Made in France – Modern Orthopedics

Renoir, Descartes, champagne…the list of French contributions to the world is extensive.

France has had an oversized contribution to world literature, art, food, and science. La République has given the world the likes of Van Gogh, Cezanne, Matisse, Gauguin. Diners in New York or Sydney can enjoy French culinary creations, àlaBœufbourguignon, Coq au vin, Escargots and crêpes.

In science, but more specifically orthopedics, France has also led the world, giving physicians remarkable new tools to relieve the shock, discomfort and fear that accompany a splintered tibia, crushed acetabulum, spinal deformity, or stenosis.

Last month we joined thousands of orthopedists in Paris to celebrate the 100th anniversary meeting of the SociétéFrançaise de Chirurgie Orthopédique et Traumatologique (SOFCOT).

The organization, founded by ÉdouardKirmisson, was the mid-wife of modern orthopedics. To this day, large joint physicians, spine physicians, trauma and extremity physicians use products and employ techniques that debuted at the SociétéFrançaise d’Orthopédie.

To put SOFCOT in perspective, it is 15 years older than the American Academy of Orthopaedic Surgeons (AAOS).

Willis C. Campbell, M.D., Edwin W. Ryerson, M.D., Fredrick J. Gaenslen, M.D., Melvin S. Henderson, M.D., Philip Lewin, M.D., E. Bishop Mumford, M.D., and H. Winnett Orr, M.D. no doubt looked to the visionary science emanating from Paris when they organized the American Academy of Orthopaedic Surgeons in 1930.

Our Guide: Professor Rosset, SOFCOT President

We sat down with Professor Philippe Rosset, the president of the congress of SOFCOT and orthopedic surgeon and traumatologist at the HôpitalTrousseau in Tours to discuss the highlights of 100 years of French Orthopedics.

“To a great extent, the history of SOFCOT mirrors the history of the world,” says Dr. Rosset. “In the 1500s, an Army surgeon named Ambroise Paréwas credited with originating the field of prosthetics. In 1741 Nicolas Andry coined the term ‘orthopedics.’ Dupuytren’s contracture is named for French military surgeon Guillaume Dupuytren (October 5, 1777–February 8, 1835).”

WWI ushered in millions of wounded and distraught souls and the medical community hastened to respond. A month before the armistice in 1918, surgeon ÉdouardKirmisson mobilized a number of colleagues and formed the SociétéFrançaise d’Orthopédie, the precursor to SOFCOT.

One of Kirmisson’s many contributions was to expand Bois-Regard’s narrow definition of the field as being one focused on treating childhood deformities to include all musculoskeletal infirmities. “It would be a serious error,” said Kirmisson, “to think that orthopedics stops at the age of 15.”

Forged in War

As Dr. Rosset reminded us, with the specter of war so intertwined with the 20th century, we must ask, “How much did war accelerate our knowledge of orthopedics?”

WWI was still raging when the organizers of the French Surgical Societymet in October 1918. Aware of the need to harness the power of science to the lessons of war, Dr. Kirmisson brought several colleagues together to form a new organization whose charter was to focus on an obscure corner of medicine—the study and treatment of musculoskeletal injuries and disease.

But the origins of orthopedics in general and the French contribution go back much further.

“During to the 1870 French war with Germany, the main problem for the soldiers was disease not the bullet wounds,” says Dr. Rosset. “During the first several weeks of WWI, because of new weaponry, the surgeons saw wounds they had never seen before.”

The horrific trend accelerated in WWI.

Bogged down in trench warfare, the emerging science of industry rolled out ever more destructive mechanizedweaponry—combat aircraft, tanks, machine guns and bombs—to break the armies loose.

Notes Dr. Rosset, “Before WWI, the practice was to bring wounded soldiers away from the front lines and into the city for surgery. But physicians in WWI were quickly overwhelmed with so many infections, amputations, and deaths that they began to think that there must be a better way. The war began in August; by the end of September they knew they were getting things wrong.”

