More than 20 years ago, the Strasbourg Trauma Centre group, then headed by Ivan Kempf, developed locked intramedullary nailing. Arsène Grosse was chiefly involved with this technique, which was eventually adopted world-wide and which has revolutionized the treatment of limb shaft fractures. Maîtrise Orthopédique met this surgeon who has dedicated himself to traumatology, at one of the workshops he organizes within the International Association for Dynamic Osteosynthesis (AIOD).

 

A. GrosseM.O. : Mr. Grosse, your name is associated with the treatment of fractures and with surgery of the spine. Are you still doing both?

A.G. As you know, I am Chief Surgeon at the Illkirch-Graffenstaden Trauma Centre, near Strasbourg. At present, I am doing mainly degenerative spines and the sequelae of fractures; emergency trauma work is being done by my younger colleagues. The people I meet are a little surprised that I should have changed tack like this; however, there is a good reason why I did. In my professional life, there have been two distinct periods. During the first, I spent over ten years as Head of Accidents and Emergencies at the Centre of Traumatology and Orthopaedics, doing trauma work in the widest sense of the term - fractures, vascular and visceral injuries, neurotraumatology, and spinal trauma. During that period, I was able to evolve my technique of locked nailing of the femur and the tibia, and a little later to develop the Gamma nail and the devices following on from there. Thus, over many years, I saw and dealt with every fracture in the book (and a few more); eventually, though, I felt that the time had come to leave all this to the younger generation of surgeons. I had always been fascinated by spinal surgery, which is why, in the second period of my professional life, I turned to that branch of surgery. To answer your question, I would say that my time is shared between surgery of degenerative conditions of the spine, hip surgery, and the treatment of fracture sequelae - especially non-union and malunion, which means that I often have to do closed osteotomies. However, I think that we shall be coming back to that subject, anyway, in the course of this interview.

M.O. : What made you go into traumatology and emergency surgery in the first instance?

A.G. I qualified for a specialty training post in 1967, and had a six month gap before I could start. There was a place going at the Trauma Centre, and since I was keen not to lose any time, I seized the opportunity - and that’s how I discovered emergency surgery.

M.O. : You are said to be a great all-rounder, which is ideal for a traumatologist. How did you become skilled in so many subspecialties?

A.G. Let me tell you about my training. I spent my first year of specialty training at the Trauma Centre, where I soon saw the need for all-round training, so as to be able to treat trauma in all its forms. So I went and spent two years with Prof. Fontaine, who did mainly vascular and abdominal surgery. Having gained experience in these fields over a period of two years, I went back to the Trauma Centre, to finish my training. There were lots of neurotrauma cases, so Prof. Ivan Kempf suggested that I should round off my training in the Neurosurgery Unit at Colmar; so I spent three months there, with Mr. Baumgartner. After that, I was lucky enough to be able to work for three months in Prof. Houdard’s Department, at the Lariboisière Hospital in Paris. This broad-spectrum training enabled me to tackle most of the situations that one tends to come across in traumatology; and that was exactly what was required, because we were then - and still are today - in a facility separate from Strasbourg Regional Hospital. The idea of a trauma centre had come from Germany and from Austria; we had found it attractive at the time, because it meant that the whole spectrum of trauma could be treated in one and the same place, by one and the same team of surgeons. In Germany, this concept has been retained, and surgeons are still being trained in all aspects of trauma surgery, to tackle skeletal injuries as well as visceral ones. In France, this is no longer so; here, the treatment of bony lesions is becoming increasingly divorced from the treatment of visceral injuries.

M.O. : Do you think that a stand-alone trauma centre, away from the regional hospital, would be inherently better able to deal with multiply injured patients?

A.G. Unfortunately, I must say that that is no longer so: nowadays, our senior and middle-grade registrars lack the training that would enable them to deal with visceral trauma, and we have to bring in abdominal and vascular surgeons to do this kind of surgery. Sometimes, we even have to transfer patients to the Regional Hospital, because of special requirements, for instance for special imaging techniques. As regards the overspecialization of our junior surgeons, I think that training in subspecialties is a good thing, but it should not be pursued at the expense of wider and more general training in traumatology; in particular, vascular and abdominal surgery are vitally important. Our traumatologist colleagues in Germany and in Austria are lucky enough still to be trained in both orthopaedic and abdominal/vascular surgery; they are all-round traumatologists and do nothing but trauma work throughout their careers, without ever doing elective orthopaedic surgery.

