. : Is a congress on the knee, it a Lyons tradition?

PH NR.: Completely. This tradition was founded in 1971 by Albert and his team of the time: Gilles , Henri , Jean Luc and Paul . Today they are the Lyons Days of Knee surgery. We are with the tenth, which over thirty years, makes an average rate/rhythm of a congress every three years. There is thirty years it was a challenge to carry out a congress on only one hinge, whereas today there are too many things to say. So that one is obliged to choose a topic.

 

. : Which?

PH NR.: This time it was the knee of the sportsman. We tackled the problems meniscals, and fémoro-patellar. Today, of the specialists can meet to speak several days only about one ligament of the knee. It is not exactly the purpose of this congress. Our project is intermediate, i.e. that while one wants to address to the surgeon expert and to swap with him the experiment of our practice of the every day.

. : You operate many sportsmen?

PH NR.: In fact a service with him only could not accumulate such an experience; this congress is the fruit of the work of a whole of surgeons all resulting from the same school, from now on guided by P. our association chairs If Gerard more implied himself in the prostheses, Pierre remains unconditional surgery . In our service, one operates 150 to 200 ligaments a year. If one gathers the whole of the various surgeons of the school who take part in it one arrives at more than 1.500 ligaments a year. Of course, they are primarily sportsmen of leisure. However it is interesting to refer to high level sportsmen because they strongly request their hinge. It is a little as when one takes Ferrari for model of performance whereas the cars are not as a whole not Ferrari. In fact I like well that one speaks people who have a top-level of activity, but that can as well be a mailman, a semiskilled worker that a sportsman of competition. What interests to me is the clinical results at those which have a high request for their knee.

 

. : Summers you sporting?

PH NR.: I like the sport. I like football because I find this sport extremely alive and pleasant with a good sense of the competition and the team but I have primarily sports practice individual. I played much table tennis, I evolved/moved nationwide, I even gained the world championship of the doctors…

 

. : Which is the specific pathology of the player of table tennis?

PH NR.: I do not know too much, but surely not the ball in the eye! I attended two or three blockings meniscals at the time of the collecting of the ball. There are players who are very embarrassed by a rupture of the former cruciate because there is much rotation, but during the competition there are few accidents. Some ruptures of the Achilles tendon, sometimes of the infarctions because it is a sport where there is much change of rate/rhythm. That is located between tennis and the . That requires an unquestionable drive.

 

. : Can one speak about major changes in 20 years, on the assumption of responsibility of the lesions ?

PH NR.: Of course. The indications are encircled better and there is more requirement as regards results. The Lyons school has something of original, dependant on the fact that the surgeons were interested in the knee as a whole and not only with degenerative or sporting pathology traumatic. Thus it established the link between laxities and osteoarthritis. And this osteoarthritis was all the more frequent as people were operated. Our objective was to discuss the instability of the patients and one reported oneself that for some operated we had given an evolutionary whiplash to osteoarthritis. It is a little the same thing as with the total meniscectomies. Albert had removed 18 509 meniscuses for the immediate good of his patients but it is known that induced a certain number of osteoarthritides. In the same way, after the surgery , one was confronted with “” young people. This led us to develop interventions which combined osteotomies and rebuildings . These interventions there go back to about fifteen years. Thus, the indications better were determined and finally one attempted to take into account the short-term objective i.e. to discuss instability while sparing the long-term prognosis of the knee.

 

. : What to make in front of a rupture of the pivot at 55 years?

PH NR.: For a 55 year old patient who has a chronic former laxity, one precisely of his functional embarrassment. According to this functional embarrassment, one considers the various therapeutic potentials. A certain number of surgeons currently propose intra-articular plastic surgeons by using semitendinosus musculus or the internal rights. I am not very favorable to this option. Initially I remained faithful to the use of the patellar tendon then I think that there is always a place among these patients for extra-articular of the Lemaire type. I very seldom make isolated extra-articular plastic surgeons, but I believe that remains a good indication for these patients who are old and for which what counts more is to discuss instability. Of course this operation is not possible that if the posterior horn of the internal meniscus is intact. All rests on the good stability of what is called the GRANDPA, the point of angle postéro-intern. Thus for these patients it is possible to propose a surgery of stabilization but it is an extra-articular surgery, whose continuations are extremely simple.

