For its 40th anniversary the Société Orthopédique de l'Ouest (SOO) held its annual conference in Tours. It was chaired by Jean-Louis Doré, a particularly active member of the society and former editor of the Annales Orthopédiques de l'Ouest. Jean-Louis answered all our questions and fully accepts the title of guest editor for this edition of Maîtrise Orthopédique.

M.O.: How did the SOO conference go ?

J.L.D.: It’s a bit delicate for the chairman to maintain that it went well, but it seemed to me to be the case.  A lot of friends said it was a good conference, but then they are friends… It’s preparation took up a lot of my time but fortunately I was very ably assisted by Jocelyne Cormier who is used to this and knows all the ins and outs of the conference, and there was also all the work done by Jo Letenneur, the secretary-general, who makes sure everything runs to plan. This was the 4th time the conference was held in Tours. There were my masters: Castaing, Glorion (who passed away recently), Burdin and myself. The choice of Tours was symbolic, while not meaning to be, because this was the SOO’s 40th conference, and one of the first took place in Tours in 1967, chaired by Jean Castaing.

M.O.: How was the SOO formed ?

J.L.D.: Initially, there was the "Group of Ten” consisting of Castaing and 9 other surgeons, all from the West of France. They would meet twice a year and one of the meetings would be given over to failures, which is a much more useful exercise than going over a series of successes. Little by little, they invited their colleagues from the region and in 1967 the Société d’Orthopédie et de Traumatologie de l’Ouest (S.O.O) was founded with an annual conference. From year to year the conference gained in importance and became structured, with the distinctive feature of having three round tables. The object of the round tables is to get an update on a particular subject, but also to get colleagues from the western region of France (of different ages and working in both public and private sectors) to work together. Friendships are formed here. Then people get together, call each other up, put their thinking caps on together. It’s a very positive and warming aspect of the SOO’s round tables. The many communications/papers presented are the second feature of the SOO. This allows surgeons, who often unfortunately don’t dare to present at the SOFCOT (conference of French orthopaedic surgeons), to present their work to us. These communications are followed by discussions, always very friendly and instructive: the mike is handed round and everyone can give their considered opinion.

M.O.: There are a great many delegates at the SOO conference, which is somewhat unusual for a regional conference, is it not ?

J.L.D.: Yes indeed. It’s the second most important general orthopaedic conference after the SOFCOT. I believe that this is because of the third feature of the conference which is the “Chairman’s morning.” The Chairman (who changes every year and is alternately from the private or the public sector), holds the conference in his home town, invites a speaker of his choice and this gives the event a national or international flavour. But let’s be modest, conviviality, which is not possible at the very large conferences, is one of the essential elements of our success.  For example, Friday at lunchtime, all the surgical dressers in the west, after having listened to two symposiums are invited to lunch with us, along with the exhibitors. The exhibitors also come along because they can get to meet the practitioners and that of course helps our finances. This year, for the conference dinner, my wife Catherine and I decided to avoid the conventional evening dress gala dinner and opted for a buffet meal where everyone can get together and talk in a relaxed atmosphere. What’s more it was held in the manor house where Leonardo da Vinci lived out his latter years. Often former university pals come along and for them it’s the annual get-together. This year there was a show by some extraordinary conjurers, and since we too also try to do wonderful things with our hands, it was a great evening, and I think it will make people want to come back. Don’t forget that we’re sometimes lucky enough to have the attraction of the seaside, and a conference in Saint-Malo or the Sables d’Olonne always has great appeal. All these elements go together to make up the customary success of the conference. This year there were more than 400 delegates registered.

M.O.: And then the papers given appear in the Annales Orthopédiques de l’Ouest journal ?

J.L.D.: Yes, indeed. At the end of the conference, the committee members meet, add their scores and those of the participants because this year, for the first time, the conference was recognized as being part of medical CDP. These scores therefore determine which papers will be published. I was chief editor of the Annales for eight years; it’s a very time-consuming job, even though colleagues help out.  The papers and the figures need to be presented cleanly and the most interesting discussions added. But the Annales had no type of referencing and that put off heads of department who might have wanted to contribute.  Recently the round tables have been published by the Revue de Chirurgie Orthopédique along with an abstract of the articles; this offers Medline-type referencing. There’s also the SOO’s web site where there are lots of interesting things.