M.O. : You were one of the inventors of a closed method of managing limb fractures. What was it that prompted you to look at the possibility of doing closed intramedullary nailing at a time when open anatomical reduction was the mainstream technique?

A.G. To answer this question, I shall have to give you a little background. I was working as a surgeon at a time when intramedullary nailing and plating had reached the limits of their capabilities. Simple (unlocked) closed nailing was an excellent technique for the treatment of simple middle-third shaft fractures. However, if was not very suitable for proximal or distal fractures, and quite unsuitable for unstable three- or multi-fragment fractures. There were many complications and sequelae; in particular, there were cases of non-union, of malunion in varus, valgus, or rotation, and limb shortening from the telescoping of the fracture fragments. In order to overcome these problems, we did, at one time, practise open nailing with adjunctive plating to prevent rotation, or with cerclage. Even so, there was a notoriously high rate of complications: delayed healing, non-union, and above all osteitis, were frequently seen. Comminuted fractures were managed differently in the two Strasbourg trauma centres: Prof. Eugène Schvingt’s department had a policy of alignment nailing, which meant inserting in a nail and putting the patient on traction until a callus had formed. At our centre, Prof. Ivan Kempf had devised a different concept, which he called delayed fixation: the patient was treated with traction for three to four weeks, until the fracture had started healing, after which the bone would be nailed. However, even with all these tricks, proximal, distal, or comminuted fractures still tended to have a poor outcome, and the technique was not popular elsewhere in France. In particular, the Judet and Letournel group were against it, since they had encountered many complications - aseptic or infected non-union - with this technique. Also, at that time, the A.O. people in Switzerland had come up with their technique of open reduction and internal fixation with plates and screws, which allowed all the fragments to be anatomically reduced. This was a very attractive idea that was taken up by many surgeons. However, once again, the initial enthusiasm had to be tempered, eventually, since this technique of open reduction and rigid internal fixation soon produced its own string of complications: delayed healing; non-union; refracture after hardware removal, due to stress shielding; and infected non-union or osteitis with sequestrum formation, due to the loss of blood supply to the fracture site. Thus, open reduction and internal fixation had also reached the limits of what it could do. In our Department, badly comminuted shaft fractures were treated with continuous traction for a period of six weeks. However, that was also fraught with major problems, in particular complications of prolonged recumbency such as muscle wasting and deep vein thrombosis that would worsen the outcome; to say nothing of the many instances of malunion or non-union in the wake of complex fractures. At that point in time, Prof. Kempf met Mr. Klemm and Mr. Schellmann of Frankfurt, Germany, who were showing their locking nail (Verriegelungsnagel) at a conference. He thought it was a great idea, and I was allowed to go to Frankfurt to see this surgery being done. That was in May 1974, and as soon as I was back in Strasbourg, I introduced the technique at our Trauma Centre; I did the first locking nail there in June 1974. After that, we improved the hardware and the instruments, and developed the targeting system; as a result, I was able to insert the first Grosse&Kempf locking nail two years later, in June 1976.

M.O. : After these clashes between the advocates of the open technique and the defenders of the closed technique, is there now some sort of consensus on the ideal mechanical and biological conditions for fracture healing?

Mechanically, the ideal, as I see it, would be to have good stabilization with an elastic construct - in other words, non-rigid fixation of the fracture site. Biologically, the periosteal blood supply is so hugely important for callus formation that it must be preserved as much as possible; equally, the fracture haematoma should be preserved. These, to me, are the ideal mechanical and biological conditions that will make for sound fracture healing. These conditions are provided by closed intramedullary nailing.

M.O. : Do you think that there is no place any more for the plating of limb fractures?

