N°280 - January 2019
Interview viewed 82 times
Just a few weeks ago, you were at SOFCOT… Where does your love of France come from?
That’s a very good question. In 2008, during my first year of practice, I was awarded the Sandy Kirkley grant by the AAOS, and I decided to use that grant to visit surgeons in Europe. It was a bit cheeky to use American money to pay for a trip to Europe, but I don’t regret it. The welcome, the reception I got, was fantastic and very warm. In France, I met Gilles Walch and Pascal Boileau – each for two weeks – and then I went to Edinburgh, Scotland. But whilst I was in France, I became really good friends with the orthopedists – and their teams – that I met. Very quickly, I found it very easy to communicate and to understand things. I absolutely loved the thinking underpinning the training, I loved the debate and the scientific research that the mentors were doing. We quickly found a real affinity, and Gilles Walch and I wrote three papers in two weeks. It was completely crazy. People remember your name, they remember who you are, when you bump into them at conferences. Gradually, I made more and more friends like that in France, that is, surgeons – both male and female. Later, I invited them to Montreal. The French have always given me a really warm welcome and a sense of genuine collaboration. I’ve never had such a welcome in the US. And that’s not a criticism – it’s just a different system, a different way of working… But, for my part, that’s how things started with France…
What are the differences between how the French and North-American systems work?
Well, in North America, there are, in fact, several systems, and they’re all different. In Quebec, we have a rather classical system, and it’s very disorganised. Each hospital works differently, so the system is all over the place… In the public sector, the way a hospital is run will depend on the person in charge. The system – so to speak – lacks a bit of structure. Ontario is only a few miles from where I live, but I think that their system is a lot more structured, a lot more rigourous: spending, revenue, the way that the health service is run, everything’s much clearer. Ultimately, the American health system is based on profit, and that’s completely different to what we have in Quebec. There is a little bit of private work in Quebec, but – in that case – we have to be paid by the companies. It’s a parallel system, and it’s so small as to have very little impact in terms of the population and the care structure itself. But our public system places no value whatsoever on research, so – if you want to do scientific work – you have to fight to do it. Actually, however, you’re constantly hounded – by everyone – to provide care. As far as the hospital is concerned, if I’m not in clinic, I’m ‘damaging productivity’. In their eyes, research, going to conferences, training, it’s all just time off. They think I’m just off having my hair done… As I say, very little value is placed on the research side of things in Quebec. For me, I do it because it’s a passion. But, on a daily basis, someone will throw a spanner in the works. It really is a grind. Despite all that, I’m lucky enough that the province gives me funding for research. However, in Quebec, and especially in orthopedics, that’s quite the exception. The flipside is that a system like this gives you all the freedom in the world, in the sense that no-one forces you to do anything. And that is its only advantage, as far as I can see. Luckily, I have the support of my boss and a few ‘idealists’, but not many supporters.
Medically speaking, are surgeons in Quebec closer to the French or to Americans?
In many faculties of medicine in Quebec, the teaching is in French, even if – of course – we’re looking at texts in English. But you’ll find more people from Quebec at SOFCOT, for example, than at AAOS. Generally, we’re more influenced by research and principles deriving from the French university hospitals. That said, if you study and train at McGill – a Quebec university in Montreal that is, nonetheless, English-speaking – you’ll be more influenced by the Americans. In fact, few surgeons trained in McGill choose to stay in Quebec… McGill trains a good number of residents from abroad, and they’re soon drawn to the (English-speaking) provinces further west.
How does it work in your department?
There’s the university-level organisation and the hospital-level organisation. In terms of the hospital side of things, there’s a head of department, Dr Denis, who is head of the department of surgery. He’s a general surgeon with a specialism in bariatric surgery – as such, he’ll never be short of patients… There are about 62 surgeons throughout the different departments at the Hôpital du Sacré-Cœur in Montreal. I’m one of about 15 orthopedists under the head of the orthopedic department, Stéphane Leduc. There are very few rules, and almost no obligations – apart from duty cover. Some – in fact, most – of my colleagues don’t do research, and there’s very little teaching. It’s true that a lot of teaching goes on in theatre in patient care, but it’s not structured as well as it is in the centre that I saw in France, or elsewhere in the US. I think this is a shame, because the potential is huge.
Do you take junior residents from France?
