|Ten years ago Gilles Bousquet died tragically and prematurely.
This issue of Maitrise Orthopédique is a tribute in memory of him.
The management of the department was then passed on to Michel Henry Fessy who has continued to work wholeheartedly at maintaining the tradition and quality of “Stéphanois” (St Etienne area) Orthopaedics.
Michel Henry has kindly accepted to speak about his arrival at Saint Etienne as well as his recollections and work with Gilles Bousquet.
M.O: What was Gilles Bousquet like towards the end of his career?
M.H.F: It was not the end of his career; he still had a good number of years ahead of him. He died tragically and too prematurely.
I believe that before anything, he was a relentless worker. It is always difficult for me to speak about Gilles Bousquet because I was not one of his pupils. I never worked alongside him on a regular professional basis. His pupils are better placed than me to talk about him.
My first encounter with Gilles Bousquet goes back to 1991, when he was a member of the jury for my thesis of Doctor in Medicine, which concerned the screw in femoral prostheses which he had developed. At the time this provoked some enmity on his behalf because I did not only say good things about the implant. However, this was constructive because deep down he knew that this stem had some disadvantages; he had modified it a number of times.
I also knew Gilles Bousquet through the visits he made to my boss, Mr Fischer in T wing, especially during the annual jury meeting for the DESCQ (Advanced Postgraduate Diploma) in Orthopaedics, but also meetings and discussions organised by the department; during these meetings there were always fruitful exchanges due to his liveliness and profound kindness.
Finally I knew Gilles Bousquet through workgroup meetings concerning a programme of work we both had in common on dual mobility cups.
He really left me with the image of a tireless worker. I was told by people in the department that he worked from early in the morning to very late at night. He kept tabs on all the patients in the department. He approved all the indications. Gilles Bousquet was a genuine legend in orthopaedics.
However it would seem that in the later years of his life, orthopaedics was not his only passion, during his free time he was devoted to painting…..this was a little known facet of this uncommon personality.
M.O: What motivated him?
M.H.F: He was always searching for something new. Albert Trillat nominated 4 pupils : Henri Dejour, Paul Grammont, Jean Luc Lerat and Gilles Bousquet. In some respects Gilles Bousquet was the free radical of the group. He was always full of ideas, maybe too many ideas. But in Lyon he was moderated by the other members of the team. When he arrived in St Etienne in 1974 he left a free reign to his ideas, which were dazzling, unfortunately his friends and colleagues from Lyon were no longer there to bring a steadying influence.
M.O: Did he consider his move to St Etienne as an exile?
M.H.F: No, certainly not, especially as at the time the department at St Etienne was still attached to the University Hospital of Lyon; the internship of Lyon included that of Stéphanois area departments. All the specialist interns with an osteoarticular orientation from Lyon went through Gilles Bousquets department; they all have fond memories of their period of training, as much for the surgical training as for the non surgical facets of life as an intern in St Etienne.
Later on, St Etienne became autonomous, with a separate choice of interns; in my opinion this was a period when Gilles Bousquet became disappointed because the interns from Lyon who previously chose to come and work with him no longer came to St Etienne.
M.O: Was he authoritarian?
M.H.F: There again it is hard for me to reply. I think quite sincerely that after what I have been told that he was open to a certain amount of discussion during analysis of patient files. In the end though, he was the one who decided. Personally, and regarding my thesis, even though he was not satisfied by what I had written, it was still possible to have a discussion with him. Apart from this, all heads of department must be able to show authority, the head of a school must set a line of conduct, after which discussion is no longer possible. All of Gilles Bousquets pupils were very touched by his disappearance, if the learned societies have lost a master innovator, the Lyon school of orthopaedics has unquestionably lost a major leader; his pupils have really lost a father.
M.O: What was the experience of the screw in femoral stems?
