surgery something of more direct. If you done it well you obtain a good performance and the patient is content. I then thought of making neurosurgery because it was with the mode at the time. But I became acquainted with the pr. which was one of the pupils of the pr. in Florence. It had obtained its pulpit with which is at two hours of Florence, and it asked me to follow it. 

. : Why you?

: I knew it. My father was doctor and addressed patients to him. We thus had a relation with him and I could speak to him about my projects. I thus went in which is a very pretty but very cold city with much of wind. I spent three years at , then I decided to make a training course in America. In Italy, it is very difficult to have a surgical practice. One starts to operate very late, the programs for the residents are very slow and one very tardily learns how to move the hands. For a long time one looks at, one helps, but nothing is done. I was likely to obtain a in New York. 

. : How did you make?

: I had to prepare and pass from the examinations here like the . When I was allowed, I wrote the Hospital Special , the HSS, and they accepted me. I was very content because in the Seventies, the HSS was with Mayo one of the temples of North-American csotcina.comedy. Then on January 1st, 1972, I arrived to America and I made a one year at , surgeon New Yorkean of Argentinian origin. The surgeon as a chief was Philippe Wilson junior. I made during one year of the hip prosthese and at this time it was the prosthesis of . But at the time where I arrived at Special , infection rate was very high, of about a 10%. And it is at this time that many measurements of disease prevention were taken, like decontaminations, laminar flows…. 

. : Were and already there?

: was there and it is him which made us the conferences of the morning to 8:30. It was obviously a very good surgeon and a brilliant spirit. John came afterwards. I was there at the time of his first successes with the prostheses of the knee in 1974. After a first year devoted to the hip, I decided to make one second year, but I could not remake hip and one proposed to me to make knee. It was one period when nobody wanted to make knee, because that did not go so much well. I returned to Italy for six months then I returned in for a second . 

. : How was held the “”?

: In fact the and the had many responsibilities. All the public patients were operated either by the resident or by the . One thus posed 50 prostheses in one year what for the time was much. I was remunerated 1000 dollars per month and I remember that I paid 350 $ of rent for my apartment. I on the whole made two years and half, then I had the possibility of continuing like “”, but if I wanted to remain I was to make foot or rachis. I was with my wife and we decided together to return to Italy. 

. : Didn't the life in New York apart from csotcina.comedy rain you?

: If, it rained me much and I had many friends. One went to the theater, one listened to jazz. But it seemed to me that to age in New York it would not be easy. All that it is quite pretty when one is young and I would tell rich. At the time when I was to decide to me, my parents were still alive, and my Owner was about to turn over to Florence to take the place of the Instructor . Finally, I did not regret being returned. 

. : Which impression did you have on your return?

: Impression to return to a very provincial life! But in the Italian academic medium, to return from abroad was perceived like something of negative. An young man who wants to learn must remain here because let us know we more than the Americans. Maintaining it is different. In any event my owner encouraged me to develop the novel methods. Nobody made really knee with Florence. In 1978 the meniscectomies were made with opened knee, and in the desperate cases of osteoarthritis one made an osteotomy.

. : How did you learn the surgery from the knee?

: John did not do much surgery , but as it had many patients, it was obliged to discuss instabilities. He had his technique with the fascia latums but which did not ensure a very good stability because it was not fixed at the femur. John had decided to make a book on the knee surgery, and for the chapter on the lesions he had asked me to contact Mr . It was in 1979, I was first assistant with Florence, and I went to see Mr in Lyon. I saw Mr who brought me to the countryside, where one drank much champagne. Then one started to write this chapter on the lesions with Henri and Pierre . It was for the first edition of 1980.

. : There was such an amount of difference in level between Italy and France?

: Yes, I remember that Pierre who was senior registrar at this time, made a surgery, for us, fantastic. It operated all the day and we did not have this form of planning at all. In any event, we made for
former laxities, of the peripheral plastic surgeons, but not of rebuilding articular. I started to rebuild the former crusader only in the Eighties with of Jones. Then I made of Mac then all the other plastic surgeons.

. : How do you explain this delay?

: The situation in the universities and the universities was very pyramidal. Only the chiefs could operate regularly; the others operated very little.

. : How did your career evolve/move?

: I always remained in Florence but I maintained my relations with the United States. I often went there and I wrote many papers. I became instructor in 1989, then in 1996, I became Director of the University Private clinic of Florence.

. : Did that allow you to change the policy of the establishment?

: A little! The reason for which the young people operate still too little, is that we do not have sufficient operational rooms. In csotcina.comedy for example, we have only one operational room per day. She works not-stop but very slowly. Time between a case and the other is one hour and half. It is thus not really a . In Florence, there are several surgical private clinics. Me I am the Director of the one of these private clinics, but there are two university private clinics and 3 hospital. It is nevertheless not much and the patients wait a long time for the programmed surgery.

. : And for the urgencies?

: For the urgencies, now that goes very well. After one period when it was the last of the things to be made, the urgencies are finally taken of charge like urgencies.

. : In spite of your admiration for the American model, did you develop characteristics?

