AN INTERVIEW WITH... LEVON DOURSOUNIAN To celebrate its 100th issue and its tenth birthday, meet Maîtrise Orthopédique in the person of its editor-in chief, Levon Doursounian.

Technique: Bilboquet - 1st version

M.O. So this is the 100th issue, already?

L.D. "Already" makes it sound as if it had been child's play all along. It hasn't: producing a monthly journal is an enormous challenge, and I cannot recall a single issue that was all plain sailing. However, the journal has now reached its cruising speed, and we are far from the stormy passage of the early days.

M.O. Stormy passage?

L.D. Right at the beginning, I was editor-in-chief, journalist, copywriter, secretary, advertising manager, librarian, messenger, office manager, and a few other things. I did not sign my own articles that appeared in the journal, so as not to make it quite so obvious that I was doing it all myself. Then, by and by, we got more people working in the editorial office, and now the teething troubles are well and truly over, and the work flow has settled down to a smoother rhythm.

M.O. What prompted you to create this journal?

L.D. To answer this question, we need to go back to the 80s. At that time, orthopaedic technology was booming. Every orthopod was producing his own device, without let or hindrance. In all the fields - joint replacement, internal fixation, arthroscopy, spinal surgery - something new was coming out every week. Much of it was never heard of again after that, but some of these innovations helped to shape orthopaedic surgery as we now know it. Since none of these novel devices had any clinical follow-up, they could not be written up in the big journals, and surgeons had to rely on seminars and various congresses to keep up with developments. So there was a huge backlog of information waiting to be published, and many authors who could only express their views in handouts of their papers at conferences. Towards the end of my specialty training with Roy-Camille, I had mentioned these problems at departmental meetings, and together with Gérard Saillant, I felt that there was ample scope in France for a new orthopaedic journal. However, we were thinking in terms of the conventional type of journal, which is immensely complex to operate; so the project came to nothing.

M.O. What happened next?

L.D. Next, I came across a "tabloid" medical journal one day, and immediately realized that that was what we wanted. With such a format, we could publish instructional material, and articles on topical questions, without interfering with the work of the big peer-reviewed journals. If we were to carry advertising, it should be possible to have a colour and lots of illustrations, and to finance the publication. Shortly afterwards, I submitted a mock-up to Gérard Saillant, who thought the whole thing was worth a try. So we thought and talked further about it, and then went and saw our chief, Raymond Roy-Camille.

M.O. What did he think of your idea?

L.D. He gave us his full support, but I especially remember one remark that he made at the end of our presentation: "Doudou, you are going to have your work cut out." The first problem was finding an original title for the journal. I was racking my brain, but could not think of a name. The one that came closest to my idea of a journal was Tribune Orthopédique, but there was already a Tribune Médicale. In the end, since I had not found a name, I said to myself that it was no good looking at it the way others had done. Instead, we had to ask some fairly basic questions. Why do doctors read a medical journal? Answer: to keep up to date, to improve themselves, to become masters of their craft. And that's where the idea of calling it maîtrise came in - a word that resonates with meaning.

M.O. And then?

L.D. Then we had to get a team together. Gérard Saillant took charge of the Scientific Committee, while I went to work on the Editorial Committee. Word spread about what we were doing, and we phoned around a bit, and this way we got a little group of colleagues together who were bold enough to embark on this venture. So as not to make this an exclusive undertaking of Paris surgeons, I tried to contact colleagues all over France. One of these pioneering collaborators was Philippe Neyret, in Lyon, whom I did not actually see face to face until some years later, and who then said to me, "You know, for a long time, Doursounian, to me, was just a voice on the phone."

M.O. So how did you get your material together?

L.D. The first number was fairly easy, because I had six months to prepare the issue. The various headings were virtually the same then as now: an interview, an update, congress reports, surgical technique, and latest developments. I had plenty of time to fine-tune the first issue, and only realized what a foolhardy venture we had launched ourselves on when it came to producing the second number, for which I had 30 days.

M.O. So how did you manage?