M.H.F: There were three successive types of screw in stems. The first model was the PIM designed in 1979; which was a screw in stem onto which a screw on modular neck was added. This stem had the disadvantage of impinging on the metalback shells and causing early loosening of the cups. Sometimes the lesions caused by the impingement can be seen on x-ray; in effect there was a visible groove on the prosthetic neck. The PIM stem was abandoned in 1981 because of ruptures of the implants after assembly of the parts. In 1981 the experience with the PF stem began. This was a screw in stem onto which a stainless steel monobloc neck was fitted of 16mm thickness with a 22.2mm head. The head and neck were monobloc. This implant gave excellent results when used with dual mobility cups. However the appearance of the first cases of intra prosthetic dislocation stimulated Gilles Bousquet to evolve towards a third model of screw in stem. In 1986 the PRO stem experience started. This was a screw in stem onto which a titanium neck was fitted of 13mm thickness. This neck was modular and could accommodate 22.2, 26 or 28mm heads. The experience with this screw in stem in its different forms was essential, and a major contributor towards the evolution of cementless stems in the Rhone Alpes region. It is true to say that the Rhone Alps played a primordial role in the development of cementless implants in France. A number of renowned groups came from the Rhone Alps. The ideas which came from Gilles Bousquet in the 1980s are without doubt at the origin of this regional evolution.
This stem was coated in an alumina spray, something of a technical prowess at that period. Behind this idea of alumina spray was the biological fixation which Gilles Bousquet was looking for. Today we know that this alumina spray is not osteoconductive, unlike other structures such as hydroxyapatite. In any case the technological process of spray coating was developed during those years.
One also has to recognise that this screw in stem contributed to proving that cementless implants were a reality. There were some cases of early loosening (unscrewing) of these stems, but when secondary fixation was achieved it was durable. They even had the reputation of being impossible to remove; which was the final result being searched for; definitive fixation between implant and bone.
It is often the case that surgical groups in the Rhone Alps area came to use cementless implants by having used this screw in stem first. In the T wing for example, Mr De Mourgues began his experience of cementless implants in prosthetic revision cases, using Gilles Bousquet implants. This was following the thesis done by his pupil Dr Jean Louis Debiesse.
Finally, this stem was not only an innovation and a source of progress, but also introduced the concept of modularity, still fashionable today. This modularity allowed for adjusting the anteversion, lateralisation and neck length. This is an often forgotten innovation of Gilles Bousquet.
M.O: How was this screw in stem perceived?
M.H.F: As I said, at the time this stem was an innovation which contributed towards the evolution of cementless implants. However, there were drawbacks. The first PIM prosthesis could provoke impingement and led to acetabular loosening. The PF prosthesis had a thick modular neck, which led to trochanteric fractures. In my medicine thesis which studied screw in stems, I was able to report 15% of fractures of the greater trochanter with PF stems; these fractures were not always displaced; did not always require osteosynthesis; but these fractures were a potential source of insufficiency of the gluteus medius. In my thesis the PRO stem, which was not as big, still had a 10% fracture rate of the greater trochanter. Today these figures would seem dramatic.
M.O: What about the survivorship curve?
M.H.F: The survivorship curve of these screw in stems is not extraordinary. The survivorship results were penalised by early unscrewing. However it must be admitted that once secondary fixation was achieved, fixation became eternal. I see lots of patients in our department who benefited from such an arthroplasty. Sometimes I need to revise them for acetabular problems, and must say that we don’t change the stems which are perfectly fixed. We are content to limit the revision to the modular neck and head. One also has to recognise that this type of cementless fixation does not allow particle passage or migration, because we never observe foreign body granulomas at the tip of the prosthesis with these cementless screw in stems.
M.O: You seem to forget the thigh pain?
M.H.F: No, I have not forgotten them. They are an important problem with screw in stems. Thigh pain reported in my thesis is present in 10% of cases. A certain number disappear in the first year, but some remain all the time. This pain is probably caused by a tendancy towards preferential diaphyseal fixation, especially with the first models of the stems. This is part of the reason why the thread design was frequently modified as time went on. To begin with the threads were trapezoidal, they became sharper, they then became progressively thinner (finer) from the proximal end to the distal tip. Just before his death Gilles Bousquet was testing a new model of screw in stem, which had a metaphyseal fixation only, in order to avoid distal fixation. Gilles Bousquet never wanted to admit to this major disadvantage of screw in stems, but the evolutions he brought to the profile of these implants was an admission of the problem on behalf of the inventor himself.
M.O: When did he develop the dual mobility cup?
