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One of the subjects of the XVIth Orthopaedics Seminar at Fort de France was revision surgery after total hip replacement. The session was chaired by one of the grand old men of orthopaedic surgery, whose name is inextricably associated with an entire era in the history of French orthopaedic surgery - Michel Postel.
M.O. : How are you, Mr. Postel?
M.P. I am very well, thank you. I retired - that is, I left the Cochin hospital - back in October, 1991. I then went on doing a little work in the private sector, but never felt at ease there. When one has been spoilt by the public hospital system ...
M.P. It was not having a team, and never being sure on arrival every morning that the implant that one needed, or the chisel that one needed, would actually be there. Also, having to leave the patients to themselves over the weekends. If anything happens, the patient is left without his surgeon. Whereas, with a team at a public hospital, the problem does not arise. Working in the private sector produces a lot of problems; and the problems are worse now than they were three years ago, when I was doing a bit of private work. However, I think it was my fault to some extent, for not having organized things properly. I had got totally used to being part of a big organization where everything was being taken care of; and then, from one day to the next, I found myself completely on my own. Since I knew that this was not forever, I did not go to any great lengths to build up a team of my own. With hindsight, I rather regret those two years of exclusively private practice.
M.P. I had a registrar from the Cochin hospital as a general assistant, as well as my son Jean-Marie. So there were some capable surgeons to finish the operation if I had keeled over halfway through. I was not that tired, but - rare though it may be - it has been known for surgeons to just collapse during a procedure; I have known such cases myself.
M.P. I travel a lot; I visit my children wherever they live; I am taking golfing and bridge lessons; etc.
M.P. No. I would either go skiing in my holidays, which I still do, or offshore fishing, which I also still do. However, these were not everyday activities.
M.P. Oh, I have not lost my interest: I still attend the SOFCOT congress, for instance. With Maconor and the French Standards Organisation, I am still looking into the problems of orthopaedic hardware. And I have even been invited to a number of panel discussions.
M.P. Quite a bit, I think. I sometimes worry, when I am on a panel, that I am in the wrong place. The different implant patterns; the battles between cementers and non-cementers; the prevention of postoperative infections; the treatment of septic lesions - when I go back to the Cochin on Mondays, I have a feeling that I have been left behind by things that have been happening more recently.
M.P. Agreed, things are not that different; but I still have the feeling that I am looking on from the sidelines.
M.P. There is hydroxyapatite. On the femoral side, nothing much has changed. Very, very often, the acetabular cup is fixed without cement; and that seems to work quite well. But it is certainly not the solution to all the problems, especially when it comes to revision surgery.
M.P. We still did a small number of osteotomies. They were for dysplastic hips, and for OA in dysplasia, at an early stage, in patients who were still quite young. We did varus osteotomies or Chiari procedures.
M.P. I think that it is a perfectly sound procedure. I was almost the only one in my Department to perform this procedure, because the junior surgeons came and went, and did not have the time to assist in a Chiari, let alone do one. These osteotomies were very suitable for younger subjects, in whom the type of OA would have ruled out varus or valgus osteotomies. It is a very good operation.
M.P. Shelf procedures in dysplastic hips without OA cannot be overdone. The Chiari osteotomy has almost the same indications as the shelf procedure; however, it should be used in cases of advanced OA, where a femoral osteotomy will not help.
M.P. This is undoubtedly a good operation in carefully selected patients; but it's too much for me, it's too difficult. And even apart from my own personal misgivings - it is a very major procedure for hips that will never be normal, anyway, and which will eventually need arthroplasty.
M.P. I would say 50, as the uppermost limit. Sometimes, this limit may perhaps be exceeded; there again, it may be too high. Overall, though, excellent results may be obtained with a shelf procedure up to the age of 45.
M.P. Yes, shelves have to be done with as little soft tissue damage as possible, with great attention to repairing the muscles. There are so many poor ladies who are left with a huge hole on the iliac crest after they have had their tensor fasciae latae taken down. That's a disgrace. A good shelf never produces poor cosmesis, if I may put it like that. However, surgeons are losing the know-how a bit. My successors are not doing that many shelf procedures any more.
M.P. It all depends on how fast the OA is progressing. I do not think that one should draw any hard and fast lines. To say, "You are not yet 50, so you can't have a prosthesis: You are 51, so you can," is ridiculous.
M.P. I think that was because of the patient mix at that hospital. For a long time, the Cochin was getting all the hip cases. That was a long time ago, when little was being done for these patients elsewhere. People came to us from the country districts to have their dysplastic hips treated; whereas nowadays there are 150 orthopods in Paris alone who would pounce on such cases. The patient mix has changed, and with the way orthopods are now trained, dysplastic hips get done where the patients live, without the need for them to travel to the capital.