M.O.: What were the main themes of this conference ?

J.L.D.: There were three round tables, as with each of these conferences.  One was on fractures of the capitellum of the humerus in adults over the age of 60 with all the problems that this can cause, in particular the eventual emergency placing of an elbow implant. The round table for “young” surgeons was on fractures of the thoracolumbar junctura. We introduced this, at their request, several years ago now; it enables interns and heads of department to get to know each other.  The last round table was on osteotomies for outward displacement of the tibia. It was very interesting because we do a lot of them and we had good long-term results.  It confirmed the validity of the procedure which in general provides 8 years of functional peace. The results are the same for osteotomies for inward displacement of the femur which I believe we don’t do enough of !

For the Chairman’s morning, I invited Georges-François Penneçot who gave us a brilliant rundown on gait analysis in CP, and the resulting surgical implications. I was concerned because it’s a specialist subject, but his exposé was very well received and it got the second highest score. The techniques of PowerPoint software enable a combination of slides, films and recordings, as in the very vivid description by Doursounian on how an edition of the Maîtrise Orthopédique is put together ! I invited Geir Hallan from Norway who spoke about the Norwegian register for total hip prosthesis; he reassured us with regard to the concerns raised in France: the register is anonymous and only those who wish to register do so. In time, the register shows the implants which tend to be better than others. Little by little, surgeons tend to choose the implants which are better, and the figures show that there is less repeat surgery.

M.O.: So how does one become Chairman of the SOO ?

J.L.D.:  I initially became a member of the society because in Tours, with Castaing, we were steeped in it. Then, during military service, I was Jean Lannelongue’s operating assistant and he was a very dynamic member.  He took me on as projectionist and I must have shown hundreds if not thousands of slides at SOO conferences, with all the usual snafus. I got a taste for the association and when all is said and done, I basically love to work with colleagues and talk things over with them. Later on I became chief editor of the Annales Orthopédiques de l’Ouest, following on from Jean-Claude Rey who did an enormous amount of work there. So, since I had given a lot of my time to the society, I was invited to be Chairman. This proof of the high regard I was held in by the committee and colleagues was a great pleasure; although I hesitated somewhat at the responsibility and the time it might require, I of course accepted in the end.

M.O.: In practice, what does the Chairman do ?

J.L.D.: He prepares the conference, at least two years ahead.  That requires a lot of time and effort and there’s a lot of stress, even if you are assisted very ably by someone like Jocelyne Cormier. I was, she said, a Chairman who was a bit more intrusive than the others because I wanted the conference to have my stamp on it.  The Chairman’s morning needed to be organized and that’s always tricky because getting interesting speakers to come along and then to tell them they only have 20 minutes to speak is somewhat paradoxical. I asked Peter Keblish to come for my morning.  It was very complicated because although I do deal with the handicapped, I myself am very handicapped by my very poor spoken English. I went to Allentown with Pierre Robine in 1986. I was very impressed by this gentleman whose Canadian wife spoke a little French. We were very well received and a few months later he came to Tours, I believe to see if I could be a correspondent in France, but my poor spoken English was a great handicap. It is of the utmost importance that young people learn to speak it fluently; it’s absolutely essential for their careers, whether medical or otherwise.

M.O.: A shadow was cast over the conference by the death of Franz Langlais.

J.L.D.: We were all very sad because Franz Langlais was run over by a hit-and-run driver when he was coming back from a lecture given to the interns a few days before the conference. Franz, who I knew well and with whom we went skiing last winter, was a spearhead of the SOO.  Mireille was going to organize our trip to India next spring with him. He was very clear in his mind, he answered all questions fully without ever being aggressive, and he was never distant with conference goers. Thanks in particular to his grasp of English, he represented the French orthopaedic sector abroad.  The sudden death of a friend always makes us realize the vanity of things !

M.O.: Where do you work ?

