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Joel Matta and Jeffrey Mast were taught by Emile Letournel. In Paris last September, they ran the course on pelvic and acetabular fracture surgery organized by AFOR. In this interview, they talk about how they met Emile Letournel and what they learned from the man whom they consider their Master. Their words are the most glowing tribute to Emile that one could wish for.
M.O.: Joel Matta and Jeff Mast - did you know each other before you met Emile Letournel?
J. MAST : Joel and I were residents in California, but had never met. At the time, we were working at different hospitals in Los Angeles.
J. MAST : : Back in 1974; I was a resident then. In those days, acetabular surgery didn't really exist in the United States. However, we had a chief who thought that it was the right idea to operate on acetabular fractures, so he made a declaration that, at our hospital, all displaced acetabular fractures would be reduced and fixed. And so we did, and it was quite an adventure, to say the least. Our chief was very stubborn in his own way, and I don't think that he spent a lot of time with techniques.
Our chief was always present: the one thing you could be sure was that at some point during the operation he would be there. So, always, your nervous system was a little on the sensitive side for the voice that would suddenly appear behind you saying, "Well, what are you doing NOW?"
So we operated these fractures, and it was a difficult experience. When I left at the end of the 70s, after having been through the initial experience in LA, to set up in Nevada, I still was interested in these operations and realized that not very many people knew them. I continued to do a few cases in the group practice in Nevada. At first, I did the simple ones, and then they escalated into complex ones. And that's when I realized that I had to learn more than I knew. So I decided to go to Paris, to Emile Letournel, who was the only person that, I knew, understood the subject. I had met him when he came to give a presentation, in 1980. I remember the date very well, because he was at a party after one of the presentations he made in Los Angeles, and there was a college football game going on. Notre Dame were playing USC, and he was there, and, of course, everybody was interested whether he liked football. So they asked him, "Who do you want to win?" And he said, "I am from Paris - Notre Dame, of course." So I realized this man had a sense of humor; and I felt encouraged to write him a letter asking him if I could spend a few weeks as a visitor in his Department, to learn some things. I got to Paris in November 1981, and as soon as I arrived, he said to me, "You must know Mr Matta, he is also from California. He left here two weeks ago." I said, "No, I don't know this guy Matta." So, you see, it was thanks to Emile Letournel that I got to know Joel.
J. MATTA : I, too, was a resident in LA, at the Martin Luther King hospital. During that period, some of the faculty were interested in the operation of acetabular fractures, of which we were seeing a lot. Unfortunately, we didn't have a very good protocol, the reductions were bad, and there were many complications. However, it got me interested in the subject.
In 1974, there was nothing in the literature, really, other than the paper by Judet and Letournel published in the 1964 JBJS. They were the only ones in the world that knew how to read the X-rays. In those days, the description in the literature was the "burst fracture," which is not scientific at all.
Everybody knew that for other fractures, for instance around the knee joint or the ankle joint, one needed to restore the anatomy; but that principle was completely ignored for the acetabular fractures in the US at that time. I was invited by Sarmiento to join the faculty at University of Southern California, so I would be working at the hospital Jeff was formerly a resident at. Gus Sarmiento asked all the faculty members as they began, "What would you like to begin as your clinical project?" So I told him that I would like to operate all the displaced acetabular fractures that came into the hospital; and I wrote a protocol for the evaluation of patients. Sarmiento had even suggested that I work on this project with Paul Harvey, who had been Jeff's chief, and who was also interested in acetabular surgery.
I knew very well that would never work, because the only relationship you ever had with Dr. Harvey was that he was "the boss", and you were "the boy." So I worked on my own, in spite of Dr. Harvey, to operate acetabular fractures.
In the latter part of 1980, Sarmiento had scheduled a meeting on hip surgery, and Emile Letournel consented to come and lecture on acetabular fractures, and especially on the interpretation of X-rays of the acetabulum. When he came, I used the opportunity to introduce myself - very meekly, as befits someone just out of his residency who is talking to, and introducing himself to, somebody who is world-famous.
I asked him if he would be kind enough to look at some cases I had done, and, above all, if he could come to the Los Angeles County morgue to show us his approach, and how he did the exposure of the acetabulum.
It was one of the great things about Letournel that he was very approachable: if somebody was interested, he would take the time to teach them.
That day, he did the extended iliofemoral. Everyone in the room just stood there with their jaw gaping, and finally somebody asked, "Are you just demonstrating the anatomy, or do you actually do this on live humans?"