 

. : But at this age, couldn't one propose an artificial ligament?

PH NR.: Not, clearly not. The Lyons school was among the first to use them. In 1971, Gilles supported by Albert and with the complicity of Henri , established a certain number of plastic ligaments. That was the subject of a marvellous publication in in which successes of this “plastic” ligament were praised at two years. Indeed at two years the results were superb, but at three years less good, and in five years… they were never published. Therefore it is said that for several generations the surgeons of the school were vaccinated against the synthetic ligament.

 

. : At 55 years will one as quickly break his artificial ligament as to 25?

PH NR.: The problem of the synthetic ligament it is not only the rupture, it is also the lack of elasticity. The cartilage is not able “to cash” the stresses with a ligament which does not have elasticity. The stresses for the cartilage become too important. It is better that there is too much articular play that not enough. Therefore at 55 years I have a preference for the extra-articular plastic surgeon of Lemaire type which prevents the projection but which does not tighten the knee. The more one advances in the years and the less the preserving or repairing surgery is justified, the less the cartilage is ready to tolerate an operative repair. The results of the meniscectomies are less good after 35 years, the results of the patellar surgery are less good after 35 years. For the surgery that remains good still at 40 years, but the more one advances in the years, the less that walks.

 

. : Why a rather than Kenneth-Jones?

PH NR.: Me, I prefer the “”; I even did it with some 52 year old patients which had a for stabilizing their knee well.

 

. : But if a certain degree of laxity is accepted, why not make a ?

PH NR.: It is another option… My recommendation is to carry out a clerk's office using the patellar tendon and even for the patients forwarding an important former laxity or a for sports with pivot and/or contact to associate an external plastic surgeon with it with the half or the internal rights. With Has If we called this operation the .

 

. : As a whole were, the colleagues satisfied of the and they are put all to make , why?

PH NR.: It is true that the realization of a Clerc's Office by using the patellar tendon, it is relatively constraining. To consider an ambulatory surgery under these conditions it is a little difficult. Recovery is in spite of a little slow. The postoperative range of the patient is not immediate and the consequent pains. The surgery using the allows a faster immediate recovery. I did very little and I was surprised by the simplicity of the postoperative continuations, but I have the conviction that the control of laxity is less good. When one tests a it there forever a hard stop as opposed to what one observes with the clerk's office of the patellar tendon or the stop is dry. Even if in both cases there is no more projection, one does not observe the same quality of the stop in . In addition not badly of colleagues entrusted to me that for a sportsman of great quality, he preferred to use one the average third of the patellar tendon.

 

. : It is a problem of cicatrization to the junction bone-tendon?

PH NR.: Perhaps there is no merger, but an better integration in the osseous tunnel. But it is not only on the junction that the problem is. I cannot it prove, but here is my impression. The clerk's office with the patellar tendon uses a ligament, it is the patellar ligament while in the internal rights and semitendinosus musculus are tendons. I am persuaded that the structure of these two elements is different. Therefore I think that with the the feeling at the time of is different. It is not only one problem of fixing, for me it is also a problem involved in the nature even of the transplant. Despite everything, some say that the revascularisation is better on the strands of the . There are also arguments for the other camp

 

. : Which are the disadvantages of the ?

PH NR.: The disadvantages relate to the area of taking away, but they are relatively miners. 2 Explanations: Firstly the osseous area on which one rests when one puts oneself at knee corresponds to the former tibial tuberosity and that hurt just like in the transpositions of the . Some detect morbidity while making “go” the patients to knees. But, I do not know of it many patients who “go to knees”. Secondly, the was touched during the taking away of the area. That was very well studied by Nicolas of Besancon, which made a good work to carry out taking away by a very small cicatrice. Despite everything it is a so marvellous operation, so reliable. It belongs to the best operations of the csotcina.comedic surgery with 90% of goods or excellent results, as well functional as anatomical when it is associated with an external return. It is of the same command as the prostheses of the knee or hip. For a surgeon, it is important to carry out an operation which goes 9 times well out of 10. Sometimes, by need and because of a specific recruitment one must carry out a surgery where success rate is lower. But if one wants to have trustful and regular customers it is necessary well to take into account the success rate of an operation. Henri told: “In a small town, it is a drama if the colleague who comes to settle opposite you is not good. Because all the population will lose confidence in the csotcina.comedic surgery. Always seek to install you opposite or with the best”. I believe that it is right and I must say that if I am very well surrounded in , in particular with , I also profit from the excellent quality of the work of the surgeons who surround me outside.