M.P. Of course, in simple OA with a well-centred femoral head, in patients of normal height, it is a bit of a routine procedure; however, it is nice to do a good operation. The other thing is that the more one specializes in one particular procedure, the less one tends to be able to do all the others. I did quite a few knee replacements, but I never really got involved. Others were moving things along, and I just jumped on the bandwagon.
M.P. Well, as a rule, if you are on to a good thing, you don't want to change. Also, I had burned my fingers before, trying out new things. At the time of the metal-on-metal McKee-Farrar, we wanted to go one better, and developed a metal cup with slip rings. The idea was to reduce friction; and in vitro it worked infinitely better than the standard metal-on-metal combination. However, we did not then know what we know now, and we got the biological consequences of wear debris badly wrong. Cobalt debris led to appalling reactions around our patients' hip joints.
M.P. We had all sorts of misgivings. One reason why we hung on to the McKee-Farrar for so long was the cavity one creates with the Charnley. You remove that big arthritic femoral head with all the osteophytes, and the big femoral neck; and then you replace all this with a tiny 13 mm diameter femoral component. In other words, you leave a cavity, which obviously is full of blood, and where the least little staph that comes wandering along could cause havoc. We were also worried about dislocation, and we actually had a some cases. It is quite obvious: The small heads are good because they do not produce much wear, but they are bad at preventing dislocation.
M.P. After some five or six years, we realized that there was subsidence of the femoral component. The implant would subside in the cement, with a sort of fissure on the medial border of the prosthesis. We found that complication in between 10% and 15% of our patients. By changing the dimensions of the stems and by getting better medullary cavity fill with the implant, we were able to get rid of one of the causes of implant failure.
M.P. That is quite true. However, whenever we reviewed the results of the patients who had had a Charnley, they were better than the others. I think that at one year the rate of excellent results following a Charnley arthroplasty under normal circumstances is 99%. So what would be the use of starting another study, in the hope of having a 10-year rate of 99.9 %, but running a risk of getting less good results? It may not have been a very courageous policy to adopt, but at least it was a reasonably ethical one.
M.P. It is easy to disparage it. Much has been said and written against cement, but I do not think that cement is causing that many problems. When all is said and done, much of what is called cement disease is in actual fact poorly-done-implant disease. We had always said that, eventually, polyethylene wear would cause problems - both by altering the dimensions of the acetabular cavity, and by producing polyethylene debris. With Langlais, we tried to research new materials. We went to the experts at the College of Technology, but they sent us packing, saying that there was no better material in terms of wear and abrasion resistance as well as ease of use.
M.P. The uncemented alumina socket seemed to me to be preposterous, something that stood very little chance of remaining soundly fixed. And using it with cement is less effective. I was sorry not to have an alumina femoral head; however, one would have needed a bigger diameter, go to 28, and then...
M.P. I cannot fully see what has changed, but it would appear that the Swiss are going back to a device that was a failure here and even in their own country. I am very fond of Maurice Muller, but that looks a bit like change for the sake of change.
M.P. Pauwels came to a conference in Paris, in 1952, and showed some X-rays which were astonishing. Like Méary, I was, at that time, a Senior Registrar in the Department. Two weeks later, we went to Aix la Chapelle to watch Pauwels at work. We spent three days in a non-stop programme of private lessons, and then took what we had learned back to the Cochin. This was a major exercise in postgraduate education and training.
M.P. You can imagine what is what like, in a Department with only two senior registrars, when both come in and want study leave at the same time. However, there were no problems, and we went off for three days, together with Roger Timal and Louis Descamps. At that time, there was also Cauchoix and Ramadier. When we got back, Merle d'Aubigné just let us get on with it. For total replacement, it was similar. One day I got a phone call from Nissen, a British orthopod, who was running a beautifully organized postgraduate course in London. That was back in '65. He said to me, "You ought to come over to Norwich, we have got something interesting going on here. You will learn all about total hip replacement." So we told the boss about it, and off we went to Norwich. It was like a little English club, and McKee was presenting his results. There were patients there, who had been asked to attend bringing their X-rays with them; and these patients were walking without crutches or sticks. On the Sunday, McKee did two patients while we were watching. We then went back to Paris, after having asked McKee to come to our centre to do a couple of hip replacements there. That's how it all started. Before that, we had only had the Moore endoprostheses. We had never seen anything like the results McKee was getting.
M.P. Yes.
M.P. Perhaps because of Watson-Jones. He was the most widely travelled and the most international of all the Brits. He was absolutely brilliant. However, Seddon, too, was a remarkable surgeon. He was very quiet, reserved, cautious, and very strict - not the sort of qualities one would have found a lot in France, at that time.