L.D. At that time, I would have said that I worked like a galley slave, and that, as the saying goes, one can do the impossible when one is young, because the young don't realize that what they are trying to do is impossible. Today, looking back on things, it is obvious that I was blessed with having superiors who were immensely understanding and helpful. Also, the advertisers, the implant manufacturers, had committed themselves to a one-year contract, and they stayed with us. Their loyalty allowed several numbers to be published, and the journal to become an established feature on the canvas of the medical press. And there was, after all, a real need for modernizing communication in our profession. Somehow or other, we managed to get articles coming in. The truth is, of course, that the journal was only 16 pages, in those days. However, I shall never forget the enthusiasm and the selfless dedication with which the members of the Editorial Committee threw themselves into their monthly task.

M.O. One of the ingredients of your success appears to have been the Interview…

L.D. Indeed - and quite rightly, too. When I was a junior surgeon, I found the rare occasions when one could talk informally with one's chief very rewarding. Because, behind every technique, every case, there is an experience and a history that cannot be reflected in a scientific paper. And yet, how things got to where they are, the trials and errors, the circumstances that lead up to an innovation in surgery, are of the utmost importance. These are the things that make each surgeon's story unique - and yet, one can only understand these things if one works side by side with these surgeons in their own departments. Of course, one is not a junior forever. I thought it was a shame that the overwhelming majority of my colleagues would not be able to benefit from the individual experience of the leading members of our discipline. So I tried, through the interviews, conducted in an informal and relaxed atmosphere, to continue, as it were, the chats that we had with our chiefs, when we were junior surgeons. And with a good interview, the surgeon reading the printed version does, indeed, get the feeling of having shared an experience with the interviewee.

M.O. Who conducts the interviews?

L.D. In eight out of ten cases, I do. What happens is that the interview goes on for two hours, without any set questions; the whole thing is tape-recorded, and then typed from the tape. From this long text, we then have to select the highlights, without misrepresenting the interviewee's ideas. If the interview was done in English, that is not always an easy task. Editing the interview is pretty hard work. Once it has been edited, it gets sent to the interviewee, who can then make any changes and corrections he or she likes. I have no wish to be the journal's sole interviewer, and delegate the job whenever I can, because I think that interviews are better if the interviewer and the interviewee know each other really well. I particularly enjoyed interviewing my former teachers, and I think this enjoyment shows in the printed text. However, the chief factor that makes for a successful interview is the personality of the interviewee.

M.O. Who was your first interviewee?

L.D. Triffaut - whom I sought out on Roy-Camille's recommendation. The interview was held in a café at the congress centre, during the 1990 SOFCOT congress.

M.O. How did you find the time to do this monthly journal?

L.D. I was lucky, in a way. After five years at the Paris Hôtel-Dieu doing mainly trauma work, I got a part-time appointment. I had a limited amount of private practice, but since I wanted to pursue a career in the public hospital system, I went on working virtually full-time at the Hôtel-Dieu. Any time not spent in private practice or on leisure activities was then given over to keeping the journal going. Also, when I was on duty, there was always plenty of time when the theatre was being set up, or between cases - so much time, in fact, that some nights I felt that I could have edited a weekly, let alone a monthly, journal.

M.O. Apart from the journal, what exactly do you do?

L.D. Not a lot - I am Professor of Orthopaedic Surgery. Seriously, though, I try to fulfil the three functions that come with a post at a teaching hospital: patient care, teaching, and research. And it is precisely because I have stayed in a teaching hospital that I have been able to do my journal. In this environment, one is in constant touch with the junior surgeons and the middle level, one has to go to and to organize conferences, and one has to publish papers oneself. So publications in one form or another are one's daily bread. Many of the articles published in Maîtrise came from chance meetings with a colleague who had started or was doing some work that he or she was encouraged to make available to a wider audience. I cannot see how one could bring out ten issues a year if all one did was look after patients, in a highly specialized field.

M.O. What do you think of the triple function imposed upon those who work in teaching hospitals?

