. : Was the exchange rate of hand surgery and the upper limb traditionally in , why this change?

A.: Because I left my functions of departmental manager with at September 1st, 2002, and that on the one hand I have less means of organization and on the other hand less possibilities of having senior registrars or interns with whom to entrust work. The idea thus came with Philippe and Jean Pierre to make an exchange rate in another place. This year, it is the hospital Européen Georges , but one can also do it in another hospital or a room of congress in Paris.

 

. : What is nine on the fractures of the elbow?

A.: For certain fractures, in 20 years there was change. In known and , one does not put any more two screws in cross or only one external plate. One makes sure of a correct stabilization allowing an early rehabilitation. That makes it possible to avoid many disassemblings or stiffnesses of front. With regard to the Radial-head fracture, one makes minicomputer-osteosyntheses to reconstitute the radial head when it is possible. If not one puts radial-head prostheses and one does not have any more the “easy” resection because one knows that gives in the long run pains and instabilities, in particular at the young subject.

. : Is it necessary to test at all costs at the old subjects?

A.: It is certain that for the old subjects forwarding of the burstings of the lower end of the non humerus by plates it is now necessary to pass to the total joint replacement. In these cases, they are arthroplasties semi-stresses. These prostheses which are stable by themselves as from the moment or one reconstituted the triceps correctly allow an early rehabilitation and it is completely interesting.

. : And what to make in the large posttraumatic after-effects?

A.: There is a whole range of interventions. I had published there is a few years the of the radius when there were losses of important substances of the upper end of the ulna. It is a technique which it is necessary to have for the spirit for the losses of bone substance. With regard to the nonunions, those which one currently sees are often nonunions on hardware and one is able to reconstitute them if it acted at the beginning of known and without large on the level of the humeral pallet. But in other case, one is in front of losses of substances of cartilaginous surfaces and it is surely necessary to pass to the arthroplasty. Is there medium term? with ? I do not have at all experience of this technique.

 

. : Which difference there is between radial-head prosthesis and that of Thierry ?

A.: They are in both cases prostheses with mobile cup. Which are the differences? We think that the prosthesis is easier to put, more anatomical, less bulky with a head which is cylindrical and not ovoid. The neck is not ahead tilted and there is a less risk of error of positioning. Finally the osseous resection is less important.

 

. : Do this prosthesis systematically now put it to you for total arthroplasties of elbow?

A.: We put it systematically because the item which will appear in the showed us that in the first the huméro-cubital generation i.e. prostheses without reconstitution of the external console with 3 or 4 years we had 30% of instability in valgus with deterioration of polyethylene. For the statistics which relate to 20 cases, set up since 97, with reconstitution of the external console by prosthesis we do not have, for the moment, any instability in valgus. I believe that as well as one reconstitutes the external console, and for this reason everyone is of agreement now, in the Radial-head fracture, it is necessary to reconstitute the external console if a huméro-cubital prosthesis is put. Or then a prosthesis semi-stress is put.

 

. : Which retreat do you have on the prostheses?

A.: 12 years of retreat on the first generation, and the generation with an associated radial head is established since 1997.

 

. : What is nine in the processing of the advanced polyarthritises?

A.: In the processing of the polyarthritises evolved/moved with lesions exceeded i.e. beyond stage III of Larsen, it is necessary to consider a total arthroplasty. There was during the 20 last years of the heaps of items with many prostheses. One currently sees restricting the number of prostheses within two large families the prostheses semi-stresses which are stable by itself but which have a certain clearance to avoid the in rotations or valgus and then the prostheses update like the prosthesis of in Japan or the prosthesis in France. There is no conflict between these two families. If the osseous inventories are insufficient and if there is a very great instability, it is obviously necessary to put a stable prosthesis by itself which it is about the , or of . On the other hand if the osseous inventories are good and that there is a good stability of the side ligaments one does not see why a prosthesis update would not be put, especially if one reconstitutes at the same time the external console. Although it is not same mechanics, it is a little the same problems as with the knee.

