N°271 - February 2018
Interview viewed 309 times
Since the first congress, the success of this event has grown.
While assuming a heavy load of care and clinical research within the Surgery Unit
of the Shoulder that he has just created, Philippe travels to the four corners of the world
in humanitarian surgery.
But above all, he focuses his energy on his main objective:
share expertise with friends and colleagues.
Philippe Valenti, what were the origins of this 2018 congress?
The idea for the Paris International Shoulder Course (PISC) came from my wanting to organise an international course on shoulder surgery here in Paris. I had thought that the shoulder courses organised in Annecy and Nice over the previous ten or so years were an excellent idea in that they brought together surgeons with a common interest in the same joint. I sought the advice of Gilles Walch, who suggested I organise the course with Philippe Hardy – who was Professor at the Ambroise-Paré University Hospital. I met with him and he told me that he had also thought of organising a shoulder surgery congress in Paris. Thus was born the idea that we should organise it together. This was decided in 2012, and so the first Paris shoulder course took place in 2013.
The next stage – in which we agreed completely with Philippe Hardy – involved organising a course dedicated solely to shoulder arthroplasty. The aim was to give a platform to surgeons who were using different prostheses, with a view to initiating debate about the choice of prosthesis and how it should be fitted. This is a 3-day course: day 1 deals with fractures, day 2 with anatomical prostheses, and day 3 with reverse prostheses.
The third stage involved organising the course in such a way that it ‘competed’ as little as possible with those courses that were already running in France. The idea was, rather, that the course should complement the pre-existing courses: the arthroscopy course that takes place every 2 years in Val d’Isère, the course organised by Laurent Lafosse in Annecy, and Pascal Boileau’s course in Nice.
Gradually, we decided to organise the arthroscopy course in Paris at a time when we knew there would be no such course taking place in Val d’Isère. This is why our shoulder course on the pathology of instability has been planned for February 2018. In 2019, the theme will again be that of arthroplasty. In 2020, the theme will be the rotator cuff and tendon transfer in the shoulder. However, the fact that there are so many courses and congresses is very problematic: clearly, it is not possible for surgeons to attend all of these courses, and laboratories are in no position to finance them all!
The aim of PISC is that it should be very specialised. Unlike the courses in Nice and Annecy, the idea is that it should not seek to deal with all aspects of shoulder surgery. For example, this year, the sole subject will be instability. It was decided, together with Philipe Hardy, that the main aim was always to initiate debate: that is, we didn’t want to promote a particular school of surgery. The aim will always be to showcase various approaches, allowing colleagues to make up their own mind as to the most appropriate implant or technique for their daily practice, according to their individual training or instincts. For this reason, the live surgeries were planned to showcase the implantation of different prostheses. It is necessary and very interesting – and humbling, moreover, as far as surgeons are concerned – to note that in following patients with different prostheses, a prosthesis fitted according to the ‘rule book’ may have excellent clinical results, no matter which type or brand is used.
In 2015, Philippe Hardy had wanted to involve Markus Scheibel of Berlin in the organisation, with the aim of giving the course a more international aspect. With a similar outlook, Markus helped in recruiting other surgeons from Northern Europe. Despite the sad loss of Philippe, we will work well with Markus to run the forthcoming shoulder arthroplasty course (scheduled by Philippe himself for 14-16 February 2019).
Who is your audience?
At the first congress, we were surprised by the number of people who registered: there were 450 delegates from some 50 or so countries. Three quarters of the delegates came from outside France. The majority of them were senior surgeons specialising in the shoulder and, unfortunately, there were not many young surgeons. That said, the sheer number of participants is essentially due to the quality of the speakers or the faculty – both from France and around the world. The programme is designed to be scientific and exhaustive, with a lot of time given over to debate, discussion, and the presentation of clinical cases. And we have always been keen to invite speakers who have been published on the subject. So, the quality of the course comes from having an internationally recognised faculty delivering a scientific programme based on their publications. In my opinion, this avoids cronyism, and the scientific level needs to be high if the aim is to attract established surgeons, whilst avoiding too much repetition. Numbers, in fact, have increased: at the second congress, there were more than 500 delegates, and at the third there were more than 600. So, there is currently an audience of some 600-650 surgeons, roughly made up of 20-30% French and 70-80% non-French. The only disappointing aspect is that there are unfortunately too few foundation doctors or heads of clinic among them. But a session for young orthopædists is to be inaugurated at the next course.