I do, in fact, have a post for junior residents from abroad, and – so far – I’ve taken junior residents from Lausanne. I have two former fellows who – to the best of my knowledge – have set up back in Switzerland. I currently have a Swiss junior resident working with me, and – in 2019 – I’ll be working with another Swiss resident. In 2020, it will be someone from Belgium. So, no residents from France, but I’m ready to welcome them. There’s still an opportunity for 2020. It has to be said that we prefer French-speaking residents because communication is so much easier with the patients, as well as with the staff on the wards and in theatre. It’s because we have a lot of operating rooms and we spend a lot of time there. If we have a good junior resident, we could have even more operating rooms. We can cover all aspects of upper-limb orthopedics: traumatology, arthroscopy, arthroplasty, and so on. I await applications!
Are there not enough hands on deck? Are waiting times long in Quebec?
It’s a disaster. Especially in upper-limb surgery. About 15 years ago, the government decided to give special bonuses and funding to hospitals in line with the number of hip or knee replacements they performed. Certain flagship operations were prioritised, but upper-limb surgery was overlooked. There is truly sizeable funding for the hip, the knee, and for cataracts, for example. Consequently, a great number of orthopedists gave up on upper-limb surgery because hospital resources – including physiotherapy, physical therapy – are all geared towards lower-limb surgery. This reform occurred at the same time as when arthroscopy was introduced. As a result, not only were people leaving the upper limb in droves, they weren’t trained in arthroscopy either… Upper-limb surgery was completely abandoned, with the result that – in Quebec – our specialism is sorely lacking in surgeons. In knee surgery, there are surgeons who don’t have enough patients. But, for our part, we have no such problem. In terms of patient numbers, there would be room for more shoulder surgeons in my department. However, nowadays, they’d have to be hospital posts – the government has put a limit on the number of posts in order to control spending.
You mentioned a fellowship in France. Did you do all of your studies in Montreal?
In 2007-2008, I did another fellowship with the University of Western Ontario. It was a fellowship focussing on the shoulder, with George Athwal, Ken Faber, Darren Drosdowech, and Bob Litchfield. We looked at all aspects of the shoulder: traumatology, arthroscopy, replacement. It was great. Occasionally, when the bosses weren’t there, I’d go and bother Graham King – he thought that was silly and gently made fun of me for spending my time like that. But I learnt a lot through him, and it came in handy. When I returned to Montreal, I found myself doing arthroscopy or elbow replacements for the first time on my own. So his teaching was really useful. In fact, during my training in Montreal, I had two seniors: Sylvain Gagnon and Pierre Beaumont. For health or personal reasons, they both gave up surgery quite young, and so I suddenly became the only senior consultant for the upper limb. At the age of 33, I was the referring doctor at Sacré-Cœur for the upper limb. All of the complex cases came to me… And they still do, as in my practice, today, I spend a lot more time on cases of revision than on primary surgery. The challenges are significant, but this way you learn fast. Having the opportunity to do revisions is an enormous help when it comes to primary surgery, because it enables you to see the mistakes – or bad luck – of other surgeons. Knowing the complications teaches you how to avoid them and makes you more careful. Nowadays, my time is shared equally between the elbow and the shoulder. Elbow trauma, shunned by my colleagues in orthopedics, is my reference area and all related cases are sent to me, be they emergencies or sequelae. It’s thanks to the vagaries of life that I’ve met people such as Shawn O’Driscoll, Pierre Mansat, Laurent Obert, Roger van Riet, and Graham King. They’re devotees of the elbow, but also excellent teachers who know their pedagogy. They have advanced things enormously.
And yet we don’t see all of the pathologies associated with throwing that you see in Canada…
I don’t think we have more such cases than you. I think it’s more a question of circumstances. Elbow problems are 10 times less common than shoulder problems, so no-one tends to see them much. For my part, I’ve rarely operated on ulnar collateral ligaments. My most famous patient was a world champion in the sport of CrossFit, which is quite a dangerous sport. She did a bit of weightlifting, a bit of cross-country running, but very, very quickly, which increases the risk factor. We do, on the other hand, see patients who’ve worked a lot with hammers or drills. Despite all the stories about the elbows of baseball pitchers, it’s really quite rare in Canada and I never see such cases.
What do you see?