“It became clear that instead of bringing the soldiers to the treatments, the treatments would have to go to them. Operating rooms, X-rays, etc…all was then brought as close as possible to the front lines. This was the time when debridement began. Previously, doctors would administer the dressing and send soldiers to the city and they would get an infection. Debridement and lavage gained a footing here; surgeons learned the importance of enlarging the wound area in order to have proper visualization. This way they could do a better job of removing the necrosis, the bullets, and the accompanying dirt.”

And the result, says Dr. Rosset, was that the rate of amputation at the beginning of the war decreased by roughly 3x.

Between Wars

In the post-war period the innovations did not slow down. Dr. Rosset says, “During the 1920s and ’30s we saw advances in traumatology, including osteosynthesis and traction. Many people were experiencing hip problems, but there was no prosthesis available at the time, so surgeons had to do an osteotomy or arthrodesis. But that left patients vulnerable to inflammation and staph infection at a time when there were no antibiotics.”

“During the years of World War II, 1939-1945, orthopedic traumatology grew enormously. We learned more about how to care for open fractures. There were actually no meetings of SOFCOT during the war, but the principles remained the same: get the wounded off the battlefield and treated immediately, use plates and screws, etc. Things shifted massively at the end of the war with the arrival of antibiotics on a large scale.”

Inventing a Scale for Hip Function:  Robert Merle d’Aubigné

Without a scale, how can anyone measure, much less treat, musculoskeletal trauma or disease? Impossible, until Robert Merle d’Aubigné.

As a teenage boy during WWI, Robert Merle d’Aubignéwitnessed the war first hand. His school was turned into a hospital and that, more than anything, sparked an interest in medicine. d’Aubignéwent on to serve as an assistant in general surgery for 12 years at the Hôpital de Vaugirard, during which time he developed an interest in orthopedic surgery.

Highlighting the place of orthopedics at that time, d’Aubignérecollected that, “The prestige of visceral surgery absorbed the interest of the senior staff. The lesions of the motor system, numerous accidents, tuberculosis, and arthritis were more or less abandoned to the junior staff.”¹

Appointed by General de Gaulle to reorganize the military health services, d’Aubignétraveled to England in 1944 to visit prominent surgeons. He commented, “Pour moi, ce fut une experience inouïe qui bouleversa ma vie professionelle.” (“For me, it was an unbelievable experience that profoundly changed my professional life.”) In 1948 d’Aubignéassumed the chair at the Hôpital Cochin in Paris, where he remained until his retirement in 1970.

This esteemed surgeon gave the world the “Merle d’Aubigné-Postel” rating scale, published in English in the American volume ofThe Journal of Bone and Joint Surgeryin 1954, updating the scales in 1949, 1954, and 1970. d’Aubigné’s scale was first presented at the International Congress of Orthopaedic Surgery in 1948 in Amsterdam. At that time, no widely-used scale for the evaluation of hip function had gained traction in the orthopedic community.²

The Fathers of Modern Joint Surgery: Robert and Jean Judet

Born to an orthopedic surgeon father, brothers Robert and Jean Judet became two of the most influential surgeons, researchers and teachers in the history of orthopedics.

In 1932 the brothers worked together at the Hôpital Lariboisière in Paris and were already publishing articles which described how to treat fractures by using external fixators.

While working with Bernard Desplas, Robert Judet suffered an injury to his right hand that threatened to end his surgical career. Desplas, employing the most advanced techniques of that time, saved his colleagues hand—if not also the future of hip surgery.³

In 1937 Robert Judet began focusing intensively on orthopedics when he took the position at the Hôpital Cochin in Paris. World War II interrupted his role at head of the Cochin clinic, however, and Judet took part in a mobile surgical unit during the Battle of France. His conduct earned him the CroixdeGuerre avec l’Étoilede Bronze (War Cross with Bronze Star).⁴

When the Germans occupied France, both Judet brothers contributed much to the Allied cause, treating American and English parachutists. They used blood plasma transfusions, closed and semi-closed-circuit anesthesia, techniques that came from America via an Army base in North Africa. For their dedication, each of the brothers was honored with the Médaille de la Résistance (Resistance Medal).⁵

Upon demobilization, Robert Judet was awarded the CroixdeGuerre avecPalme(War Cross with Palm), becoming the only surgeon to be so honored. In 1945 he was made Chevalier de la Légion d’Honneur (Knight of the Legion of Honor), becoming an officer in the Legion of Honor in 1957.⁶

In 1946 “Team Judet” revolutionized hip surgery by using the first acrylic prosthesis in a femoral head replacement, in 1952 publishing on 400 cases with positive results. The brothers, who masterminded the anterior approach to the hip, in 1947 performed the first such hip replacement in Paris, using a Judet acrylic prosthesis. The “Judet Table,” designed by Robert’s orthopedic surgeon father Henri, was specifically designed for the anterior approach to the hip, an approach that turned the tables on the popular posterior approach.