What is the particular focus of this year’s congress?
This year, PISC will focus on the diagnosis and arthroscopic treatment of shoulder instability. Laurent Lafosse (a friend for over 30 years and my head of clinic when I was a foundation doctor at Bichat Hospital in Paris) kindly accepted my invitation to join me in chairing the course. The time will be dedicated to examining acute instability, chronic instability, whether anterior, posterior, or multidirectional, through short presentations, organised debates, and presentations of clinical cases. Technique will be amply explained through the use of many ‘relive’ surgeries (or recorded surgery) and 7 live surgeries, covering Bankart, Bankart remplissage procedure, Trillât, and different Latarjet augmentation techniques (using screws, 1 or 2 endo-buttons, and not forgetting the iliac crest).
It’s true that the programme is somewhat intense, with events running from 8am to 8pm. But the focus will be on clinical examination, indications, and matters of technique. The original idea remains: to give surgeons more of an edge, in their indications and techniques alike, in order to improve patient care. In other words, it’s not a purely academic exercise: we have to go into the details in order to improve results.
What’s your background?
My background evolved through a series of encounters. The first I should cite was with Professor Alain Deloche: everyone studying medicine in France in the 80s would have met him whilst preparing to be a foundation doctor. The quality of his lectures was such that – having passed the first exam of the Hospitals of Paris – I was appointed in 1985. Alain Deloche inculcated in his students the desire to work hard, to succeed, and to experience life very intensely. He was a key figure and a role-model in my own trajectory: accessible, ready to listen, and able to rally the troops and bring people together, even where a cause had been largely abandoned. The surgeon is not only a technical expert: above all, he or she is a doctor who is accessible and ready to treat or advise patients to best effect.
The two individuals who laid my path to orthopædic and reconstructive surgery were Alain-Charles Masquelet and Alain Gilbert. It was they who gave me the desire to repair bone, soft tissue, the tendons, skin, nerves, and the vessels. It was they who taught me rigour in the act of surgery and in surgical indication. The time, back then, was ripe for describing new skin flaps and fasciocutaneous flaps in the hand and limbs, and a few times every week we would meet at the Fer à Moulin Institute of Surgery in order to try and systematize the flaps that we had sometimes taken, in the morning, in emergency cases.
It was an extremely productive period: for 10 years, we were all devoted to this work. In addition, it was they who taught me how to teach, as they led the degrees in micro-surgery and hand surgery: we were asked to deliver classes on a frequent basis. In doing this, I learnt that the best way to progress was to teach, and the same is true to this day! Writing and publishing your work is necessary as a way of clarifying and putting your ideas in order.
I did my first 2 years of specialty training in the department of Professor Nordin. I had asked him to grant me one free day per week so that I could consult and operate at Melun with Didier Patte. He okayed this, for which I thank him once more.
Every Tuesday, for those 2 years, I worked alongside the shoulder surgeon and founder of SECEC (ESSSE), Didier Patte. That was the veritable beginning for me in my work with the shoulder, which now makes up 95% of everything that I do! It was there, moreover, in 1990, that I met Gilles Walch, who came to visit Didier Patte quite regularly. Didier’s characteristic way of selecting patients for operations was quite ‘harsh’. In particular, he would study the psychological aspect of each patient: it was a significant factor for him before deciding to operate. I learnt much in consulting with him, but also – of course – in working with him in theatre. It was here that I learnt Patte’s augmentation technique. He would schedule two patients: I helped him with the first, the instrumentist would close up, and then he helped me with the second patient. During the time I spent with him – all too short, due to his untimely death – I performed many a large anterior release, as well as open surgery, which I no longer practise at all, as we now have arthroscopy. Back then, I was a micro-surgeon, a hand surgeon, and my training had not covered shoulder arthroscopy, not least because arthroscopy was still in its early stages of development.
