N°274 - May 2018
Interview viewed 57 times
Christophe was one of the pioneers who at a very early stage dedicated his practice to foot surgery exclusively, and he has a solid grounding in medicine and surgery, acquired from working alongside the most learned rheumatologists and radiologists at Lariboisière Hospital.
He has been treasurer of the Association Française de Chirurgie du Pied (AFCP - French Association of Foot Surgery) for the past 4 years and this year he will preside over their spring conference in Reims.
What are the main topics for the conference in Reims ?
The topics we have chosen are nothing new but they may not always be understood or they may not always be straightforward to treat in 2018. Out of these, there are four topics that we feel are important. Morton’s neuroma, in which we are still unsure whether the preferred treatment should be removal, decompression through neurolysis or even a more mechanical intervention consisting of metatarsal osteotomy, based on the idea that the cause is excessive pressure, and it logically fell to Thomas Bauer to lead this session. The second subject is metatarsophalangeal instability. Where there is a failure of the first ray, this may destabilize the lateral rays, starting with the second metatarsophalangeal joint. This instability ranges from synovitis only to complete dislocation with deterioration of the cartilage. Our aim is to understand now what to do in patients with a dislocation or simple instability, with or without hallux valgus. What stage is the instability at, what treatment should we offer? It can be as clear as mud - should we perform percutaneous osteotomies drawing back, elevating or realigning the structures? Capsular reefing? Always treat hallux valgus at the same time and using which specific technique? One of our American speakers will be talking to us about this topic. The third subject will be led by Julien Lucas and it is the pathology of the 5th metatarsal, going from the base of the joint up to and including the head. Finally, Carlos Maynou will be speaking to us about a subject that is close to his heart, and in which he has a huge amount of experience, cavus foot.
Let’s start with Morton’s neuroma.
Morton’s neuroma can be treated by excision, neurolysis or osteotomy to correct the causative structural defect. Thomas Bauer is right in thinking that Morton’s neuroma is caused by a phenomenon of excessive weight-bearing and that it is logical to suggest correction of the causative factor by osteotomy. So we have asked him to share his thoughts with us, to give us his results, and if possible the longer-term outcomes of these osteotomies and the adjacent metatarsals. We have also asked him to invite advocates for neurectomy and neurolysis, bearing in mind that Morton’s neuroma is a disease intrinsic to the nerve, or rather the axons. Unlike carpal tunnel it is the nerve itself that is pathological in Morton’s neuroma, affected by extensive fibrosis.
Isn’t there already an established treatment algorithm for metatarsophalangeal instability?
The treatment algorithm is not yet clear at present, and our goal is to be able to clarify it and make it as practical as possible so that we have an approach and an action plan that surgeons will be able to use on a daily basis.
Will it be possible to reach a current consensus in this area?
There are three stages in metatarsophalangeal instability: stage 1 is said to be “synovitis” with an intra-articular effusion and visible synovitis on MRI or ultrasound scans. At this stage of the disease, it is often possible to treat only the hallux valgus if there are no significant structural defects in the forefoot. The hallux valgus is corrected, returning function to the first ray, and logic dictates that it was a functional destabilization of the second ray. If, however, there are marked structural defects, I believe that it is not enough just to correct the hallux valgus, we should then be proposing osteotomies to realign of one or more lateral rays. At stage 2, there is deterioration of the plantar plate with metatarsophalangeal instability in the sagittal plane, which translates into an abnormal increase in dorsoplantar drawer with a positive Lachmann’s test. This is the point of no return where there is an irreversible plastic deformity of the plantar plate. Correction of hallux valgus only will not be enough, it must be combined with osteotomies to M2 and M3 if they are long, and if not there is a place for plantar plate repair. At stage 3, there is MTP dislocation that it is sometimes possible to reduce, and while surgery to the hallux valgus is indispensable, even repair to the capsule or plantar plate is in my view insufficient, and what is needed is an osteotomy to draw back and elevate the structures. Which osteotomy should we offer? This will depend on the type of structural defect.
What about the next topic?
That is the 5th metatarsal. We are fortunate at the AFCP to have an office of very active young people who have chosen pathology of the peroneal tendons from origin to insertion. Pathology of the 5th metatarsal follows on from this, and includes overlapping 5th toe, bunionette, fractures including fractures of the base such as a Jones fracture, which has been a hot topic recently concerning footballers, up to somewhat more complicated problems of excessive weight-bearing on the base 5th metatarsal.
