Marcel Lemaire and Albert Trillat are two of the great pioneers of knee surgery and sports medicine. Marcel Lemaire is a fascinating man whose career has not followed the usual pattern, and he has kept his enthusiasm for everything around him. We talked to him ...

 

Marcel LemaireM.O. Monsieur Lemaire, how would you describe yourself?

M.L. Nowadays I would say I’m an old surgeon. My father was a doctor at Colombes. I went into surgery because when I was a child I very much admired the surgeon my father worked with, René Toupet.

M.O. Did you grow up in a particularly surgical environment?

M.L. No, I grew up in a medical environment, but I didn’t want to be a doctor myself as I knew what a doctor’s life was like, and I thought it was dreadful. But then I did have this great admiration for René Toupet. He was a great surgeon, and later on I did my specialty training under him. The extraordinary thing was that he quite naturally became the boss wherever he was. He just managed everybody. I was fascinated by some of the eccentric things he did. For example, he had a chauffeur, and one day when I was about 10 I asked him why he didn’t drive himself. He said that surgeons should never drive themselves because driving makes your hands shake.

M.O. Was he very high and mighty?

M.L. No, he was a very friendly man; later on when I did my specialty training he was at Bicêtre and I think he was the best teacher I trained under. He used to take his students around with him and make them operate on fresh cadavers. I spent the fourth year of my specialty training with him and he got me doing some advanced surgery.

M.O. Was your specialty training in general surgery?

M.L. I did general surgery with a tendency to specialise in chest surgery. I was lucky enough to work with Orsoni, who was not a hospital surgeon; I’d met him at René Toupet’s. Orsoni was a wonderful chest and abdomen surgeon who virtually adopted me. I spent 30 years with him doing oesophaguses, stomach cancers and so on. I also spent some time working with Ménégaux at Lariboisière, at the same time as Méary. I also did some of my training with Mouchet in the night-time trauma centre at Marmottan, when Marmottan was a night-time emergency hospital. One unfortunate thing I do remember from those days is that they reduced fractures under fluoroscopic control. I use the word “unfortunate” because I still have the effects of it in my hands. And then I did the last part of my specialty training under Quenu.

M.O. What was Jean Quenu like?

M.L. It would be a bit of an understatement to say he was a cold man. He was the sort of boss who would call you into his office and just leave you standing there. He would be writing away and would pretend not to see you for a good 5 minutes.

M.O. But his book on specialty training suggests that he did have a sense of humour...

M.L. In his book, possibly; but to work with, he was not a bundle of laughs.

M.O. Where did you do your advanced surgical training?

M.L. At Hôtel-Dieu, under Brocq. He had a very large department which included the whole ground floor of the Hôtel-Dieu. He had a lot of people working around him. Cerbonnet was training there at the time, along with Houdard and many others. It was an easy working environment as there were so many of us, including four registrars and a couple of senior registrars. I don’t remember learning a great deal but this was the period when I was already helping Orsoni, who taught me so much. He was regarded as the top surgeon in France for the oesophagus. He got me to do my thesis on the use of colon as an oesophageal replacement.

M.O. I gather you went to Greenland during your specialty training?

M.L. One day two skiing instructors came to Marmottan to see me and said “You’re keen on sport, you must come with us, we’re going to ski across Lapland.” It was a very interesting experience, a 700 km trip with all our equipment, as there were no supply stations. We were trying to find out what people could do in isolated conditions. I agreed to go with them, and off we went. When I got back to Paris after the trip, I had a phone call from Paul Emile Victor who said “I’ve heard what you’ve been up to, you must come to Greenland with me. I’m off in three months”. I said, “Fine, let’s go!”. I had to take a sabbatical year to do it all.

M.O. What did Paul Emile Victor want you to do?