He smiled and said that he did this sort of incision in patients with acetabular fractures, and that he put all the muscles back, and that they functioned all again. You must remember that at the time the most one would do was a Kocher-Langenbeck incision; some surgeons would go so far as to take the trochanter off to get the gluteals out of the way, to go to the front and the back.
And then we found the descriptions of extended iliofemoral or ilioinguinal exposures in Letournel's textbook!
Afterwards, he looked at some of my cases; with hindsight, I have to say they were not great.
J. MAST : You showed him some of the cases you had been doing at the time?
J. MATTA : Yes, that's what I did.
J. MAST : Emile realized that a block to learning from somebody else is your own ego. An awful lot of young people are more interested in showing an older surgeon their cases than they are in learning from the older surgeon's cases. So where Emile was extremely clever was that he used the showing of your cases like a carrot to a rabbit: in other words, he got you to perform, and if you performed well, then he would look at your cases. He was extremely smart, because this way you had to learn something before he looked at your cases.
J. MATTA : When he was in LA at that time, I summoned up my courage and asked if I could visit him in France, to watch him operate and try and learn from him. There was something else that happened when he came to LA, late in 1980: he did an operation. We had a patient, who was a police officer who had been injured on his motorcycle and was admitted to a private hospital. He had a both-column fracture. Emile was asked if he would come over and operate the patient, and show us how he did it, especially since he had some of his tools - his Farabeuf clamps, and his plates and screws - which he had brought with him, to show us at the course. So he came over to the hospital. Now, as you know, it's very difficult in the US to go into an operating room, because the laws are very strict, and there is a liability problem with lawyers. There was argument about this, but finally he was able to do it. So Emile went into the operating room, made the entire exposure on the ilioinguinal, and then all of a sudden the door of the operating room opens: it's the head nurse, and she says, "Dr. Letournel will have to leave immediately. He has no privileges at this hospital."
Emile Letournel replied, in his best English, "I am sorry, Madame, but the plane is already in the air, and I am your only pilot."
He did, however, wonder whether the police were waiting for him outside the OR. In the end, though, everything sorted itself out, and the patient did very well.
It was an experience watching him operate. One thing was that we were so used to drill a hole, and use the depth gauge, and tap the screw - a very disciplined AO technique. He would drill a hole, and say, "75 mm." So we asked, "Aren't you going to measure it? You have to measure it." So he took the depth gauge. Seventy-five millimeters!
J. MATTA : In 1981, just a little before Jeff.
J. MAST : I also went in 1981, and although I explained that I was going to do surgery in Paris, there was a certain innuendo: somebody even said that it was interesting that, to understand the pelvis, I should want to go to Paris. They suggested that this could be understood in other ways. Staying in Paris was a big adventure - if only because the exchange rate was very favorable at the time. In 1981, you got 10 francs to the dollar. I was able to get a little hotel in Choisy, and I could live for $35 a week.
So off I went to the Clinique de la Porte de Choisy. The first people I came across were the receptionists, and I asked them if I could see Prof. Letournel. The charming ladies said they didn't know whether he would see me: maybe he would, maybe he wouldn't; but if I wouldn't mind waiting, they'd go and see what could be done.
Five hours later, nothing had happened; so I went to see the ladies again. At long last, they made an effort, and after that, I was able to see Letournel quite soon.
The first meeting was quite brief. He simply asked me if I had read the first two chapters of his textbook on fractures of the acetabulum. I was smart enough to have the textbook with me. He asked me into his office, and showed me a closet. All the X-rays for the first few chapters were there, he said. I was told to go to the library, read the textbook, study the X-rays, and then he would see me again.
After this somewhat brisk first encounter, things went really well, and I spent some unforgettable weeks working with him in the OR.
J. MAST : I was there just over 3 months. It was a great time. I immediately got to like the man. He was a fierce worker, quite indefatigable; but he also knew how to relax, and it was thanks to him that I discovered aspects of French life that I would not have known otherwise. The atmosphere at the Porte de Choisy center was very stimulating. We would do very, very difficult cases. Everybody worked like beasts all day, and in the evenings, all one could think of was to go home to one's hotel and relax. However, he would then go on until goodness knows when, to explain his surgical techniques. And that was not the end of the day, either: he might go on to take us out to some oyster place or to a restaurant, where they would drop everything and serve him. And none of this would keep him from starting again next morning at the crack of dawn.
J. MATTA : I went to the Porte de Choisy for slightly different reasons than Jeff. As I already mentioned, surgery for acetabular fractures was not really accepted in the US at that time. Whenever one stood up to present one's cases at conferences, the others thought that was crazy surgery. Our colleagues would ask us what we could promise our patients: complications were horrible, and one stood a good chance of making one's patients worse rather than better. Of course, there was this French surgeon, Emile Letournel, who seemed to be able to read the X-rays, who seemed to understand and address the problem; but one wondered whether these patients were properly followed up, whether there wasn't a high rate of complications, etc. etc. In fact, I must say that I went to France with a little bit of scepticism.