And cavus foot?
Cavus foot remains a difficult issue, which was addressed 8 years ago in the SOFCOT (French Society of Orthopaedic Surgery and Trauma) teaching sessions and it is now time for an update. While there certainly have not been dramatic changes since that time, progress has been made on assessment of cavus foot, the effects of neuromuscular blocking agents and Botox, meaning we are able to specify which tendon transfer to perform, and whether surgery to the tarsus is useful, specifying the site and in what order this should performed. Should we lengthen the gastrocnemius or Achilles tendon, or perform calcaneal osteotomy or arthrodesis?
Are the cases of cavus foot that you are seeing now more or less constitutional?
Let’s say that cavus foot has a neuropathic origin in the vast majority of cases. However, this may be missed by the orthopaedic surgeon but after some slightly more sophisticated investigations a neurologist will be able to bring this to light, and it is important to understand, especially in tendon transfers and prior to deciding on arthrodesis. Cavus foot is very rarely idiopathic, and it is acquired for the most part.
Would it be possible for a congenital planus foot to become cavus due to acquired neurological damage?
I want to emphasize that both cavus and planus foot are acquired diseases, rather than congenital. They develop once walking is clearly established, never before two to four years of age. I don’t think or I hope that paediatric surgeons aren't going to contradict me on this point.
But why do you say that it is acquired? Aren’t the constitutional conditions already present?
Of course! Any condition that does not exist from birth I would call acquired, otherwise it is congenital. This is not a congenital condition, unlike tarsal coalition. Except in cases where there is a history of acute anterior poliomyelitis followed by development of cavus foot, it is clear that there is an element of determinism in this deformity. In practice, we more often see cases with spasticity and deficits, caused by damage to the central or peripheral nervous system or spinal cord, especially hereditary sensory and motor neuropathies that lead to cavus foot such as Charcot-Marie-Tooth disease, Dejerine-Sottas disease and some polyneuropathies.
Is this something we are seeing more and more of as people are living longer?
It would be logical to think so. We are seeing many more minor forms of cavus foot usually with varus of the heel and deviations and deformities of the forefoot, especially hallux valgus, but this is not the main event. We will treat instead true cases of cavus foot where there is a marked change to the lateral talo-first metatarsal angle or Meary’s angle. On this subject, when we mentioned the Méary-Tomeno angle in front of Tomeno, he protested that he should not be blamed for it!
Now that around 10 years have passed since the introduction of minimally invasive and percutaneous foot surgery, what is the current situation?
There has not been any noticeable revolution in terms of arthroscopy in joint surgery. That is to say that where there is a good indication for open surgery, this remains a good indication for percutaneous surgery and vice versa. The rules and decisions still remain almost identical. Post-surgery, the percutaneous technique has of course contributed something not so much in terms of the mechanics, but rather in the way of proceeding and recovery. It does indeed seem that there has been a knock-on improvement for the lateral rays and especially the 5th, which is why we wanted to discuss these topics. It’s true that I now only perform surgery to the 5th ray percutaneously. As for the lateral rays, some of the surgery I perform is percutaneous and some remains open, especially in certain stages of MTP instability.
Do you still perform syndactylization for overlapping 5th toe?
No! Syndactylization does not produce glowing results and you feel that the problem will spread and it is the 5th toe that will end up training the 4th toe. We used to do the same thing for isolated instabilities of the second ray, we performed a syndactylization of II – III and the two were split again the following year.
So what do you do?
In overlapping fifth toe with dorsal soft tissue retraction, I perform a Z-plasty of the skin, extensor lengthening, MTP arthrolysis, dermodesis of the plantar skin following Lelièvre and very rarely an M5 osteotomy, unlike for bunionette in which osteotomy is required.
Let’s go back to the conference!
The conference has some very interesting speakers. One who is coming to us from Holland is Van Dick, who will be talking to us about partial resurfacing of the talar dome. Lesions of the talar dome remain difficult to treat, although we have a much better understanding of them with the FOG classification which separates out talar dome lesions and which comes to us from a sister group, the Société Orthopédique de l’Ouest (Western France Orthopaedic Society). F for fracture, O for osteonecrosis and G for geode.