A.G. Of course, plating still has a place in the management of metaphyseal or epiphyseal fractures, where nailing cannot reduce or stabilize the fracture adequately. At our Centre, we have rolled forward the frontiers of nailing, to make the technique suitable for very distal femoral and tibial fractures. To this end, we have used nails with a sawn-off lower end, so as to be able to lock them as far distally as possible. In these borderline cases, one may use a locking nail, providing one can insert two screws, with a good purchase, in the distal fragment. There is, thus, clearly still a place for the plating of metaphyseal and epiphyseal fractures, in patterns where this double locking cannot be obtained. For shaft fractures, I think that nailing is vastly superior, and plating has no role to play, except under very special circumstances. To me, plates have too many disadvantages, which I have already mentioned; and even with the various “tricks” recently suggested, such as biological internal fixation, plates cannot produce the same benefit as nails. So I think that the proponents of plating for all fractures are now fighting a rearguard action. To my way of thinking, the fixation of a shaft fracture consists in closed fixation with a locked intramedullary nail.

M.O. : Reaming of the medullary cavity has often been criticized because of the way in which it may destroy the blood supply and cause ischaemia. How do you see this, especially in the treatment of open fractures?

A.G. Yes, there has been much criticism of reaming over the past years; in particular, it has been said that reaming promotes infection, that it increases compartment pressure, and, above all, that it can cause fat embolisms. In actual fact, the comparative studies of nailing with and without reaming have shown these ideas to be wrong: the teams working with reaming did not have higher complications rates than did the non-reamers. On the contrary, without reaming the nail and, consequently, the screws must be of smaller diameter, which leads to hardware-related complications such as screw or even nail breakage, and rules out early weight-bearing. We are therefore still completely convinced that reaming should be performed - obviously, within reasonable limits and not to excess. We would no longer consider inserting 16mm or 17mm diameter nails in a femur, the way we did early on. Nowadays, the usual diameters are 11-13mm for the femur, and 10-11mm for the tibia. We have remained with this technique, because, as we see it, the problem is not related to reaming as such but to the design of the reamer. The reamers currently available are very sharp instruments, and they are used at low speeds. These instruments no longer cause the thermal damage that one would see with the earlier, blunt-tipped reamers. As regards the use of nailing in the management of open fractures, our policy has evolved a great deal. Early on, we said that Grade I and II, sometimes even Grade III, open fractures of the femur and the tibia should be nailed; however, we had frequent complications, especially after tibial nailing. Thanks to progress in plastic and reconstructive surgery, we now know that these complications had nothing to do with nailing or with reaming; they were related to the management of the soft tissues. Now, we can treat a fracture and the associated soft tissue damage in one go, and the complication rate is much lower than in the past. The present-day policy at our Trauma Centre is as follows: In the femur, all open fractures, regardless of grade, are managed with nailing. In the tibia, Grade I, II, and IIIA open fractures are nailed, with additional plastic surgery in these cases. We would use an external fixator only for Grade IIIB or C fractures, and for limb salvage cases, especially where there is total ischaemia and speed is of the essence to stabilize the bones so as to be able to repair the damaged blood vessels.

M.O. : The technique developed by you in Strasbourg spread rapidly, to the extent that there is hardly a country left nowadays that has not heard of the Grosse&Kempf nail ...

A.G. The locking nail was a success from the word go, probably because this technique allowed the surgeon to avoid the shortcomings both of nonoperative management and of plating or simple, unlocked nailing, which were producing unacceptably high complication rates, especially in complex fractures. Once we had gained three years’ experience with locked nailing, we organized our first symposium in Strasbourg, in April ‘77; that early event was attended by no fewer than 250 surgeons, who had come to learn the technique and hear the first results obtained with this new method. This symposium was followed, from 1978 onwards, by a series of theoretical and practical courses, which were initially held at the Trauma Centre, using such facilities and equipment as were available there. Soon, however, it became necessary to expand the range of languages in which the courses were held: German and English were added to the original French. In addition, may colleagues from different countries were interested in the technique, and started organising conferences in their countries. So we travelled a lot, visiting other centres, reporting the results obtained with our locking nail, and above all teaching the technique - and that way, the word was spread and the technique established in a large number of countries. It was chiefly thanks to the sustained teaching effort both at home and abroad that locked nailing became known in the five continents. We have published our results in many French and international journals; in particular, there was our pioneering article in the Journal of Bone and Joint Surgery, detailing our experience over the first ten years. And finally, we set up AIOD - the International Association for Dynamic Osteosynthesis - in Strasbourg; this organization serves to promote the dynamic fixation of limb fractures, especially locked nailing. AIOD has set up branches in many countries, and there are now some ten or so national Associations, which are instrumental in teaching the method.