M.L. He wanted me to be the expedition doctor. I must admit I made a bit of a mess of the first operation I had to do on the trip. We were by the sea with our camp set up, and one of Victor’s friends, who was also one of the expedition’s managers, had a toothache. I had a look and said that the tooth probably ought to come out as there could be an abscess behind it. He told me to go ahead and take it out. I had a box full of dental forceps in my equipment. Someone asked me if I realised there was a special forceps for each tooth. I was a bit lost; I knew it was a premolar, but I didn’t know what to do with it. No-one could help, and although my brother was a dentist I’d never seen a tooth being taken out. Everyone was most amused. In the end I picked up a forceps which looked about right and had a go - and fluffed it. But I did manage to get the tooth out at the second attempt; it had been hanging virtually by a thread and I could easily have got it out some other way.

M.O. Without any anaesthetic?

M.L. Yes. He was a brave man. Having said that, everyone on the trip was that sort of calibre. A lot of scientific work got done by the CNRS (the National Science Research Centre) on that trip. Amongst other things, we spent a lot of time measuring the thickness of the ice.

M.O. How did you spend your time?

M.L. The scientists had a lot things they had to do, but I didn’t have any specific job. So I was the ideal subject for Jean-Jacques Languepin, who was filming the expedition. When the film of the expedition was released in the cinema I was very proud because I was the leading actor. Well, I rather had to be, as all the others were busy.

M.O. All these opportunities came from your reputation as a sportsman.

M.L. In 1948 I was “Champion of Champions” of the Paris sports club known as the Racing Club. I was a member of an amateur football team in a regional championship; there was no amateur league in France in those days.

M.O. Was this what started you working with athletes?

M.L. Yes. I was being given professional athletes to look after when I was still fairly junior. I began working with the Racing Club’s professional players, even though I did not know the first thing traumatology. Even so, I should add that I was better qualified than my predecessor, who was a radiologist. As I had this responsibility, I thought I’d better learn a bit about trauma care. It just so happened that the managers of the Paris Racing Club were keen golfers, and almost every Monday a golfer from Lyons would turn up to play with them; that was Trillat. So eventually I got to know Trillat, and whenever I had a problem the two of us would discuss it. He taught me so many things.

M.O. When would this have been?

M.L. About 1949 and during the fifties. Trillat was already the top man for knees in France. He had a great reputation and he operated on practically all the professional players in France.

M.O. What did you do in those days when one of your athletes had a damaged cruciate ligament?

M.L. A damaged cruciate ligament? Don't laugh, but in 1949 no-one had heard of anterior cruciate ligament injuries, at least not in Paris. Some people even said the problem was genetic, as arthritic knees were often ACL-deficient. Meniscus injuries had to be diagnosed clinically, as arthrography hadn’t been invented. So if you had persistent pain in the medial joint space, you got a meniscectomy.

M.O. How did you do meniscectomies?

M.L. This wasn’t my idea, it was Trillat who showed me what to do. He started by making a nice long vertical incision. He left the medial collateral ligament intact and he did a nice neat surgical procedure. Then gradually he began using a smaller incision. He did an almost total resection, leaving the wall of the meniscus. That was his basic procedure, and he used it for years. I regularly sent athletes to him until one of them, an international athlete from Morocco, told me he didn’t want to go and see Trillat, he wanted me to operate on him. He had a torn meniscus. I had already done meniscectomies in hospital, so I did one on him. That was when I started getting really hooked on it all. After I had done this meniscectomy, the other athletes started coming to see me. In particular there was Roland Mesmeur; we were both regulars at the Racing Club and he was the top journalist on the sports pages of the Figaro. So every time I took someone’s meniscus out, it was in the Figaro. It went on like that till 1958. In 1958 Trillat went off to the World Cup, which was being held in Sweden, and I saw him again when he arrived in Paris. I talked to him about cruciate ligaments as I couldn’t get the idea out of my mind. I thought I was seeing an awful lot of ruptured cruciate ligaments.

M.O. How did you diagnose them?

