Apoil A. Argenson C. Arlet J. Beaufils & Chambat Capana Cartier Cartillier Dambreville A. Doursounian L. Grosse A. Gschwend N. Herbert T. Judet J. Kapandji A. Kelly I. Kerboull M. Laude M. Louis R. Maigne J.-Y. Maigne R. Matta & Mast Müller Nguyen Van Nhan Puget J. Postel M. Pouliquen J.-C. Saleh M. Simmons J.W. Tubiana R. Vidalain Wagner H. Weber B.G. Zweymuller

Jean Puget organized and chaired the International Hip Congress '99, held last autumn at Toulouse. This event was very well attended, and allowed the dynamic Toulouse school of orthopaedic surgery to give a broad survey of where hip surgery stands today.

M.O.: What was the main idea of the Congress?

J.P.: The main idea was to try not to follow the present-day trend of splitting subjects up into too many facets, but to treat surgery of the hip as a general subject. However, we had to establish certain chapters: trauma, nonprosthetic surgery, etc. Obviously, if each of these chapters had been developed in depth, the Congress would have taken several weeks. Of course, spending several weeks in Toulouse is very pleasant, but in order to fit everything into the standard three-day timeframe of a medical conference, we decided to emphasize the subjects on which there is no consensus nowadays, and where the Toulouse surgeons had done a great deal of work. In traumatology, these would be trochanteric fractures, and fractures of the acetabulum. Trochanteric fractures, because they remain a surgical problem with major medical and social implications. There is still endless argument about the role of prostheses in the management of such fractures. We ourselves found some ten years or so ago that one can overdo prostheses. We have now cut back to a level that is more sensible and realistic. Some 10 per cent of elderly patients with trochanteric fractures will benefit from a prosthesis, since they will be up and functioning soon, and since the construct will be stable. Acetabular fractures are an important subject that has been much developed by the Toulouse school, and first explored by our teacher Guy Uthéza. He loved the symposia at the Garches trauma centre, and went there every time when he was still in training. I went there twice. These events were very interesting: Robert Judet had created a very special, very "southern" atmosphere, and laid on demonstrations of what, at times, were daredevil techniques. When practised at a sensible and reasonable level, these techniques helped to advance orthopaedic surgery. Guy Uthéza delighted in passing on the experience of Judet and of Letournel, and to introduce us to the treatment of these acetabular fractures. We even came to develop "our own little tricks." The shell holding the patient on the operating table was one of the results of this experience.

M.O.: And what about nonprosthetic surgery?

J.P.: Osteotomy comes to mind here, but nowadays orthopaedic surgery has better things to offer. The arthroscope has invaded the hip joint. It was interesting to see where we stand as regards hip arthroscopy. These minimally invasive techniques tend to be decried by those who have not mastered them; however, those who have learnt to handle them tend to find that these procedures work. When shoulder arthroscopy first came in, one could not see very much; now, a lot of arthroscopy is being done, in appropriately selected patients. In the hip, we are past the pioneering stage, and in some cases where conventional techniques fail to show anything wrong, especially in young subjects, arthroscopy can be of value. In experienced hands, this technique should be reasonably safe; and it can provide some answers. One example is the labrum syndrome that has been discussed for quite a few years. In fact, I remember rheumatologists talking about it some 30 years ago. And rheumatologists are curious, perhaps even more curious than orthopods, because they cannot go and "have a look-see." With the advent of arthroscopy, orthopods have become interested in the condition, in particular Philippe Chiron, who has suggested several pathophysiological mechanisms by means of which these lesions of the labrum may contribute to the development of OA.

M.O.: All right, you can see things - but what can one do?

J.P.: For the time being, arthroscopy is undoubtedly a diagnostic rather than a management technique, although some lesions of the labrum may be treated, rather like meniscus lesions, with partial resection. Result-wise, it's a bit of the law of all or nothing. Currently, two out of three patients are improved.

M.O.: Apart from the labrum syndrome, what arthroscopic treatments are there in the hip?

J.P.: Arthroscopy may be used in osteochondromatosis. Fragments of the fractured head may be removed in cases of dislocation with fracture of the posterior rim of the acetabulum. Synovial membrane samples may be taken, and some inflammatory conditions may be improved. All these procedures used to require a large arthrotomy. I think this is a good start.

M.O.: However, even if more patients could and should be managed with arthroscopy, how many hip arthroscopists would be needed in this part of the country?