After my specialty training, which lasted 4 years (2 spent working with adults, and 2 working with children), I set up a private practice near Paris in Pontault-Combault, where I developed a 24-hour hand emergency centre.
Did you live on-site?
Initially, I did, and I operated every day. I would receive emergency cases on a 24-hour basis, and after 2-3 years Dr Thierry Dubert joined me, and gradually the group got bigger.
I took up shoulder arthroscopy, in private practice, around 1991. In 1988, as a foundation doctor, I had assisted Laurent Lafosse at Bichat, and he had shown me arthroscopy which – at that time – was performed by eye, with no camera! I could see nothing at all, but he could see something and he thought arthroscopy was wonderful! Laurent, in that light, really was a pioneer of shoulder arthroscopy. So, I really started in shoulder arthroscopy around 1992: I met with surgeons using arthroscopy, attended congresses, and generally tried to mug up on arthroscopy. My first results were quite disappointing because, back then, a minimally invasive superolateral approach was used for cuff repairs, and those results were satisfactory. When I operated on cuff repairs using arthroscopy, I assessed the results after the first 50 cases and observed that I had more re-tears! Perseverance has, however, shown us that the technique is now reliable.
I saw a certain similarity in using a microscope and looking at a screen in arthroscopy. Gradually, I was drawn more to shoulder surgery than hand surgery. For me, hand surgery was the domain of Guy Foucher, Alain Gilbert, Michel Merle, and toe transfers. I felt that this field was not evolving much, whereas shoulder surgery was evolving very quickly – and not least thanks to arthroscopy. With fewer and fewer shifts at the hand emergency centre in Pontault-Combault, I saw myself more and more out of the loop. After a 5-year period of splitting my time between there and the Hand Institute, in 2000 I decided to work full-time at the Hand Institute in Jouvenet with the group founded by Raoul Tubiana and Alain Gilbert.
As part of a group of 8 practising surgeons concentrating on upper-limb surgery, with an international reputation due to the aura of Tubiana, Gilbert, and Caroline Leclercq, it became easier for me to develop shoulder surgery. As part of an organisation made up of fellows and requiring publication, 90% of my work now involves degenerative disease, sporting injuries, and nerve damage in the shoulder.
I should also mention Dominique Le Viet, who joined the Hand Institute at the same time as me, in 1995. Throughout his professional career, he has passed on his techniques to the youngest surgeons, he has improved and developed new techniques, and has had them published in leading journals. For contributing so much to the national and international standing of the Hand Institute, I should like to pay tribute to him.
Originally the Institute for the Hand and Upper Limb, and founded by Raoul Tubiana and Alain Gilbert in 1985, we should remember that in 1995 it became two separate entities. Within the Institute that I joined, I can assert that Tubiana and Gilbert, these pioneers and great figures in hand surgery, consistently taught us to assess our patients, to review cases, to publish, and to organise symposia on a yearly basis. Teaching was involved in every aspect: in particular, 5-6 selected surgeons from outside of France would come for training in repair surgery for the upper limb lasting 6 months. The Hand Institute is a place for treating patients, but it is also a place of research, publication, and teaching. And when you are immersed in this modus operandi, you have but one desire: to carry it on. I very much believe that people are not shaped by themselves alone, and all of the aforementioned surgeons – with profuse apologies to those not mentioned – enabled us to slowly find our own way: whether in terms of operating, consulting, helping patients, teaching, describing new techniques, or conducting research. The main thing is not to do what one does for oneself, but to work in such a way that others might go even further. Teaching is very important to me.
Yet the Hand Institute has changed recently?