M.H.F: The first work on dual mobility cups started in 1976. At the time this was not a true double mobility as we understand it today; at the time it was in effect a retentive polyethylene placed on the head of the prosthesis. This polyethylene articulated directly in the acetabulum. This first series produced catastrophic results and was quickly abandoned in favour of a new model where there was mobility between the head and the polyethylene, and the polyethylene and the metal back which itself was mobile within the acetabulum. This series had disastrous acetabular pain and was abandoned in favour of the first fixed dual mobility system, cemented into the acetabulum. This implant was abandoned in 1979 in favour of the Tripod cementless system which Gilles Bousquet used for the rest of his career.
He used 22.2mm heads in order to respect the low friction arthroplasty concept proposed by Charnley. The metal back shell was coated with an alumina spray further to collaborative work with Jean Rieu from the Ecoles des Mines at St Etienne.
This implant which was designed in 1979 was very little modified afterwards, there was a modification to remove the lateral wings which could come into conflict with the psoas; the polyethylene was redesigned to include chamfers in order to improve range of motion within the first mobility, ie between the head and the polyethylene. At the same time Gilles Bousuet advocated 26 and 28mm heads when polyethylene thickness allowed. All this was justified further to the first episodes of intra prosthetic dislocation.
M.O: Why did it take so for the concept to be accepted?
M.H.F: There are numerous reasons. First of all there was a question of the personality, who did not only have friends within the orthopaedic community. Also this can be attributed to the fact that the dual mobility concept was the opposite of systems which were unanimously accepted and known throughout the world. Finally one must accept that the Stephanois school, Gilles Bousquet, and his pupils did nothing to publish on the subject. For a long time the only known publications on the subject were those of J.H. Aubriot from Caen.
M.O: He had also developed a knee prosthesis?
M.H.F: I think that Gilles Bousquet brought a lot to hip surgery, but in most of our colleagues’ minds he was first and foremost a knee surgeon. It’s true. He wrote his thesis on the central pivot (cruciate ligaments) under the auspices of Albert Trillat, and at his side therefore participated in unravelling knee instability. His name will remain inexorably associated with postero – external instability; his name will remain associated with the (PAPE) )and (PAPI) internal and external angles insertion points ….and his name will remain associated with the politeus. In the realms of knee arthroplasty he had in effect developed a rotating prosthesis, which associated automatic rotation with flexion extension movements. This prosthesis was developed in the 1970s.
M.O: He had a reputation as an excellent operator, though a bit aggressive…..
M.H.F: Everybody who worked alongside him acknowledged his surgical qualities. As far as the knee was concerned he covered all aspects of this articulation. Alongside this his results were exceptional, which earned him an international clientele for ligament surgery. He operated on numerous professional football players, especially from the Italian league, as demonstrated by the many pennants still hung on the walls of my office. This renown within football circles very well demonstrates the surgical qualities of Gilles Bousquet. He had a hold over the Italian league for many years. I think football really is the sport by which you can quantify the results of ligament surgery. Many of Gilles Bousquets patients continued an international career after having been operated on in St Etienne by this undisputed Master.
M.O: What happened to Gilles Bousquet?
M.H.F: He died in an accident. He went for a rest in the Seychelles and drowned. He was only 59. It has to be said that he led a terribly busy lifestyle. He worked without stopping. He smoked cigarette after cigarette. He probably had a heart attack. There are rumours surrounding his tragic death….These are based on absolutely nothing. I personally learned of his death from his assistants who phoned me. I remember the emotion within the orthopaedic world of Lyon when this sad news was announced.
M.O: When did you arrive in St Etienne?
M.H.F: On the 1st of September 1998. Before that I was at The Edouard Herriot Hospital, Lyon, T wing, with Professor L.P. Fischer, where I thought I would spend my whole career. At the time I was Master of Conferences in anatomy. I taught for 9 hours per week. The University of Lyon wanted to nominate me, but there was no position available in the short term, so it was decided I should wait.
The availability of Gilles Bousquets post presented me with an opportunity which I seized. At the time those at Lyon were sad to see me go, many people tried to make me stay. But it is so difficult to obtain a post of PUPH (Professeur des Universités, Practicien des Hôpitaux), University Professor, Hospital Practitioner, that when a post is proposed to you, you should not hesitate for an instant. Therefore I immediately accepted the post at St Etienne. I was nominated the same year, Professor and Head of Department at Saint Etienne.
M.O: How did your arrival at St Etienne work out?
