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PIERRE LASCOMBES

Published in N°279 - December 2018
Interview viewed 70 times

PIERRE LASCOMBES

Pierre Lascombes carved a career in pediatric orthopedics in Nancy (NE France), where he was head of department.
He has been greatly involved in his specialism’s organisation.
For a number of reasons, he decided to up sticks and take up a post as head of department with the University Teaching Hospitals of Geneva. To say that he does not regret this decision is an understatement…

Does Switzerland have any pediatric orthopedic pathology specifically its own?

Not really. As in all Western countries, we treat cases of scoliosis, limbs of unequal length, deformity, and so on. And yet we see a significant number of cases involving anxious mothers, and – more than that – many pathologies deriving from musculoskeletal overexertion. These conditions are all linked to physical overactivity: for example, we see 12-year-old girls who are spending 15 hours per week practising dance, and they present with fatigue fractures of the calcaneus or with muscle tear in the obturator internus. We’ll see some of them with their mother, who will say – unfazed – something like: ‘Whatever, she’s down to attend summer school with the New York ballet school.’ In another area, I regularly see young patients with unusual pain symptoms which need decoding, some of which resemble a form of algodystrophy. For this reason, I established a multidisciplinary surgery devoted to so-called complex regional pain syndrome (CRPS).

What about trauma? Does Geneva have its own specific cases?

There’s ice hockey. That’s a sport that causes a good number of breaks in upper limbs, especially the collar bone. There’s also skiing, which can cause serious breaks. I remember, when I first arrived, I saw a young man who had fallen skiing and who fractured both femurs, a tibia, and his fore-arm. Skiing often causes multiple fractures (even including pelvic fractures).

Do you have the facilities to deal with that?

We do. And if there’s a big accident in France, nearby, the injured are flown to us by helicopter. If there’s a big accident involving serious skeletal trauma in Chamonix or the Grand Massif, for example, the injured are not taken to any hospital in the valley: they’re brought straight to us.

In terms of common pathology, what’s your geographical range?

Geneva only has a population of some half a million inhabitants: on the one hand, they are completely surrounded by France (whose patients can’t access care in Geneva for financial reasons) and, on the other hand, by Swiss Romandie (whose university hospital centre in Lausanne, CHUV, caters amply for its population of one and a half million inhabitants). As a result, in reality, with a population of 500,000 people, we see cases of clubfoot and hip dislocation, for example, but not many, of course. Extra work comes to us through the work of certain foundations and humanitarian aid: in particular, we see patients from Africa with conditions rarely seen in Europe, such as serious cases of Pott’s kyphosis and spina bifida. We also see a number of children with wealthy parents, generally from Arab states, who – even for quite benign pathologies – insist on their having operations in Geneva.

Why so?

The countries of the Middle East have a special affinity for Switzerland, which – generally – is a country synonymous with quality, security, and luxury. In Geneva, for example, shops used to organise a night when they were open exclusively for people living in Gulf states, who would fly over in their private planes. The shops would be open to them only, all night, and they would buy their watches and jewels there. The same reputation extends to medical care.

You mentioned financial reasons preventing young French patients from accessing care in Geneva… What are they?

The French Social Security system does not pay out for medical costs in Switzerland – which are from two to three times more expensive – except in case of emergency. In the context of trauma, there are exceptional criteria: for example, if a doctor from the French hospital of Sallanches requests that a patient be admitted to Geneva, that patient is transferred to us and the French Social Security system pays for his/her care for 21 days. However, such instances are always very complicated.

How is the pediatric orthopedic department organised?

I’m the head of department and I’m assisted by three senior doctors, all of whom are academic surgeons. Dimitri Ceroni specialises in serious hip pathology and lower limb lengthening; Geraldo de Coulon concentrates on clubfoot and everything concerning neuro-orthopedics or neuromuscular disease; Romain Dayer is the spine specialist. In this way, they all cover their specialism both clinically and academically. That is, the three of them teach and research their specialist area. Moreover, the four of us provide cover for all patients on a daily basis, dealing with joint infections and trauma, for example. Thus, we all take it in turns – one day and one weekend in every four – to cover emergencies.