J.P.: As things stand, I think that just a few teams should do.

M.O.: Arthroscopy apart, what is the role of nonprosthetic hip surgery in this day and age?

J.P.: The interesting thing is that, thanks to Ganz, periacetabular osteotomies for the correction of minor degrees of acetabular dysplasia are in again. This was very obvious from Jean Philippe Cahuzac's paper on the development of treatments of the dysplastic paediatric hip with Salter, Pol Lecoeur, and other osteotomies. We saw that, beyond the treatment performed by paediatric surgeons, adults may, in borderline cases, require further pelvic osteotomies, and even osteotomies of the proximal femur, in order to improve the mechanical pattern of the hip joint. In an age where total hip replacements are perfectly routine procedures, it is comforting to see that osteotomies, which were becoming just a bit of theory to be taught to our students, are not only enjoying a second spring, but a new rationale. I grew up with McMurray osteotomies, which Rieunau used to do to correct the alignment and to improve the positioning of the foot. The pain relief achieved was excellent; with regard to function and ROM, the outcome was less good. Nowadays, these results are less appreciated, even by farm workers, who do a lot of heavy manual work or spend hours sitting on their ever more comfortable tractors. They would rather have a hip replacement (with all its unforeseeable consequences) than an osteotomy.

M.O.: The problem with osteotomies is that this is major surgery, with a far from easy postoperative course.

J.P.: I do not think that we shall ever see the sort of osteotomies again that used to be done in advanced OA - the Pauwels, for instance. What we are going to have is "minor readjustments" to hips at risk from OA. This will still be fairly major surgery, but not fraught with a high rate of morbidity, because there won't be any major moving about of bones. The acetabulum will be tilted 15°-20°, using navigation systems that allow very accurate and precise osteotomies and realignment of the joint in space. The very slightly dysplastic hip that may develop OA when the patient is around 50 may benefit from these techniques, prior to the stage where a total hip replacement needs to be done. Whether this will be as safe as the shelf used to be - possibly, but we will need evidence of a very low morbidity. I believe in navigation systems, rather than in robotics, in this context. Having a robot reaming the femur ready to receive the implant is, I think, not a good idea. Whereas a navigation system that shows the surgeon where he or she is during surgery, and how to position the implants correctly, that's what orthopaedic surgeons really need.

M.O.: What is the bottom line with regard to the different osteotomy techniques?

J.P.: Osteotomy in necrosis was a subject about 10 years ago, but it all petered out. However, periacetabular osteotomies appear to be working well. The Chiari shelf is losing ground. Orthopods are a bit teleological in their way of thinking. Perhaps they reckon that if a procedure such as the Chiari corrects in one plane only, while another one corrects in several planes, then the one with multi-plane correction must give better results. In "nonprosthetic" surgery, there is one interesting chapter that has barely been discussed - cartilage grafts. At first sight, one might think that these grafts would be the end of orthopaedics as we know it. That is not quite so, however. Initially, a cartilage graft will be a patchwork in hip joints that have suffered from osteochondritis or which have localized posttraumatic lesions. If these hips could be managed with grafts, it would certainly be progress. Arthroscopy could play a useful role in these conditions.

M.O.: Would the femoral head need dislocating?

J.P.: Not necessarily. If the joint is pulled apart with 20-kg traction, the load-bearing zone is readily seen through the arthroscope. What will be required is some special tools for the job. We have virtually everything that is needed to make a go of this kind of surgery. Cartilage is nowadays being harvested from the non-load-bearing areas. Tissue culture has been developed to a high standard, but will still need optimizing.

M.O.: And what about necrosis?

J.P.: In this condition, imaging techniques have made a major contribution - but whether that means that the actual treatment has been changed is a different question. Overall, treatments have remained unchanged. Osteoinductive proteins are a subject of great interest. They are very new, but the results are inconsistent: they work in pigs, but then, when electrets were being used, they, too, worked all right in rabbits.
We shall have to wait and see the evidence from multi-centre trials.

M.O.: Electrets...?