J.L.D.:  I’m an orthopaedic surgeon in Tours. And I am at last working in a new clinic.  I say at last because I have been trying since the 1990’s to build one, but problems with shareholding meant that the project fell through. It’s only recently, when clinics were about to reach rock bottom that they’ve been bought up and a lovely new clinic called Alliance opened on August 15^th last. This clinic has what in is called an UPATOU in France (local A & E unit for treatment and/or referral). In practice, it’s a place where there are one or two full-time emergency doctors assisted by nurses and nurse aides 365 days a year. It’s obviously not a unit that could deal with a bus falling in the Loire river, or even a motorbike rider with multitrauma. We deal with about 80 patients a day: fractures, allergies, appendicitis, dehydration, etc.  Initially, I was concerned, but there are 8 orthopaedic surgeons employed here and this gets us out of our routine of hip replacements and osteotomies. Besides, if you do medicine, it’s to be able to render service and the emergency medicine side of things is pleasing. We see tattooed young louts, it makes me feel younger, and it’s a change from the knee implants of middle-class matrons. We see very difficult professional or personal situations and that puts our certitudes into perspective; we see real down and out’s who are poverty stricken and others, who have somehow obtained social security cover, parking their Mercedes convertible on the pavement outside the surgery doors. Woe betide profiteers pretending to have a handicap !

M.O.: But from the financial point of view, is it profitable ?

J.L.D.: For the clinics, yes, I believe so. The various political masters wanted it to work and I think they have put their money where their mouth is and provided the UPATOU with the wherewithal to work. For us, the surgical teams, 3 hours mending a pilon fracture of the tibia are not as profitable as a total hip prosthesis and three arthroscopies.  In addition, the surgeons here don’t practice extra billing for emergency work. So it’s a bit like working for the glory of it, but it’s our job. It doesn’t occur often, but sometimes a few years later, this or that particular patient will be back for an arthrodesis !

M.O.: It’s not just a question of the time, do you think you have the right human and technical materials ?

J.L.D.: As far as equipment is concerned, yes.  The clinic makes a charge of 10%, 7% of which is for the purchase of equipment.  If it wants to have good people, and therefore numerous clients, it has to provide the right equipment.  We have monthly discussions with the clinic, and if we work well, it plays by the rules. For surgeons the future is more worrying.  To go back to my pilon fracture of the tibia, it would seem that plates with locking screw heads are a real plus, but they are more expensive, and yet the  GHM (Groupe Homogène de Malade)   a    M     ansnd the T2A (Tarification A l’Acte) are the same whatever plate is used, so the clinic management coughs and sputters. In the future, it is absolutely essential that accounts managers, whether in the private or public sector, be on the same wavelength as the directors of the facility’s medical board. From the staff point of view, I only have one operating assistant, no instrument nurse; that’s amply sufficient except in the case of shoulders and repeat TKP’s.

M.O.: And the future of the private sector ?

J.L.D.: A distinction needs to be made between the facilities and the surgeons For surgical facilities, the private sectors are more reactive, more flexible, smaller, less expensive, less administrative and less encumbered with archaic unions, so I think that the bodies responsible for payment, whoever is in power, will always rub private operating theatres up the right way. For the surgeons their future depends on the attitude of governing bodies, of our unions, and of our learned societies: if governing bodies continue the progressive pauperisation of surgeons as is the case with those in sector 1, if they force surgeons to use standard implants, if they want to restrict procedures with regard to this or that disorder, in a word if we become simple technical agents, we might as well do 40 hours in a sanitized environment while protecting our future, but you would need three times more surgeons and what with the feminisation of the medical profession, welcome to the Polish doctors ! But we need to be optimistic, because this profession is a wonderful profession, and if we don’t just sit back, if we take part in trying to find solutions, we will be able to care for the entire population, under good conditions, at a price that taxpayers can afford. The problem of teaching will then arise, as is the case with surgery of the hands in some university teaching hospital centres, but there too, if there is dialogue between the private and public sector, nothing is impossible !

M.O.: What type of regular surgery do you do ?

