. : Which is the guiding idea of this congress?

CP: The idea of the congress, it is to make an continuous medical education on the hip for young surgeons, but also for experienced surgeons. Very often of a great congress, one retains only one more or less realistic tendency, but few practical data which will be usable the every day. With , we tried to cause a debate between experts starting from a significant clinical example of which they received the iconography before. A well documented clinical example is teaching and makes it possible to go further in the analysis than a conventional communication which generally flies over the private clinic and the procedure. At the time of the first congress “” in 1999 in Toulouse this formula had been a success of regard and thus strengthened it to us.

. : Of agreement so that the group of expert does try to release from the consensuses, but how to mean itself if all the room starts to speak?

PH. C.: You will notice that when the experts covered the subject well, there are not often more questions to pose. But when the experts are confused each one in the room needs explanations. The regulators and the experts thus have a big part in the dynamics of this congress. So that is really interactive, we used double video-projection. The speaker has a screen to argue his convictions and the regulator has another screen to forward contradictory clinical examples or to raise complementary questions. It is the public which is charged to choose the consensus, if there can be one of them, as a voter by a show of hands.

 

. : Which are the subjects?

PH C.: Biomechanics of the normal and abnormal hip, the hip of the sportsman, fractures of the femoral head, the painful hip, channels initially, the joint replacement on luxated hip, of hip, surgery computer-assisted, the rebuilding of the stems, the complications of the arthroplasties… We started from very practical situations. For example, of the patient who badly has with the hip for a long time, for which the basic examinations complementary do not direct the diagnosis, the symptomatic medical therapy either; If a MRI had quickly been carried out the diagnosis of necroses at the stage I of the Classification of the would have appeared obvious, but it is difficult to have quickly a MRI today in France. Elsewhere the patient comes with scintiscanning, scanner, , MRI whereas it is about tendinitis. We thus made a roundtable around the painful hip with a rheumatologist B. , a c.f. Castlings, an csotcina.comedic surgeon, a radiologist . with varied cases for which a shaft diagnosis must be considered and especially a good hierarchy of the complementary examinations.

Another example of practical situation: the arthroplasty of hip on architectural defect. Is it necessary to preserve at the time of the realization of the arthroplasty the initial defect for reasons of muscular balance or is necessary he to correct this architectural fault to recreate a hip a priori normal? Then there the divergent opinion; for example is able to make to measure a prosthesis so that an abnormal hip reaches normality and conversely will use a standard prosthesis to preserve the . To answer these questions as well as possible it is of course necessary to be interested in biomechanics of the hip, to understand the dynamics of a femoral neck which functions with a strong valgus and a or conversely a retroversion.

The everyday practice of the surgery does not have, by negotiable instrument of mode, to make adopt a new technology too early, too expensive, not yet at the point… What is it prosthetic surgery of the hip computer-assisted? Three experienced surgeons, , and , give us their point of view, advantages, prospects, but also disadvantages, limits.

Then, the per-operational complications appeared very interesting to us. What to make when one has a fracture of the femur by posing an uncemented prosthesis, that to make when one has a shock with cement, that to make when the prosthesis is luxated after very having cemented, and that it appears difficult to us to stabilize? Is there a good solution to avoid an inequality length?

Finally the topic of the rebuilding of the femurs during the recoveries is impossible to circumvent. In 1999 we had primarily insisted on the choice of the voting rights initially and the major therapeutic options, but not enough on the details of procedures. I.e. it is not enough to tell, I make a technique of filling by a parcelled out and I impact a cemented prosthesis. It should be known how one fills, how one parcels out…

 

. : How does Toulouse csotcina.comedy go?

PH. C.: Like the national csotcina.comedy, i.e. which it is wobbly. One with the impression which the public authorities do not support this speciality which is however in full rise. It there forever have as many average therapeutic effective, nor a better knowledge of these pathologies and one with the impression that with each time one wants to look after a patient, it is necessary to beg to have means, and as for knowledge, we soon will miss pupils for forwards. I exaggerate a little, for the Toulouse moment does not go so badly; there are still interns, they have the air interested by csotcina.comedy what motivates us to make teaching. In Toulouse the concept of school is a strong engine.

 

. : Precisely, which is your school?