M.H.F: Gilles Bousquet died on 14 april 1996. I arrived in St Etienne two years later. The department had suffered enormously. There were only 35 beds instead of 70. The department had been stripped bare. When I arrived in St Etienne I knew nobody. I didn’t even know the structure (of the organisation). On the 1st of September 1998 when I sat in Gilles Bousquets chair, I realised that things were going to be complicated.
The main problem was in re- organising the department. My first year was devoted to this re – organisation. I was made to feel very welcome by all the personnel in the Orthopaedic Centre. I was helped also by the support from Gilles Bousquets secretary who was the real soul of the department; I was lucky to keep her at my side. She knew everything, one only had to ask. She never made judgemental comments about her young 38 year old Head of Department, and was intelligent enough not to make comparisons. I dreaded hearing the phrase “Mr Bousquet never did it like that” but I never heard it. It is however a phrase one hears a lot at the semester changes of interns……
I was also helped by my surgical colleagues, Hospital Doctors, Assistants, and Interns who enabled me to re dynamise the department. In a year and a half we were able to recuperate our 71 beds in order to maintain our traumatology and orthopaedic activity.
M.O: How did you organise your department?
M.H.F: It is a classic type organisation. There is a traumatology staff meeting every morning in order to update with the on call surgeon and intern on hospitalised patients. X rays taken during the night are examined. Deferred emergency operations are programmed for that day or the following days dependent on their pathologies and degree of urgency, but also on the availability of operating theatres. This is discussed with the theatre supervisor. All the surgeons of the department are present.
Following the Lyon tradition all monday afternoons are given over to a weekly meeting. This is when all the files of patients to be operated on during the week are reviewed and analysed. We also keep an eye on the work of the previous week. There may be discussion on the
operations and implantations We will discuss difficult trauma cases where care may have to be staggered. Finally all those present at this meeting, all the surgeons of the department, all the interns, the theatre and anaesthetic supervisor, will discuss the order in which the patients will be operated on during the week. I must admit that the role of the theatre supervisor is essential in the smooth running of the programme. We are lucky at St Etienne to have a Theatre Supervisor (executive post) who has come through the specific theatre nurse training school (IBODE), and who is vary knowledgeable in orthopaedic pathologies, and who has an extraordinary sense of organisation. Without her it would be difficult for us to have efficient management.
Speaking for myself, I operate on Tuesday and Thursday morning, sometimes on Friday if there are patients waiting or who need to be planned in quickly, and who are difficult to place on a normal cold list. For 15 years I have also been in the habit of operating in a district hospital in Saint Vallier on Wednesday mornings. Every Wednesday morning I do one prosthesis and then consultations.
The architectural set up of wings 1 – 3 at the Bellevue Hospital where we work is not very favourable, because the building was refurbished, but there are communication difficulties between the two wings because of the architecture of the building. This difficulty in communication has been partially sorted out by the computer network. Live, everybody in the department can know dates of hospitalisation, programmed operations, and equipment needed in theatres.
The departments activity is orientated towards traumatology which represents 40%. It is the only traumatology department in the “Ligérien” basin. We are the reference department. 60% of our activity is orientated towards orthopaedics. In orthopaedics we have a large hip activity but also knee and shoulder. I am fortunate enough to have at my sides two hospital specialists.
Fréderic Farizon is the “memory” of the department, since he was a pupil of Gilles Bousquet. He has a general orthopaedic activity, but is the department reference in knees. I am also accompanied by Laurent Beguin who has developed our shoulder activity as well as managing other activities within the department. They are the motors which have contributed towards the development of our department. At our sides we have 3 assistants and 4 interns. Since I have arrived at St Etienne, I was always chosen by them to work with, none have ever left. I’m very lucky. I’m conscious of this because a number of departments are having difficulties due to the lack of surgical interns. They know I am grateful for the confidence they have in me. I think that in their own way, all my collaborators have contributed to their professional training. Finally the team is re –inforced by part time colleagues: Michel Colas, first assistant to Gilles Bousquet, surgeon at St Chamond; Philippe Girardin, one of Gilles Bousquets favoured pupils, surgeon at Montbrison. The team is also re – inforced by Giorgio Gresta, ex intern with Gilles Bousquet, surgeon at Montbrison. Doctor Henri Olagnier manages the sport consultations for the department.