And so you are still relatively adaptable?

I am, yes, because it allows my partners to blossom and to develop their skills. To this end, we made an agreement from the very beginning: they can focus on their particular field and I can do a little of everything I wish to. In this way, I’ve maintained my adaptability. But I have stopped operating on cases of scoliosis. With regard to limb lengthening, I no longer fit external fixator devices, but I will – in some cases – use magnetic intramedullary nails.

Are you all sufficiently adaptable as to be able to treat the gamut of trauma issues?

I should say so! What’s more, our results are outstanding, because not a single patient is operated on without one of us four being present.

Do Swiss orthopedists in clinical practice also provide trauma care for children?

Very few do. There are three orthopedic surgeons working in private clinics who specialise in pediatrics: they all do a certain amount of trauma, depending – in particular – on the clinic in question. Depending on the clinic’s opening times, the decision may fall to the pediatricians or emergency doctors: a small fracture will be entrusted to their own surgeon, but after certain times or given a certain level of complexity, the patient will be brought to the university teaching hospital, that is, to see us. It’s organised as it is elsewhere.

How many beds do you have?

Just nine beds in nine rooms, but that number can double. In practice, that is, if we should need to cater for 15 patients, we do that, and the nurses don’t complain. Of course, in such instances, things can get a little cramped because the mothers are allowed to spend the night by their children’s beds on a camp-bed, if they wish to. Even so, a patient will be with us for fewer than three days. So, for example, an adolescent with idiopathic scolosis may come in on a Tuesday morning and leave on Friday. Given that nearly all of our patients come from Geneva, they will typically arrive on the morning of the day of the operation for same-day surgery. And in trauma, for example, an operation performed in the afternoon/evening involving elastic stable intramedullary nailing (ESIN) will see the patient discharged the following morning.

How many nurses do you have for nine beds?

We have thirty or so. Three or four nurses are always present during the day, and two nurses will be present at night. That’s double the provision in France. And out of the 30 nurses, 28 of them are French.

And they live in France?

Yes, they do. A number of them live in Annecy or down in the valley, not far from Chamonix. They cross the border every day, and encounter the traffic jams you’d expect. Apparently, when I first arrived, they were worried that I would cut staffing levels. Of course, I did no such thing. The comfort we enjoy really is enough to make our French colleagues jealous.

Do you do much outpatient surgery?

As much as possible. When we can, we do it. It takes up a third of what we do in surgery. However, foot or pelvis osteotomy in a patient with cerebral palsy, for example, cannot be performed as an outpatient procedure. In such a case, the patient would need to be monitored for two to three days. Even a simple Achilles tenotomy in the treatment of clubfoot performed without local anesthetic will be kept in for the night, owing to the risk of sudden death. In that case, however, the monitoring would be anesthetic or medical in nature, as opposed to surgical.

Besides your senior doctors, what surgical staff do you have?

I have two clinic leaders but only two junior residents. As such, with regard to age, the department can be see as an inverted pyramid. Yet, given that our staff are ever-present, and given that we have 50% less work than what I had in my post in Nancy, we have the time. Much of this time is taken up by appointments. My appointment slots last 20 minutes, but if a patient desires a 40-minute appointment, then s/he will see me for 40 minutes. One thing to note in the Swiss context is that the cost of the appointment depends on how long it lasts.

Is it on a meter, like in a taxi?

It’s split into five-minute segments. This means that seeing two or six patients in any one hour affords roughly the same income to the hospital or to the surgeon. In any event, if we were to skimp on this time, we’d pay for it later, some other way, because the parents, for example, would not be happy. They want to understand what’s going on and they want detailed explanations. We’re dealing with a high-revenue demographic, here, and if there’s a shadow of doubt they will seek a second opinion, if not a third opinion. In fact, in pediatrics, as soon as surgery is involved, parents will often seek a second opinion.