PH C.: Before csotcina.comedy is not specialized, directed the “general surgery and ”. In after war, required of its pupils to specialize. was the first to be specialized in csotcina.comedy: In 1947, it made the effort go to the United States to the Massachusetts General Hospital of Boston. It went there with his wife who was anesthetist and they returned from there both with new enough ideas for the time; intubation, processing csotcina.comedic by traction at the hospital and home-base; the executives of and the system of geared down pulleys did not disappear from our services… For the anecdote, had an ankylosis of hip in poor posture on coxalgia and he limped enormously, certainly more than much of his patients. Thereafter appointed in the Sixties; appointed 10 years later his/her Gay colleague; then appointed in the Seventies; This last “line” is continued by and me even! as for him, in parallel founded its own Ecole by developing in Toulouse the surgery of the upper limb; it appointed . There is for a long time a collaboration between Toulouse csotcina.comedy and that of Mayo , and spent one period of formation there!

 

. : Which kind of man was ?

PH C.: A man who gained with being known. Seemingly, probably by timidity, it appeared enough contained and did not deliver itself easily. It was a man computer. It stirred up the ideas very a long time before making a decision. It succeeded in making a School because it always supported its pupils. It was not the kind to promise posts with all those which required it of him, but when it was the case, it fought to obtain the post, it fought so that one remains at the hospital and if one wanted from to go away, so that one has a good place in a private clinic. It was a secret man, but of word.

 

. : It was your Master?

PH. C.: Yes. At the beginning I prepared the boarding school with a rheumatologist, Rene , who involved me towards the musculoskeletal system. I found the reasoning intellectual in rheumatology very interesting, especially that held by him (the rare diseases are exceptional/one should not seek to look after the idiots…), but it seemed to me that the medical care was not gratifying. In 1973, medical student of third year, whereas I followed it in consultation in a center of rehabilitation in de , I pushed the gate of the room of at side where consulted which was then 38 years old; it was looking at radios of a pseudarthrosis of leg discussed by the “technique of the comb of ”. In spite of the obvious side “joinery”, he defended that csotcina.comedy is also the surgical speciality most intellectual! With the block, readily let operate some is the surgical level. It made part of the intervention and it let do the other; from time to time it was going to walk in the room while going in round; one day one made the channel initially, a day one closed, a third day one posed a . It took its time for that, not because it was slow, but because what interested it, be to teach. It was teaching above all I think.

 

. : It was a surgeon of the hip?

PH C.: Yes, but it was interested only in that. It made good about fifteen years of guards before stopping and always followed closely the development of the ideas in traumatology. It returned always impassioned meetings of in . He had liked the school of Maurice also much. What it found of good to the hardware of the , they is that metals of the screws and the plates were compatible, the screwdriver was adapted to the heads of screw and the screws passed by the holes, which was not the case of all the hardware at the time. There were exchange rates, and he/she liked this idea much. It pushed all its pupils to follow them; I went there initially like monitor in 1981, then as raises!

 

. : He proposed a very interesting classification of the fractures of …

PH C.: In thirty years, it made make good ten theses on the subject. The horizontal, mixed and vertical fractures, were already described; showed that these three forms are characterized by displacement from the fundamental feature from Micrometer caliper which separates thalamus; the mixed forms with a feature of separation in the medium are most frequent.

. : Why did it appoint you?

PH C.: It is a good question! …?

 

. : You were there at the good moment?

PH C.: If I had been there at the good moment, I would have been appointed much earlier. I passed twice the contest, the first in 1987, received without post, then in 1996, is ten years of waiting to hope that a post is available to Toulouse! I was not there at the good moment, but my owner felt that I was ready to wait the good moment. I was motivated. For a university career, it is necessary to be projected in the future and to have the . It is the emulation which causes the production of scientific work. To answer your question I would say that I was selected in the way in which I will probably choose my pupils. It is necessary for the basis somebody of qualified and worker, and there is much among the interns. Then it is necessary to share with him common securities, to feel that it will transmit to its turn the same spirit, turned towards teaching.

 

. : How are you organized for the assumption of responsibility of the urgencies?

PH C.: We are disorganized for the assumption of responsibility of the urgencies! For an good organization, one would need that all the patients are received with the urgencies by a surgeon able to make the diagnoses, to pose the indications and to discuss them, or to entrust them to that which will be able to discuss them. But the current urgencies do not arise under this aspect. They function with doctors A&E doctor who have a double contract. The first to have the thesis to be responsible legally, the second to direct, with the assistance of the interns, the assumption of responsibility of the patients whom they consider it necessary to hospitalize towards a qualified specialist physician. The presence of this corporation of Doctors was essential because of demography, because the restricted number surgeons of the hospitals does not enable them to remain permanently with the urgencies and that will not be arranged with the 35 hours. The initial role of the doctors A&E doctor was not to discuss the patients with the urgencies, but we undoubtedly will have to integrate them in the organization of an emergency service, care, consultations provided that they agree to be suitably formed and framed by specialists. It seems to me however that it would have better been to increase the number of pH surgeons at the beginning! They would have taken part by bearing in the reception of the urgencies and also in the activity of the services.