L.D. I myself have always been entirely in favour. I have dedicated myself to teaching. I have tried to train the juniors, to let them operate under my guidance as often as possible. I have written the list of subjects for the orthopaedic specialty training entrance exam, published as part of the Impact series, which has gone through several editions since it first came out. I have done research in such diverse fields as the junction between the medulla and the cervical cord, MR imaging of the rotator cuff, and a magnetic shoulder prosthesis. Looking at teaching hospitals overall, I think that patient care and teaching are well looked after. I know it is a standing joke that the professors do so little lecturing; however, that is overlooking the fact that they are in day-to-day contact with the junior doctors and with the medical students, that they do a lot of examining, and that their teaching role is by no means confined to the lecture theatres and seminar rooms. The workload is considerable. On the research side, things are getting increasingly difficult. Anyone who wants to dedicate himself to research is finding the path very stony indeed. I am reminded of Bernard Palissy, back in the 16th century, who had to burn his furniture to be able to produce his famous enamelwork. Those who want to do basic research encounter endless difficulties; and often one is left with no option other than clinical research. However, the Ministry does not seem to be aware of the problems we have trying to juggle all these functions, because in addition to everything else, we are being snowed under with admin.

M.O. That goes for all surgeons…

L.D. Of course - and if we don't react, things won't get any better, because we have to say how much we are prepared to do. I think the time has come to draw up a sensible work schedule for orthopaedic surgeons. The reference could be what a staff consultant at a non-university hospital has to do. I fully agree that patients and their families have to be properly informed, and that those who have had surgery must be properly followed up in the short and the medium term. I also think that time should be given over to dealing with the patients' records. Over and above all this, the surgeon should also attend the various meetings that govern the activity of his or her centre. And I am convinced that a surgeon who does not keep up with developments will be hopelessly out of touch in five years' time. However, given today's conditions and the means available now, I cannot see how a surgeon could do surgery more than one day a week. If surgeons are still required to fulfil all their duties, and to operate, they must be enabled to do so. However, for that to come about, the entire orthopaedic fraternity would need to establish, realistically, what an orthopaedic surgeon's working week should look like.

M.O. Which aspects of orthopaedic surgery do you like best?

L.D. Since I come from traumatology, I have always been interested in a great many fields. It is difficult for an orthopod to do only hips and knees. However, the highlights of my specialty training were my time in André Apoil's department at the Saint Antoine Hospital, and when I was with Raymond Roy-Camille at the Pitié-Salpétrière. This gave me a special interest in the shoulder and in the spine. For those of my generation, the shoulder was the territory that was least explored, surgery-wise. So I started looking in greater detail at this joint. The magnetic shoulder prosthesis was an interesting avenue to explore; however, the device was very sophisticated, and not very widely used, since the cost of manufacturing it was out of proportion to the clinical benefit that could be obtained. However, for complex fractures of the upper end of the humerus, I think that the Bilboquet has made a real contribution to the management of trauma patients. During the past few years, when I was at the Boucicaut Hospital, I became interested in hand, and in particular wrist, injuries.

M.O. How long is your follow-up of the Bilboquet?

L.D. I started using this implant back in 1989, very cautiously, at first; however, over the following years, there was nothing to suggest that I had got it wrong. In complex fractures, the necrosis rate was about 30%; half of these patients do not have a problem. Following such complex fractures, which usually happen in the elderly, the functional outcome will depend mainly on the way in which the tuberosities heal. With the Bilboquet, the head is preserved, so that the tuberosities are in contact with bone, whereas with a prosthesis, they are placed against the metal of the humeral stem.

M.O. What prompted you to design such a device?

L.D. With most of the complex fractures of the upper end of the humerus, the metaphysis is comminuted. This means that the fracture site will need to be distracted, if one wants to restore the anatomy. In other words, one needs a "jack" between the shaft and the head. However, with the poor purchase that one can get in the bone of the head, conventional fixation will fail, and the head will tilt into varus. If one does not want to resort to a prosthesis, one has to accept fixation with so-so alignment of the fragments. The Bilboquet allows the distraction to be maintained, and to push on the entire surface of the head fragment, which makes for a more uniform stress pattern. Providing that the insertion of the device is done without undue damage, the rate of necrosis should be very acceptable. The Morse taper on the humeral stem is designed to accept a prosthetic head; however, I have needed to "convert" the device in very rare cases only.