J.L.D.: My predecessor did a lot of hips, so I do a lot of hip implants and repeats. At present in planned surgery, I do almost only lower limbs. I do hands too because I have always liked that. Initially, I would’ve liked to be a “hand surgeon.” When I arrived in the private sector in Tours, I wanted to set up an emergency “ hand” department, like my friend Guy Raimbault in Angers. I went and did a training stint in Michon’s department for two months with Merle and Foucher in Dommartin-les-Toul and I found that fascinating. I was one of the first in Tours to reimplant a thumb. I suggested to Bernard Glorion that I become a children’s "hand" consultant, but he didn’t proceed and my private sector director wrote to me that this type of surgery was not lucrative enough, so “hands” went out the window. When I first started out, I did everything: spinal columns, herniated disks, spondylolisthesis, cervical vertebrae, hands, feet and even appendectomies ! Progressively, I concentrated on hip and knee surgery.  For two reasons: what you do often you generally do well and, since I have lots of other activities, the handicapped, politics, implant design, I feel happier operating on what I believe I just about know how to do well.

M.O.: Have you changed much in your options ?

J.L.D.: After having had a on-on-one discussion with Furlong in his office despite my very basic English, I was one of the first, in great trepidation, to use hydroxylapatite 3/3 implants. That was in 1988, almost 20 years ago, and I’m very pleased with the results. At the SOO, with Epinette, Passuti and Massin, we’ve talked about this. For 10 years now, I haven’t used a drop of cement, except for repeat TKP’s.  I do however, worry about the question of coupling ! The polyethylene even the reticulated 22, will no doubt cause granulomas, alumina-alumina causes awful vibrations on the back of the metal shell which in the long run leads to a risk of loosening, the large metal acetabulum with screw thread cannot be removed, the alumina–PE insert is no doubt interesting but not widely used and there are still not enough long term results … I keep a careful eye on the results of the Scandinavian registers; many French surgeons in the private sector have series of single implants with considerable follow-up and it’s very regrettable that they don’t publish their results. So, at present the rule of thumb is: over the age of about 70 - alumina or metal-PE, or dual mobility; under that age - alumina-alumina, but the problem remains of the long term resistance of the back of the cup and the rarefaction of bone behind it, especially if the metal shell is thick.

M.O.: Your procedures are not a source of pain for your patients ?

J.L.D.: No because I use 3/3 stems, fully coated. I followed a continuous series of around a hundred THA’s which only varied in the extent to which the stem was coated in HA: 1/3, 2/3 or 3/3. I presented my results in Fort-de-France in 1992, then this exposé was turned down by the SOFCOT.  As the saying goes, there was no competition: For the stems fully coated in HA that was fine. For the others, it all depended on the state of the surface of the non-coated part.  That is, with 1/3 of the stem coated in HA and the distal 2/3 in grit-blasted titanium, things didn’t go too badly. However, if the uncoated 1/3 or 2/3 were in polished titanium things didn’t go well at all, as with the dual-coated stems, alumina-HA, even 3/3; after the resorption-substitution phase, the newly formed endosteum needs to be able to attach itself to the non-coated part, so the simplest thing is to have the stem entirely coated with HA with, underneath, a degressive T40 size distribution.  In the mid 1990’s there was hesitation because a diapason effect was feared with in the long run completely transparent greater trochanters and metaphyses. The Arthro group proved that after 20 years this was not the case. In addition, HA does away with the space between the bone and the implant which decreases the risk of infection and of foreign body granuloma. So why do without the 3/3 ?

M.O.: You trained under Castaing ?

J.L.D.: Indeed. I did my last semester as a resident and my clinical practice with him. When I arrived, Tours hadn’t been a medical school since 1962, and only became a full medical faculty in 1969. Mr Castaing, who was part-time, became full-time like Bernard Glorion and André Gouazé, the future Dean. The arrival of senior consultants from Algeria, some of who were excellent, created emulation with the Parisians. Castaing was a master, a master we adored and who never raised his voice. He was the opposite of his colleague with whom he did the famous anatomy handbook collection. If he so much as raised his tone ever so slightly, we took that to signify a huge reprimand. We worked hard just to please him, and we wanted him to be proud of us. Castaing was also an artist and music lover. He was one of the founders of the Touraine Music Festival around Siatovlav Richter. He was a man of many talents and looking back, the only weak point I can find is that he wasn’t open to the medical world abroad, but at that time few teams were.