Only the topography of fractures tends to be…
On the lateral side, absolutely. And geodes and osteonecrosis tend to the medial edge. But in spite of everything, there remains the problem of distinguishing between true osteonecrosis and its sequelae and geodes which can rupture, complicating things somewhat. This nosography is interesting and it makes a good basis for discussion. For these geodes, what do we do? Do we treat them percutaneously, arthroscopically? Is it logical to simply fill a cavity with bone that will only repeat the cavitation process? Should we be performing resurfacing? Other possibilities are chondral, osteochondral or cancellous bone grafts, and finally resurfacing in the same way as for the femoral head in some contained areas of necrosis. Van Dick will share his experience.
Is mosaicplasty an aggressive technique?
The problem is choosing where to harvest from. Use of the femoral condyle raises a medical and legal question, since if there are complications you would have to ask yourself if there were not a less dangerous technique. The very anterior portion of the talar dome could also be used although the quality is perhaps not the same. The grafts are taken during a short arthrotomy, then embedded in the decorticated geode as long as there is one peripheral wall intact.
Has Van Dick developed implants?
Yes, an implant with partial metal resurfacing, as used in necrosis of the femoral head; he will be sharing his experience with us and data from the literature but of course he will also talk about other techniques.
Do you have other speakers?
Yes, we have been in touch with AOFAS, the American Orthopaedic Foot and Ankle Society, our American counterpart, who are sending two representatives. The first, Vichod Panchabi, will explain to us their vision for management of hallux valgus and instability of the second metatarsophalangeal joint and the second, former AOFAS president Steven Haddad, will talk to us about ankle replacement surgery. The title of his talk will be “Is there anything left to be solved?”.
No speakers from France?
Yes, Gérard Morvan. He is a renowned radiologist who is passionate about the foot and although not a surgeon, he is a member of the Académie de Chirurgie (French Academy of Surgery) and he has an encyclopaedic knowledge of this field. He will be sharing his thoughts, superbly set out as “The undersides of the foot”. Also, for the second time at an AFCP conference, there will be a session for chiropodists that they have organised themselves. The aim is to improve the partnership between chiropodists and surgeons. To make this official and long-lasting we got in touch with their highest authority, the College of Chiropody. So, a day of chiropody is planned as part of the joint sessions. Finally, on the last day, the Saturday, we will have a CPD session dedicated to the foot in rheumatoid arthritis, managing it medically and surgically and in particular the implications and consequences of new treatments for the surgeon. In spite of progress in terms of treatments, there are still those with feet affected by rheumatoid arthritis whose treatment is monitored poorly or not at all, or even stopped due to an infectious complication. So there are still indications for surgery.
Should these indications only be handled by a few highly specialized foot surgeons?
It seems to be difficult to decide whether only those who have considerable experience of the foot in rheumatoid arthritis can do it. We have had the same debate concerning ankle replacements. Some advocates have said: “Only those who fit a lot of these should be allowed to fit them”. We could then be cynical and view TAA as a bad operation because it can only be performed by an elite. And who will be the new members of this elite? A registrar who is starting out won’t do more than one a month. So the rheumatoid foot must be accessible to all.
But there is such a steep learning curve!
The purpose of a scholarly organisation is to develop knowledge and communicate it openly. An important message, however, is that surgery and especially to the hindfoot in rheumatoid arthritis is not easy, and that it should be done in the morning when you are at your best and when you are well supported. A rheumatoid hallux valgus, treated by rheumatologists, becomes almost commonplace. Afterwards the only remaining problem is medical treatment. Anti-TNF therapies and biological therapies increase the risk of infection, especially in foot surgery. JAK inhibitors are a new category of treatments that have only become available in the past year and that have quite a few side effects. It is important not to be reassured by the CRP, which can be normal in patients on these treatments in spite of an infection.
Tell us about your professional background
I come from the Henri Mondor University Hospital in Créteil, where I spent a good part of my career and I am still a part-time consultant there.
That’s a sought-after position!
It certainly is! So I practise at Henri Mondor Hospital and I am also an associate at Lariboisière University Hospital, specifically the Viggo-Petersen centre with the rheumatologists. It was here that I developed such a taste for surgery in rheumatoid arthritis and inflammatory rheumatic diseases in general. I have been working for many years alongside rheumatologists and radiologists who are specialized in bones and joints such as Jean Denis Laredo, it’s always exciting. However for hospital surgery, I only operate at Henri Mondor.
