. : Since when do live you in Oxford?

. : I started to operate in Oxford there is now more than 40 years! I finally passed most of my life to Oxford and in any case it quasi totality of my professional life. I made my medical course in London. I then chose the surgical career and I tilted towards csotcina.comedy as of my arrival in Oxford. Thereafter, with the experiment, I felt the need for travelling. I left to the United States where I remained one year in California at the hospital . This voyage enabled me to improve and acquire strong foundations in general csotcina.comedy. Then I returned to Oxford where I then worked in a more or less permanent way.

. : When be you become an csotcina.comedic surgeon with whole share?

. : In 1960 when I was appointed first assistant of Pr Joseph , a famous surgeon who, for the little story, was escaped head office of Barcelona in 1939. After its escape from Spain, it remained in Oxford with a statute of immigrant and nevertheless was appointed instructor of csotcina.comedic surgery of the faculty of Oxford. I was his assistant and this for many years. This bond probably corresponds on your premise to that of hospital practitioner. I became then surgeon consulting in in Oxford. I was then in charge of the pediatric department of csotcina.comedic surgery and the 10 to the first 15 years of my surgical activity were devoted to the children. At that time the prosthetic surgery of the knee did not exist and the hip prosthese was still at the experimental stage between the hands of John .

 

. : How did you live the beginnings of the prosthetic surgery of the hip?

. : That was the most enthralling adventure for the surgeons of my generation and we all are more or less gone to study the prosthetic surgery of hip at John . Besides we have with one of my colleagues carried out the first prosthetic replacement of hip in Oxford and we had of course used the method of . I thus have following this first crowned experiment of success, practiced the hip surgery with a great enthusiasm during many years. The knee surgery was then for us completely additional and with its very first stammerings. I had the great chance have a friend appointed Michael in London which was one of the first large initiators of the prosthetic surgery of the knee. With his contact I was interested in this hinge and I reported myself gradually that the mechanics of the knee interested me more than that of the hip.

 

. : It was about the mechanics of the total prostheses?

. : Yes, I think however that the prostheses (PUC) were invented and used before the total prostheses. In 1960 I went in the service of to Toronto. At his place, the prostheses were at least as numerous as the total prostheses. Immediately after having left Toronto I went to see in Los Angeles which made him also a great number of prostheses with a rate of success which appeared amazing to me. To the review of the cases of we had reported ourselves that the results of the were much better than those of the . In fact the 2 types of total and partial prostheses coexisted about at the same time. The was a favorite technique of the Anglo-Saxon countries. I do not know why but the prosthesis of gradually left the place to the prosthesis , especially in the United States. In the same way in the United Kingdom nobody any more used prosthesis partial of the knee. We converted all with the total prosthesis when John and Michael published their results.

 

. : Was it difficult to reintroduce the in England?

. : I think that one can say it without lying. At one time the general opinion in England was that the was an incomplete intervention, only one “half operation” as one could say it. The results were often poor and makes some we succeeded in not restoring the image of the on surgical results but especially on biomechanical arguments. When I started to initiate this surgery in Oxford we were only some surgeons to dare to practice such interventions in England. In fact it is only very recently that the became an intervention spread in the United Kingdom. There was certainly a revolution in these 5 last years, at the same time in Europe and America with the reconnaissance in certain series that certain indications of gave much better results than a total prosthesis of knee. In spite of this rehabilitation there remain still surgeons not convinced of the founded good of the installation of a prosthesis even when the indications are well posed.

. : When have is made your first in Oxford?

. : It was in 1982 and my attempt had mainly with my nonsatisfactory experiment of the total prosthesis with mobile plate. I had worked with my friend the instructor John on biomechanics of the knee for several years. We had then drawn the conclusion from our studies which the meniscus was a fundamental anatomical element. We had then thought that it was necessary of set up a kind of meniscus inside an artificial knee. We had started to work in the end of the year 1970 on the knee with mobile plate which was a first outline and which we had ended up improving then to validate. In the years which followed between 1977 and first half of 1980 we had had disappointments. Our prostheses were associated with a mobile plate and their results were much less good than those which we had operated with a simple stationary star as drawn by . Since 1982 we gradually abolished then completely the total prostheses with mobile plate of our surgical unit.

 

. : Why this failure?