That’s right, it has changed recently because personalities sometimes clash and people’s paths will veer in different directions. Some were more drawn to building their clientèle rather than publishing or participating in any scientific pursuits. First and foremost, the Institute is a place that promotes publication, the description of new techniques, and development: its international profile means that there is more to it than solely filling one’s operating schedules! This is very important because the Institute’s rules – laid down by Alain Gilbert – dictated that group members should consult no more than 3 times per week, and that they should operate on no more than 2 days per week. In other words, at least 1-2 days per week should be dedicated to research (clinical trials or basic research) and to assessing results. It is my belief that these are excellent rules: when one is a young surgeon, one always wants to do more and to operate ever more. In fact, one should, on the contrary, limit the time one devotes to surgery – consulting or operating – in favour of freeing up more time for reflection.
Can you tell us about the ‘Chain of Hope’?
The Chain of Hope is a NGO founded in 1995 by Alain Deloche and Éric Cheysson (who is the current head of the organisation) with the aim of treating children currently excluded from the health system. Before the Chain of Hope, we worked with Médecins du Monde (Doctors of the World). Indeed, Chain of Hope was initially founded – financially –under the auspices of Médecins du Monde. Over the course of 2-3 years, Chain of Hope became financially independent. Its mission is to operate on children with heart pathologies, as well as those requiring treatment that is orthopædic, cosmetic, or digestive in nature.
To begin with, the children were brought to France, taken in by a host family, and operated in a hospital or clinic. Host families would look after children at the peri-operative stages and, having received treatment, the child would be reunited with his or her family back home.
Then we thought that we could do more, and that we should travel to certain countries and operate and teach there. To begin with, we went to Asia (Vietnam and Cambodia). Alain Deloche suggested we do more: we were operating and teaching, but why not build a hospital? Then, in this new hospital, we could operate on children in poverty, train surgeons, and that was the third stage. So, the first stage was to bring children to France and operate; the second stage was to travel abroad to operate on children and train surgeons; the third stage, based on the concept that we should operate using the same standards as in France, was that we should build hospitals abroad. Charitable hospitals were built in Vietnam and Cambodia. For the record, Éric Cheysson played a key role in this, as he was responsible for the hospital built in Kabul, Afghanistan: namely, the Fondation Médicale pour l’Enfant (or Children’s Medical Foundation). That hospital, built by Bouygues industrial group, is currently run by the Aga Khan Foundation, and training there is provided by the Chain of Hope. All specialisms are covered: the heart, orthopædics, digestion, urology, and there is now a maternity unit. The hospital has MRI, CT scan, and so affords European standards in a country wrought by danger and insecurity. I started training micro-surgeons on-site and there are now three micro-surgeons who can repair nerves and arteries.
The Chain of Hope’s budget derives primarily from private donations (80%). The remainder comes from corporate sponsorship and occasionally from institutional donors (but that is always difficult to obtain and demands an awful lot of effort). We started with an annual budget of some 4-5 million euros and now have an annual budget in the region of 30 million euros; we have 70 salaried employees in Paris, with branches in the rest of France, and the Chain of Hope has a presence in some 82 countries worldwide.
The problem now – and this is a point I want to get across – is that we are short of staff, we need more surgeons! We need to find surgeons – from all specialisms – who can be available for up to a week, maximum. In today’s world, it isn’t easy to recruit surgeons who work in both the private and public sectors: surgeons are typically quite busy, they worry about their future, and they are concerned about their future finances, such that there are very few colleagues out there who can regularly free up time to go on such missions. That said, these surgical missions are a part of what makes an accomplished surgeon. I think this for a number of reasons. Firstly, some pathologies encountered abroad are just not seen in France, these days. Secondly, if you’re out of Paris for a week, say, a colleague will operate perfectly well on your patients, and they will be perfectly happy – but if you don’t go to these children, they will never get the operation they need. And the third reason is that the way the world is going, at the moment, is increasingly making some people in some countries more isolated.
We have carried out such missions in Libya, Irak, and Syria – countries now dangerous and often inaccessible. The few surgeons who are still out there are themselves completely isolated. And this brings me to telemedicine. The Chain of Hope is currently attempting to develop telemedicine on an international level, through remote consultation, and trying to give as much assistance as possible to these isolated surgeons. This is why we need to recruit more surgeons for these NGOs: we have no right to abandon colleagues, fellow surgeons like ourselves, leaving them isolated. Not in today’s world, when divides are growing.