Despite this, you still have some time left over…

I do, yes. And that time is devoted to my university work – to teaching and research. Conducting research is an absolute must: it is impossible to climb the university teaching hospital ladder if your publication rate is low. By way of illustration, in order to become Priva Docent – the first rung of the university ladder in Switzerland – it is necessary to have published 20 papers, for the most part as main author, or as co-author. Without such publications, there is no point in even applying. Moreover, in addition to the number of papers published, appointment committees will always look at the impact factor and h-index, and so on. Working at publishing one’s research is therefore important: one’s entire career can, potentially, come to a standstill if, at some point, one’s publications should dry up. The old adage, ‘Publish or perish’, is now an absolute given. That said, the University Teaching Hospitals of Geneva do help us in this regard. For instance, we have a clinical research centre and a research platform, both active, which provide support in completing applications to the ethics committee, in compiling statistics, and in finding specialist nurses when blood samples are needed for a study. In the pediatrics department, some hospital staff are devoted exclusively to research.

So, the hospitals are very supportive when it comes to clinical research?

Yes, they are, and their encouragement is constantly punctuated with offers of grants, from all manner of sources, that we can apply for, such as from Fondations Suisses. Last May, for example, six competitive grants – each worth from €100,000 to €200,000, for a period of three years – were awarded to departments in Geneva University Teaching Hospitals. Foundations are private entities and the funds that they put into research are deducted from their tax bills. To quote the example of one such Foundation, which is very generous and very discrete, it is run by a Genevan businessman with interests in the luxury sector: every year, it gives several million Swiss francs to the University Teaching Hospitals of Geneva.

As such, you have the means both to provide care and to publish…

We also have the means to teach. As doctors, we have to teach. And from the third year of studying medicine, teaching is done in small groups of three to four students. The teacher will work with three or four students at a patient’s bedside, or with around 10 students sitting down for three hours to discuss, for example, what to do when faced with a child with lower-limb pain, using the well-known problem-based learning methods of Sherbrooke University. This way, the students are the ones doing the talking: they will suggest that it could be due to an infection or a tumour, and that what is needed is a blood test or an x-ray, and so on. By definition, all doctors in the university sector are obliged to teach on this model. If they don’t, it’s quite simple: their career will not progress and they’ll end up leaving Geneva’s University Teaching Hospitals.

The answer might seem obvious, by now, but let me ask you this: why did you leave France for Switzerland?

I’m not sure I’d say that I left France for Switzerland. I left Nancy for Geneva, and it went like this: whilst giving a lecture about the spine, under the auspices of the Anatomy Laboratory in Nancy, Gérard Bollini informed me that André Kaelin’s post in Geneva would be available from the end of 2011 and that the post would be advertised internationally. I was already aware that Kaelin was leaving, as I was secretary for EPOS (European Paediatric Orthopaedic Society) when he was its head. However, I couldn’t imagine that I could ever step into his shoes. Bollini asked me if I was interested in the post. I was 56, my wife had given up her main job as pharmaceutical researcher, my three children were grown up and leaving home, and so I said, ‘Why not!’ That very evening, André Kaelin called me to say, ‘But, of course. I’d not thought of the obvious.’

In other words, you left your department in Nancy on a sudden impulse?

Not quite. I said ‘Why not!’ because I’d had enough of where I was. I’d been head of department for 18 years. Pierre Journeau had been appointed teaching professor some seven or eight years previously, and it did not seem proper that he should wait until he turned 60 before becoming head of department. I was also being encouraged to go for higher posts, such as head of faculty – but my heart wasn’t in that. It was suggested I become head of a regional unit – but that, infamously, merely involved managing the lack of funds: it was a waste of time, because heads of regional units have, in fact, no financial leverage and all they can do is resign themselves to consoling colleagues, crying in vain, in their office. Besides, I’d realised that project meetings with management always ended with the words, ‘we’ll think about it, we’ll form a committee’, only for the project to be abandoned two years later. We were wearing ourselves out, being made to think that something was going to be built, when it wasn’t.

Can you think of an example?

An example? In the children’s hospital in Nancy, there was a time when all pediatric specialisms were due to be brought together to work in an operating theatre with six rooms. Marvellous! The rooms were built, they were kitted out magnificently, and then – in the end – we were told: ‘Now we’re all going to work in four rooms because we don’t have the staff for six rooms…’ And so, after several years of planning, we found ourselves squeezed into this new operating theatre. Moreover, in the process, pediatric orthopedics lost at least a third of its operating slots.