. : We had noted at the time and we continue to think that the main cause of failure of a prosthesis with mobile plate that it is total or is a bad function of the former cruciate and sometimes of the 2 cruciates. When the 2 cruciates are destroyed or ineffective there does not exist any more stability . If you carry out a prosthetic replacement on unstable knee, it is impossible to have a mobile plate which is effective and which gives again normal kinetics with your knee. With the years this knee undoubtedly will have to be revised because of a mechanical failure. It is completely necessary so that a prosthesis with mobile plate functions normally that there is a primary stability of the knee. We published this in a paper which showed that the predictive mailman most important of durability of a prosthesis with mobile plate was the presence or the absence of a functional former cruciate. In the event of absence of the former cruciate, the reliability curves of the prosthesis fell very quickly and at 6 years there was a clear degradation of the scores. The results were about 8 times lower than those of a prosthesis whose ligaments were intact. Thus and because of what we know about mechanics knees , we thought that the total prosthesis with mobile plate did not have a future very smiling.

 

. : Because of these observations, did you begin your with a stationary star or a mobile plate?

. : We immediately started with mobile plates! We did not have in fact any experience of the prosthesis . We had carried out some interventions with the prosthesis of what gave a good performance for one year or 2 and then the prosthesis was loosened. We in spite of very decided to make replacements. The continuation gave us reason because our experiment shows us that when a knee is , if the is intact and it were it in our studies once on 3, the results of the arthroplasties were then excellent. The observations showed us that the external compartment often intact or was degraded very little, the disease is in fact only .

After review of our cases we wrote an item and indicated this type of osteoarthritis to which we refer, osteoarthritides antéro-intern. This pathology is an alternative of the general disease: it is characterized by a present, a good LI and the attack is limited to the former party of the internal compartment. Currently we think that these wears antéro-interns are the ideal indication for the with mobile plate. Finally it is the anatomical stripping of the pathology which literally forced us to operate these internal osteoarthritides by a .

 

. : Thus you created a new implant?

. : In fact what we did is to take some that half… I am explained. We had taken the practice to use 2 for overall osteoarthritides, we placed an internal prosthesis and external. What we finally did, it is to abolish the external prosthesis and to continue to operate the patients with the prosthesis which we of course use in-house by leaving the free external compartment and by paying great attention to preserve a and an intact .

 

. : What would you propose with a young person forwarding a osteoarthritis of the internal compartment and who does not have more former crusader as one can see it in the sportsmen having forwarded accidents to repetition?

. : This question is interesting and becomes increasingly extreme as the modern medical world forwards a passion to my unreasonable direction for sports medicine. The first thing to say on this subject is that traumatic osteoarthritis or after rupture is anatomically very specific. It is often called also rotatory osteoarthritis. Extremely fortunately these osteoarthritides are very little frequent. We as tried others to think of this type of problem which seems very difficult to us to solve. If you follow the dogma that I gave you before on the you should obligatorily make a total prosthesis. This however does not appear reasonable at a young patient who wants to continue to make sport. In any event we know all that the durability of a is less good at the young patients and very assets. Of another quoted if you made a in the absence of a failure rates are also very important. It appears rational to me to tell with prudence: in first made a repair of the and then made a . A certain number of this type of repair of the knee was carried out but I think that it is honest to say that nobody and I including really know if this type of operation is with being advised or not. It would be surely necessary to make series with a view be published with a follow-up beyond 10 years but nobody has currently more than 4 or 5 cases of this type of operation and he appear really adventurous of advising to make this surgery in a routine way as long as we will not have carried out a national test with a long-term follow-up. In all the other cases of figure, one will be able to say that association repair of the / is not that a hunting story.

 

. : Think that there is a place for an osteotomy of in these types of osteoarthritis?

. : And well I am a little hesitant to give you my opinion because I think of having seen in France the most impressive results of tibial osteotomy of . We cannot in the United Kingdom show such results because we do not have same experience.

In fact in our hospital we did not make any higher tibial osteotomy except for unscathed primitive tibial of any osteoarthritis. In this type of we make an epiphyseal osteotomy of correction the purpose of which is only to prevent the internal risk of osteoarthritis. We are accustomed to carry out this type of osteotomy only on knees apart from any phenomenon and as soon as there is an important gristly destruction we direct ourselves towards a knee prosthesis. In our hands the replacement is a more reliable processing and gives a faster rehabilitation to the patient than the tibial osteotomy. I believe that there exists in this type of pathology a very great difference between the French and English points of view.

 

. : What think of the external ?