Trauma, obviously… In elective surgery, we mostly see bashed elbows, osteoarthritis, and corpora mobile. There are also unresolved issues involving epicondylitis and biceps pullout – we see that quite a lot in the distal biceps. In fact, when it comes to the biceps, I suspect we’re a little more interventionist, in Quebec, for aesthetic reasons. Our patients are not the same. For instance, when I do a shoulder biceps tenotomy because I think it’s the best option, it’s a nightmare. The patient will criticise me, afterwards, saying, ‘What have you done?’ I get calls from the physio, the GP, and everyone starts panicking about the sectioned biceps. Trying to explain – ‘It’s better that way, you’ll have less pain’ – is futile: they just won’t believe me. It’s probably a cultural issue. Patients in Quebec are very demanding in terms of their health service. They’ll put up with waiting times in emergency that French people would never be exposed to. But, when they’re in the system, they expect their doctors to be ever-present, ever-perfect, ever-ready, and to have a constant smile on our faces. And patients here are also very demanding with regard to the nurses. But, as I say, when it comes to delays in being seen, they’re really quite willing to wait. Despite all that, the quality of care, when you’ve managed to access the health service, is always very good. I’m not saying I’m the best surgeon in the world, but I do think that what I do in theatre is as good as what is being done elsewhere. When people get access, things go well and we’re not limited in what we can do. I can, for example, use any prosthesis I want. The cost of surgery is not a problem: whether I need to do a one-step or three-step procedure, if I need a made-to-measure prosthesis costing 30,000 dollars, no-one will stop me from doing it. But we do have delays, and these delays are due to a lack of organisation. The operating rooms run slowly and theatre will close at 4:00pm. We’ll deal with barely three cases per day – which is not exactly efficient.
So how do you deal with shoulder instability if you’re working in North America but were trained in France?
There’s a question! Shoulder instability is a fascination of mine. On the whole, my indications are similar to those given by the ISIS score combined with a 3D CT scan. But, as ever, it’s ultimately the patient – and his/her physio, frequently – who’ll decide on the surgery… When my practice began, some 10 years ago, there was no approved questionnaire in French, so I translated and approved the WOSI index. Being the only surgeon working on the shoulder, I began the systematic monitoring of my patients with a view to translating my questionnaires. Throughout my practice I therefore compiled the details of every instability I worked on. I analysed my results, and there’s a clear functional advantage in using the Latarjet technique. I do have one patient who re-dislocated after Latarjet, but that was caused by a big ice-hockey accident, which fractured the implant. But none of my other patients has re-dislocated after Latarjet. When I’ve used the Bankart technique, after an average of three and a half years, my failure rate today, in a fairly heterogeneous population, must be around 17%. And most of them are patients for whom I should have done a bone block in the first place: I knew as much and told them this. When they come back to me, they say, ‘You were right. But please will you do the other operation for me?’ Generally, the bone block is a better operation. But – as we all must – I’ve analysed the complications I’ve seen, and I’d say that smoking and revision surgery are risk factors that increase the risk of failure significantly. The other risk factor revealed by my series is the body mass index. As a result, big chaps – because it tends to be men who have big shoulders – cause me to discuss the Bankart with them. In fact, in patients such as these, the bone block is much more difficult to perform, and they have a lot more complications: the correct positioning of the block is harder to achieve and I tend more to re-operate in order to remove the screws – either because they were too long or too close to the surface of the joint.
And so – to answer your question – I’d say that I see the Bankart as an American technique for American-sized patients, whereas the block is a French technique for patients of a more French – that is, slimmer, more slender – build. Furthermore, I’m not completely sure that arthroscopy solves everything in the block technique: in nearly all cases in which surgeons started the bone block using arthroscopy, there have been neurological complications. It doesn’t interest me too much. I’m not afraid of blood, and I absolutely love open surgery: I’m better at that than at performing arthroscopy. I think endoscopic surgery is fine, but – even then – I’ll occasionally open up the odd cuff without a second thought. The experience I’ve acquired in open trauma means there’s nothing I can’t deal with. It all depends on your level of expertise, I think. Other surgeons, with expertise in arthroscopy, would probably do the opposite. When they open someone up, they don’t necessarily know what they’re doing: they’ll fiddle about with the tissue, and they’ll damage all the tissue they get their paws on. They don’t think logically in terms of surgical tissue planes, they have little respect for the tissue, and so it’s probably better for them to use arthroscopy. Opening up a patient is sometimes a more delicate procedure than just pushing a few big needles through the deltoids. If I’m treating a big smoker, even if there’s a risk of recurrence – especially if there are few bone deficits, I will lean towards arthroscopy. If the patient is slim, with bigger deficits, and keeps suffering dislocation, I’ll say, ‘I really think we’ll go for the bone block – it will be an easy operation’. After that, I’ll immobilise the patient for six weeks. For sporty types, who are more motivated in making a fast recovery, I’ll prescribe a scan at three months in order to ensure that the implant has taken. If it hasn’t, I’ll give them vitamin D, and then wait another six weeks before checking.