 

. : Which is the mining area of population?

PH C.: The town of Toulouse counts about 500 thousand inhabitants, and the area a little more than one million three hundred and thousand.

 

. : There how much hospital is to face?

PH C.: Two hospitals pertaining to the of Toulouse where urgencies are received: and ; we work networked with the Regional Hospitals of , Saint , , Saint Bosoms, , Castres, Albi, , Cahors, Lourdes, and perhaps I forget some, forgiveness for them. and Carcassonne to m of Toulouse depend on
the paper of Bordeaux and Montpellier which are to m!

 

. : How much beds of csotcina.comedy in ?

PH. C.: About 90 beds
by service; on the whole there must currently be 180 beds of adult csotcina.comedy-Traumatology.

 

. : It is enough?

PH C.: If our administrative are listened to, it is too! One should have practically only beds of day and the patients should even leave the evening. In practice, we are practically always full, and when it arrives an urgency of too, we “put it” in the close services, sometimes medical with a personnel not accustomed to this type of patient. There is an real issue of organization; the shortly after guard, it is necessary to find a score of patients broken down randomly in the hospital. Our supervising their time passes to seek places to repatriate in the service these casualties on standby. It unquestionably misses a score of beds buffers.

 

. : You developed a plate intended for the fractures of the lower end of the femur. Why?

PH C.: Because there was a need. I had been internal at in Bordeaux in 1978 and I remember that one night of guard, with Laurent, currently surgeon with , we had to discuss a fracture known and of the femur. My “chief” had made a great channel initially with a release of the tibial tuberosity and one saw very well the chamber of fracture. It had reduced the fracture perfectly, then implemented a screw plates of and as it tightened the screws, the fracture moved quite simply because the hardware was not adapted to this anatomical localization. At a meeting of service I forwarded some cases of fractures
lower end of the femur, and I showed with my Master that there was a problem of form of the hardware. He listened, and a week after the medical delegate of one manufacturing of French hardware came to see me to start the implementation of my idea. I found that very elegant on behalf of my owner, more especially as I was only at the end of the boarding school. The Director of society received me at his place, with his single engineer. When the plate was plantable, I dealt with all the fractures of the lower end of the femur of the service during three or four years; I then reported myself that there were not only one hardware problems, but also of comprehension of the various forms of fractures, strategy and experiment of the surgeon for these fractures which are relatively not very frequent.

 

. : Why didn't you also think of locking the epiphyseal screws on the plate?

PH C.: We thought of it, but it was not easy to make. There was a technical obstacle because the hardware is forged. I think that the idea to lock one of the screws on the plate is in the air for a long time and that it will be concretized soon.

 

. : What do you think of the retrograde ?

PH C.: The idea is very tempting theoretically this hardware associates the advantages of the minimal incision, conservation of residual vascularization and the hematoma . The problem is that these fractures are often articular and that into percutaneous there are large risks to leave a . Then it is rather difficult to preserve the axes; the lower screws are perpendicular to the nail; with a central point of introduction, if the screws are parallel to the line space, only visible radio operator reference mark, that Ci is automatically perpendicular to the axis of the femur whereas there should be a valgus of 5° with 9°; all the layers of know that! A defect of axis of 5°, it is not negligible in , that corresponds to the average correction of the tibial osteotomies of . And then the hardware is intra-articular, but part of these fractures become complicated infection and an infection on an intra-articular hardware that led to an arthritis. I think that the retrogresses has certain indications, the high fractures condylar with metaphyseal size reduction, but did not can be appropriate for all the fractures of the lower end of the femur. From where the interest of a surgical classification practices, which makes it possible to choose within sight of the anatomical form the hardware more adapted, and to analyze the series simply. Classifications with data-processing sighting as that of the do not guide to operate.

 

. : Which are your different subjects of interest?