. : External osteoarthritis is relatively rare, it represents less than 8% of the cases of attack . Pathology is completely different. The patients are notably younger of approximately 10 years than those carrying an internal osteoarthritis, there is a female preponderance in this type of pathology. The localization of the external attack is different from that of the attacks . Wears are rather in the posterior party of the knee, these two diseases are thus not comparable and the postoperative results are not either comparable. When you read the literature you report yourselves that the majority of the authors had less good performances with the external compartment that with the internal compartment. In what relate to me I think that the elasticity of the system of the external compartment makes the prosthesis less stable and the operation in way very meticulous person forces with a mobile plate to carry out. Luxations of prostheses are extremely rare with the compartment , we could note on several hundreds of internal partial prostheses which there existed 1 to 2% of luxations. On the other hand for the prostheses of the external compartment we had almost 10% of luxations and this percentage is completely unacceptable. We disadvise using here the prosthesis of Oxford with mobile plate. Besides we have here even in Oxford set up a research program on a new prosthesis whose amendments would avoid luxations of the mobile plate but for the moment this product is not yet available.

 

. : We understood well the importance of the in the but which are the other big factors for you?

. : In the past, a certain number of surgeons gave the reasons for which they did not make prostheses , for example, they said that they did not have to be carried out among young patients where whom you should not pose a in an obese patient or elderly. All the reasons were good to disparage the . We have a completely different opinion. The important thing for us is well to determine which are the conditions which make it possible to pose the indication of a . This osteoarthritis is often very specific sometimes the patient present a deformation in of its knee when it is upright and charges some, but in a surprising way when it is put the deformation disappears. This type of patient complains in a very regular way of its knee and in general remains very active. This pathology appears in general with the ripe age or later and worsens gradually, it is often bilateral at 25% of the patients. In this case the deformation in is moderate (less 15°) the radiographs in stress show that this is reducible. In other words LI is not retracted.

The radiographs of profile of the knee, that the csotcina.comedic surgeon looks at often only little, show that the lesion of the tibial plateau is in its center or in the party. The external tibial plateau is never reached by the process . These conditions are really the best for a . Thus let us summarize the indications of the : the must be lower than 15°, it should not have higher than 10° there, the must be reducible by maneuvres in stress and the must be present. These indications are now well codified and well-known, let us insist however on the fact that osteoarthritis should be located only in the former party of the tibial plateau and does not have to extend backwards.

 

. : Do you correct the by the prosthesis?

. : Yes, we correct the by the prosthesis. I think that you ask me this question to know if one corrects the by making a soft parties and in particular of LI. It is quite obvious that it should not be made of gesture on the soft parties because if you detach the LI of its insertions, you amend his function. The knee that you rebuild must have the whole of its intact ligaments and the integrity of LI is checked by a maneuvre of setting in stress of the knee. In other words when you pose a , LI is never short and it forever need to be lengthened. There is for us a very direct relation and very close friend between the fact that the is intact and that the length of LI is preserved it is for us an absolute truth.

 

. : Think as Philippe that one can pose a in ?

. : Yes I think it. For example, if you have a patient who forwards a mixed due to an articular wear and a tibia either congenital or acquired, you can correct part of the into intra-articular while leaving the extra-articular component of the such as it was into preoperative. In this case you will have very a surgical good performance. A post-operative with a is not as worrying as with a total prosthesis. The fact of leaving a correction with a is not a disaster and it is even better to correct a than the to correct. If you create the deformation on the other hand reverses for example a release of LI by lengthening it and by producing a dynamic valgus, you will have a very early degradation of your post-operative result. In general the corrections in the 2 or the first 3 years after firstly the implantation. What occurs in general it is a premature wear of the external compartment which is put in pressure and if the rule for the total prostheses seems to be “never put ”, for the it would be rather “never put valgus”

 

MO: And there is really no problem with a partial prosthesis with mobile plate?

: And well we mentioned this problem, one of the great complications of the prostheses with mobile plate is luxation. In fact so between expert hands the rate of luxation is relatively low, we spoke about 1 to 2% of luxations for our series, certain studies can in particular so show very important rates of luxation of the technical errors occurred into per-operational. For example a group of Swedish surgeons had unfortunately in its first experiments 5 to 6% of luxation of the mobile meniscus on internal prostheses. There is certainly with this prosthesis an important learning curve. However one can say that the complication rate and in particular of luxation cannot be opposite with the advantages of the prosthesis with mobile plate. It should not be forgotten that the major advantage of this prosthesis remains in the congruence which allows completely negligible wears of polyethylene. We found average wears of 0,m a year on the prostheses and this advantage makes it possible to gum the rate of luxation of 2% which in spite of an irreproachable technique became noncompressible with this type of prosthesis.