: Certainly, the Americans should not be followed the closed eyes. What I found of good in the USA, it is that the publications are a true aid in the profession. I.e. it is necessary to be known in a scientific way to have a good recruitment. One cannot have very large will have in America if one does not publish. It is very different on our premises. The research tasks and the publications are still looked like something separately. There are those which write and those which operate… To return from there to your question, we do not make badly osteotomies yet that American forgot. In America, the prosthesis plain-compartimentaire is little known. With regard to the surgery I was brought to develop my own technique bus of the cadaveric studies showed us that with the conventional the kinematics of the knee was not perfect. On the ligaments, I started with the in the Eighties. I made patellar tendons without external plastic surgeon and that was the main intervention for several years. Now, one uses the taking away of ischio-leg or the patellar tendon about in same the proportion. For the , one uses a technique with two beams.

. : You nevertheless had good performances with the ?

: Yes, but I think that there is always the possibility of improving our results. Indeed, much of biomechanical results show us that stability is not ideal even if the patient is content, plays football, from the point of view of the kinematics of the knee, it was not perfect. In vivo, it is difficult to prove this improvement. One obtained an improvement of sagittal stability with the conventional techniques with a beam but the result on the control of rotatory stability is very difficult to show because the clinical trials are not so quantitative. Then one made studies on corpses with electromagnetic booking in order to show that the control of rotation is better after technique with two beams. It is what one could show when the knee is close to the extension. In private clinic it would be necessary to insert something in the thigh and it is impossible. While on the corpse you can put pines, pins in the bone and study rotation in the knee. One tries nevertheless to study that on the alive one by using a snap fastener and other artifices. 

. : Which technique do you make?

: The internal rights is prepared and the half, one makes 2 tunnels independent of m in the tibia and two others in the femur. I lead a comparative study which I will forward to the Academy and in which one showed that if one makes the 2 femoral tunnels through the tibial tunnels there are many errors. It is much better to carry out the 2 femoral tunnels with a sight behind of the condyle, “ Guide”. One is more precise. Fixing is ensured by a screwing, outside with the femur. The graft is looped around an osseous bridge on the tibia and is fixed on the femur. The postero-side beam because dominating in extension is fixed in extension. As for the beam which is isometric, one can fix it at 50 ° bending. 

. : With do this technique of the two beams, you have a better stability than with a ?

: Not, I compared the two beams with the technique with a beam, in term of clinical stability, term of control of rotation. One did not can highlight of difference… But in the USA, the team of showed that one needs the two beams to have a perfect stability. However, I think that one should not give up Jones, because one speaks about small improvements, because the operation is more difficult and cannot be used everywhere. I have made these two beams for two years and half and it is necessary to wait before slicing because the is effective in the majority of the cases.

. : You must be the whooping-cough of the sportsmen?

: I am consulting of the team of Florence. But in the footballers I make Jones. I do not want to innovate in a high level footballer because with the least made problem that of the dramas.

. : With regard to knee prostheses how did you evolve/move?

: I think that the prostheses of the knee reached a plate and that the results are overall very good. Now one is interested only in details, such as for example the size of the incisions. We are making a randomized study on the invasive minicomputer…

. : And then?

: Of course, there are complications at the beginning: a rupture of the patellar tendon, a fracture of the femoral condyle, tibial in , an escape of cement behind of the tibia. But one progresses… I am to 150.

. : Operated are more content than front?

: Our study shows a statistically significant difference on the pains and the postoperative bending. I do not know if that will make a difference in the long term. In any case, a bending with 90 ° is regularly obtained in the immediate continuations, that makes a great difference for the patient. New the is splendid.

. : Did you test navigation?

: Not, but navigation could combine advantageously with the mini incision.

. : What do you think of the mobile plates?

: I collaborated with John on a prosthesis with mobile plate. One posed some not badly in the Nineties. But our controlled study did not show a clinically appreciable difference between the mobile plates and postéro-stabilized. There are theoretical advantages, of course, for the mobile plate, but in the facts it is difficult to show. Now, I have the possibility of putting a mobile shelf on the prosthesis which I use, but I wonder why.

. : Can one say today that Italian csotcina.comedy is close to American csotcina.comedy?

: There is always a great difference in management of the hospitals. The Americans are very effective in what they do. On our premises there is too much policy. In the United States there is work for all the surgeons, he there had bread for all, on our premises there is bread that for some. And yet Florence votes completely on the left, Tuscany is on the left, but that did not help to change the situation. It is perhaps an economic problem…

. : The figure of marked csotcina.comedy …

: Mr was the Director of the university private clinic with Florence until the Nineties. He had taken part in the construction of the hospital of Florence He was a “” of csotcina.comedy, he worked on 8 operational rooms, while going from the one with the other. He had 700 beds. He made the turn of the hospital Monday and that took a good part of the day. He to some extent “industrialized” the surgery. It was a boss. Physically, it measured eters for ilos, enormous. It was very authoritative and made fear. It had many pupils who are now brought together in an association of the pupils of . He was a very good surgeon but he had neither time nor patience to publish.

. : Do you have time to make another thing that csotcina.comedy?

: Yes, of the boat and the study of painting. I am interested much in Italian painting 19th century. On our premises, there are of course the museums but he there also much of paintings at the private individuals. And the painting of 19th is very appraisal. The do not learn painting, they are born inside.