M.L. 90° anterior drawer tests. But there was one thing which really struck me. On a number of occasions I had seen players have an accident on the field and when I examined them in the locker room immediately after the accident, they had a huge anterior drawer. I ewould put them in plaster for a month, and when the plaster came off the drawer would have disappeared. So stupidly I concluded that the way to cure ruptured cruciate ligaments was to put the leg in plaster. So I suggested this to Trillat when he got back from the World Cup. He had a bit of a go at me because he wasn’t keen on other people having ideas before he did. He said that the cruciate ligament was very simple ... “You take your patient and you sit him down with a 10 kg weight hanging on his foot and make him do a set of 10 extensions and flexions; two weeks later he’ll be better,” he said. I was a bit taken aback. A bit later I phoned him as I was looking after a dancer from the Opéra; I’d taken her meniscus out and she wasn’t getting any better. I got him to have a look at her and asked him if he agreed she’d ruptured her cruciate ligament. He said “No, it’s an unstable medial collateral ligament, all you’ve got to do is re-tension her medial collateral ligament”. Which I did, and it actually made things worse. Her drawer sign was getting worse and worse, and in the end I found myself wondering what the cruciate ligament was there for anyway. I looked it up in my old Testut Anatomy and found that the main role of the anterior cruciate ligament was to control internal rotation. Then I had a think about how one could restrain internal rotation, and I decided that you could do it either anterolaterally or posteromedially. I would get lost trying to do a posteromedial control, and that’s when I got the idea of using an anterolateral restraint. Which meant that Trillat and I fell out between 1960 and 1978.

M.O. Why didn’t you think of reconstructing the cruciate ligament?

M.L. Hold on, I’d already done that, I’d done Hey Groves procedures. He published a paper in about 1918 (in English) on reconstructing the anterior cruciate ligament using fascia lata. He passed his strip of graft through the lateral condyle and came back through the joint. He must have had good results as he published his technique, but it didn’t work in my hands.

M.O. But why not use another intra-articular reconstruction?

M.L. Because it was simpler to do an extra-articular one, and at the time it was a major surgical procedure to open a joint up far enough. One day in the sixties I met Castaing in the street in Paris. I knew him well as we were both more or less the same generation. Castaing was already in Tours, and he said: “You must come down one day and explain to us why you see things the other way round.” This was because Testut’s idea that the main role of the anterior cruciate ligament was to control internal rotation was the opposite of what people thought then. It may see a bit odd now, but at the time the accepted wisdom was that the role of the ligament was to control external rotation. People thought that ruptures of the anterior cruciate happened through a combination of valgus-flexion-external rotation.

M.O. How did you get the idea that you had to have an anterolateral restraint on the reconstruction you’ve described?

M.L. With the Hey Groves reconstructions I had already worked with strips of fascia lata, so it wasn’t too difficult to work out how to attach a transplant to the lateral surface of the condyle.

M.O. You didn’t try restraining the anterior drawer?

M.L. No, because when I did my external reconstruction for professional footballers, they could get back to playing football and were just fine. That was good enough for me.

M.O. How long have you been doing the operation?

M.L. Since December 1960, but I’ve made a few improvements over the years.

M.O. When did you realise the relevance of the pivot shift in cases of anterior instability?

M.L. I can’t tell you exactly, but it would be about 1962 or 63. It was a patient who showed me, he said, look, this is what happens. He locked his right foot and pivoted. This confirmed what I had been thinking about ruptures of the anterior cruciate ligament, and I was delighted. I adopted it as the pathognomic sign of a ruptured anterior cruciate ligament. I published my surgical technique and this characteristic sign of ACL lesions in the Journal de Chirurgie in 1967. Méary, who had just started the Méary files, summarised my article for the Revue de Chirurgie Orthopédique. One minor point, unlike may authors, I don’t use valgus stress when I’m doing a pivot shift test.

M.O. Throughout the 1960s, did you just get on quietly with doing your reconstruction, amidst general indifference?