 

. : What think of the current evolution of the overhauls of knee prostheses?

. : And well, initially it is really very sad that there are as many surgical recoveries! There is however a paradox in the csotcina.comedic literature which shows that the arthroplasty of the knee is more reliable than the arthroplasty of hip. Many series bring back 95% and more survival at 10 and 15 years, nevertheless, in a surprising way, there is a passion of industry for increasingly sophisticated systems of recovery and that wants to say that ultimately the clinical outcomes are less good than those which are published. However this matter should be balanced, because there is an obvious relationship between the surgeon who establishes the prosthesis and the clinical result. In fact plus a surgeon joint replacement realizes, better will be its results and that was indeed shown in a statistical way in Sweden as well for the hip surgery as of the knee. If one pushes a little more the reasoning it seems me that the surgical recovery after knee prosthesis is more one question of procedure that of “design” of prosthesis. Between hands , the modern prostheses have very immediate good performances and completely amazing reliability curves.

 

. : And resumptions of ?

. : It is much easier to make a resumption of than a resumption of . The facility of surgical recovery after a is an argument of choice at the time of the indication. That became a common idea in England and in the United States. could introduce the idea that the was a kind of solution intermediate before a whose limit is thus moved back. Us have already this idea at the beginning can be aircraft when we designed our prosthesis but makes of it we reported ourselves with time that the results of the went well beyond our hopes and that the good performances of the were equivalent to those of the .

 

. : Think that one can always take again a by a prosthesis of first intention?

. : To usually can it you. We made a paper concerning the overhaul of prostheses of Oxford whose causes of failure were relatively varied and which we had taken again by total prostheses. In all these cases except we used a prosthesis standard . In the only case where we used a special prosthesis that was a forced prosthesis and causes it in was the deficiency of LI besides discovered in . The follow-up and the results of these prostheses were very satisfactory, score of the revised knees was not significantly different from that of a total prosthesis of first intention. On this series, only one prosthesis imposed a “” and that was due to a post-operative instability which secondarily required the installation of a strongly stabilized implant.

 

. : Does you made a teaching of knee surgery in Oxford, how do this exchange rate?

. : I would like to still insist on the fact that one of the mailmen determining of the success of the knee surgery is the experiment of the operator. When one designs an implant as specific as the prosthesis of Oxford it is very important to develop an exchange rate which makes it possible to the surgeon beginner in full safety to pose this implant. We think of being able to give strong foundations for this future surgery. We have thus creates a basis of teaching in Oxford with annual exchange rates and we founded a program of international exchange rates in addition where we move in several countries. The program of these exchange rates is completely specific since he does not address himself to initial surgeons but to experienced surgeons who know already the knee surgery which wants to improve in the and in particular in the techniques of the installation of the Oxford prosthesis. We their thus give an intensive teaching and we try to have the education system most didactic possible. It is obvious that with the with mobile plate there is a learning curve and we test by these run to minimize it as much as possible. We have returns of surgeons present who show that statistically those which set up prostheses of Oxford after being come with the exchange rates had had much less trouble of starting than the surgeons who began only with set up this type of prosthesis. It is certain that the individual quality of each surgeon and the personal enthusiasm which it will put to learn the technique from installation of the prosthesis is surely one of the mailmen determining of the success of the implant.

 

. : Your teaching is famous very formal with little place to the discussion. Why not let each one express itself?

. : Because it is acted in fact of an exchange rate of operative technique and not of a scientific congress where each participant could express his own opinion.

 

MO: On what currently do work you?

. : On several subjects. First of all on a vast topic which is the development of the methodology of analysis of the results of the joint replacements. We in addition study in laboratory the transmissions of the forces during the movement on prosthetic components established on a cadaveric knee. We analyze the phenomena of wear of the EP and we reported ourselves at which point it was difficult to interpret in laboratory the phenomena of wear because there is no correspondence between the movements obtained on machine and those of a knee operated during the functioning. We noted wears on the mobile meniscuses after failure of arthroplasty but that can give us only one incomplete idea from what occurs in a knee which functions well. Indeed, the EP comes from a surgical failure and the stresses on this element can have been abnormal. It is now however possible by the methods of analysis by to measure the wear of a EP and to compare it with the implants which could be removed.

 

. : It appears that you are a pioneer of the invasive mini surgery for the ?

. : And well it is not true because the real pioneer for this type of surgery is Dr. . It is American of Italian origin. Italian is very inventive people.