M.O. It's not easy to get hold of a Bilboquet…

L.D. Yes, it has not been aggressively marketed. Indeed, there was a long time when I did not want it being sold at all: I wanted to find out first how it would behave in actual use. When I was satisfied that it was beneficial, there was the question of whether it should be developed further into a hemiarthroplasty or even a total shoulder prosthesis. If there is necrosis, or even during surgery, it should be easy to add a head, and make the device into a hemiarthroplasty. And in the long run, if the patient develops OA, it should be possible to make it into a TSR. The manufacturer was, understandably, keen to save money, and wanted to wed the Bilboquet to an existing range of shoulder prostheses; so we tried to combine it with the Solar pattern. There were some advantages, but, unfortunately there were more disadvantages than we had originally thought. The Solar stems and instruments were perfectly matched to the requirements of shoulder replacement, but proved too bulky in the management of fractures, and sometimes made surgery more complicated. So more trauma-oriented stems and instruments had to be devised - and given the general climate of company mergers and regulatory affairs, this process took several years.

M.O. And what about the spine?

L.D. As far as spinal surgery goes, I was trained at the Pitié, so I learned about internal fixation very early on. The Pitié was the birthplace of the pedicular screw and the spinal plate. At the same time, Dubousset, at the Saint Vincent de Paul Hospital, was exploring everything that can be done with rods and hooks. Screws, hooks, plates, and rods - that's four different bits of hardware. I knew that the infinite variety of life on earth is encoded by four bases - adenine, cytosine, guanine, and thymine. So the four basic hardware elements of spinal fixation should allow an infinite variety of combinations. But that was without thinking of the many commercial possibilities that this would open up. Anyhow, in the end, I did not develop this spinal hardware, and, in retrospect, I am sorry I didn't, because designing a system like that is a fascinating intellectual exercise. At the Hôtel-Dieu, I used to work a lot with Robert Maigne, in his department of vertebral medicine. Working closely with Jean-Yves Maigne has allowed me to discover the medical treatment of back conditions, and has taught me to look at low-back pain in less mechanistic terms.

M.O. You do a lot of coccyx surgery…

L.D. Well, there's got to be an end to the spine somewhere. This particular facet of my work as a surgeon came about because of something that Jean-Yves Maigne discovered. He showed that in coccydynia, a comparison of sitting and standing x-rays of the coccyx will reveal abnormalities of coccygeal movement. This way, one can see hypermobility or subluxation. These dynamic x-rays have provided a rationale for surgery of the coccyx. Nowadays, there is a coccyx clinic at the Hôtel-Dieu. Medical treatment, with infiltration, has a high cure rate in chronic and disabling pain in the coccyx. Where this treatment fails, surgical resection of the coccyx will be offered. This has an overall rate of good results of the order of 80%. So, as you can see, coccydynia is being taken seriously nowadays, and treated accordingly - a big difference from bygone days, when the condition was thought to be "all in the mind" or due to hysteria.

M.O. Let's go back to Maîtrise Orthopédique. What have you concocted for the anniversary issue?

L.D. Everybody in the editorial office thought it ought to be a spoof issue, so we could let our hair down a bit. This is why the supplement is called Traîtrise Orthopédique, and I hope colleagues will find it funny. For the interview, I thought that a lot of mileage could be got out of interviewing a famous person from the past. I decided on Dupuytren, for a number of reasons. His is a household name, and he was obviously a surgeon with a very strong personality. He worked in the centre of Paris, not exactly in the present-day hospital buildings, but in the old Hôtel-Dieu the other side of the square in front of Notre Dame. This makes him very much like one of us today. Also, his statue is in the courtyard of the present-day Hôtel-Dieu, where I spent eleven years of my working life. Believe me, every time I had done a bimalleolar fracture, I felt his marble gaze on me, looking to see if I had done a proper reduction. In other words, I have known him for a long time.

M.O. So how did you go about it?