 

. : The Lyons school insisted much on the repair of the points of angles. You continue to open and suture the points of angle in the serious distorsions?

PH NR.: In the United States during very a long time, the processing of the peripheral formations was privileged. On the contrary, in Lyon, Albert insisted on the central pivot. There was an opposition between or Lemaire which defended the gestures anti-projections and which discussed rotatory instabilities and Albert who was interested primarily in the central pivot. What occurred they is that Europeans observed well what did American, they integrated these concepts and studied this anatomy. Thus they described the postéro-external point of angle, and the point of angle postéro-intern. In parallel, described what it called the POL. ( oblique ligament), on the internal side. These points of angle appeared all the more essential, the reconstruction of the anterior cruciate ligament was insufficient. In the same way when the patients were too old, rather than to rebuild this central pivot one directed oneself rather towards the control of the peripheral formations. remained very attached to that by reconstituting the point of postéro-external angle in particular the popliteal one. Henri had the concept that the clerk's office of the former cruciate went well but that if there were something in more it would perhaps not be badly and it added the antéro-external plastic surgeon of Lemaire there. It is enough interesting this concept to associate these two plastic surgeons, I remained faithful there for many of my patients. I still believe in the virtues of the peripheral gestures, while knowing that those at the young subject or very applicant are insufficient on a purely isolated basis. But when one has a distension of the peripheral ligaments it is random to do everything to rest on the central pivot, the more so as it is known that this Clerc's Office does not reproduce exactly the anatomy of the former cruciate (even if efforts are made to rebuild 2 beams and to approach the anatomy…). That can sometimes happen to me to retighten the in a very important laxity or failing to take into account it and to carry out an osteotomy. I believe that one should not neglect the secondary brakes if not there is too much solicitation on the Clerc's Office and one exposes oneself to a failure.

 

. : , at one period, had very centered on the repair of popliteal…

PH NR.: I had much admiration and affection for Gilles . It was an enthusiastic surgeon who brought much innovations in the knee surgery and probably it was one of the first to carry out meniscal sutures, clerk'ss office of the former cruciate associated with osteotomies, and to be interested in the point of postéro-external angle. But undoubtedly it was impassioned too much by its search and it pushed very far the indications. The great force of Henri , with his direction of the analysis, it was to recognize in each operation, to which it was addressed. Even Henri with fact of small popliteal among certain patients because it knew that it played a part in certain external . He thought that the postéro-external point of angle was touched in 5% of the cases whereas for Gilles he was always injured. But the creativity inhabitant of Saint-Etienne was important. If and were often opposed, they remained very dependant.

 

. : They was very different personalities?

PH NR.: Yes, of separate strong personalities that of m; Henri was the godfather of one of the children of Gilles ; they were like two enemy brothers to some extent, but two brothers nevertheless. They were same school. When Gilles left to Saint-Etienne, it did not have any more same the . Among his many and brilliant pupils, Joseph Million was one of rare to be opposed to him. Henri remained more wait and see and careful. He constantly was essential the discipline to re-examine his patients, to follow them, publish his results. What quickly enabled him to be reported what went and of what did not go.

 

. : Which is your attitude with respect to the meniscus?

PH NR.: The surgery for me it is the meniscus. One of the main functions of the former cruciate is to protect the meniscuses. It is the rebuilding of the of course which makes it possible to the patient to turn over to sports activities and physics, but the forecast of the knee is with the meniscus. I am thus extremely demanding on what can support the conservation . I know that a certain number thinks and probably rightly that one can leave a meniscal lesion in place and that it will cure all alone. But if this meniscal lesion has a small risk not to heal then I prefer to suture it.

 

. : How?