 

. : When discovered the invasive mini surgery of the knee?

. : It was there are 6 or 7 years, I met Dr. . It then used a completely standard with a stationary star. Whereas the majority among us used an skin incision and muscular strictly identical to that of a total prosthesis he had imagined that a small latéro-patellar cicatrice could decrease the traumatism and to avoid luxating the ball joint. The end result was a very fast functional recovery of its patients. had two qualifications: he was at the same time dentist and csotcina.comedic surgeon. He brought to the knee surgery techniques of dental surgery by using strawberries of dentist and he felt able to make interventions by very an small incision.

 

. : Which was your reaction to this approach?

. : And well we immediately and since 1998 changed that our channel initially. We abolished the opening such as we did it before we do not luxate more the ball joint and we are now able to make the intervention thanks to a which was amended and dedicated to this type of channel initially. The incision 6 cm length is on average. The benefit of such a technique are so obvious that they must absolutely be shown in a scientific way. We for our part tried to compare 2 series of patients: a discussed first in a conventional way and the second by invasive mini channel. The conclusion of this study is that the patients operated by mini incision find their mobility and their range approximately 2 times more quickly than those which had an intervention by conventional channel and about 3 times more quickly than in a . Morbidity and the stay at the hospital are reduced and of course the patients find benefit secondary important with this technique. We do not have any doubt with respect to the immediate advantages of the invasive initially mini channel but we should not lose sight of the fact that to use an small incision does not allow to be as precise or as complete in our intervention as when we were with open sky. We thus hope that our long-term outcomes with the technique of mini incision will be as good as that with the conventional openings. Time will undoubtedly give us more precise information on the benefit to await invasive channels minicomputer.

 

. : How amended the ?

. : We mainly amended the instrumentation by miniaturizing it. Since 1986 we use for the preparation of the femur a strawberry which is introduced in contact with the condyle by a former incision and this grinding of the condyle is completely appropriate to an invasive initially mini channel. We think however that the invasive initially mini channel is difficult and we thought that the surgeons who were allured by this channel were to start by carrying out the operating sequence with “open knee” and to pass only secondarily to the initially minimal channel. But we reported ourselves that finally that the surgeons passed in fact to the invasive initially mini channel. It should be noted that paradoxically certain operational times are much easier when the ball joint is not luxated. For example the relative position of the femur compared to the tibia remains natural if you leave the ball joint in place. If you luxate the ball joint you induce in an automatic way a sometimes considerable external rotation of the tibia and alignment of the components becomes more difficult. Nevertheless this intervention is very demanding, requiring attention and requiring to take account of a crowd of small details . For more security it is undoubtedly necessary to begin its training with a surgeon who with the practice of this surgery, to assist it for some interventions before even launching out oneself.

 

. : There-have-you he a place for prostheses without cement by invasive mini channel?

. : We of course tested prostheses without cement covered with hydroxyapatite but we have too short experience to be able to make an assessment. It was of course published of very good performances on uncemented and we followed with interest work of Jean Alain Epinette who reported excellent results with a prosthesis without cement fixed by screw to the tibial plateau. Is it possible or not to realize of such intervention by invasive mini channel? I do not know.

 

. : What is necessary he to think of the edgings around the cemented tibial plateaus of the ?

. : I believe that one should not worry some because with our cemented implants the rate of edgings can approach the 95% of the tibial plateau. What is remarkable it is that this edging is completely stable in time and remains identical for periods as long as 10 years. A recent review confirmed that in the internal the rate of edgings on this subject bordered 70% of the case confirming our point of view. Other authors also reported a very significant number of prosthetic edgings perished in its series with in particular of the complete peripheral edgings around the tibial plateau in 45% of the cases. It would thus seem that the edgings of the cemented plates of a must have a significance completely different from what one can see with the total prostheses and who testify in this case there to a prosthetic unsealing. To be frank, it should be said that I still do not understand why the presence of an edging is nonsignificant in the and testifies to an unsealing in the total prostheses.

 

. : Which is the origin of your name?

. : It is a Anglo-Saxon name which was to be probably present on the English ground before the Norman ones did not break on the United Kingdom. I think that wants to say the same thing as “catch” in France. There is a character of the part “dream the one night of summer” of which is called Robin . Can be is this besides one of my ancestors…

 

. : There is thus a kind of link between you and ?

. : And well I would like to believe it! I was high in Stratford-upon-Avon and I went when I was little boy at the same school as … finally where it was supposed to be gone to the XVI ^E century.