 

. : Which is the place of the elbow in the overall surgical strategy of PR to the upper limb?

A.: When there is a polyarticular attack on the same upper extremity, I think that it is necessary to start in rule with the wrist, would be this to only recover or avoid the stiffnesses of the . One has some experiences where this had not been done and or one put a prosthesis of elbow before dealing with the wrist and one saw well that at the time of the movements of and in particular of supination, it occurred a on the level of the cubital part which was probably harmful on the biomechanical level. It is necessary to have a good pronation, a good supination, for the installation of the prosthesis. Wrist in first. Then shoulder before the elbow if the shoulder is in internal rotation, or if there is no passive external rotation because, in these cases there, the movements of windshield wiper will produce too important stresses on the elbow. On the other hand the arthroplasty of the elbow before the shoulder, if it persists a mobility in external rotation, because the fact of obtaining a stability and an indolence on the level of the intermediate hinge of the upper extremity brings a functional gain some.

 

. : Did the good performance of the prostheses in the polyarthritis finally decrease the indications of synovectomies?

A.: Yes, I do not remember to have made synovectomy since 4 or 5 years. The prosthesis of elbow they is best prostheses of the upper extremity for the PR. With regard to the surgical synovectomies, they were replaced for stages I and II by the which the rheumatologists make.

. : What do you think of the of the elbow?

A.: I think that it has an interest less than for the shoulder but undoubtedly more than for the wrist. For which pathologies? For the synovitis for example in stages I of Larsen in the polyarthritises , in the primitive , and perhaps also in relatively young osteoarthritides with which one can make pass a difficult course by a washing and a resection of the osteophytes. The under , that is done now as from the moment when people ask that one give up the concept of sector useful of the elbow. There are heaps of young people who say that 30° deficit of extension that the embarrassment.

 

. : 20 years ago one nourished many hopes on the development of the surgery of the nerves…

A.: The surgery of the peripheral nerves always existed with more or less interesting results, but micrurgy transformed this field. If you made surgery of the median nerve or ulnar nerve with the front armlever you can also launch you in the surgery of the brachial plexus which is another experiment. In my development, it is what I also did and Jacques encouraged me in this direction. I went to see with which I was very friendly and it is at this time there that one started to evolve/move in this field. Now one perhaps arrived at the limits of the operative technique with the microscope, wire, the biological adhesive, the approximations and the fragments in healthy area. Because when one makes a nervous Clerc's Office which one recuts one centimetre more or of less it is not a problem length, but of fragment in healthy area. If there is one centimetre less one finds with 30% of fibrosis which persist, whereas 1 cm with the top one has a fragment in completely healthy area and it is what one did not do at the beginning. However one found the panacea forever. During one moment there were medicines on the market which claimed that the nerves pushed back at the speed of a Jaguar and either of a 2CV but that did not give results.

 

. : Did the adhesive hold its promises?

A.: The adhesive holds its promises completely because on the one hand it makes it possible to put less wire, on the other hand it produces a sleeve tight around the joining which prevents that axons do not slip by outside.

 

. : Can't the adhesive infiltrate in the section?

A.: It is what one thought of the beginning but there were heaps of experimentation which showed that did not obstruct the progression of the axons, this the more so as the biological adhesive disappears into 10 to 12 days.

 

. : Today what makes a surgeon well trained on a section of the median nerve to the wrist?

A.: Initially it inspects the nervous ends and it makes a resection of the nervous tissue which makes hernia on the level of the fascicular groups. Then it sutures in according to the description of , because it is a technique which proved reliable. Previously it put 10 points for a joining of the median nerve, now it puts only 7 and of the adhesive of them. Lastly, it immobilizes the wrist during three weeks in the position where it made the joining, slightly slackened, but neither in hyperflection of the wrist nor of course in voltage.