Why vitamin D?
In North America, 75% of people have a vitamin-D deficiency caused by a lack of exposure to sunlight. Anyone deficient in vitamin D will have relative osteopenia. In the US, studies looking at American-football players have shown that students who have a vitamin-D deficiency when they start their sporting career at university are three times more likely to suffer serious injury than those without – and that could be anything from a torn anterior cruciate to glenohumeral dislocation. Therefore, vitamin-D deficiency increses the risk of injury. We don’t really know why, but several studies have shown it to be the fact. That’s why I give them vitamin D, and – if need be – I’ll also prescribe it before the operation. That, at least, is one advantage of having long waiting lists – it gives us time to compensate for any lack in vitamin D.
Is it easier being a female orthopedist in Quebec than in other places?
I couldn’t say. When I started working, 10 years ago, I had a really small house. I held a Christmas party, invited all of the women orthopedists in Montreal, and the house was more than big enough for everyone. Nowadays, I couldn’t do that at home – I’d have to book a big room somewhere because there really are lots of us, now. Generally, I think it’s easier, even if we still hear the occasional sexist comments. What does disappoint me, however, is that there are few women in Europe with a prominent role. Maybe that’s because of the system… For example, it has to be said that – when it comes to anything to do with maternity leave – it’s a lot easier to organise in Quebec than it is elsewhere. That means that a lot of women in other places tend to abandon a part of their practice for their family. In Quebec, we’re paid up to a year following the birth of a child, and the father can even take a part of that leave. The child-minding system funded by the State is also very user-friendly and flexible. This way, women can keep their jobs. Of course, it demands a lot of organisation. But the work of an orthopedist can be done just as easily by a man or a woman. In terms of physical strength, if you’re having to use an awful lot of force in an operation, it’s because there’s something going on that you’ve not understood. Having to use force is the exception – except in performing certain revisions, for example, in removing a screw. But, apart from that, strength doesn’t come into it. Surgery is a matter of the mind. And so I don’t understand why women find it hard to get established. What we need to do, when we’re given an opportunity, is to seize it and never let go – one should never give up.
Are your patients surprised when they see a female surgeon?
They’re funny. But, yes, they are surprised because my first name is Dominique. That’s a man’s name, as well, and so – as a rule – they think I’m a man, especially if they’re sent to me by some ageing male orthopedist for revision or a complex case and they’re told, ‘It’s too complicated for me, so I’m referring you to see Dr Dominique Rouleau in Montreal’. When I turn up, they’re generally a bit grumpy because they’ll have been waiting for two hours to see me. Then they’ll say, ‘Can I see the head doctor? Can I see Dr Rouleau?’ I tell them that’s me and they’re always surprised. But once we’ve got over that, they’re very happy. People like the way I do things. I’d say that, in general, women are more sensitive to patients’ aches and pains, and we’ll even occasionally cry with them. They’re also more prepared to talk with women surgeons about more intimate things, such as wiping oneself in the toilet when one has difficulties with internal rotation caused by an inverse prosthesis.
Let’s talk about rotator cuffs. Is there a case for revising a repair that hasn’t scarred over?