M.O: What problems do you encounter as head of department?
M.H.F: The real problem is emergencies; the real problem is respecting legislation. The department is the only one in the area which looks after traumatological osteoarticular surgery, for 24 hours a day. The surgeon on call sleeps at the hospital. We have 71 beds at our disposal. Unfortunately there are only 5 senior surgeons to share the on call duties and ensure continuity of care. This creates daily problems in managing surgical activity, because one surgeon is off on recuperation as security. In summer it is obviously impossible to respect all the legislation and so we find ourselves working illegally. Our General management is totally aware of the problem and they are doing all they can to help.
M.O: What course have you followed?
M.H.F: I always wanted to do orthopaedics and surgery; though I do not come from a medical background. I was born in Lyon and grew up in Roanne where I passed my baccalaureate. Interested as I was by the living world I said to myself that I would go into medicine. I was very good at maths and so I was told no, you should not go into medicine. You must do Advanced Maths. So off I went to study Advanced Maths at the Lycée du Parc, Lyon. I spent an extraordinary year there since I really like maths, less so physics. At the time my friend in the student lodgings had a friend in medicine in Lyon. This person gave me a photocopy of Articular Biomechanics edited by Louis Fisher. I was fascinated; and decided that that was what I wanted to do. The following year, 1978 despites my good results in Advanced Maths, I started medicine at the faculty of Lyon, Grange Blanche. I passed my first year (competitive examinations). From the second year onwards I put my name down for human biology, articular biomechanics and in the third year for a certificate in Anatomy. After this I had to prepare for the internship….I had a very general orthopaedic training. However I decided I would do hip surgery as of my first semester. I was a young intern with Claude Régis Michel, who, even though he was head of infant surgery had a huge activity in adult surgery, especially total hip replacement surgery. I was fascinated by this surgery, and today I still use techniques he taught me.
M.O: In University terms, you are an Anatomist?
M.H.F: Yes, for the university I am in effect Professor of Anatomy. I continue to teach anatomy at St Etienne. There is no Professor in Orthopaedics, and I also teach this too. I was nominated in anatomy as an MCU. It was through anatomy that I obtained my university titles; it is a discipline I have never sought to abandon, despite the teaching workload. Anyway, on my arrival at St Etienne I had negotiated to be able to continue in Anatomy, whereas Gilles Bousquets post was in Orthopaedics. This was a calculated risk because I knew that as an Anatomist, I knew that one day I could nominate someone in Orthopaedics. It is a discipline which generates a colossal hospital activity and trains young surgeons who will in future have responsibility for the population.
M.O: What do you think of teaching Anatomy in general?
M.H.F: It is a discipline which I like a lot. Unfortunately these days only a thin veneer of Anatomic culture is taught at the Faculty of Medicine. It is true that one must adapt, because the Faculty of Medicine prepares for everything, except medicine. Out of 700 students, only a hundred or so will go onto study medicine, many will have no other options; some may go to dental school, midwife school, or into physiotherapy. The paradox of the first year of the Medical Faculty is that one must teach this huge mass of students, whilst not going into detail for the future doctors who should be our preferred target of our teaching. Today we only teach the rudiments; it is dramatic that this anatomy is no longer taught. This is especially dramatic for the teaching of surgery. The main criticism of todays organisation is that there is no re – injection of anatomy in the 3rd cycle for our interns. In our specialisation, anatomy is unavoidable and remains the compass which guides the steps and the hands of the surgeon. In our specialisation, besides what we do on the bones, one must learn the surgical approaches; which must be learned in the anatomy lab.
M.O: In the end, you came back to Mister Fischer?
M.H.F: I was an intern in Mr Fishers department in 1986, in my 2nd year of internship. I liked his department due to the hip orientation. I requested a position of Chef de Clinique (= Head of Clinic). In 1991 I was a gold medal intern in his department and became Chef de Clinique in 1992. Those years working at his side in T wing were marvellous. I was truly able to learn hip surgery because this department had a tradition in this orientation, it being the old department of Mr De Morurgues. Mr Fischer always showed me his utmost confidence, and with him I participated in the organisation of the department. These years were equally marvellous because I strengthened my links with Jean Christophe Chatelet who now works at the Clinique du Beaujolais. We were always confident in one another. We have remained very close, as much in our professional activity of surgery concerning the hip, as with more private meetings. It was also within this department, with Louis Fischer, that on a number of occasions we organised the Lyon Hip meetings (Journées lyonnaises de Hanche) which were decisive in the development of my career. Due to these meetings and Mr Fischers support, I was able to meet hip surgeons who always reserved a warm welcome for me. It was also with Mr Fischers support that I was able to become Master of Conferences in 1994. I owe him a lot, perhaps he does not know how much, so I take the opportunity of renewing my thanks and respect.