J.P.: They are substances with a positive charge on one side, and a negative charge on the other side. Prof. Chiron wrote his thesis on the subject of electrets. He produced a nonunion in a rabbit, and put the charged or the uncharged side against the nonunion site. It seemed that contact with the charged side made for superior osteogenesis. However, anything works in rabbits. Quite generally, anything that may have an economic impact tends to get developed fast. If it is thought that the added value of cartilage cell culturing is low, then this technique will advance more slowly than the use of BMPs produced by the pharmaceutical industry. To come back to the main idea of the Congress, this is a chapter that the Toulouse school have done a lot of work on, since necrosis research means Arlet-Ficat. The work then continued with Bernard Mazières and Philippe Chiron, who did a lot of research into BMPs and followed up necrosis. In this way, there is a continuous line from the early researchers to the present day.

M.O.: What was Ficat like?

J.P.: He was a typical southerner, and a very warm person. He loved pathophysiology. He was not a mechanic, and, in his time, saw things a bit differently from Pauwels and Maquet, who used vectors. He met Arlet, who introduced a bit of organization, system and method into his creativity. Ficat worked hard, and loved the good life. He was forever developing theories, but once he had developed a theory, that was it - his theory was a fact. Unbeknown to him, he gave rise to my thesis. When I was training in his department, he used to do a lateral release in patients with a lateral overpressure syndrome. He showed me the technique, and said, "You see the patella. It's obvious that if one releases the lateral retinaculum..." However, the lesions were frequently on the medial side. He had some vague explanation, and would say, "There's excessive pressure there, so as a result, it goes like this..." I was so impressed by all this that I thought that, surely, I would not be trespassing on his preserve if I were to look more closely at the medial side, which, obviously, was of no great interest to him. So I developed the idea of the rotational stability of the patella provided by the vastus medialis and the fascia, which sort of controls patellofemoral congruency. Ficat was an excellent surgeon, he would operate with great ease, almost by instinct. He died in January 1986, six months before his retirement.

M.O.: And Rieunau?

J.P.: There was about 15 years between Rieunau and Ficat. Rieunau came from general surgery, and had been given orthopaedics by Ducoing, the last great consultant in true general surgery. Ducoing was the first in a long line of university hospital surgeons in Toulouse. Just after the war, he told each of his students what they were to do. One was told to do gastrointestinal surgery; another, gynaecology; yet another, neurosurgery; and that's how Rieunau finished up with bones and joints. Later on, he was put in charge of the department of orthopaedics at the Hôtel-Dieu. From what I hear, it appears that Rieunau made people try to emulate him, which is why his former students all bear the mark of his personality. However, he was also a true modernizer at his hospital. Just after the war, he and his wife, who was an anaesthesiologist, went to Boston, to the Campbell Clinic, and to the Mayo Clinic. There, they saw modern surgery being performed, and they brought back lots of new ideas to invigorate our slightly old-fashioned facilities. In this respect, Rieunau went beyond being just an orthopaedic surgeon. He was a complex character, and very open to new ideas. Thus, he allowed Uthéza to put in the first Moore endoprostheses, and then the first total hip replacements.

M.O.: He was rather conservative, though...

J.P.: Yes, he was quite conservative, but one got the feeling that he had become frozen in time, at the stage of what had made him famous: skeletal traction. He had produced a detailed description of the uses of skeletal traction, and went on improving the apparatus, to get the cords absolutely parallel etc. But I think that in his heart of hearts he knew that traction was becoming a bit outmoded. However, it was his thing, and it was what he was famous for.

M.O.: Let's go back to the Congress...

J.P.: One of the subjects was tumours. As the Toulouse centre was getting increasingly interested in acetabular fractures, there was also a growing interest in reconstruction of the pelvis; and it's almost 20 years since the first description of the technique involving an autograft of the ipsilateral proximal femur.

M.O.: How does that work?

J.P.: When removing the tumour means taking out the acetabulum or the surrounding bone, there will be a huge defect. This can be managed in a variety of ways. One may not do anything, in which case the patient won't be in a very happy situation - he or she will have a terrible limp and major loss of limb length. One may try to fuse the femur to the ilium or the ischium; one may do pelvic allografts; or one may use customized prostheses of the pelvis. The trouble is that the functional results of fusion are not good, and the allografts and prostheses have a high morbidity. This is why we went for a technique that is easier to perform, gives good functional results, and has low morbidity. The principle is this: where the tumour has spared the femoral head and has not gone beyond the acetabular cartilage, the proximal femur is resected at the distal border of the lesser trochanter. That produces 10 cm of femur, which is then turned as required and placed between the remnant of the iliac wing and what is left of the pubic ramus. If the graft is positioned correctly, the greater trochanter will be roughly where the acetabulum used to be. And then, as it were, all one needs to do is put in a THR.