M.L. No, not indifference, it was general disapproval right up until 1978. I’d been out of touch with Trillat since 1960, but in 1978 he was organising the first meeting of the International Knee Society in Lyons, and he phoned me and said: “There’s a Canadian who wants to come and speak about your operation, so you ought to be there.” He was kind enough to put me on before Galway. So when Galway got up to speak, he was a little put out, and said: “The new world has just discovered the old; I am going to describe 200 cases of the operation for which Dr. Lemaire has just described 2000 cases.”

M.O. During the period when you were developing your reconstruction procedure, did intra-articular reconstruction have any supporters?

M.L. Not many. The least bad of the intra-articular reconstructions was the Lindeman procedure. But in France in those days orthopaedics was more concerned with hip surgery than ligament surgery. Not many people outside the Lyons school were interested in it.

n M.O. What did the Lyons school think about the “Lemaire” during the 70s?

M.L. Awful things .... Don’t ask me what Bousquet thought about it.

M.O. What did Bousquet say?

M.L. Not a lot. He was keen enough on extra-articular procedures but only in bits of the knee where it didn’t work.

M.O. Looking back after 30 years’ experience, do you think your reconstruction is still valid?

M.L. It depends on the knee that’s being operated on, what’s expected of it and when the procedure is done, or to put it another way, it depends what the patient wants. The problem is to satisfy the patient rather than to please the surgeon. The ideal would be to rebuild the anatomy of the knee, everyone agrees on that. The only problem is that the Kenneth-Jones type of operation is major surgery with uncertain results, and I don’t think you can suggest it to a man of fifty who wants to be able to play tennis.

M.O. Do you do the Lemaire procedure in patients over 50?

M.L. Oh yes, and I’ve even done it on patients as old as 72. I remember one poor woman who had a very unstable knee, she didn’t even dare cross the road. She was reduced to just going round the block; fortunately, where she lived in Paris, she had plenty of neighbourhood shops. One day she’d had enough and she came to see me.

Now she can walk very nicely.

M.O. But the Kenneth Jones type of reconstruction has got much simpler and the complications aren’t too bad.

M.L. Well, if you say so. The results aren’t always so good. I see a lot of cases where intra-articular reconstruction has failed, and if I wasn’t so lazy I’d publish something on the subject. If you did a study of patients who had managed to return to their original level of sports activity after an intra-articular reconstruction, I think you’d be disappointed, and that might be why no-one’s done it. There are still an awful lot of complications. Dejour, who is a surgeon I respect a lot, started off doing intra-articular reconstructions, and in the end he started adding the lateral extra-articular reconstruction as a matter of course.

M.O. How useful do you find arthroscopy of the knee?

M.L. I was too lazy, I never got round to using arthroscopy, but I must say that I’m surrounded by colleagues who are delighted with it. I could have used the first arthroscope that was brought into France. It was Marie-Claude Tesson, who later went on to start the Quotidien du Médecin, who brought it back from Japan. I was at Levallois at the time. The problem was that the instrument had to be sterilised in formaldehyde.

I said to her: “I wouldn’t put anything impregnated with formaldehyde into my patients’ knees; if you want to operate on your own patients, bring them here.”

M.O. How old are you?

M.L. Seventy-eight.

M.O. How long should surgeons go on operating?

M.L. For as long as they enjoy it and don’t get too tired.

M.O. Do you still do a lot of surgery?

M.L. Yes, I operate as much as I did at 40.

M.O. Are you still enthusiastic about knee surgery?

M.L. There are a lot of things I’m still enthusiastic about. At the moment I’m very keen on problems of patellar stability.

M.O. Do you have any hobbies you’re keen on, apart from surgery?

M.L. I have always kept up my physical activities. Even now I still need to relax physically. I go riding; I keep a horse in the paddock at my house, which is on the edge of Chantilly Forest. The horse is looked after by a former jockey who rides it when I can’t. I think it is important to keep up a certain level of physical activity.