M.O.: Tell me about one of the anecdotes involving Jean Castaing

J.L.D.: Once every two months what we called the Black Mass was held. It was a meeting convened against the backdrop of the fine Paul Klee-type painting in the boss’s office, where we entered only on exceptional occasions.  We didn’t really talk about cases, rather about the department, the future, about teaching. We, or rather he, set orthopaedics to rights.  One day, the boss, somewhat excited, told us that he was going to brief us about a technical tip, but we had to undertake not to divulge it until he had written it up, and more particularly, drawn it.  We, of course, felt like co-conspirators. He explained his idea and we washed it down with whisky. During the night he drew out and described in great detail in his beautiful handwriting the various stages of the anterior tibial tuberosity transfer with his idea of an oblique plane which means that at 45° you advance as you transfer the tibial tuberosity, so you don’t need grafts. We were all under the impression that we had been let into the secret by the Master, shared only with his trusty companions. Only members of the surgical clinic for orthopaedics and traumatology in Tours, combining private and public sectors, for which he himself had designed the logo, were let into the secret.  I’m sure that if pins had existed at that time, he would have created one and presented us each with one, somewhat solemnly, after a period of training, but only to those who had earned it, you understand, a bit like being dubbed a knight.  This was why the boss really didn’t like us to have attitudes on the outside that he didn’t approve of because, for him, our opinions outside involved in some way the clinic “family” a bit. Since I was one who never hesitated to give my opinion, once or twice our relations were a little cool, but after a while they went back to being warm again.

M.O.: How did you get to Tours ?

J.L.D.: I was born in Chartres, opposite the hospital, where a certain Levon Doursounian would later become a resident. I “pursued”, is the word my teachers said was the appropriate term, my studies in Chartres. At that time it was part of the all-new Orléans-Tours Academy, but my parents wanted me to go and study medicine in Paris where my brother had just finished his internship. But I was in love with a young history student who was also from Chartres, and as she had a scholarship she had to go to Tours, so I followed her.  Then I was resident at the hospital in Loches. I was 25 years old and had two children and there were no lodgings for the resident.  However, since the caretaker had just left, I was named “resident caretaker.” Sometimes there were people who had had a bit too much to drink who would arrive at midnight and ring the hospital bell, shouting: "Is there a doctor on duty ?” I’d turn up in pyjamas and say: "Yes, there’s a doctor on duty 24 hours.  Come this way, he’s waiting for you.”  I’d take a short cut round the other side, pull on a white coat and go out and greet them. And the guy who was tipsy would say: “I’ve seen you somewhere before, haven’t I ?”  I’d go to Tours twice a week to attend the lectures for residents and would get back around 2 in the morning. Fortunately the car knew the way. Catherine would sit up worrying. What with the two children, her teaching job, the caretaker’s office and her husband preparing his internship, she was wonderful. Apart from the relaxed atmosphere of small hospitals, there were a great many negative aspects peculiar to small operating units, particularly the dramatic deliveries carried out by some of the country doctors. Ever since then I‘ve had an aversion to these small operating units because I saw too many stillborn babies, too many women who became sterile. Childbirth is much too serious a moment in a baby’s life, for it not to be carried out in well equipped structures carrying out at least 500 deliveries a year. In addition, this small operating unit was a financial abyss.  There was an anaesthetist, a radiologist, x-ray technicians, anaesthetic nurses, dressers, replacements, and all that to treat one Pouteau-Colles and one appendicitis case a week.  I truly believe that local A & E units for treatment and/or referral need to be created in these small towns, and that patients with serious conditions should be sent to large structures, public or private, well equipped in material and in skilled personnel. These patients could then rapidly continue their convalescence back in the small town where they would be close to their homes, family and friends, which would enable the staff at the small hospitals to keep their jobs. There needs to be a change: we need to stop trying to do everything everywhere. A badly repaired extensor tendon is very costly, both for the patient and for the community.

M.O.: How did your internship go ?

J.L.D.: I was offered two internships, one in Rennes and one in Tours. I chose Tours and immediately wanted to do orthopaedics. The woodwork of humans was something that really appealed to me, and even for an orthopaedic surgeon human mind is sometimes difficult to treat, and that appealed to me too !

M.O.: Where did you meet up with woodwork ?