There is, but you have to assess it in order to understand why. What you have to ask is what’s happening and why has this tissue not healed? In rotator cuff surgery, my number one enemy is Cutibacterium acnes. In order to identify this bacterium, which is very frequently present, you have to do needle biopsies, as with tumours. I have five biopsies done, and they’re cultured for 14 days. If that’s not the problem, you have to look for other causes, of course, as there are other biological reasons for wounds not healing. One, obviously, is smoking, and another – yet again – is vitamin-D deficiency. Sometimes, patients are on medication that’s preventing the wound from healing. In fact, more and more studies are reporting that proton-pump inhibitors are slowing down healing in digestive surgery, and I’ve been wondering if it could be the same with the rotator cuff. They’re the sort of things that you have to check out with the patient. Then there’s diet: a lot of people are malnourished. Compliance is an issue, as well: did they really wear their sling, afterwards? So that’s what I’ll do: I’ll go through the assessment with the aim of understanding why the repair failed. In cases of infection, I’ll do a two-step revision, involving debridement in order to remove the anchors, wires, and so on. After six weeks of antibiotics, they come back to me for the repair.
How can you tell the difference between that and a simple – and all-too-common – repeat tear?
An infection causes pain – it doesn’t just cause weakness. The main thing that a patient with Cutibacterium acnes will say is that they’re in pain – typically, they’ll describe it as a burning sensation, including at night. You might think that the patient is exaggerating, that what they’re saying is hard to believe. You can listen to the patient and they describe what sounds like the end of the world. So, with infections, their main concern really is pain, not weakness. However, if you’re dealing with isolated weakness in a broken cuff, there are all sorts of factors at play – but I have re-operated, in such cases, in order to perform partial repairs. Cuff revision is never simple, but it can be successful in a young patient with motivation. But I’m referring, here, to technical failure in a patient in pain, and not to lesions – with no clinical repercussions – revealed by scan.
Do you have any tips or tricks regarding how best to perform elbow arthroscopy?
I know a few tricks, yes. Elbow arthroscopy, as I taught myself somewhat, can be very scary to start with, because of the close proximity of all of the neuro-vascular structures. That said, the first thing to do is get trained, read up on the subject, and then watch videos before having a go yourself. When it comes to elbow arthroscopy, positioning is very important. To be honest, I have, sometimes, been unable to complete a job because patient set-up was wrong. Therefore, the elbow support is extremely important. The patient is put in the lateral decubitus position. It’s very important for the support to be very close to the armpit and for at least half of the humerus to be hanging free, so as to allow access to the elbow, and to permit good positions for the instruments. In terms of safety, in order to avoid compartment syndrome, the water should not be under pressure. It should be left to gravity, with the fluid bag at eye-level, which isn’t high at all. Another safety tip: ensure you have set the shaver at the right level. I have a colleague who once aspirated a median nerve because he hadn’t realised that the nurse had set the shaver to maximum, as for a procedure on the shoulder. He turned the shaving tool on, and woof! The nerve was gone. That was a complete catastrophe, of course. So it’s really very important to check everything. Another thing – which has been proven – is that the elbow must be infiltrated before the camera and instruments go in, as it keeps the neuro-vascular structures away. The structures in the anterior compartment are a lot more at risk, so I always start there, as it allows me to make the most of the inflation of the joint caused by the fluid. Also, in elbow arthroscopy, you should really start with simple, easy things, such as corpora mobile. That’s really the easiest and most interesting thing to do. And I love doing that – dealing with that, for example, is like having a little rest in your day. I always count the number of corpora, but – to be honest – it’s harder when there are lots and lots of them. If there are only two or three, I’ll scan them properly, just to be sure that I get them all out. In cases such as these, an articulation scan is a must. I operate on one or two cases, maybe, of chronic epicondylitis per year. Using arthroscopy for that works extremely well. What you need to bear in mind is that, in elbow arthroscopy – and all of the research shows this, the biggest risk of nerve lesions lies in the trauma sequelae because the nerves will have moved from their original position. In arthroscopy, that should be saved for the advanced stage. And my final piece of advice is this: never hesitate to open a patient up.
Do you have time for pursuits other than orthopedic surgery?
Before I had children, I was an avid reader. Now, as a mother, I’m lucky enough to have two beautiful children – one’s 16 months and the other is four, so that keeps me really busy, of course. I love cooking, as well. It takes hours, every week, to be a good cook, and I make up new recipes. My favourite dish is cheek of veal with black cherries. Then there’s sport – I do all sorts of sports. But my true sport – the one I’d do if I had the time – would be rowing, which is something I used to do when I was younger. Sport, I find, helps me unwind, and it makes me more relaxed for the following day. Another of my passions is travel.
Published in N°280 - January 2019