PH NR.: The most favorable meniscal lesions are the very peripheral lesions in area red-red; these sutured are very well. Perhaps that not sutured they well also go, as the recent publications of and show it. But each time there is a rebuilding associated with a meniscal suture that heals very well in this area. There are systems of joining now, which allow to do everything by in inside. Me, I like to use wire. I study the results of the joinings by within a study coordinated by Philippe . By the channel that does not weigh down the gesture to suture a meniscus of the interior.

 

. : How much do you carry out meniscal sutures?

PH NR.: A year, I will say that one makes some between 30 and 40. They are very often lesions complicating a rupture .

 

. : Where is one Clerc's Offices ?

PH NR.: It is a surgery of exception. I carried out of them four in Lyon with the aid of Rene (here is a fabulous “type”!) by using Clerc's Offices from Belgium and made safe by a French tissue bank. All that requires a heavy infrastructure but it is a possible surgery. She addresses herself rather to the after-effects of external meniscectomy and remain seldom associated with clerk'ss office with the former cruciate. It is an interesting option which deserves to be evaluated in specialized centres.

 

. : With such a conviction on the role of the meniscuses why to have taken delay on the prostheses with mobile plates?

PH NR.: We were not late on the mobile plates. Prosthesis it is the first postéro-stabilized prosthesis with mobile plate and that made 6 years that it is used. The mobile plate brings a certain comfort for the installation of the prosthesis, a certain security in the installation but I am not yet certain of one difference compared in the long run with the stationary stars. We follow them uninterrupted and to date our results are excellent. I would say that rotatory prosthesis allows a certain tolerance which one should not accept during the intervention but it is a tolerance in fact. I.e. that one can tolerate a small error even if it is not wished. But it would not have to be believed that this fémoro-tibial amendment releases us from the patellar complications. I want to say by there that it is understood sometimes that thanks to the rotatory prosthesis one will regulate a certain number of fémoro-patellar problems. It is not exact; what one regulates it is fémoro-tibial alignment. I.e. that one obtains a good amendment of polyethylene to the femoral metal part. This is constantly obtained since there exists a modularity in the faces between tibial polyethylene and the tibial base plate. The additional degree of freedom authorized by the rotatory prostheses allows a good fémoro-tibial alignment, but it is seen well that at this time there one uncouples alignment between polyethylene and the tibia. Thus there is an alignment of the former tibial tuberosity which is done but in a way a little independent of fémoro-patellar alignment since there is this authorized mobility. Thus to in no case this system of amendment of the rotatory prosthesis between polyethylene and the femur does not allow a good alignment of the system bungee cord. The system bungee cord positions as he wants, independently of fémoro-tibial alignment.

 

. : One is thus still exposed to the fémoro-patellar conflicts?

PH NR.: Oui! the alignment of the system bungee cord more appears to me to depend on the mechanical fémoro-tibial axis and the rotation of the femoral component. It is that which dictates really the operation of the fémoro-patellar hinge. It is the element which has the most importance on the fémoro-patellar hinge, it is not at all the fact of having a rotatory prosthesis in lower part as opposed to what one understands that and there of repeating.

 

. : Let us change register; where did you make your studies?

PH NR.: In Lyon. I was born in Lyon, I made all my studies there, I exert in Lyon and I believe that I will die in Lyon. And it is to the great displeasure of my wife who dreams of sea and sun. It was born in Algiers and it likes the sun and hot sand. I from time to time try to reach his desires… fortunately we share the same love of Polynesia.

 

. : Why surgery?

PH NR.: It is a meeting with Albert when I was 17 years old.

 

. : How does one meet at 17 years?

PH NR.: He liked much billiards and came to play house with a family friend who was champion of billiards. Me I played billiards badly but it is as that which I was brought to meet it. One day, he told me: “you want to make what you?” I answered: perhaps “I do not know surgery” Then it told me “come with me” and it started to take me along to the hospital. I spent my holidays to help it with the . It is where I met all his dear pupils of the time: Joel , Jacques , Jean Luc it is there that I drank my first content of whiskey glass in the office of A. with Henri . I was very young. I will always remember his voting right strong and serious telling me, you recalls that at 40 years my liver was virgin…! always his way of warning without making some too much and I did not have really any idea of which it was, nor of what it represented. I addressed as vous by respect because it was 50 years old more than me, but I never told him Mr. I was not with the current of the uses and it was far from offending of it to Him what amused it, it was to upset suitabilities and the hierarchy; it was able to impassion a 17 year old young person, being unaware of all medicine.