M.O.: Who invented that technique?

J.P.: I did. And I have used it in some thirty cases since.

M.O.: What gave you the idea?

J.P.: It all goes back to '81. One of my colleagues, who is a the Centre Claudius Regaud, the big cancer centre in Toulouse, said to me, "Look, I've got this patient, she has a plasmocytoma that is still isolated, but which involves the whole iliac wing, the whole of the acetabulum, and half of the ischial and pubic rami. She is 40, and is bedridden with sciatic nerve compression. She is in terrible pain, and will have to have surgery. If you operate on her, you can save her." I went and saw her, and thought that a disability like that was unacceptable in a 40-year-old woman. And then it occurred to me how similar the curvature of the proximal femur was to that of the pelvic inlet. I had my teachers of applied hip and acetabular anatomy to thank for this realization. Guy Uthéza had always told us to "walk around" the hip, to look at it from in front, from behind, and sideways. So I had quite a good picture of the region in 3-D. I went to the dissecting room, to see if the whole thing was at all feasible. I was worried about the vessels, because this sort of thing had never been done before. I took endless precautions, far more than I would do nowadays, because by now the technique has been simplified; and then I did it. It worked, and the lady is still alive, 20 years after that operation.

M.O.: Would you recommend the procedure for primary tumours?

J.P.: Yes, but also for some metastases, providing survival prospects are good. The patients will be up and walking within a fortnight.

M.O.: How do you fixate the ends of the graft?

J.P.: Fixation is very straightforward. At the top, two screws are inserted in the direction of the sacroiliac joint, with a slight slant, to follow the lines of load transmission. Below, a small plate or cerclage wires are used, because the important thing is to make sure that the construct has sufficient give.

M.O.: But does that not make cup orientation difficult?

J.P.: The cup must not be cemented until the graft has been fixated. Once that has been done, the situation is like any THR; just that the cup may need to be on the small side. Overall, in the thirty or so cases we have done to date, it has been fairly plain sailing. There have been a couple of complications, in inappropriately selected cases - osteolytic lesions in the course of locoregional spread of a colon or a bladder cancer, that sort of thing. These patients are not suitable candidates. Skeletal metastases may be managed with this technique provided that the expected survival is longer than a year or eighteen months, because secondaries in this region are extremely disabling, and the technique provides pain relief and allows the patients to lead independent lives.

M.O.: How do you stabilize the hip?

J.P.: I believe in retaining gluteus-vastus continuity over the greater trochanter. It is perfectly possible, with this procedure, to leave the trochanters in situ, by doing as it were a trochanter slide, and by resecting the lesser trochanter with the psoas still attached. The trochanters will provide useful landmarks when it comes to putting in the femoral prosthesis. Also, the length of proximal femur that needs to be resected is quite short, only 10 cm or so, measuring from the highest point of the femoral head - really not a lot.

M.O.: What would you say are the indications of conventional prostheses? And what do you think of cementless hip replacement?

J.P.: I don't find it at all surprising that cementless fixation works at the acetabular level. Stem-wise, I used to be more sceptical. It's not nice having to tell patients that one is going to do a hip replacement that may give them pain in one out of every five cases, whereas with a cemented implant they are OK straight away. Perhaps there is a difference regarding implant longevity. Why should there be problems? Because, mechanically, the proximal femur is more complicated than the acetabulum. The upper end of the femur is exposed to torsional stress, to compressive and tensile loading - and then one goes and puts in a prosthesis, which will upset this complex mechanical pattern. The femur is a living structure, and it's obvious that, in the long run, it will not be happy with this thing that has been put into it. What it means it that - regardless of how they have been put together - the implant and the femur will part company sooner or later. Add to this the fact that the implant materials will wear, and you know the whole thing is bound to fail. In order to prevent loss of bone stock in the proximal femur, one has to meet certain requirements. First of all, there must be less wear debris. And there, progress has been made, with contemporary bearing combinations. However, when it comes to the mechanical conditions under which the hip replacement has to work, there has not been a lot of progress. And I do not think that hydroxyapatite is a lasting solution, because in the proximal femur it finds itself in a pretty hostile environment, with huge shear stresses precisely where these poor little ceramic molecules are trying to hang on to each other.

M.O.: Could the problem be solved by improving the design of the implants?