So, when I went to the OR with Letournel, I was sceptical about what he called a "perfect reduction." I wondered whether that wasn't a term used only by the French, something that we wouldn't use that much: we call them "anatomic reduction." Maybe it's a different mindset. To us, "reduction" is a term that doesn't need any further qualification - so why describe it as "perfect"? I wondered how he managed to get his famous 75 per cent rate of perfect reductions.
I was watching him operate a transverse fracture from a Kocher-Langenbeck approach. He used the Farabeuf clamp and the screws, and reduced the fracture, and asked me what I thought. I looked at the fracture site, which, I thought, had been perfectly reduced; so I said, "I think that looks great." He shook his head, and said, "No way; you are wrong, this is not a perfect reduction. To look at, it may seem perfect; but if you run your finger through the greater sciatic notch and feel the quadrilateral surface, you will feel that there is still a little step-off. There is still some rotation, which absolutely must be corrected."
So he took everything apart again, and started the entire reduction all over again. Then he turned to me again and said, "Now it's correct." I must say, that's one of the things I really did learn from him: how to recognize these tiny imperfections, which finally make a big difference for the patient.
J. MATTA : Jeff, weren't you also a bit sceptical when you first went to the Choisy clinic?
J. MAST : No, I wasn't, because I had spent a year in Switzerland, with Maurice Müller; so I was probably more open to the different techniques of internal fixation than a surgeon trained in the US. Internal fixation was not, at first, very readily accepted in the States. Internal fixation started early this century; but then there were problems with metallurgy, problems with infection, problems with surgical technique, problems with anesthesia; and it went into disrepute. In fact, the English school then became very strong, because it offered treatments that did not require surgery. Everybody had seen how disastrous the results of poor IF could be, and, as a result, great strides had been made in the nonoperative treatment of injuries. It was really thanks to the work, in isolation, of some researchers such as Danis, and of the Swiss school - the AO - that the benefits of internal fixation could be demonstrated.
When I was in Switzerland, I came to appreciate these techniques, which were quite new in the States, and I felt sure that surgery, properly done, could be very beneficial to the patients.
So, by the time I went to see Emile Letournel, I was already convinced that good internal fixation was better than bad nonsurgical treatment; and I thought it was great that fixation could now be extended to acetabular fractures, which, until then, had been one of the last strongholds of conservative treatment.
J. MATTA : He was very intelligent, committed to his work, with a will to win, a very hard-working and tenacious man. He taught me, in a surprising way: he was taking somebody who hadn't achieved anything. All I'd said was, "I'm interested in what you do," and he was happy to teach me. I am very grateful to him for having taken the time to teach us his technique.
J. MAST : As I said before, I joined Letournel after having spent almost a year in Switzerland. So I had seen a lot of Maurice Müller, who had a very strict technique. The atmosphere was far from relaxed, and I thought that that was probably the same all across Europe. So it was a big surprise to me to find this very energetic man. He wasn't any less accurate or less demanding than the Swiss; he just did it quickly, and with such immense energy.
J. MAST : It was obvious that English was not his native language. Having said that, he would use expressions that were so apt that you wanted to copy them.
J. MAST : Instead of saying, as one would in English, that the fracture line goes from the pubis into the ischium, he would say, "This fracture of the pubis is interested in the ischium." That's much more subtle!
He had no problems speaking English. He could make himself perfectly understood, and what he said was always very clear.
J. MATTA : Also, during the time we knew Emile, his English developed quite a bit. Initially, in Los Angeles, his talks would be written out in English, but later on he was able to make do without these notes, and managed to speak very freely.
Over the last 15 years, he did not publish in French any more at all; everything was in English.
J. MAST : French is a fantastic language for orthopaedics. For the description of orthopaedic problems, French is so much more precise than English. And Letournel was able to use this precision even when writing in English.
J. MAST : For me, yes, immediately. I had learned things that suddenly enabled me to do things that I could not do before.
J. MATTA : I learned more in a few weeks with Emile Letournel than I had done previously in the course of several years. It's amazing what being with a teacher like Emile can do. If you have a question, you may ask it; and you get an immediate reply, which is not always the case in your routine work. I remember the first time I met him in Los Angeles, he gave us a one-hour session on how to read the X-rays of a normal pelvis.