That freed up some time for other things…

But paying surgeons not to operate is not good. And I’m not just thinking of the surgeons. For example, I used to operate on cases of scoliosis: because of such restrictions, my waiting list for an operation went up to more than six months. The upshot was that a patient scheduled with 50° curvature would turn up, on the day of the operation, with 60-70° curvature: at that time, the difference was a game-changer as far as the patient was concerned. Furthermore, the department might have made the most of this ‘fallow’ time by doing research, but what with the level of funds allocated to quality research being as they are…

Did you at least have all of the hospital equipment you needed?

Obviously not. One big problem we had, for example, was the constant battle to ensure perioperative monitoring in cases of scoliosis. In contrast, in Geneva, we have no such worries. When I arrived here, the person in charge of the major equipment came to me, saying, ‘You’ve not ordered any new equipment, this year!’ I told him that we were well equipped: we had a scanner, navigation tools, and a carbon table. He said, ‘Well, you’ve only got one carbon table, so let’s buy an extra one’. Another example: the Nadine de Rothschild Foundation gave us a perioperative monitoring device for scoliosis, and the eponymous woman herself came to inaugurate it. More recently, we’ve just acquired a 3D fluoroscope – without having requested it – to replace the classic 2D equipment.

How did your career progress in Nancy?

I sat the competitive residency entrance exam in 1976, and – from the start – wanted to work in trauma and orthopedics. My first residencies were with Jacques Michon and Michel Merle in hand surgery, and then with Jean Sommelet in orthopedics. I did my military service as a doctor with the French skiing team because I was involved in the sport and the French Skiing Federation. When that was over, and I went into pediatric orthopedics, I knew it was in that field that I would be a clinic leader.

How so?

To begin with, I knew I liked the specialism of pediatrics. My father was a pediatrician, so he probably had a hand in this – not to mention my mother, who was a midwife. Apart from that, I found the atmosphere in adult orthopedics somewhat tense, whereas in pediatrics, Monsieur Prévôt allowed his team – particularly Jean-Paul Métaizeau and Jean-Noël Ligier – to blossom, so the atmosphere there was very enjoyable. Thanks to Monsieur Prévôt, moreover, I spent a year as a Fellow at Sainte Justine Hospital in Montreal – that international experience is something that I recommend to all young medics. Working abroad is essential because you get to spend a year discovering so many things and working somewhat selfishly for your own ends. When young medics work abroad, they don’t necessarily have to worry so much about what their boss thinks of them because they’re only there for a short time. Typically, they’ll hit the literature and spend as much time as they can in theatre. That’s how I learnt spine surgery: Morris Duhaime had a splendid scoliosis team whose work was outstanding. That was the era of the Harri-Luque technique, just before the Cotrel-Dubousset came in. I had a great year there. I returned to Nancy as a university-hospital assistant because, as a resident, I was also an assistant in anatomy. At that time, I got a great deal of help from Rémi Kohler and from the pediatric orthopedic bibliography group, BIBLIOP, which was a springboard for us all: that’s where we learnt our skills and got to be recognised by our peers. That reminds me of more advice for young medics: like birds of a feather, flock together, and work with each other.

Who set you off down the anatomy route?

That would be Gilles Grosdidier. One day, when I was a young resident, he suggested I do some anatomy. The person in charge of anatomy was Jacques Borrelly, a thoracic surgeon at Nancy Teaching Hospital Centre, who developed the famous Borrelly staple-splints for the chest wall. So, it was Grosdidier – who worked under Borrelly – who set me off on a career in anatomy, which led to me spending five years as a university-hospital assistant in anatomy and child surgery. One day, someone said to me: ‘You know, you won’t go any further if you don’t apply for a post as lecturer-practitioner.’ Nobody had ever told me this, not even my boss. But I’d understood that I needed to get a move on, to learn how to teach in front of students, and make contact with the number-one university specialist in anatomy, Maurice Laude. Preparing for that role was very tough and, at the time, if you passed the competitive exam, a post was created for you where you lived. So, I set about working towards this post and I got it in 1988, on my first attempt.