J.P.: Leaving wear aside, loosening may be described as the problem caused by a container that becomes bigger than it was to begin with. Made-to-measure implants will always only be a compromise that works on the day the implant is inserted - next day, it won't be "to measure" any more, because the femur will have reacted by then, and will be trying to get rid of the intruder. The best one can hope for is that the odd couple will stay together for 15 years. What are the considerations in choosing an implant? It's the shape of the femur, and the quality of the bone stock. So there are all sorts of shapes available - but why not simply use one shape and change the size of the implant, using a thinner one with, and a thicker one without, cement, as required? That also solves the problem of bone stock quality. This is the essence of the Omnicase concept advocated by Chiron - it is useful, because with the same instrumentation one can cater for all the different patterns. It sounds a bit rough and ready, but given that hip replacement is not an exact science, I think that it is perfectly justifiable. Made-to-measure implants, though, are just a pipe dream. Also, designers see things differently now: they no longer go for stems that are made to measure in the femoral shaft, because they realize that both the insertion and the removal of the device require a certain compromise as regards the shape of the implant; nowadays, the aim is to have the part of the implant that protrudes beyond the shaft made to measure. However, that is odd, to put it mildly, because the object of hip replacement is to restore a physiological joint pattern - it is not to reproduce the abnormalities that existed before arthroplasty. Where customized implants score is in the design of the implants in general. This is why cementless prostheses are now better tolerated than they used to be. In this respect, the customized designs have helped the standard devices, which can now be fitted much better. And I am sure that this is why cementless implants are now so deservedly successful. Even so, it does not make sense to try and give every patient a cementless hip replacement. Not all femurs are shaped in such a way that they can accept a cementless device. That's what we have learnt from the development of customized implants. If one bears in mind these improvements that have been made over time, one can evolve towards cementless fixation - and that is the road we are travelling on.

M.O.: What about revision?

J.P.: There has been a lot of work on reconstrucive arthroplasty, for instance with the P.P. system; however, the actual hardware used is of lesser importance. All it needs to be is handy. The important thing is to allow the metaphyseal bone, which has been physcially abused by the primary implant, to find happiness and contentment once again. If it is happy, it will rebuild. So one has to do things differently from the way they were done first time round, at the arthroplasty that resulted in the need for revision. Support will have to be obtained more distally, in a zone where the functional geometry is simple. If one places the compressive loading more distally, and one leaves the proximal bone with a good blood supply and allows it to get on with it, then one will find that even poor-quality bone stock will rebuild. However, there are rules that need to be obeyed: the proximal part must not be excessively stiffened; the construct should be elastic but stable - which is why I insist so much on choosing the right approach and on doing a trochanter slide. Why always do a femoral osteotomy? I do not think that there is a need for one in each and every case.

M.O.: How do you see the treatment of hip disorders developing in the future?

J.P.: I think that in future, too, hip disorders will have to be dealt with by orthopaedic surgeons. It is true that progress has been made with biological treatments, but I think navigation systems will be important, because they will allow us to improve the positioning and the geometry of hip replacements. The differences in experience between different surgeons will be ironed out. As regards materials, there will be substances that will improve bone regrowth. I think we are past the time when bone graft substitutes were used purely as defect fillers.

M.O.: Why did you go into orthopaedic surgery?

J.P.: My father was a vet. He was head of the Toulouse College of Veterinary Surgery. He was a great personality, and had a profound influence on his discipline. As a surgeon, he had a great interest in traumatology, which was unusual back in the mid-50s to -60s. I was not looking at any particular career; I wanted to do medicine, but had no particular wish to go into surgery. I also had an uncle, a great "inventor" and a neurophysiologist. With all these influences, it was more or less natural that, when my father died, I should decide to go in for medicine. If my father had lived, I might have been an architect, because I find architecture fascinating and am forever drawing plans. But, as things turned out, I went into medicine.

M.O.: And then you had to prepare for the specialty training entrance exam...

J.P.: I was lucky enough at that stage to have excellent help. It was the time when functional studies were coming in, in all the disciplines. My uncle was a physiologist, and he was working for Yves Laporte, who had become Director of the Collège de France. He was the one that first described the inverse stretch reflex. Several of the chiefs to whom I applied for a training post thought that I could be the ideal link between their departments and the world of physiology, of functional studies. I had offers from neurology and gastroenterology, but those disciplines did not attract me. My first training post was in rheumatology, and Guy Uthéza, who had helped me prepare for the entrance exam, had advised me to apply to Rieunau. So I went to see him - and just then I got my fellowship to go to the States.