J.L.D.: In my father’s workshop.  My father always said he’d have liked to be a surgeon, but the peritonitis that carried off my grandfather meant that the he had to take over the family business at the age of 25. As a wholesaler, he bought up foodstuffs and general commodities and his trucks distributed them to all the grocer’s shops in the Beauce. He had huge warehouses, garage mechanics and joiners.  When I was a child I’d skate for miles on roller skates in the warehouses where there was paint, perfume, coffee, oil, socks, and clogs.  The business roasted the coffee and made the clogs.  I got on well with the joiner and the garage mechanic and often went to work with them.  Perhaps that’s my first link with orthopaedics ! “You never get over a happy childhood" the saying goes, and I had a wonderful childhood, surrounded by six super brothers and sisters, loving parents, a father who worked hard, and we therefore lived well.  Later on, I got on well with Castaing who had us doing placements with journeymen in Tours, to teach us how to use scissors properly, with the grain of the wood.  Wood is less forgiving than bone, and Nature, wonderfully accommodating as she is, often mends imperfections.

M.O.: And after your internship ?

J.L.D.:  I did my internship with Glorion in paediatrics,  Vandooren in internal, then with Barsotti in traumatology and vascular and finally I was taken into Castaing’s team and his well-known orthopaedic surgery clinic in Tours. I knew that a new hospital was going to be built in Chartres, and that a job as head of department would soon become available.  I asked the boss if I could go to Chartres from time to time during my last months in clinical practice, and he agreed. So I would go off to Chartres from Tours at 6 am. There I would operate all morning, do consultations all afternoon and return around 8 pm to start again the next day in Tours. I finally settled in Chartres in June 1980. I was the first full time surgeon there.  The director, very keen, bought me everything: nailing equipment, image intensifier, osteosynthesis fastenings etc… I was quite dynamic and determined and I worked hard.  That got things moving a bit and changed some of the habits, which meant that one day I received a letter from the director saying that I was working too much on the “perimeter” of working hours and that that was problematic. Working past 5 p.m. as I was, I was irritating everyone: there was no administrative staff around, no radiologists, so it was better to stop at 5 p.m. At that time I learned that there was a job available in the private sector in Tours and I came back.

M.O.: It wasn’t the question of workload that made you stop your activities at the hospital in Chartres ?

J.L.D.:  I guess I was too much of an individualist to accept the red tape of the local public sector hospital. It has surely changed since. Then, I was the only full-time surgeon working there. I was unhappy with reception in the emergency department where damaged fingers were treated off-handedly, depending on the team on duty. I saw them a month or so later with stiff fingers, hands done for completely and which needed re-operating, and that annoyed me enormously. I could’ve stayed in Chartres because this type of surgery for serious trauma, often late at night, is gratifying; seeing a man that you operated at 2 in the morning for a splenectomy with a diaphragmatic hernia due to trauma a year later with his family, is more gratifying than a TKP that bends at 125. And it was a difficult time for my wife; for women who are not state employees and who have jobs, it’s terrible; husbands get posted and you have to move home ! She had a good job, which she liked, as an editorial researcher for a newspaper in Tours, and she lost it when we moved to Chartres. When we came back 9 months later, the job had been taken and she didn’t find another one like it. By now the statute of limitations has run out, but she bore a grudge for a long time. However, she did become an operating theatre assistant because when I arrived at the clinic in Tours, all the surgeons were assisted by their wives. We’ve been operating together for 20 years now and I have to say it’s been very pleasant.

M.O.: Having one’s spouse as operating assistant is a pleasure ?

J.L.D.: It’s a pleasure if one makes a point of not talking shop too much at home. It’s very nice from a practical point of view because we’re on call the same day, we’re out at night at the same time and when we decide to take a vacation, we don’t have the problem of having to get the boss to agree ! She likes the job; she wouldn’t have been able to spend her life not working, and even after two hours of an attempt at osteosynthesis, if I say: “this isn’t working, we dismantle and start again from the beginning,” she makes no comment and backs me up. Since we’ve been working together for more than twenty years, she knows my every move, and sometimes she’ll say: “Did you really mean not to do this operative phase?” Sometimes it is deliberate, sometimes not, because I’m thinking about something else. It’s a real plus to not have to change assistant. Given the legislative developments concerning theatre staff and the push for state diplomas (and in passing may I say that state nurses were insulting to private surgeons on their Web site, and I’m being polite here), she sat and obtained the required diploma. 