And you built your career in anatomy?

I gave my weekly lectures, ran my seminars, and worked hard. In 1988, my Head of Faculty said to me: ‘Lascombes, you annoy me… You don’t know what you want.’ My reply was: ‘Sir, if you appoint me, next year, to an anatomy post, I shall serve the discipline faithfully. However, if you’re waiting until 1994 for Monsieur Prévôt to leave before giving me a post in anatomy, I’ll decline and request I be appointed to a pediatric surgery post.’ As a result, in 1990, I became a lecturer-practitioner. And when Monsieur Prévôt retired in 1994, I took over from him, as is tradition in France. That’s how I found myself as head of department, in 1994, at the age of 40.

With a university post in anatomy?

Indeed, because I kept my word. I’d told the Head of Faculty that if I were appointed in 1990, I would work in anatomy for 20 years. What’s more, I’d understood that, as head of department in child surgery and as professor in anatomy, I could save Monsieur Prévôt’s associate professorship post for someone else and thereby increase the size of my team. That someone was Gilles Dautel, who came to the children’s hospital to develop pediatric hand surgery, and – if you’ll forgive the pun – he’s made a good fist of it. That said, Gilles Dautel did not deliver the lectures on child surgery. I got landed with teaching scoliosis, clubfoot, and so on. As such, I had a lot of teaching on my hands. In 2002, when Michel Merle left for Luxembourg, Dautel took over his role in plastic surgery, which enabled me to appoint a new professor in pediatric surgery. I offered this post to Jean-Paul Métaizeau. At the time, he had a very successful practice – both private and in hospital – in Metz. He thought about taking the post, but finally decided to stay there.

Did you not have anyone ready on-site?

In Nancy, Thierry Haumont wasn’t ready. Therefore, I offered the post to Pierre Journeau: he’d been trained by Pierre Rigault in Paris, but had gone to Le Mans after being sidelined following the premature death of Philippe Touzet at Necker Hospital. Pierre spent a year with us, as a practitioner – I’d not trained him but we got on very well with each other.

Why had Jean-Paul Métaizeau left Prévôt’s department?

You’d have to ask him that. I do know that he had put himself forward as a candidate for an assocaite professorship at the end of the 1970s, but Michel Merle beat him to it. The following year, Prévôt offered the child surgery post to Michel Schmitt (in visceral surgery). That was a big blow for Jean-Paul, so his departure is easy to understand. I didn’t get much opportunity to work with him, because of my time in Montreal, but I did benefit from his experience during my residency.

Can you remind us of Métaizeau’s technique for osteosynthesis of fractures in children?

Métaizeau’s method was original in fitting two curved intramedullary nails so that they diverged as far as possible from the fracture site. This method gave better stability than could be obtained by using Rush nails, which are straight. It also had the advantage of being a minimally invasive operation, which was innovative at the time. More than that, it respected the biology of the bone callus as in conservative treatment. Such advantages did not, of course, accrue from the use of screwed plates or from centromedullary nails which went – dangerously – through the growth plates. That’s why this technique was successful. There was, it’s true, a a time when we went overboard with it, because we were pushing the technique to its limits. It’s also true that nobody has to perform an ESIN on a 14-year-old’s femur, but it can be done if you know what you’re doing. Nowadays, the main indications are quite clear: they’re fractures in both bones of the fore-arm, the neck of the radius, and – for certain ages – the femur and the tibia.

Are specific nails required for this technique?