What about your private practice?
For my private practice, I have been working exclusively at Victor Hugo clinic not far from Place de l’Etoile for a good twenty years now. In the past I worked in an enormous clinic, the kind you find in the large suburbs of Paris. I was the only one there performing foot surgery for a long time and in front of me I had a group of ten hand surgeons, who were very active, very dynamic. I told myself that it was a good idea to link up with and work in a convergent way with colleagues of the same specialty.
Why did you change your place of work?
It was becoming increasingly difficult to get there by car but mainly because always being on my own was not easy. This is because there are some days when you can’t be there, and there is a real benefit to having a colleague of the same specialty. I searched amongst the people that I knew from AFCP, those that I knew and those who I had previously worked with, and I asked two surgeons, Cyrille Cazeau and Yves Stiglitz, who I got along with particularly well, to work with me in my Paris clinic. They accepted and now we can always share our ideas, have discussions and stand in for each other. The strength of a cohesive group is very important.
In your current practice, what proportions are taken up by day cases and inpatients?
I have quite a unique way of working because firstly I now only do ankle and foot surgery, I have given up all other practice although in the past I was interested in many other things, such as the anterior approach in spinal surgery when I worked under Goutallier. Highly specialized caseload in the foot means that the usual clinic or hospital pathway changes. We see patients who have come a long way, which makes seeing them as day cases complicated, especially when they are elderly and live alone. 8 years ago it was 20%, but now 50% of my practice is day cases. However, I very rarely operate on the hindfoot as a day case because of pain management, which is at present too complex to organise well enough for it to be taken over by the GP.
It also requires patient preparation.
Yes it does. Anything is possible when you live in Paris or the inner suburbs but in the outer suburbs, or even in the countryside, are you going to find a group of nurses ready to bring intrathecal pumps, to monitor them, and to visit the patient at home twice a day? Equally, will you find a GP who is prepared to travel? It’s not manageable. This is why I only treat 50% of my patients as day cases. Nonetheless, day cases do offer advantages for the surgeon and the clinic: you can increase the number of patients and increase the turnover. From a selfish point of view, it’s quite useful for the provider.
But for the patient?
As one of my junior colleagues said to me when I was at Cochin: “When I have nothing to do, I'd rather be doing it at home!”. He was quite right, when there is no need for you to be at the clinic or hospital, you may as well be sent home; it’s much better to be well looked after by your family than badly looked after by an overworked nurse. One word of caution though: if patients live alone or are isolated, you can’t in good conscience send them off to fend for themselves on their own. That is why I have always “put the brakes on” somewhat for day cases. To say nothing of the overall cost which is far from being a saving for the public purse as we showed in the AFCP book on day patient treatment of hallux valgus. As a result, I do a lot of “American style” day cases. This means that the patients arrive in the morning and stay one night post-operatively with us. This way we have reached a rate of 99%. There are a number of advantages for the patients. Firstly, we can reapply a dry wound dressing, because a bulky dressing is uncomfortable; then pain management is taken care of perfectly and finally the following morning, we perform the repeat x-ray and then, the patient is back on his feet, so to speak, and can leave the clinic.
At what point does pain normally hit its peak?
Within the first 24 hours, after that would be very unusual. The lack of input needed post-operatively is a pleasure, a development that has a snowball effect on caseload to say nothing of the effects on recovery.
Leaving the other arguments aside, are you penalized in terms of reimbursement if you keep patients in hospital?
Not for surgeons, no, unlike in Switzerland; however the clinic does not gain anything, quite the contrary. They have to pay for catering and accommodation since the GHS [hospital billing classification system in France] is the same. For the last two years the GHS has converged irrespective of whether the patient stays for 0, 1 or 5 nights. A clinic can, however, benefit from this by offering additional services such as a private room, premium meals, but this is a type of selection that is less appealing to me from an ethical perspective.
And has your caseload increased?
Yes! I think that generally, after being established for 10 years things run really smoothly, especially if communication is good. Also foot surgery is an operation with visible improvements, although the recovery times are long, and if it is done well it really promotes itself. This is also one of the advantages of a narrow specialization, that you can be sure of a high-quality result for patients.
How did you come to work in such a niche specialization?