M.O.:  How did your move to set up in the private sector in Tours go ?

J.L.D.: Initially we worked in two clinics which were 20 minutes apart; one was called Velpeau, the same name as the well-known bandage which, by the way, wasn’t invented there ! I do remember on one occasion, after having telephoned instructions for the patient to be anaesthetized, going off to the second clinic on a Vespa scooter with the sterile STACA kit taped up with sticky tape and my operating assistant riding pillion ! They weren’t all suppurating ! When I first went into practice in 1981, all the surgeons, orthopaedic and others, pooled their fees: that ended up 10 years later with lawyers involved, so then only the orthopaedic surgeons pooled their fees: that also ended up another 10 years later with lawyers involved ! I don’t believe in liberal communism; you need to have very unambiguous, signed documents for on-call rosters, holidays, sick leave, successions, team enlargement, etc., then those who want to buy an apartment in Paris for their student children work more, and those who prefer to play golf, or take their grandchildren out, work less, and all without any bitterness or resentment. I was keen for there to be agreement and harmony between colleagues so in 1986 I formed an association for young orthopaedic surgeons from the Tours area (JOT). One evening every two months those colleagues who wish (whether from the private or public sector), meet in turns in the office of one of us who undertakes to supply the pizzas and the Chinon, with no sponsors. Here we review case files, we talk about any concerns we may have had, the conferences we’ve been to. It works very well, to the point that for the last 6 years, at the beginning of each meeting, if someone has a patient who is causing concern, they come along too and we examine them. It’s very pleasant and quite instructive. When a certain patient absolutely insists on an operation, it’s easier to convince them of the non-necessity of said operation if all eight of us say the same thing !

It was around this time that we discovered that our daughter was handicapped, which led me to take up the chairmanship of a team wanting to create a centre called the Institut du Mai for people with motor disability, and today it is a pilot centre in France. It’s an institute specialised in teaching the handicapped to become self-sufficient and get on in the community. Sometimes young handicapped people with cerebral palsy live in homes where they’re in tracksuits all day in front of the television making collages and doing some painting. I exaggerate somewhat, but not that much ! But these are children who have real potential if they’re given the means, in particular home automation. The structure that we founded enables them to discover that they’re able to press a knob to open a door, or a switch to put on the TV, and that with a word synthesis system, by pressing the keys, they’re able to say: “Hello, could I have a bottle of milk, please.”  Once they’ve got over these hurdles, they can live in an apartment in town. The foundation, with others, of this Institut du Mai has been a real joy.  It works so well that the Ministry has asked us to found another one in Nancy.

M.O.:  How is it financed?

J.L.D.: Finance of the Institute is two-tiered: 2/3 come from the Conseil Général of the person’s domicile, 1/3 from the Social Security department. I managed to put this together using a somewhat singular technique. In the past, you went to the politicians and asked them for a little charity. I introduced myself saying: “ You’ve made it obligatory for us to give you our money through taxes for, amongst other things, national solidarity; your role is to redistribute it, so give us some of our money back."  This approach was a little destabilizing no doubt. In addition, I’ve been in politics a bit, and that certainly helped. Furthermore, I was backed in the financing package by one of my brothers who works in volume retailing; it was complicated because private and public sector management systems don’t talk the same language, but as in every other sector, there are the useless idiots and a lot of wonderful people. We got there in the end, but it was a long and difficult road.

M.O.: What does the Institut du Mai currently consist of ?

J.L.D.: It offers places for 40: 25 one-roomed flats and 15 apartments spread throughout Chinon. When they arrive, the young adults that we call “clients,” are a bit worried and their families are too. When you have an 18-year old child who has always been in a home, practically never going out, and after spending a few months at the Institute he’s told: “Get into your electric wheelchair and go off and do your shopping in town” there’s reason for concern ! You need to reassure the parents, teach the occupational therapists and the carers about this new way of managing handicap. It’s a new approach to the handicapped person.  They stay about two years in a one-roomed flat in the residence, then they spend one or two years in one of the apartments in Chinon, and finally they move into their own places in Lyon, Paris or La Rochelle, where they’re helped by local home support workers.