 

. : Into did 30 years the assumption of responsibility of the wounds of the hand really change?

A.: It changed whole with the whole. After having been internal in the service of Jacques , where I was interested in the hand surgery, I was one year in the service of the Instructor Merle D' with where Raoul was. I must say that it expressed me much sympathy and learned to me enormously from thing on the hand surgery. There was, at a certain time, the dogma not to suture the flexor tendons in urgency and to make secondary Clerc's Offices. Then the experiments came from Claude and Jacques which made it possible to evolve considerably to the primitive joinings. From the moment when it was seen that it was possible, the development was done towards improvements which are always with the day order. Previously, one immobilized three weeks without rehabilitating and one obtained adherences and stiffnesses which required secondary . Then one saw appearing the technique of , rehabilitation with rubber band, and the technique of . Now, one can that if perfect joinings are made it is possible under certain conditions and certain sectors of mobility in particular while exploiting the phenomena agonistes-antagonists, be able to rehabilitate actively.

 

. : What does it arise from the product anti-adherences?

A.: Nothing spectacular.

 

. : Which certainty did you acquire in the traumatic surgery of the hand?

A.: At least one, it is the essential character of the centers urgency-hands that they are public or private. The capture charge in urgency is fundamental and Raymond Vilain was the initiator of that.

 

. : Why not to advise with nonthe specialists: you wash, clean, disinfect, put at antibiotics and to tell the casualty to take appointment with an hand surgeon?

A.: Initially because to take one return with an hand surgeon, that will take days even weeks. If it is about a clear wound of the hand with a section of the two flexor tendons to 4:00 of the afternoon, that can probably wait the following day. But if there are a crushing, a or multiple fractures, that cannot wait. Beside the need for the gesture in urgency, another certainty that I acquired, it is the importance in the manner of doing it; importance not to plow tissues, to have a completely precise and meticulous operative procedure. Only it is not a question to have an ocular equipment, it is the whole of the control of the surgical operation which makes that the continuations will be simpler, that there will be no edema and of infection.

 

. : What is it necessary to think of the in hand surgery?

A.: The preventive in an open traumatism of the hand appears completely logical to me and contributes to the best results than one obtained. This preventive is not 4 days nor even of 24:00, it is an antibiotic flash during the surgical intervention.

 

. : These 20 last years, there was a current very favorable to reimplantations of fingers at all costs. Which is your experiment?

A.: I do not think only it is necessary to make accept the casualties whom one will reimplant them at all costs. When one is qualified in this field the indication passes better near the patients. With regard to the inch obviously it is necessary to try to reimplant to the maximum but there still if one does not arrive there there are points of operative procedures and points of development which should absolutely be started immediately. With regard to the long fingers I think that so for my part I had an amputation on the level of I would not be made reimplant. All the other cases of figure are specific in particular the lesions .

 

. : Which is your feeling on transplantations of hands?

A.: My feeling it is that one will transplant a hand which one does not know yet which will be the long-term function, but which one will transform the “healthy” amputee into sick man because immunosuppressant medication will cause him big problems. Now, did immunosuppressant medications make progress? I do not know. Which is the result of both or three patients in the world who were reimplanted, and why the Lyons team which obtained five possibilities of reimplanting bilateral amputees only indication with my direction, if indication there is, it used only one of them since three years?

. : You at the end of a career of hand surgeon, which glance do you relate arrive to your speciality?

A.: I carry a favorable glance on the development of this speciality, and this qualification does not appear surface to me. I think that the hand surgery became into 20 or 30 years a true speciality. When I started, the csotcina.comedic surgeon and made of all. Gradually, one saw appearing guidelines which it is of the knee, the hip, the rachis or the hand. The hand surgery is now a true speciality.

 

. : How was held your individualization within the service of Jacques ?