Orthopaedics was probably the only discipline that I was convinced I didn’t want to work in when I did my training. I came from Saint-Antoine University Hospital where the major surgical discipline was abdominal. Gastroenterology and hepatology reigned supreme, we focused a lot on jaundice, post-operative obstructions and I found that exciting. The atmosphere in abdominal surgery was very strong and it had a very positive image at that time. I trained there at the start of my DCEM4 (second cycle of medical studies in France) aged 24 and I knew that I wanted to do surgery, but for me orthopaedics was somewhat the poor relation. I even thought about urology.
Urology, that’s great!
Absolutely, in fact when I passed the concours de l’internat (competitive junior doctor entrance exam in France) in ‘82, I returned to see my teacher Malafosse, an abdominal surgeon, and I told him: “Sir, I’ve got through the exam”. “Ah! What do you want to do Piat?” I told him that I wanted to go into urology. His response was: “Oh, but I thought you were interested in surgery!” In the end, I did one year of general surgery at Créteil Intercommunal Hospital, next to the big Mondor University Hospital. There were various small departments. As I was at the bottom of the pile, I was made to understand that I would go wherever there was still a place, so I found myself in orthopaedics, the very place where I didn’t want to be. So for six months I went to work in orthopaedics, well, mainly trauma, and I didn’t find it uninteresting.
Was this a branch of the Henri Mondor department?
Not at all, it was local surgeons who had a mixed working practice, part-time hospital consultants doing mainly trauma surgery. I learned a great deal because they had a huge experience and were happy to hand over. So, one thing led to another and because I had to do it, I became genuinely interested. I then left to do my military service, after six months in abdominal surgery.
Where did you go?
I was assigned to the Laveran Hôpital d’Instruction des Armées in Marseille. I was all alone in a hospital that was deserted in the evenings since all the local conscripts returned home, except for me who was Parisian. I was put in orthopaedic and trauma surgery for 4 months, I saw parachute accidents and bullet wounds, because there was the training centre for the legion that was based in Aubagne. Then I managed to get moved to Dijon to a regional army hospital that was much less interesting, but it did have the distinction of being next door to the Dijon Bocage Hospital where one Paul Grammont worked. I crossed the road and I went to see him and said: “Sir, I am a junior doctor from Paris, I’m doing my military service opposite, could I come to your team meetings?”.
He replied: “Of course, come to my clinic and that way you will certainly learn a few little things”. There I had stumbled across someone truly exciting, extraordinary. Obviously with my military status I couldn’t do anything other than watch but he managed to get me into the experimental surgery laboratory to operate on sheep. So for the remaining six months of my service I attended Mr Grammont’s clinics, his team meetings, and I have to admit that unfortunately I didn’t understand everything he explained to me. He was working at a very advanced level, and I used to read over everything in the evening so I could try to get up to speed.
Did you manage to fit in anything else during your military service?
I made the most of it by gaining the diploma in legal remedies for personal injury. That was not much use to me later, except that it gave me a legal polish, a patina that I already had because both of my parents were lawyers: one specialized in personal injury and the other in divorce. Their office was our home, in an era when you received clients at home. They would ask me to keep it down when clients were visiting and my parents often discussed their cases over meals.
After a year of military service had your options improved?
Yes, my options were better and most importantly I had a long discussion with my future wife explaining to her that I was finally finding orthopaedics much more interesting and that I was tempted to do it for another 6 months. I had identified a department, under Goutallier at Mondor, that had the reputation of being a “prison camp” where I would be put through my paces. I told myself that this way, I would be sure whether I had an appetite for orthopaedics.
What happened next?
I started in Goutallier’s department, and there we really did start at 7.45 in the morning and finish at 9 at night except for Fridays, when we would finish around 1 in the morning after the team meeting. And we always returned on Saturday mornings. The on-calls were busy and difficult. The senior registrars were fortunately really friendly, great teachers and, at times, patient, because I was only in my third rotation. I spent a year on that ward because that was one of the conditions for becoming a registrar and clinical lecturer, and another was having written a publishable clinical article.
Did they let you operate?
Yes, once you were there, you were rewarded. You would certainly be able to operate and not just when you were on call. The registrars were very competent and happy to hand over to you. This was a department where you learnt a great deal. Let me share a memory:
When I arrived early in the morning on the first day, there was a gentleman who made an impression on me. There were 4 junior doctors there and this man came towards our group, and asked us each to talk for 15 seconds and at the end of my 15 seconds he said to me: “You, what’s your name?” - “Piat!” - “Do you have a subject for your thesis?” - “No.” - “Come with me!”. He was Philippe Hernigou and you could say that I had just endured a quick and selective interview.