M.O.: In the one-roomed flats in Chinon who looks after them ?

J.L.D.: Trained care workers, occupational therapists, advisors in home and family economics… One of the big problems is that we have a fixed per diem price; whether the handicapped person needs three hours assistance or 8 hours, it’s the same price. And that’s not good. As Chairman, I’m unfortunately obliged to say to the Director:  this young person could come to us, but he/she will need too many hours, so we have to refuse them. There should be an AGGIR-type scale, which would mean obtaining a variable per diem price. A handicapped person in a home costs two to three times more than the same person in an apartment in town, so our Institute requires a lot of money, but in the long term it creates savings.

Times are financially hard so we need to be able to care properly, but for less, and the medical establishment is all for that ! During the 2003 SOFCOT conference, our daughter Elsa passed away. She was 31, she was myopathic, she never worked. She was cared for by society and right up to the end was treated like a queen, both from the technical and psychological points of view. Towards the end she was in an intensive care unit that must have cost around € 2000 a day… It’s fine that that’s the way it was, but there is the cost and that raises the real question: would that money not’ve been better spent on a training centre ? If you’re sensitive to things social, you absolutely must have a dynamic economic policy; you can’t distribute money you don’t have.  Talking of which, I’d like to explain something which is not very well known, what in France is known as the  "domicile de secours" or assistance domicile. In a nutshell, if I am a motor-handicapped adult, my benefits are paid by the Département in which I live, so if one Département does a lot for the handicapped, I am going to move there to live, and it is this new Département which will pay my benefits !

M.O.:   That type of situation is like a magnet, isn’t it?

J.L.D.: Yes, of course ! When there is a structure which corresponds exactly to the handicap you have or that your child has, you’ll do anything to get posted to that structure; and if the handicapped person then becomes self-sufficient, after three months, the new region will then have one more financial aid recipient, that’s a real drawback.

M.O.: And the political arena ?

J.L.D.: I ran on a municipal list in Tours against Jean Royer. He who loathed posters of women in stages of undress - naked breasts and suggestive cinema posters. We wanted to develop a "Loire Valley" project, centred on the life sciences with INRA, Coronna, Pfizer, the teaching hospitals in Orléans, Blois and Angers; it was a magnificent project. I ran against him twice, in particular with Jean Lannelongue as campaign manager.  It was exciting and very instructive. I was a municipal councillor for six months; I found that very interesting because in small towns you have real power if you’re in the majority party, otherwise you’re just playing a bit part. I’d have liked to be a deputy mayor. But the few surgeons who’ve held important political positions, MP’s in particular, all come from the public sector. When you’re elected, you rapidly loose your clientele, the clinic will find a replacement, and if 5 years later, you’re not re-elected and want to go back to being a surgeon in the private sector, you no longer have a job. That’s a real obstacle.

M.O.: Let’s go back to the field of orthopaedics.

J.L.D.: At the same time, I worked with the industrial sector and I loved that. I collaborated, alone or with others (but when there are several of you, you go a lot slower), with Landanger, Aston, and a lot with Biotechni. When you develop an implant, the responsibility is considerable, for future patients in the first instance, but also vis-à-vis the company and its personnel, because it’s spending a considerable budget on research and development.  Working in 3D on the computer with the engineers, cogitating, carrying out trials in the anatomy lab, seeing the product made in titanium and then starting to use it, were all part of the creative process which I thoroughly enjoyed.

M.O.: And did you succeed ?

J.L.D.: Yes, 15 and 10 years ago I developed two reliable implants which are still being used, and, recently, a modular hip system for repeat surgical implant. The TTHR has been registered in Norway since this year; it has an excellent reputation. This implant is useful in repeat surgery and in cases of fracture after an implant has been placed. Currently there’s fortunately less loosening of implants, but we’re seeing more and more spiroid fractures of the femur after an implant has been placed: rather than fitting a plate and have elderly women unable to put weight on their leg for three months, it’d be much better to change it for a locked stem which will enable them to walk immediately, with full weight on the leg.

M.O.: And where will the next SOO conference be ?

J.L.D.: In Le Havre, chaired by Bernard Debeaumont. We look forward to seeing you there !