Finally T wing also has more personal memories, because that is where I met my wife, with whom I share happy times. The role of wife is essential in our line of work to support us in what are sometimes difficult times in a university and surgical career.
M.O: Is Mr Fischer still in practise?
M.H.F: No he is retired. However he has not abandoned medicine. He is still interested in the history of medicine. As you know he is an extremely cultivated man; knowledgeable in painting, literature and architecture. I very much like painting(s). In T wing we often had discussions about this art form. I think he knows as much about painting as any great museum curator. I remain in admiration.
M.O: How are the University Hospitals organised in Lyon?
M.H.F: In Lyon there are three University Hospital poles. There is the Hôpital Edouard Herriot, the Hôpital Croix Rousse with the Centre Livet which looks after orthopaedics and the Center Hospitalier Lyon Sud. Jacques Bejui and Jean Paul Carret are at T wing in Edouard Herriot. Guillaume Herzberg in M wing at Edouard Herriot is in charge of upper limb activity; he also has the heavy task of looking after traumatology and is assisted in this function by his deputy Doctor Jean Christophe Bel. At the Hôpital Croix Rousse Philippe Neyret is at the Centre Livet. At the Hôpital Lyon Sud, Jean Luc Lerat and Bernard Moyen look after orthopaedic and also traumatological activity.
M.O: It is said that you are leaving St Etienne for Lyon?
M.H.F: Jean luc Lerat will take retirement in September 2006. In agreement with Bernard Moyen, he has asked me to succeed him to look after the large hip activity in this department. It will be a great pleasure to work with Bernard Moyen whose activity is more concentrated on the knee articulation.
I will leave St Etienne with regret. Saint Etienne gave me everything. I obtained my title of Professor, I became head of department, I had all the confidence of the department personnel and also my colleagues and patients from the St Etienne area (Stéphanois). I will really leave St Etienne with regret because I developed a constructive activity.
However I was disappointed not to have been nominated in Lyon in the past, in retrospect it felt as if I had been abandoned by the organisation which had trained me, and for which I had spent a lot of energy. Today Lyon wants me to come back. It is like a second nomination for me…
M.O: What are you preferred subject areas?
M.H.F: Hips and more hips….I am also interested in traumatology, in particular traumatology of the pelvis. Since I arrived in St Etienne I abandoned spine traumatology which I practised in Lyon. I am still also interested in tumour surgery and am responsible for care of infectious pathologies of the locomotor apparatus.
M.O: What do you think of dual mobility?
M.H.F: I discovered this principle in Lyon when I was in Professor Fischers department, who used it readily in revision surgery. As of 1986 when I worked as an intern in this department, I was able to understand the significance of this equipment to prevent instability. It is true to say that this is the foremost quality of dual mobility cups. When I was a Chef de Clinique and already very interested in prosthetic hip surgery, I would readily use this system in patients presenting with a risk of instability, but also to treat chronic instability. I also remember happily using it in fractured necks of femur for patients who needed a total hip replacement, and also in tumoral resection surgery.
M.O: Don’t you think that the indications have become excessive?
M.H.F: I don’t know, a lot of surgeons say so. Some even say that one in two acetabular cups sold in France are dual mobility. What is the truth? I don’t know. It is true to say that this type of system has developed very much in the last 10 years. There must be high demand, because all the manufacturers now propose such a system. You must however admit that dislocation is dramatic amongst the problems of prosthetic hip surgery. Obviously causes of dislocation are multi factorial, but surgeons always feel that a dislocation is their error; patients feel that it is a failure of the method even if they often don’t blame the surgeon; many patients say rather philosophically “I did something that I shouldn’t have done”. The operator always feels responsible. What is even more dramatic is that one out of two dislocations becomes recurrent. It is true to admit that Dual mobility protects against this unfortunate accident, from this thunderclap in the anticipated clear sky of the results of an arthroplasty.