M.P. The French had no proper patient records, they did not examine their patients thoroughly before surgery. The results were always "excellent." Why? Because they were. It was all pretty simplistic. Nowadays, people tend to overdo the statistical approach: At the time, there were no statistics; there were no proper case notes; there were no scoring systems.
M.P. I was involved in the exercise, but the actual system was not my brainchild. My name is always quoted, but the idea was Merle's. He had drafted the rating system, and presented it to a SICOT conference in '49 or '50. Nobody took any notice at the time, but two or three years later, when acrylic devices were in full swing, the Americans invited him to give a lecture on hip arthroplasty, which was subsequently published in the Journal of Bone and Joint Surgery, together with a table showing the score. I had prepared the paper, which had Merle d'Aubigné and Postel as authors; however, I did not invent the rating system.
M.P. That was a very strange story. At the time, junior doctors would apply for four different posts where to do their four years of specialty training. So, as soon as one had one's examination results, one had to find a consultant in whose department one thought that one might like to work. And all one had to go by was some word-of-mouth recommendation. It was Morel Fatio who said to me, "I think you should see Merle d'Aubigné. He is not yet a Professor, but that won't take long." During my first year as a junior surgeon, I came across a special issue of Semaine des Hôpitaux, which was all about Merle's centre. I realized then what a thorough researcher he was. I read about his idea of a scoring system, the explanation of the quality of the results obtained, the importance of follow-up. To me, this was something utterly new. I had put patients in plaster of Paris casts in the two departments where I had worked before as a junior orthopaedic surgeon; but those casts were awful, just horrible. Merle, on the other hand, did beautiful orthopaedic surgery, real orthopaedic surgery; Merle operated on patients that had been properly examined. The training year I spent in his Department was not a disappointment - it was an experience. However, it was also a case of me getting on with him, or he with me: We were on the same wavelength, and I was one of the few that could get near him on days when he was in a rage.
M.P. Méary was six months ahead of me. We qualified for specialty training at the same time, and we both started out in Merle d'Aubigné's department in 1947. We got on very well with each other. He was a tremendous character; he would organize anything - the Department, medical illustrations in the Department, a panel discussion on any subject under the sun. He was a workaholic. I liked him very much, and when we were doing ward rounds together, we would secretly think that it would be nice if we could both get jobs in the Department as fully qualified orthopaedic surgeons. And that is exactly what happened.
M.P. That is so. Robert Méary did not get on with our boss as readily as I did, because he would put his feet on the table, and annoyed the old man by his laid-back way of doing things or saying things. But he worked extremely hard, he worked fast, and his papers were always ready on time. When Merle gave up foot surgery, which was boring him, Méary took over, with great efficiency, and did studies and produced results. And then came the time when old Merle d'Aubigné retired - and a successor had to be found. Méary and I had got it all fixed to make sure he would be the next head of department. I had had a bit of a row with the boss, because he wanted me to be his successor, and I didn't want the job, because I thought that Méary had what it took.
M.P. It was a somewhat unusual situation. The only way of making sure that Méary would be back at the Cochin was for me to stay put and for him to be made the immediate successor of Merle d'Aubigné. At the time, Méary and I were at exactly the same level of seniority; we were both professors with tenure.
M.P. That was why he was so heartily disliked by quite a few of his colleagues. Also, he was not very tolerant. When something needed saying, he would say it, without mincing his words. But it was also a bit of a game, because he was always spoiling for an argument. The other thing was that he couldn't stand being called "Merle", because in his class of society, one said "Monsieur d'Aubigné", not Merle. One day, Léger wrote to him, addressing him as "Dear Merle". So he wrote back, "Dear Lé".
M.P. Yes, that is a saying by a Greek philosopher. I have never been able to figure out quite what it means - whether it implies that what one says should reflect what one does, or that what one does should reflect what one says. As Merle understood it, talking about an operation was valid only if it reflected what one did. Or to put it differently, what one said should agree with what one did.
M.P. No myth at all. They always remained gentlemen, and never came to blows. They never got particularly abusive, but the difference of opinions on fracture healing was patent, as were their diametrically opposed views on the practice of our profession.
M.P. Basically, it was that Merle was extremely cautious. Judet, on the other hand, once he had had an idea - and did he have ideas! - would immediately tell everybody about it and write it up.
M.P. I got the impression that some colleagues would dream up a modification to an existing implant during the night, or think of something completely new, and then go and apply that next morning. Not surprisingly, some of these implants created overnight were a disaster. I myself did some preliminary research and still finished up getting it badly wrong, when I designed the slip ring prosthesis. However, we should remember that, at that time, industry was there to serve the surgeons. And the orthopaedic surgeons were full of go and energy, and efficiency in their research. It was not till later that they were spoilt by industry, to the point where a number of colleagues started doing just about anything, changing some minor detail on an implant to get royalties.