M.O. : So your teaching activities have always been conducted outside the universities?

A.G. Unfortunately, yes.

M.O. : So what are your relations with the medical schools?

A.G. At present, we have none.

M.O. : Do you regret that you were never given a Chair?

A.G. I used to, but that was in the past. You see, I am often invited by professors and universities all over the world. I regularly teach on traumatology courses organized by famous hospitals or medical schools, especially in the United States, the UK, Germany, Austria, Hong Kong, and many other countries.

In Strasbourg, we annually run several courses that are attended by surgeons from all over the world. Sadly, however, all of this has always been done outside the University. This goes to show that one may be known world-wide without being a professor - and I am not the only one in France to be in that position. It is sad, though, that the courses that we organize in Strasbourg count as postgraduate training in Belgium, whereas our French participants, at present, get no credit for attending.

M.O. : Closed intramedullary locked nailing is a comparatively difficult technique, where every detail counts - from patient positioning to the targeting of the locking holes. It has been said that the technique is easy only at your Centre, where you have a highly skilled team. You have done nailing in many other countries - so how would you counter this criticism?

A.G. It is true that closed intramedullary nailing is comparatively difficult, and even at our Centre, where we do this day in, day out, we occasionally run into difficulties. Like any closed technique, intramedullary nailing has to be learned patiently and practised meticulously, with attention to the smallest detail. One also needs a certain minimum of equipment, especially a good fracture table so as to be able to reduce the fracture correctly; an image intensifier that can be turned in all directions without having to reposition the patient; and, above all, highly skilled radiographers. But, as with other techniques, I would say that everything can be learned, providing that one follows the recommended technique step by step without trying to change things, since that might only make one reinvent the errors of the past. Above all, the surgeon must be familiar with the many special tips and tricks associated with this technique; these are always taught at our courses and workshops that are held every year. I have done nailing in many countries - indeed, I could go so far as to say that I have done surgery in all five continents. As a result, I have been in modern theatres with all the required facilities, in such places as Hong Kong, Singapore, Canada, or the United States. Equally, there have been countries where conditions have, sometimes, been more difficult. However, I have always managed to complete the procedure; and I think that with a little technical skill and common sense one can perform closed nailing anywhere, even without the latest equipment.

M.O. : What do you think of the different distal targeting techniques that have been developed in order to reduce the radiation burden on the surgeon?

A.G. We have always been keenly aware of the radiation problem, and have developed our own method of distal locking using a targeting device to keep the surgeon out of the radiation field when putting in the screws. When targeting the screw holes, the surgeon is outside the field; and when the screws are being inserted, there is no radiation hazard. If the surgeon does not have the targeting device mounted on the image intensifier, he or she may use the free-hand targeting device; I myself have frequently done so when travelling abroad. However, the free-hand device has the disadvantage of exposing the surgeon’s hands to radiation, which is why we prefer the traditional device. As far as I am concerned, radiation protection has been resolved; it is no longer a problem.

M.O. : Intramedullary nailing has been gradually extended to the management of humeral fractures, and recently to that of hip fractures using the short and the long Gamma nail. In the recent literature, there has been some criticism of the Gamma nail. What do you think?

A.G. Once femoral and tibial nailing had been found to be reliable, we started extending the technique to other bone shafts. For the humerus, Mr. Seidel in Hamburg developed a nailing technique, while ulnar nailing was developed by Prof. Lefevre in Brest, who is now working on a nail for the radius.