 

. : What did you help like operation?

PH NR.: Knees, hips. It had its chiefs, its interns, Marie her assistant and they accepted me. During all my first year of medicine, one morning per week, I was going to help it at the hospital. I “closed” his patients. In 1977 I was for the first time, at the days of the knee in Lyon.

 

. : You fell into soup very small?

PH NR.: It is that, it was the magic potion. Because it is true that it was interesting. Obviously I never touched a centime and I adored outward journey to help it, one was never bored, each operation was like a play of failure. It cultivated the paradox and always woke up curiosity; A. helped me to remove my first meniscus in its private clinic at 17 years… and since, I do not have of cease to preserve them.

 

. : You passed at his place as intern?

PH NR.: When I became internal, it was with the retreat. But it is him which had made me prepare the proof of surgery for the contest. It was a large pedagog and it really made me understand how to go to essence. I learned later that it had prepared with the boarding school the majority of the owners of the city. For my first choices I did not have csotcina.comedy (at the time it was very run), but I asked him for consulting. It always indicated incredible choices to me. For the first training course, he told me “you will make surgical reanimation, that will serve all your life to you”. He had put to me in the legs of one of his former students, , which was the owner of the urgencies with #FFFFFF Grange, and which completely protected me. The first day when I forwarded myself as an intern I had a letter of and I did not know any more where to put to me. He opens the envelope and “ it tells me is the Albert who sends to you take a cigar… you know he made me pass the day school”. I typed myself six months of surgical reanimation, but I understood the operation of the anesthetists and the …

 

. : How did that occur to ?

PH NR.: I arrive in third year, and was together but did not understand themselves very well. liked much but he wanted that I follow which was the departmental manager. I chose at Jean Luc but made my thesis with H. . The day when I introduced myself Henri told me if you are good intern and you make a good thesis, you will be senior registrar at home.

 

. : Why did it protect you so much?

PH NR.: Perhaps because it did not have a child? To tell the truth it had affection for all its pupils and it helped them much. It was somebody who had much plume. One day he tells me: “Philippe you love Raymond Devos, he is necessary that one will see it”. It was not simple; I ask my mother to occupy myself some but it was not possible two hours ago of line for the bank notes. Some time after, he recalls me for the places and I tell him that it is very intricate… He tells me: “you have to only go to ask the caretaker of ”… One is re-examined 15 days before the date of the spectacle and I explain to him that it is quite simply impossible to have bank notes for Raymond Devos. He is astonished: “ good!” Three days before the spectacle it calls me: “Does Philippe one find himself where for will see Raymond Devos? Come with your parents”. The car is travelled by, one arrives in the hall of the theater instead of going to make the tail he moves directly towards the openers and asks for the cabin of the Mayor. Indeed, one finds oneself in the cabin of the Mayor which is free and at our disposal. I think that the situation is nevertheless exceptional. leans over the balustrade and he sees Jacques in the forefront. He challenges it and appointment with the interval gives him. With the interval it forwards to me in Jacques . He tells him: “you know Philippe of course, you know that it goes to (Michel), you will occupy yourself some”. Then does A. require of how it obtained its places? Jacques answers “I have a subscription; but you then what you did it is fantastic Mr”. I exclaim “But what did it make? You did not read the newspaper, it have just made a gift at the town of Lyon of a board which the Americans wanted to buy to him illion dollar!” It had quite simply given a board of , “Two women with the bath”. The more so as in Paris, on their they have only one of them! You understand, tells me , in this moment the mayor cannot nothing refuse me!

 

. : It was one less competitive period.

PH NR.: Unfortunately our stresses were accentuated. We must be more demanding with ourselves and our collaborators. I feel well the shift which gradually is established between the obligation of formation, result and between multiple temptations, leisures, etc… which are with range of weekend.

I remain however thorough by the enthusiasm of my bosses of private clinic.

 

. : Today, the department head that you are, thinks also much of his Masters?

PH NR.: A day ago which passes without I not thinking of or . Without Albert I would not have made this trade and without Henri I did not can do it.