What were the criteria for his decision?
Maybe the spontaneity and speed of my answers. He must have thought: this one is really hungry for this, he’s answering straight away, one question after another, I’m going to be able to make something of him… he suggested a topic for my thesis, we worked together and later published together. Once the six months of my rotation ended, the fatal moment came and I had to reflect on my future. Hernigou suggested that I go to see Goutallier. I went in to the boss’s office, which was some sort of Aladdin’s cave, a real mess. We sat down on piles of files in a cloud of smoke and everything smelt of tobacco. He asked me to stay on the condition that I would write an article, and my thesis, and after that it was highly likely that I would have a registrar post. At that moment I said to him: “I really want to stay as long as you are not saying this just to please me, if you’re really interested in me then my answer is yes! "
What was he like as a boss?
Demanding. He had a broad medical and surgical grounding. He admitted patients in advance and examined them painstakingly, checking the smallest details. He had a staff meeting in the evening like they did elsewhere except that he pushed the exercise beyond all reasonable limits. The boss knew his house officers well, he had a secret service who told him if you had been around, at what time, for how long, on the wards, in theatre and even in the emergency department. This meant that we were really under a lot of pressure. There were two staff meetings per week and they seemed never-ending.
And after Henri Mondor hospital?
After that I went to Cochin hospital under another demanding surgeon, Marcel Kerboull with Bernard Tomeno as associate although he had somewhat abandoned the foot in favour of tumours. I stayed at Cochin for six months and I applied for a possible registrar post that Kerboull granted me; this didn’t change my planned schedule with Goutallier. Then I went to do a bit of children’s under Bedouelle and Guillaumat. Then only my fourth year remained. I went to do six months of abdominal surgery with Xavier Pouliquen in Argenteuil so that I could master the steps that seemed to me to be needed for the anterior approach to the spine. Xavier Pouliquen was an exceptional teacher in every respect, from the theory to the practical. The first on-calls we were followed closely; he would hide in a corner and watch us and if he felt we were reliable, he could leave feeling reassured. Then finally I did six months at la Pitié Hospital under Roy Camille, a figure who was quite out of the ordinary. Gérard Saillant was also there but at that time he was a government advisor and we mainly saw him at the sports clinic on Friday evenings.
What happened when your house officer years were over?
I returned to be the registrar under Goutallier, and in spite of my new status nothing much had changed. Even though it was no longer me who presented the cases, if the house officer was given a dressing down, I was responsible because I hadn’t taught them what I had been taught. Philippe Hernigou was in the process of becoming a university professor and we continued to work on articles together. But for my part, I was intrigued by the foot. I had been at Cochin in the former department of the legendary Robert Méary, I had got to know Tomeno who had wonderful cases. Then at Mondor, I came across Antoine Denis who was doing surgery of the forefoot and hindfoot as an associate and I helped him in his clinic. He was a former President of the Société Française de Médecine et Chirurgie du Pied (French Society of Foot Medicine and Surgery), and he was closely connected with the rheumatologists at Lariboisière. I quietly developed my work in foot surgery with the advantage that nobody else was going for this niche.
And what happened when your registrar position was up?
Then the boss asked me if I wanted to do a third year, which meant I would have to give up going to Cochin and hinted that there would probably be something for me after that. He explained to me that he needed someone to accompany him to the rheumatology staff meeting at Lariboisière and that Philippe Hernigou who would soon be appointed would be leaving his place open. I accepted and we went to Lariboisière on Friday mornings, where I received a lukewarm welcome. This was where a medical and surgical team meeting took place, with big names in rheumatology and radiology and a single surgeon: Goutallier. I was clearly a 5th wheel and Kuntz gave me a backhanded welcome, calling out: what has he come here for?
Were they expecting Hernigou to come?
Yes, probably, and they were disappointed that it was a registrar who came to get the word out to university professors and other senior figures of the faculty of Lariboisière-Saint Louis. I spent a year listening to the buzz of the meeting and then one day Goutallier was away and I was in charge of the surgical part. One thing led to another and it went quite well and Daniel Kuntz got used to my presence. Then, they offered me the chance to spend time focused on the spine and foot and ankle. In those days arthritis in multiple joints was treated with corticosteroids, methotrexate had perhaps just arrived on the scene, and we operated on them a lot. This rheumatology work has continued throughout although it has decreased.