At the Chain of Hope, we’re trying to develop digital teaching tools. By way of example, every Wednesday morning, from based Necker Hospital in Paris, the cardiologist and pædiatrician Daniel Sidi, who specialises in echocardiography, conducts live training online. There’s a cardiologist in Kabul with 2-3 children, and Daniel teaches that cardiologist how to use the ultrasound. In other words, the cardiologist in Kabul sets about diagnosing what’s wrong with the heart, and Daniel – more than 4500 miles away – explains where the cardiologist should put the probe and so on. For me, that’s astounding. And I think that, as a surgeon, we must give some of our time to helping colleagues in this way. There are many arguments as to why young surgeons should continue to do what isn’t – in my eyes – humanitarian work, but simply teaching. In other words, let’s say we’re in Paris, we’re working very hard, we’re getting published, and we’re happy when our publications are accepted, but they must be useful: not just for our colleagues but also – and especially – for those surgeons working in isolated countries with no easy access to the internet. When I get a message via Facebook from a former fellow living in Alep in Syria, saying that he wants to collaborate with the French Arthroscopy Society because he’s organising the first arthroscopy-themed days there, I think we have a fundamental role to play! Moreover, I now have a female fellow from Iran, who is spending a year in France for training in arthroscopic shoulder surgery. Iran is one of the countries to which we go on children’s surgery missions, and I’m delighted at having had our article on 13 bipolar latissimus dorsi transfers – co-written with Iranian colleagues – published in the JSES. Ultimately, we’re not talking about humanitarian work: it is, rather, a question of passing on knowledge to our fellow surgeons.
What would you say makes you tick?
Great question! I’m still at a stage in life where I’m interested in the technical side of shoulder surgery! Simplifying techniques in order to teach them is still an area that interests me greatly. But to achieve this, you need a lot of patients, you have to spend a lot of time consulting, and you have to operate a lot. I’d say that’s what probably makes me tick, as it were, the most at the moment, here in Paris.
Another thing that keeps me going – abroad – is the fact of meeting people. It’s not because of technique that I travel a lot. If I travel a lot, it’s because I like meeting people, I like watching how they work, and seeing if I can offer them anything. In return, I get so much from them – it’s a constant exchange. Meeting people renews the need to write and thus to order one’s thoughts. As the years have gone by, it seems to me that writing is a particularly important aspect of teaching.
When we go abroad, we meet surgeons whose training has been different to ours. For example, in South America – where arthroscopy is very developed, but arthroplasty is less so – the surgeons there will say something like this about arthritis in a young patient: ‘when we perform anterior, inferior, and circumferential capsulotomies, and arthrolysis, by means of arthroscopy, we observe reduction in pain’, and so they reject indications for arthroplasty.
Another point that I wanted to get over – and it’s something these missions have taught me – is that treating someone in Asia who plants rice, involving extrememly delicate movements, is completely different to treating someone working in Columbia, performing rougher movements with a machete. For me, this is what you might call ‘ethno-surgery’.
When operating outside of France, we never operate alone. We work with local surgeons who teach us what the patient needs, what the patient’s background is and how he or she lives, what their job is, and how they do their work. This relationship with local surgeons is what enables us to adapt our indications and techniques. For example, I have used techniques abroad that I will never use in Paris. This diversity enables us to evolve but also enables us to see things in a different light. Sometimes, what we consider to be the best technique, in a certain case, is not in fact the best one to use!
To conclude, in simple terms, the exchanges – in consultation, when operating in theatre – between young, enthusiastic surgeons (of whom there are so many) and more experienced surgeons, whether in France or during child surgery missions abroad, are mostly what keep me ticking so strongly. But finally, I should like to thank everyone at Maîtrise Orthopédique for giving me the opportunity to talk on subjects that are so dear to me! I just hope that what I have said is of interest to your readers!
Published in N°271 - February 2018