Hip fractures are complex patterns that are difficult to manage because of the underlying osteoporosis, and because these patients should be up and weight-bearing as soon as possible. None of the previous methods - whether hip screws, blade plates, or even Ender nails, which we were using a lot - had proved to be ideal. This is why we developed the Gamma nail, which we have been using since 1987. The design goes back to a pattern originally developed by Küntscher, who used a Y nail for the management of such fractures. The Y nail never became widely used, because it was difficult to insert. There was no targeting system for the neck screw, and eventually the device came to be used only in simple and stable pertrochanteric fractures. We got the idea for the Gamma nail from the nailing of proximal femoral fractures. At this site, we would use inverted nails - for instance, a right-hand nail for a left-sided fracture - which allowed the proximal locking screw to be put in the neck and the head. However, the inverted locking nail was not really suitable for this kind of fracture, and there were many complications, especially non-union with nail breakage. So we devised a new implant, the philosophy of which was still the same: intramedullary fixation, a closed technique of insertion, and anatomical reconstruction of the proximal femur. The result of this design work was the Gamma nail, which met all the requirements of our specification, and also allowed for full and immediate weight-bearing postoperatively. To the standard Gamma nail was added a long version, to cater for fractures involving the trochanteric region and the shaft, neck fractures or pertrochanteric fractures associated with shaft fractures, or metastasis-related fractures. The Long Gamma nail makes it possible to bridge the fracture zone from the epiphysis to the diaphysis, with proximal fixation by means of a lag screw in the femoral neck and head, and distal locking by means of two screws lower down the nail. The Y pattern produced by the intersection of the nail with the lag screw takes the load off the fracture zone, no matter how extended this zone may be; this, in turn, makes it possible to weight-bear immediately after nailing, regardless of the fracture pattern. Healing can be very rapid, since the nail is inserted by a closed technique. While there has been some criticism, especially in a paper published in the Journal of Bone and Joint Surgery stressing the large number of technique-related complications, the Standard and the Long Gamma nails are the gold standard management principle for hip fractures in the elderly, and for fractures involving the trochanteric region and the shaft in young subjects, because these nails are ideally suited, both mechanically and biologically, for the management of these fractures.

M.O. : What further developments of the technique do you have in mind?

A.G. I think that the indications for shaft nailing are now well established, and that anything nailable has been nailed. In our development work, we are now concentrating on closed osteotomy techniques. A very efficient intramedullary saw has been developed, which makes it possible to cut through bone without making an incision down to the osteotomy site. This way, the periosteal blood supply is not interfered with, and healing will be speeded up. These osteotomies may be used in the treatment of valgus or varus malunion, and in the management of rotatory deformities. We also use the technique for closed bone shortening, and for intraoperative lengthening by a maximum of 2.5cm. Of course, we are also interested in the gradual lengthening of bones over an intramedullary nail.

M.O. : Can shortening of a bone shaft still be done as a closed technique?

A.G. That’s a very good question. One needs two bone cuts to define the segment to be resected. If the segment is right in the middle of the shaft, there is no problem. The intramedullary saw is used for the cuts. The bit of bone that one wants to get rid of is then removed, either by cutting the segment in two and spreading the bits apart as the nail is being introduced, or by grinding the bone into a pulp with a burr. In some cases, a complete bone cut cannot be made via the intramedullary route, and then the technique has to be a little less closed. I do not think that this really violates the principle of a closed procedure, because all it takes is a short incision one to two centimetres in length to admit a sharp chisel that will complete the osteotomy.

M.O. : Let’s go on to spinal surgery. How did you change from being a trauma surgeon to working on the spine?

A.G. When I started my specialty training, all that was done for spinal fractures, generally, was reduction and casting, which would often lead to skin complications; and Harrington rods in the thoracolumbar spine. The Harrington rods did not always stabilize all the lesions, and additional immobilization was required. When pedicle screws came in, plating made it possible for very much more stable constructs to be inserted, and the patients no longer had to be casted. I have always had a liking for spinal surgery, and was very happy to cut back my trauma work in order to concentrate more fully on spinal surgery. Initially, I was interested in the surgical treatment of spinal injuries, but then I went on to work on degenerative conditions of the spine. I was also lucky enough to have been trained in abdominal and vascular surgery, so I had no problems with anterior approaches.

M.O. : There is still a lot of argument about the respective roles of nonoperative and operative management of certain fractures, especially of comminuted fractures without neurological impairment. How do you treat such cases at Strasbourg?

A.G. Quite generally, I would say that there is no doubt that some spinal fractures may be managed nonoperatively; the choice between operative or nonoperative requires a great deal of experience. As regards the specific problem of burst fractures, I think that the indications are now clearly defined. Surgery would be used if there is 50% canal encroachment by a fragment; if there is > 30° kyphosis; or, of course, if there is neurological impairment. In the emergency situation, we would reduce and stabilize these fractures through a posterior approach, since that route makes it possible to carry out laminectomy for decompression, where required, and to push the encroaching fragment forward. If decompression is incomplete, or if there is an anterior vertebral body defect, we would secondarily perform an anterior approach for interbody grafting. Alternatively, decompression could be performed through a primary anterior approach, with bone grafting and plating.