What did Goutallier offer you at the end of the 3rd year?
He said to me: “That went well at Lariboisière, it’s still going well on the ward, now you must become a consultant; but you have to publish more and you have to get a DEA (research master's degree)”. In the end I found a place at the Orthopaedic Research Laboratory which was run at that time by Pascal Christel and Laurent Sedel and I dashed off there once my registrar post was finished. This was at the Villemin faculty, opposite Gare de l’Est. In two years I obtained my DEA in medical and biological engineering with research on bone regrowth in porous hip implants and following this, a consultant post at Henri Mondor university hospital.
Full time consultant?
Yes, this was in the years 90-91, and it wasn’t straightforward to get this post. In the three years that I was a consultant there I did the whole A - Z: emergencies, non-emergent cases, visits and current publications. But in order to have top quality publications and to prepare a list of titles and works with a view to a university post, you needed to have publishable material provided by your predecessors. At my age I have the means to produce this level of publication but I didn’t 30 years ago.
Didn’t your supervisors help you?
Goutallier viewed things in the same way as Debeyre, his former boss, that a top dog could appoint who he wanted when he wanted. It’s true that he was well thought of at the hospital, because he took care of emergencies, the morning staff meeting, because he was always available and competent. However I think the faculty thought very little of this. Although I had my DEA and a few key publications, this was not enough. It so happened that I was looking after someone very close to the dean of the faculty at that time who confided to me one day: “The hospital really likes you, but you must understand that it is the university that gives out consultant-professor posts, and in your case, it’s a no. "
So no prospect of a university post for you.
It wasn’t pleasant news, but it was delivered clearly and frankly. I knew so many consultants at the University Hospital who had spent years trying to get a professor post in vain. So either I would remain a consultant even working privately at the university hospital, or I could take another route which was quite simply to set myself up privately. It turned out that a colleague who had been turned away for different reasons had set himself up in a nice place. He invited me to join him because my field of surgery complemented his.
How did Goutallier react?
He told me that he would be full of regrets if I left the department, but that I should comply with the university’s requirements. He didn’t even have another young doctor lined up to promote. He just hadn’t mastered the way in which the faculty worked. Apart from that I never knew what he thought. I wasn’t really one for publishing, too much a surgeon, too much a clinician.
Where did you set yourself up?
In Quincy sous Sénart, an enormous private hospital with 300 beds, run by the Générale de Santé group. At the same time the legendary old foot surgeon associated with the Mondor Hospital that I was helping said to me: “I’m retiring in three years and I’m counting on you”. I made myself available and then I resigned pure and simple from my consultant post, and became a part time consultant.
How did it go initially?
In the first few months it wasn’t easy, there was hardly anyone in clinic and what’s more, it was open to whoever turned up and not very interesting. But we managed to create a pleasant atmosphere, a dynamic, and it started to take off in a couple of years. After five years my diary was packed with stimulating things. The anaesthetics team was very good, very dynamic and heavily involved in the ALR (French-speaking anaesthesia group) and it was really positive, all was going well.
Did you never regret choosing to go private?
No because it freed up my time, and for the first time in my life at age 55 I was able to give myself a day off. About time! This meant I could spend time on something other than care, my clinical research work which meant a lot to me. And then I got more involved with the AFCP which had been founded. I left the SFMCP for the AFCP and there I made friends including the president at that time, Jean Alain Colombier who invited me to work in the office with him. And then I still go regularly to the university hospital where I, in turn, help the junior doctors.
In the meantime the situation at the hospital must have got worse?
It has got worse at every level and that makes me happier with my decision. When Goutallier left, Hernigou became head of the department and his aura enabled him to maintain the reputation of the department. At present Hernigou is no longer head but still practising and in the meantime two consultant-professors have left, who had been appointed several years after my departure. There is still a unity of place, but no longer the same type of team, although I must admit that the young doctors are trying to maintain and preserve a certain level of discipline and relevance. This aside, I have wonderful memories of my training years at the Henri Mondor hospital. Was it my youth, the working atmosphere or the quality of my colleagues?
Perhaps it was simply something of a golden age in French orthopaedics.
Published in N°274 - May 2018