PH C.: I made my first of hip in 1984. My colleagues rheumatologists had entrusted a patient to me who had a with very small grains. I found damage to luxate this hinge to make a small articular cleaning simply. The pioneers of the were in fact very few, ten, with beginning of the year 80; the number of cases was weak, a score in all; each author used a different point of penetration! That led me to make an anatomical study on the various points of penetration. The first was in fact easy; One saw very well the cartilage of the femoral head and , the synovial one; it appeared simpler to me to walk me in the hip than in the knee. Informed of that I listened to of another ear the meetings of rheumatology to which I assisted regularly. I reported myself that our colleagues rheumatologists did not see the patient at the same stage as us. The painful hips for which the whole of the complementary examinations do not bring an formal evidence, are numerous within the framework of customers of rheumatology and not very numerous within the framework of customers of surgeon. This last sees patients to be operated and whose pathology is advanced. I spoke to the Instructors and about the new diagnostic possibilities which the offered and they entrusted patients to me. That allowed me, at one time when there was not yet the MRI, of the more precise diagnoses and in certain case to bring a surgical solution.

 

. : On which indications?

PH C.: At the beginning they had been quite simply painful, rebellious hips with the medical care for more than nths, without obvious diagnostic guideline. Thus we discovered foreign body articular of any type, of the which passed unperceived, of the fragments of , but also in almost half of the cases a lesion of the ; a tear as one can observe it on a meniscus, or a as on the circumference of humeral . It is very interesting to think of the role of the . It is an element rather different from a meniscus; it is very vascularized and is not interposed between two joint surfaces. This very vascularized element and very mobile and which can tear cheek an essential function. The contributes to the passive of the hip by suction cup negotiable instrument. He plays a part of shock absorber in the negotiable instruments of ; he occurs exchanges by lower part the transverse ligament of the between the two virtual cavities which are the and the area around the neck, the central zone and the peripheral area, that made of the liquid exchanges as in a shock absorber. A third role, it is a role of centering. When we make an extension of hip, the capsule is bored, comes to rest on the which itself comes to be pressed on the head. It was often claimed that a stop was to cause a transformation of the capsule which became cartilage. Never nobody showed a histological cut which proves it. The stop comes into extra articular resting on the capsule and the , and stabilizes it.

 

. : How much do you make of hip a year?

PH C.: I will say about thirty what is not much more especially as there exists a skew of recruitment.

 

. : With share of hip?

PH C.: When we left the old hospital of for , we were solicited by the department of rheumatology of the instructor to make drillings in cases of necrose already diagnosed and which did not forward fracture of the head. We were a little perplexed as for the therapeutic effectiveness of drilling, but did we it readily because that often meant total prosthesis of hip in the year which follows. Half of the drilled patients needed a prosthesis later one year. We badly did not simplify the technique of drilling. I saw with work, it was a true access of the hip; it made a rather important cortical window. We modernized the technique into percutaneous. Today with the MRI we do not have any more a diagnostic justification of the gesture and the line of the necrotic zone is more easily carried out with the fuse rather only with the perforator.

 

. : You continue to practice drillings?

PH C.: Yes, because one did not only simplify the technique but one improved it thanks to ostéo-inductive proteins. We took part in two series of studies on the processing of necrose femoral head with ostéo-inductive proteins. The results show a real effectiveness since the pilot series, i.e. a simple drilling not of drilling highlights 50% of development towards a fracture, whereas one arrives at 25% in the series with ostéo-inductive proteins It is equivalent to the figures obtained with a vascularized fibula, but it is much easier and more rapid to make a drilling and to place a sponge soaked with protein at the content of the tunnel. This product hardly is marketed today but only in the processing of the pseudarthroses and soon the open fractures of leg. Although we do not have any more access to this product we wanted to continue in the same spirit. We followed work of which sorted original cells in the #FFFFFF line which are producing inductive proteins and we tried to put the technique into practice. In our the surgical teams and the are not ready to implement this constraining technique in a routine way. We now use an intermediate solution which consists to make a conventional drilling and to introduce a spongy autograft of iliac crest into the necrotic zone. For the moment, we are studying the results. They appear at least as good to us as with inductive proteins. All is taken on the spot and it takes only half an hour to make this type of operation.

 

. : It is what the ostéo-inductive proteins?

PH C.: These are proteins that the #FFFFFF airframes of the marrow of all the mammals manufacture and which induce the osseous formation. The ostéo-inductive proteins understand an active channel and an inactive channel. In a chamber of fracture, blood is mixed with bone marrow in a medium in hypoxia and acidosis. The ostéo-inductive protein channels break and the protein will be activated and will transform the muscle cells which are around in mesenchymal cells which themselves will be transformed into osteogenic airframes. One thus finds concepts known like the interest to preserve the hematoma , the interest of boring… Of the beginning one thought of dealing with only one protein common to all the mammals, then , and the team of researcher of discovered of them 7 and now they are to 22! It seems that each one of these proteins acts at one different time. For example, protein 7 will support the share of the osteoblasts at the stage of cartilaginous cal; it would thus be adapted to the processing of a hypertrophic nonunion. Protein 2 will act as of the beginning by supporting the formation of the cartilaginous cal and also by inhibiting osteoclasts; it would be adapted to the filling of the losses of bone substance!