M.P. Together with the Internal Fixation Committee of SOFCOT, I tried to establish quality criteria for hip replacements, but it was horrifyingly difficult. How can one justify the selection of a particular criterion? And sorting out the economics of joint replacement is equally difficult: If one fixes a very low price level for implants, one deprives the companies that do good R&D of a proper reward for their activities.
M.P. I think some surgeons got what was coming to them. Those who "designed" implants that were copies of some other device, with just a little whisker that had been changed so as to increase the price; those who set up little "ghost" companies that were supposed to buy the implants from the manufacturer and to sell them on via a middleman, who happened to be the surgeon-company director's wife; etc.
M.P. I was - in fact, we thought that infection would be the most important complication, the more so since we were unable to control it. There was one principle then: An infection in the presence of a foreign body is halted by the compulsory removal of that foreign body. It was Charnley who said that if the functional status of a possible candidate for joint replacement was better than the result of a head and neck resection, one should leave well alone. Initially, we thought that we had escaped the problem, because we had had a run of good luck in the first three or four years, without any acute infections. In fact, it took us a long term to learn to interpret the X-ray films of cases with septic loosening. These things were not obvious initially.
M.P. Quite late. We had started putting our patients on antibiotics, but not correctly, not before surgery, and not necessarily using the right antibiotics. The appropriate regimens took some time to emerge. Then, we tended to give prophylactic antibiotics in excessively large doses and for too long a time, so we were probably causing resistances that would not have occurred with better dosing. Research into the problem of infection was immediately assigned to the unit in our Department where I was. Evrard had already started working on infection, together with Merle d'Aubigné.
M.P. He had offered to do a first survey on postoperative infections, back in the '50s. Evrard was a quiet, self-effacing man, who was not interested in a grand title, nor in making more money.
M.P. Yes - and he would defend his ivory tower tooth and nail. He could be a bit of an old so-and-so, but by and large it was very nice working with him. I told him straightaway that he could do as he pleased, but went to see him every now and again. Whenever there was a problem, he would talk to me about it. He was the ideal person to work with.
M.P. He had worked like a galley slave for 25 years, without seeking any honours. He was officially attached to our Department, and had a contract with the French Science Research Council. Considering all the work he did, the hospital administration was very mean to him. Five years before his retirement, it was noticed that he had both a hospital and a Research Council contract, and I was told that he could not hold both these appointments and keep all his session fees (which amounted to about 5000 francs a month). I was forced to cut back the number of his sessions at the hospital to three, and finally to stop them altogether. However, he went on doing his work, keeping his records with the most meticulous care, and writing important papers.
M.P. Basically, Evrard was less aggressive. He wanted first of all to obtain healing, and then the treatment of the infection would be completed. Letournel would pounce on an infected non-union of the femur, taking out everything septic, removing the nail. Evrard would not on any account have removed the hardware from a properly fixed fracture site. To him, ensuring bony union came first; once that was obtained, the septic focus could be tidied up.
M.P. I cannot see why not. The X-rays were shown to the journalists; everybody was talking about him. It was a simple subtrochanteric fracture.
M.P. Very good, very easy, if I may say so. Fortunately, all went well. The only problem was that of resisting the pressure of outsiders who wanted to get details. But if there had been a hitch, it would have been quite a drama. I still remember, on the day of his accident, the crowd of people waiting for him outside the Ollier orthopaedics block. The ground floor of the Accident and Emergency department was full of people - it reminded me of the crowds during the student riots in '68. He was expected to come in a 6 p.m.; by 8 p.m. he still hadn't arrived. Then somebody stops me and says, "I'm from the television station. What has he got, and what are you going to do?" And I say to him, "Look here, I can't tell you anything. I haven't seen him yet, I haven't seen his X-rays. I know nothing about him." "But," says he, "I've got to tell the viewers something on the eight o'clock news." "Well," says I, "You'll have to ask someone else."
M.P. Yes - not having spent more time teaching.
M.P. By doing less surgery myself, and assisting other surgeons more.
M.P. Yes. It was different at first; but, by and by, I allowed myself to be taken over by the system, with almost daily revision operations that would take all morning. When one has finished that sort of list, one doesn't feel like assisting a junior surgeon.
M.P. Yes, and many of those I trained have become friends, more or less. My greatest joy was a well-run research meeting in the Department, with some interesting case presentations - original cases, nothing too simple - and an audience of junior and senior surgeons, who took a real interest in the cases.
M.P. The feeling that one was conveying to the audience why these patients were being operated on, and how the decision had been arrived at. Assisting somebody at surgery is important; assisting somebody in the decision-making process is more important yet.