M.O. : In the cervical spine, you were one of the pioneers of screw fixation of the odontoid. Tell us about your experience.

A.G. We actually have considerable experience in this field. Odontoid screw fixation had been developed by Böhler in Vienna; I came to use the technique when, one day, I had to deal with a displaced odontoid fracture with a diastasis of almost one centimetre - in other words, a very unstable lesion, in a patient who also had neurological manifestations in the form of a Brown-Séquard syndrome. In those days, such a lesion would be managed with ungrafted posterior wiring as described by Judet. However, this would not have been adequate in this particular patient, who would have needed immediate occipitocervical fusion. Since the lady was still young, I decided to do an anterior fixation, and put a screw into the odontoid. After surgery, all went well, and the patient made a virtually full neurological recovery. At several months from surgery, she was able to walk with just a stick. To date, we have carried out 84 odontoid screw fixations, with very satisfactory results. The important point is that this is internal fixation, not fusion - which is why it is so good. We recommend this fixation chiefly for fractures with posterior displacement putting the cord at risk; for very unstable transverse fractures; and, above all, for “bobby’s helmet” fractures. Of course, nonoperative treatment still has a role to play; however, in all unstable fractures, especially transverse ones with to-and-fro displacement, and fractures with backwards displacement, we consider screw fixation to be mandatory. This method can be used in patients of all ages, since it brings about fracture healing without fusion, and, hence, without functional impairment; it is particularly useful in the elderly, who have problems with prolonged immobilization in a Minerva jacket.

M.O. : Who have you been particularly influenced by in spinal surgery?

A.G. In France, we are spoilt for choice when it comes to spinal surgery. All the great surgeons, in particular Roy-Camille, Louis, and Sénégas, are recognized not only in France, but in Europe and world-wide. I went and worked with all three of them. Initially, I was most influenced by Raymond Roy-Camille’s teachings on cervical spine surgery, and by Louis’ teachings on the surgery of the thoracic and the lumbar spine. Then, I worked out my own ideas, especially regarding the cervical spine, where I, too, came to abandon the posterior approaches, to the extent that we are now virtually only anterior ones, using the techniques devised by Sénégas. Within the AIOD, we are also organising spinal surgery courses, which are held every other year and which bring together the great French and European schools of spinal surgery.

M.O. : Finally, let’s talk about yourself. You come from Lorraine, originally. So, how were you received in Alsace?

A.G. Let me go back in time a bit. It is true that I come from Sarrebourg, and I went to school in that little Lorraine town, which is on a border between two language areas: on one side of Sarrebourg, people speak French, and on the other, the dialect of Alsace. So I can confirm that there is a certain rivalry between the people of Alsace and those of Lorraine; the Alsatians always think that they are “superior beings”, which they most certainly are not. This good-natured rivalry, in fact, goes back quite a long way, and has historical roots. I was turned towards Alsace, because at that time the Moselle, my native Département, was linked with Strasbourg University, so I took my school leaving exams in Alsace. I immediately fell in love with Strasbourg, and with Alsace in general, and that is why I am still here.

M.O. : All the people who attend your courses in Alsace are full of praise for the warmth of your welcome. You not only teach surgical know-how, but introduce your course participants to the food and drink of your region.

A.G. Being a good host to my course participants is very, very important to me. Unfortunately, I must say that in France hospitality is not always what it should be, certainly not compared with how we are received when we go abroad. Alsace is a beautiful tourist country, with excellent food and wines, and a very rich cultural heritage. So one does not have to search for what one could offer - as a host, one is spoilt for choice. I think that this is an important aspect of human life - and it is quite possible to work hard all day in the lecture room and in theatre, and to relax afterwards, over some good food and a good Alsatian wine.

M.O. : You teach all over the world, and thereby help to make French orthopaedics and traumatology known abroad. How would you say we, the French, are seen by other countries?

A.G. Sadly, there are not that many French people around in other countries; our compatriots are not very mobile. Also, many French people have problems with foreign languages, including English, so our work is not very well known abroad. I think that there will be much to do, in this respect, for the younger generation.