Simple Kirschner pins were the first ones to be used, despite being difficult to bend and support. If the curvature is correct, the nails go in very easily. But if there’s not enough support, they get caught or get stuck in the bone. We understood the principle perfectly well, but teaching it was not easy. More than that, everyone outside Nancy wanted to create their own version of the technique. Later on, they started making specific nails. But the real difficulty is finding manufacturers who are prepared to make ancillary instruments for operating. When you’re lucky enough to find a company that will make good tools for you, it’s a joy. ESIN was Jean-Paul’s brainchild and I’ve never laid any claim to this technique. But when he left, from 1985 onwards, I had to organise training courses, embracing the theory as much as a practical component in the anatomy lab. In this light, certain courses ran for 10 years. After that, I moved away from the subject, as I felt that I’d gone over it enough. Indeed, in that 10-year period, those courses spread and spread, ultimately attracting surgeons from America and Asia, as – increasingly – European surgeons had been trained in this area. I started running cadaver courses in spine surgery, using new implants such as the CD Legacy and the CD Hopf. Rémi Kohler encouraged me to write a book about ESIN in French – it was, later, translated into English. The time for it was ripe, because we’d understood that the Americans were on the verge of publishing a book which would tell us how to go about performing a successful Métaizeau. When it came to the English-language version of my book, we included a chapter about surgeons working in less-than-ideal situations, with no sophisticated nails, with no image intensifiers, for example, but who can – nonetheless – perform the technique successfully. This is relevant for all of our foreign interns serving as junior residents, who will return to their own countries.

And now, what have you concentrated on in Geneva?

Given that my colleagues are responsible for many aspects of pediatric orthopedics, I’ve developed a number of unexploited areas. The first involved creating a multidisciplinary approach to CRPS-type pains, which resulted – for instance – in a teaching conference (my fourth) on this subject at SOFCOT. The second involved a cross-disciplinary approach to treating pectus excavatum and pectus carinatum. My initial project was to develop navigation and minimally invasive techniques in pediatric orthopedics. We had the tools for navigation, and I thought we’d achieve a lot, especially with the O-arm®, but – unfortunately – it’s a perioperative scanner that produces quite a lot of radiation. As a result, we had to start from scratch. That is, we had to find out perioperative radiation levels on children, as we had no precise idea. On the one hand, we did tests on dummies to compare radiation levels from a perioperative scanner and from fluoroscopy. We found that radiation from CT was equivalent to one minute of fluoroscopy. But what did that mean? So I set up a multi-centre prospective study including Nancy, Brussels, and Lausanne, to measure fluoroscopic times and doses in procedures such as pelvic osteotomies, ESIN, and scoliosis. Using 3D fluoroscopes, I’m hopeful that I’ll be able to demonstrate the possibilities of navigating with acceptable levels of radiation.

For which indications?

Navigation is indicated in malignant bone tumours: it involves making templates for cancer removal and reconstruction using a perfectly accurately-sized graft. It’s also indicated in all of the many smaller, precise procedures, such as that for osteoid osteoma, biopsy, or percutaneous drilling. Recently, for example, I did a disepiphysiodesis of a distal radius using navigation. That was only six months ago, but – so far – the results are encouraging. It can also be used in an epiphysiolysis, if only for screwing the femoral head exactly in the middle, using the right length of screw and without touching the adjacent joint. If you look for indications, you can find them. Another example: hip dysplasia. Doing a MRI scan, so as to avoid radiation, gives precise preoperative coxometry. And given that the normal coxomtery desired post-operatively is known, a ‘rustic’ approach is recommended, using an old-fashioned osteotome and image intensifier. On the other hand, 3D tools provide the exact results desired, to the very degree. After pelvic osteotomy, for example, there’s no longer any need to say that the correction is either too little or too much with potential risk of femoroacetabular impingement. I doubt I’ll see the day when navigation is standard, but I’m doing everything I can to ensure that – little by little – we acquire the basics of navigation in child surgery. In adult surgery, it’s already made a lot of progress, and there’s no real reason why children shouldn’t benefit from it as well.

And it will be done using the 3D C-Arm more than the scanner?

Yes, because the 3D C-Arm will give exactly the same results, but with a lot less radiation.

You’ve been head of the European Pediatric Orthopedic Society…

I have, indeed. I’ve worked for learned societies, including SOFOP – as committee member, treasurer, and head, as well as EPOS. I was head of EPOS from 2014-15, which seemed too short a time to make much of a change. I think I was a lot more effective in this society during the five years when I was its general secretary. I clarified the statutes, defined the member countries, and instigated a certain role by organising courses in Europe following the first Marie Curie session. Since 2009, we’ve seen six trilogies of three times three days of training in pediatric orthopedics, with each session attracting more than 100 youngsters from around Europe. This last year, I’ve made the most of the splendid surgery centre in Geneva to organise cadaver courses in a technological environment that is the envy of many a theatre. This teaching means that surgeons from all around Europe are improving. Our aim is that if your child is on holiday and breaks his/her leg in Austria, Ukraine, or Portugal, you won’t have to bring him/her back to Paris or Geneva for fear of poor treatment abroad, because primary treatment will be satisfactory. We need to achieve a proper level of care throughout Europe.