L.D. When it came to writing the interview, I didn't really have to invent things. There is quite a lot of material on Dupuytren, and his story is so fascinating one doesn't have to embroider it with any details. He was a much more complex personality than people might think, and much less of the bluff and supercilious character he is usually made out to be. Yes, he was a proud man, and haughty in his dealings with his colleagues; but he was also a superb surgeon, and had acquired his skills through many years of privation and hard work. He certainly didn't get to where he was because of a father who could pull strings for him. Above all, his story was full of the sort of conflicts and the wheeler-dealing one gets in any professional body or society. As a result, I was able to stick quite closely to the historical sources. Quite a lot of the material came from Paul Garnière's 1933 MD thesis. The time chosen for the fictitious interview was just after the Glorious Insurrection - the three days in July 1830 when the people of Paris rose up against an unpopular king. On July 25 1830, Charles X had signed four ordinances, which provoked revolution. The first curtailed the freedom of the press; the second dissolved the newly formed legislative chamber; the third cut back the number of deputies and reduced the size of the electorate, in favour of the Crown; and the fourth ordered new elections to be held in September. This coup brought the Parisians out on the barricades, and the three-day insurrection - on July 27, 28, and 29 - swept away the Bourbons. On August 9, the Duc d'Orléans became not King of France, but King of the French.
The description of the surgical aftermath of these three great days comes from a book written by Prosper Ménière, in 1830. Dupuytren's disease is not mentioned in the interview; that is because, by the time of the fictitious interview, it had not yet been described.

M.O. Having delved into the past, let us now look into the future. Where is Maîtrise Orthopédique heading?

L.D. Wherever our colleagues want it to head. This journal is not an institution, and it has to be guided by its original mission statement: to be a forum for communication among members of the orthopaedic fraternity. One of today's issues is the growing importance of communication via the Internet. We have, by and by, set up a Web site, which is free and open to all, and which has by now accumulated some one hundred articles complete with illustrations. The large number of visitors to our site shows that there is a real interest in this medium. I think that, nowadays, everyone everywhere should be able to access technical information on procedures or implants that they are interested in. Of course, publishing a scientific journal costs money, but the old system was often less than logical. Surgeons would develop their techniques at centres that would make the data available free of charge; the papers would then be reviewed and revised by the surgeons' peers, who, again, would not receive any fees for their efforts. In the end, however, those wishing to learn about the innovations produced would have to pay a comparatively high price for information that had been produced free of charge, in the first instance. It is these practices that the Internet may change.

M.O. But somehow the scientific publications will need to be paid for...

L.D. Agreed. But with the Internet, more people will have access to more information, at lesser cost. The real problem that needs resolving is that of checking the validity of the information provided on the Web, and the setting up of "official" sites.

M.O. Why did you go into surgery?

L.D. That is a question I often put to my interviewees. In my case, the answer is very simple: I grew up in Dakar, in Senegal, where my father had a little cabinet-making business. As a little boy, I loved the workshop, where all these craftsmen were working to create a piece of furniture. Did this influence my choice of orthopaedic surgery as a career? What I really wanted to do was architecture, and if I had been in Paris, I would probably have gone to art college; however, in Dakar, there was not much choice. The medical school diploma was recognized in France, and with the reforms in the wake of the 1968 student unrest, getting into medical school was easier. I was most impressed by René Louis, one of my first teachers and a superb teacher of Anatomy. I have never seen anyone that could rival him when it came to doing a "chalk-and-talk" anatomy lecture. At that time, I did not yet feel drawn towards surgery, but given René Louis' influence, once I opted for surgery, it had to be orthopaedics. It was a very moving event when I interviewed him at Marseilles, 25 years later.

M.O. And then?

L.D. I finished my medical studies in Paris, and then went into specialty training. The results of the specialty training entrance exam did not come out until quite late; so what people did was go and work in the provinces, where junior appointments could be had, in non-teaching hospitals, even if one had not yet passed the required exam. This way, I ended up doing cardiology at Chartres. A few months later, I heard that I had got into specialty training in Paris, and decided to do surgery, starting orthopaedics while still at Chartres.

M.O. And you never regretted this choice?

L.D. Ours is a beautiful profession. However, I think that practising it is becoming increasingly difficult. I do not think that we are being encouraged to excel ourselves. And if, as was once said, true freedom is known only by those who are confined and constrained, then I must say we are, currently, very free indeed.