A.: It is in the service of Pierre Lance that I met Jacques when I was internal at the hospital Saint Louis. I started thanks to him to interest me in the csotcina.comedic surgery and . It was the time when Jacques with Raoul , Pierre , Raymond Vilain and Jacques had founded the Group of Study of the Hand. That corresponded to a real need. In the services, everyone could not do everything and if somebody chose a field, it was necessary that the others are implied in other S fields because that made it possible to enlarge the pallet of competences of the service. Jacques had a sight on the unit of the csotcina.comedic surgery. He was very qualified in all these fields. When we passed in new , it evolved more to the hip surgery, of the knee and the tumors that towards the hand surgery. For my part, I took the path of the surgery of the upper limb.

 

. : This turn did not create a voltage?

A.: The time of Robert Merle of with services where the assistants did not do what they wanted and could not take any initiative was finishing. When I was with Jacques , it is possible that it did not see of very an good eye creation of the group but he said anything of it, and did not prevent anything. At that time, we were senior registrar in the various departments of csotcina.comedic surgery of the Paris region. We were aware that it was necessary to evolve/move and speak together and not to make sterile wars of schools more. The fact that one could meet and speak between senior registrar about various schools advanced much the comprehension of the csotcina.comedic surgery and .

 

. : You had all the same point of seen within the ?

A.: There was surely from the points of view different not on the spirit from the group but perhaps on technical plans. But it should well be recognized that the personality of Raoul and the four other founders ensured a cohesion and that this cohesion led to the creation of the French company of Hand surgery. Up to one recent period it there forever have any problem between us. One by choosing each one a field.

 

. : One with the impression that currently this of the hand regresses in the hospital services?

A.: I am well of agreement with you and I am very sad of this development. I think that a certain number of my colleagues csotcina.comedic surgeons and did not understand, or do not want to understand the development of the csotcina.comedic surgery and . Into private clinic the csotcina.comedic surgeons who are often 4 or 5 because of the regroupings are divided the subspecialties and excellent in their field. Contrary one with the impression that in the , one recreates departments of csotcina.comedic surgery and told general and that appears completely aberrant to me. If this tendency were to be confirmed, one could not evolve/move any more nor to have any national or international fame. It is necessary that the various services of , in particular in Ile de France, are directed by saying that at such place one more particularly makes the hip, the knee, the rachis or the hand. I believe that one needs at least two formative centers in teaching hospital hand surgery because the problem is not to know if it is necessary to send the patients in private clinic so that they are quite neat. They will be forcing quite neat because these surgeons leave our services. I do not say that to be pretentious, but the success of those who were pupils is very important and estimates, the reconnaissance, even the friendship, are quite as important. How to form the following generations? Will it be necessary that the young people abroad will be formed? It is not tolerable.

 

. : In spite of your retreat you remain active in the curricular area…

A.: Yes, as long as I will remain consulting. The consultant remains for two or three years not only at the university but still at the hospital with the possibilities of operating. I will continue to have an activity in teaching because I believe that the formation and teaching it is completely essential and that made party of the role of the instructors of the universities. Concurrently to that, the leaves a little more free time since one does not have any more an administrative task. Thus with the one created an association which is csotcina.comédie Traumatology Without Border. This allows, with agreements of states in states, to accommodate and to have possibilities of collaboration with in particular the Maghreb countries but also the French-speaking countries African and soon the . These agreements make that one obtains purses for young surgeons who can come to spend one year to France to be formed with the surgery that they wish after they obtained their diploma for the occupation of surgeon in their country. And then there are exchanges of surgeons of the country considered which comes to spend one month or 15 days to France and then French surgeons who will spend 15 days in the country considered. Currently, that develops since one will make an association not only with the , but also with the Association of the csotcina.comedists of French language.

. : In conclusion?

A.: I think that an hand surgeon can be interested only in the wrist and with the hand but that appears well too restrictive to me. The good level of specialization it is that of the surgery of the upper limb. I believe that which makes surgery of the upper extremity to better seen overall of the whole of pathology and thus milked best the hand surgery. But it is a personal opinion.