Robert Judet took over as Chef de Service at the Hôpital Raymond Poincaréin Garches in 1956, transforming what was little more than a service for the chronically ill into a true orthopedic and traumatology institution with a worldwide reputation.⁷

In the early 1960s the Judet brothers turned their attention to the issue of non-unions, developing a technique known as osteoperiosteal decortication. The process involved using a sheath comprised of vascularized bony strips that helps to stimulate the bone healing process. Judet stated that “by elevating cortical chips that remain attached to the periosteum and overlying soft tissues surrounding the site of non-union, combined with mechanical support, the bone consolidated.” Their technique remains viable in the modern era, with researchers publishing in 2012 that “osteoperiosteal decortication remains a highly effective surgical technique in the management of failed fracture union.”⁸

Observing the high rate of cemented hip failures, Robert Judet undertook a mission to investigate other options, culminating in his development of the Porometal cementless hip prosthesis in the early 1970s. The concept was to have the bone and metal in as direct contact as possible, with sufficient surface irregularities to promote bony ingrowth. Also critical was that Judet obtained a solid head-neck fixation via use of a Morse taper. It was, according to Judet, “A metal that welcomes the bone instead of a cement that violates it.”⁹

When Robert Judet passed away in 1980, the famed English surgeon Sir John Charnley wrote, “France has produced many important orthopedic surgeons, but among them, Robert Judet is certainly the most well-known.”¹⁰

Postscript

As Dr. Rosset reminds us, “So many innovative prostheses originated in France. In 1963 Raymond Roy-Camille performed the first spine fixation using transpedicular screws and plates. Paul Grammont revolutionized orthopedics in 1970 with his reverse shoulder prosthesis…and many more which you will address in your upcoming articles.”

Sofamor, the French spinal implant company, merged with the U.S. firm Danek in 1993 and created the largest supplier of spinal implants and instruments which, today, is known as Medtronic Spine. Still the largest supplier.

Tornier, the French shoulder and extremity implant company, is now part of the $3.3 billion Wright Medical Company.

Pro-Disc, the most commonly implanted lumbar motion-preserving spine disc, is a French innovation. MOBI-C cervical discs, the most commonly implanted cervical motion-preserving spine discs—another French innovation.

It goes on and on.

If you have an example of French orthopedic technology and innovation, please post a note following this article.

Je vous remercie!

References:

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2600977/#CR5
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2600977/#CR5
3. PP http://www.biusante.parisdescartes.fr/sfhm/hsm/HSMx1988x022x003_4/HSMx1988x022x003_4x0249.pdf
4. http://www.biusante.parisdescartes.fr/sfhm/hsm/HSMx1988x022x003_4/HSMx1988x022x003_4x0249.pdf
5. http://www.biusante.parisdescartes.fr/sfhm/hsm/HSMx1988x022x003_4/HSMx1988x022x003_4x0249.pdf
6. http://www.biusante.parisdescartes.fr/sfhm/hsm/HSMx1988x022x003_4/HSMx1988x022x003_4x0249.pdf
7. http://eknygos.lsmuni.lt/springer/484/167-168.pdf
8. https://www.ncbi.nlm.nih.gov/pubmed/22542168
9. La prothèsede hanche sans ciment. “Actualitésde Chirurgie Orthopédiquede l’HôpitalRaymond-Poincaré.” Tome XIV. Masson, 1975.
10. 10.http://www.biusante.parisdescartes.fr/sfhm/hsm/HSMx1988x022x003_4/HSMx1988x022x003_4x0249.pdf