M.O: Do you systematically use a dual mobility system?
M.H.F: No, certainly not. In young active patients I prefer to use an Alumina ceramic – ceramic bearing to avoid long term wear. However in case of a pronounced risk of instability, regardless of age, I will use this concept which ensures against the risk of dislocation. In patients above the age of 70, I also use dual mobility. Survivorship curves demonstrate that there are no revisions of these types of patients; dual mobility protects against the risk of dislocation which is the foremost complication in this elderly population of patients.
M.O: What is the status of your studies on dual mobility?
M.H.F: Upon my arrival at St Etienne I knew I would abandon screw in stems. I am a convinced proponent of a cementless quadrangular stem covered with hydroxyapatite, and not of the screw in type. There is such a continuity of results with the ARTHRO group that there is no place for the screw in stems and its attendant problems. I also knew that upon my arrival at St Etienne as a hip surgeon, that there was an inestimable scientific heritage about dual mobility. However the system was still relatively unknown. The Stéphanois School had published very little. We had everything to do. I was very much helped by my colleagues. Remi Phillipot devoted his thesis in medicine to reviewing a 10 year cohort of patients. He produced a survivorship curve. The results are good and entirely compatible with more classical methods.
Fréderic Farizon worked on the outcomes in patients under 50; the results were published by the French Society of Hip Surgery during a symposium organised by Henri Migaud and Christian Delaunnay. The results of our department were criticised, but considering our confidence intervals, dual mobility is not inferior compared to other systems. Our survivorship curve was penalised due to the somewhat debateable revision of two cups for intraprosthetic dislocations where we could have been content simply to change the polyethylene.
Philippe Adam is devoting his thesis in science to dual mobility. He is working on the analysis of polyethylene wear. Laurent Béguin, Olivier Vanel and Sophie Grosclaude are contributing to the results.
We are working in two directions. The first is in examining the constraints at the interface between the cup and the bone. The question being asked is does dual mobility reduce constraints at this interface. The second is the analysis of intraprosthetic dislocation. We have a cohort of 60 patients who presented this type of problem. We are looking at factors which may favour this type of intraprosthetic dislocation. We have already incriminated the young age of patients. It would appear that this intraprosthetic dislocation is not only a consequence of neck impingement. The head – neck ratio does not alone explain this complication occurring. There are effectively two mechanisms which lead to this intraprosthetic dislocation. It is the design of the neck which contributes towards this dislocation. It is probably necessary to optimise the neck design which would be implanted opposite a dual mobility cup.
M.O: Are you active in fundamental research?
M.H.F: I am a member of an INSERM team. I participate towards the activities of the laboratory on bone tissue managed by Laurence Vico in St Etienne. This team is looking at the adaptations of bone to constraints. We have a project on the analysis of constraints around a cementless femoral stem. The transmission of constraints in a normal femur has been well known since the work of Koch in 1917 and Blaimont in 1968.When a femoral implant is implanted, the fact that the neck is cut means that the head no longer transmits traction forces to the lateral cortex or compression forces the medial cortex. After implantation of a femoral stem constraints are transmitted via the head to the femur by the femoral stem. We are conducting a analysis by Extensometry at the Ecole des Mines, as well as a prospective radiological analysis and especially a prospective study on density. We are hoping to establish a predictive model by finite analysis, in order to quantify the role played by prosthetic factors; alloys, size, quadrangular or round shape, ….surgical parameters such as femoral “fit”, restitution of lateralisation, and patient physiological parameters such as osteoporosis.
We are also looking at navigation in hip surgery, and with the Ecole des Mines we have been able to do some work on the functional mobility cone of range of motion of a normal hip during different activities; this physiological data on normal patients is compared to the possibilities offered by arthroplasty, as a function of the different relative positions of the implants. As part of the same axis of work, we are analysis different references on the pelvis and femur.
M.O: What are your objectives for this year?
M.H.F: First of all I hope to be able to maintain the activity of St Etienne right up until my departure. Obviously I am also organising my return to Lyon, because the post was opened in the Official Journal.
In the short term I am preparing the 20 years of CORAIL with the ARTHRO group.
As you can imagine I will continue on the fabulous journey of dual mobility.