M.O.: How did that happen?

J.P.: That was quite a funny story. An American, a Mr. Starck, who was big in asbestos (at a time when asbestos was A Good Thing), had decided to offer a fellowship to someone from France - probably for tax reasons. He used the fellowship system of the Figaro newspaper, which was very well organized. The fellowship was advertised in every university department in France; and in Toulouse, Yves Laporte heard about it and told my uncle that going to the States could be useful for someone my age. So I filled in the forms, I was short-listed, and there were 20 of us who went to Paris, at the invitation of the Figaro. The tests went on for three days. By the end of the second day, there were only three of us left: a girl who was reading Agriculture at Nancy, a guy from the Civil Service College, and myself. We had a bit of an argy, and after quarter of an hour, the girl burst into tears and left. So I was left with the mandarin-to-be. That guy - whenever he was asked a question, he said he knew. I realized that I had to do things differently if I wanted to win through, so when they asked me, I said, "I don't know, but I'd very much like to know." That's how I got my fellowship that allowed me to spend a year at a university in the States. When I was back in Toulouse, I agreed with Guy Uthéza that I should go and see Rieunau. And Rieunau was delighted to hear that I was off to the States, because it reminded him of his earlier years. He said, "You absolutely must go to the Campbell Clinic; I'll write to my good friend Boyd." At that time, back in 1970, letters went by surface mail, and I left a fortnight after my interview with Rieunau. When I got to Memphis, Tennessee, where I was going to spend my fellowship year, the letter hadn't arrived yet; in fact, it took another fortnight to get there.

M.O.: Elvis Presley was still alive at that time!

J.P.: Yes - and Martin Luther King had only just been assassinated. I had a great year over there. Everybody was very nice and helpful, which was just as well, because I was completely lost at first. These Southerners thought it very funny to see this French guy pitching up thinking that everything had been laid on, when in actual fact no one knew he was coming. However, I think I learnt more about organization than about orthopaedic surgery. When the chief said in the clinical conference, "I saw this guy called Smith 20 years ago; can't remember his first name, but he was 25 then, and his case was virtually the same as the one we've got here," the resident got up and came back with the notes three minutes later. I was terribly impressed, and am still very keen on organization, even if we don't always manage to be that efficient. But then we are not in the States...

M.O.: Did you watch the Americans during that year?

J.P.: Yes, and I assisted them. I learned a lot, because I was there from half past six on Monday mornings until lunchtime on Fridays. And since all my board and lodging was provided by my hosts, I was able to use my fellowship money to travel quite a bit. I covered the American continent from the Arctic Circle to Guatemala, and from east to west.

M.O.: And you got back to Toulouse all right?

J.P.: Of course there was a huge difference. But I managed to settle in all right again. Guy Uthéza, who had more or less pushed me into orthopaedics, looked after me. He was a tower of strength, and did everything to ensure that I made it in orthopaedics. We always had a tacit understanding.

M.O.: Anything else you want to look at?

J.P.: The future! We are living in a time of change, because of economic and management problems. These things were bound to happen - we need to do things differently. But once one has spent some time over in the States, one realizes that change can be useful. Of course, one should not overdo things, and one has to give priority to the conditions under which we work. If those conditions are taken care of, I think people would adopt whichever system appears to be most suitable at the present point in time; but, obviously, this system will change over time.

M.O.: But all these structural changes cost money...

J.P.: I think the administration has realized by now that evaluation and accreditation are expensive; and after having gone in with all guns blazing, they are now doing it a bit more gently, because there isn't always enough money available to pay for all the innovations. However, there is a need for change, so things will change quite naturally. It's just a question of how fast this change will come about. It must happen - so funds will have to be diverted from other activities to enable the structural changes to be carried out. Perhaps there will be fewer operations. I also think that we are heading for a manpower shortage in medicine, and especially in surgery, because the young people coming up through the schools aren't very keen to work 70 hours a week, under increasing pressure, and with less and less recognition of their worth. So we won't have enough surgeons any more. However, I believe that here, too, we shall see people and systems adapting themselves, so being a surgeon will still be a great thing for quite a few years to come.

 

Maitrise Orthopédique n° 97 - September, 2000