Is the technical side of things important?

If you’re referring to surgical equipment, it’s definitely less important in child surgery than it is in adults. In pediatrics, it’s the strategic side of things that counts most. For instance, you have to know how you can ‘play’ with the physis, that is, the growth plate: this way, to protect it, that way, to use it as an aid in growth changes. The right basic knowledge, correctly applied, is much more important than just the technical aspect of operating.

How would you explain the differences between more or less developed countries?

I think that in a less developed country, colleagues – those pediatric orthopedists that I meet, in any case – are very attached to their old boss. The line is: ‘I’ve always done it like that.’ And they’ll carry on operating and performing femoral derotation osteotomies on a two-year-old walking with feet pointing inwards, and yet we know that this has the potential to correct itself with growth. I’d say youngsters need the opportunity to learn the rules respecting osteo-articular biology in children and they should avoid transferring the principles of orthopedics to little children. The aim, today, should be that – throughout Europe – we don’t do what we were doing when we were residents, copying our bosses because they were doing their best.

Have we gone overboard with clubfoot?

We have. And, unfortunately, we’re responsible for that. That said, it is true that the Ponseti method – which explains perfectly how to make casts and other manipulative techniques – makes it possible to provide marvellous treatment for clubfoot in Africa, Asia, and Latin America. Ignacio Ponseti, who was born in Majorca, is certainly one of the greatest pediatric orthopedists around: he does a lot with a little.

What was the reaction when you left Nancy?

To begin with, all of my friends told me I was making a mistake: ‘You’re fine in Nancy, you know everyone, you’ve got everything you want.’ But there wasn’t much there, so – in effect – I didn’t have much. And then they told me: ‘To be fair, you’re brave to move, at your age, because you never know how you’ll be received. If they don’t take to you in your new department, it’ll be hard.’ Anyway, there are lots of departments where colleagues come and go, all the time, for all sorts of reasons…

How were you received in Switzerland?

Very well. It has to be said that the selection process is rigorous. The post is advertised internationally, the Head of Faculty sets up a panel which spends six months defining the role, they interview candidates, and then they come to their decision. After that, the chosen candidate is accepted by everyone as being the best person for the job. Of course, it’s tough on local candidates who get pipped at the post. It’s natural that some – understandably – will leave, while others will stay. In my department, they all stayed. Generally speaking, I’ve had to become a different sort of head of department, but there have been no problems whatsoever. It’s been a beautiful experience. It’s true that I’ve had to make certain concessions, develop some staff, and tempt all of my colleagues into the academic route. But the pace of work, here, is appropriate for me. Initially, being able to devote time to patients struck me as an incredible luxury. I’ve also had time to return to research projects: in particular, research into chest deformities, for which my hope is to be able to quantify, measure, and come up with a solid algorithm for managing care between conservative and surgical forms of treatment. And yet time is all I’ve lacked because seven years is not enough time to achieve all of these aims. As for Switzerland, the surroundings are magnificent and the climate is lovely: I’m next to the Alps and beside the great Léman lake – which the locals defiantly call Lake Geneva.

What’s next?

Good question. My contract comes to an end, next year, as it must: that’s when I reach the age of 65. I have a few choices… I could retire – but do I really have nothing more to do, in terms of work? I could go private in Geneva and set up in a beautiful spot known as the ‘clinic of the dinosaurs – that’s where lots of former department heads end up. Or I could resume my lecturer-practitioner role in France – the post, currently seconded, is still open. In fact, I think I’d like to carry on teaching, helping colleagues with research, whilst offering my services to university staff and to SOFOP – if they want them, of course. We’ll see…

Published in N°279 - December 2018