 

. : Much hope is placed in these proteins…

PH C.: One expects miracles from them. When us were explained that one could have synthetic osté-inductive proteins, pure, in industrial quantity, without risks of canceration, one very imagined! One will make more quickly consolidate the fractures, one will start again the consolidation of the pseudarthroses of leg, one will make vertebral arthrodeses which go each time, one will help the hip prosthese with being better integrated more quickly… All csotcina.comedy and all traumatology will be upset. The first three studies succeeded. The first on the osteonecrosis of the femoral head, the second on the leg fractures, and the third on nonunions. The results statistically significant, but in a way as spectacular as are not provided for. Statistically, in the series of 450 leg fractures operated with inductive proteins pilot, there were twice less resumptions with opened chamber, twice less secondary surgical gestures of dynamization, and it was also noted that among the pilot subjects, the locked reamed nails went better than the not reamed locked nails. When a boring is made one introduces inductive proteins in a natural way. On the other hand when one puts ostéo-inductive proteins in contact with a chamber stabilized by a locked nail not reamed, the results approach the reamed locked nails. The future of this product for the moment is related to its price. If it were cheap one could put some in enormously indication and that would bring a benefit to many patients. But to the current price requiring of the specific budgets, one will attack only difficult cases who will not lead inevitably to a good performance. That is likely to discredit this product which is however a good product.

 

. : You developed a percutaneous technique of butted of hip…

PH C.: This technique was largely widespread in France in the Sixties and it gave overall good performances among patients who had a painful hip which started with , but also in cases of more advanced osteoarthritis. However the weather is damage to be a great channel initially, and to maintain operated confined to bed several weeks only to affix a short period of bone of two centimetres to the former party of the hinge. I took as a starting point the of hip because I that each time one was mislaid in the channel initially to make enter the chuck, it precisely fell into the area or had to be put a stop had noticed. It seemed possible to me to take a piece of iliac crest and to screw it along a pin by using the channel initially of hip. My Master who was with the retreat, and still very critical feared that does not go because the Clerc's Office not being solicited, it would be lysed. Two years later we noted that the Clerc's Offices were well integrated and I could develop the technique.

 

. : Where are you are as regards hip prosthese?

PH C.: Prosthesis PCA was a prosthesis without cement, curved in the sagittal plan. But makes the curvature of the PCA of it was too low. That involved negotiable instruments of stress in end of stem and suspensions of prosthesis which one knows the role on the pains of thigh and that in general has even a moment discredited the uncemented prostheses. The basic idea remains good, but it is necessary that the curvature is more . I made party of an Working Group on a specific prosthesis which would be curved in the sagittal plan but could be at the same time cemented and uncemented. One of the initial questions that one was posed is: what good was it to make a cemented prosthesis which is curved since once cemented that takes the form desired and very adapts? In there reflective, there is interest because more the prosthesis is centered more the layer of cement around is homogeneous. When with the uncemented prostheses, it appears obvious that they must be curved if one wishes to multiply the something to lean on. The femur being curved a right prosthesis will seek three something to lean on and when it finds them it does not move more, and they will be three points strong stresses. Finally this curved prosthesis with and without cement appeared interesting to us and the group went until the development. When it was marketed, I continued to cement according to my practices; then I tested gradually the uncemented model, and today I cement only one third party of my cases. Conversely I noted that the surgeons who did not cement had ended up cementing a third party of their patients. Thus that wants to say that one arrived gradually at the same indications. This prosthesis makes it possible to make learning curve towards without cement.

 

. : What do you think of the private sector of the hospital? Is necessary it to defend it or abolish it?

PH. C.: To operate patients in private sector should be obligatory for a Surgeon of the Hospitals - Instructor of the Universities. Not only that makes it possible to be closer to its customers, but especially that obliges with completion to deal with its patients until the retreat. That makes it possible the customers to choose her surgeon and that makes it possible the hospital to prove that it is as powerful as the private one. To do private that also makes it possible a to have a retreat to compensate for the emolument without social contributions which the state condescends to pour to him. Finally if the desire to settle into private becomes stronger than that to be an official, customers are a strong foundation on which one can be based at the time of his installation.

 

. : With when the next edition of ?

PH. C.: 2005. has to follow on the www.csotcina.com site