It was quite amazing, because all the audience were orthopaedic surgeons, hip specialists, who, before that lecture, had seen thousands of pelvic X-rays. And they were absolutely spellbound for an hour, because nobody had ever seen all these things on the X-ray. These things had been before them all the time, and they had never seen them before.
The chapter on normal X-rays in his textbook is wonderful. Anybody with an interest in the hip - not necessarily in acetabular fractures only - should read this chapter. Once one has read it, one tends to look at conventional hip X-rays in a completely new light.
J. MATTA : Jeff and I got in touch, and we have stayed in contact ever since. We don't work together. At the time, Jeff was in Reno, Nevada, and I was in Los Angeles. Jeff is now in Detroit, after having worked in Tampa, Florida; while I am still in LA. We meet several times a year, and compare notes when we meet. This has been very useful, and was particularly helpful in the early stages.
We have also been able, in a way, to pioneer this surgery in the United States. Both of us have a high case volume, so we quickly developed a fairly large experience.
J. MAST : Of course, we were also members of the AO Group, which was vital if one wanted to be listened to in the US, in matters of internal fixation. Jeff and I became two of the main authorities on acetabular fractures very quickly, within the AO Group. This way, we were listened to much sooner than if we had been working each in his little corner, and publishing only our case reports.
It was also good for Emile Letournel. When we went back to Switzerland, to report on our first cases and to show the importance of properly done internal fixation of acetabular fractures, the Swiss suddenly discovered this little Frenchman, who was not in the AO and who had his very own technique.
So, in the end, the Swiss went out and invited Emile to join the AO.
J. MATTA : . It wasn't actually as simple as that. At one point, Emile had gone to Maurice Müller and suggested that what they didn't have was hardware for the management of acetabular fractures, with special curved plates and special long screws. Maurice Müller completely rejected that concept; he reckoned that the AO had plates and screws for everything.
This created a certain schism between Maurice and Emile, although Emile later joined the AO and advised them on the design of a set of implants. But it was really the Osteo company that finally did the best work with the plates and screws, as well as the reduction instruments, and really brought Emile Letournel's philosophy to bear.
J. MATTA : When I got back to the US, I tried, of course, to use what I had learned in France. Unfortunately, that was not always possible. For example, we didn't have a Judet table, and had to with what was available. We tried to use ordinary tables, but things really only got better once I had got a proper Judet table.
By the time that we, in the US, were getting interested in acetabular surgery, Letournel had been doing these operations for over 25 years, and it was he that had established virtually all the principles that guide this surgery. Every time we tried to make some slight modifications, we found that that was not the right way, and we almost always went back to what he had taught us. To give you an example: You know that I have worked a lot on the screw fixation of fractures and dislocations of the sacro-iliac joints. He had developed an open technique; I changed it a bit, using an image intensifier and trying to insert the screws percutaneously. He had always recommended removing the screws 5 to 6 months after surgery. For a long time, I did not follow his advice. In the end, I did - and I find that the results are better by doing this.
J. MAST : I haven't so far, but probably will do so from now on.
J. MATTA : There wasn't really a problem. When I came and said that I wanted to treat all the displaced pelvic and acetabular fractures, all my colleagues sent me their cases. I think nobody was interested in this work, except some crazy guys like us. As I said earlier, they thought at first we were crazy. It was when they began to realize that the results were far from poor, and better, in fact, than what they could achieve with simple traction, that things started changing by and by. However, we had by then secured a position, and become "the experts."
J. MATTA : I must have done somewhere around 750 with full documentation; and a grand total of nearly 1000 cases.
J. MAST : My follow-up is not as extensive as Joel's, because I have worked at three different centers; but I must have operated on between 600 and 700 patients.
J. MATTA : I do the cases pretty much myself. I have a fellow who is with me, but I'm not that anxious for him to hold all the instruments and do the job. This is difficult surgery, and most of the patients come to you and want you to do the job, and not somebody else. I shudder to think what would happen if anything went wrong, and the lawyers found out that someone else had been doing the operation.
J. MAST : He was very proud of us. He was like a great father who supports his sons; he was absolutely great. It all worked very well: we had made his name famous in the US, and he supported us wherever he could.
J. MAST : I went to Tampa, Florida, where I was offered a post in the University Hospital. I was able to run a trauma center for several years. There was a large case volume, and it was there that I started specializing in complex injuries and in acetabular surgery.
I did between five and eight cases a month. That way, one can gain experience quickly.
J. MAST : I believe very much in surgery for acetabular fractures. Of course, sometimes the injuries are huge, and associated with other injuries - nerve injuries, or ruptures of muscles and ligaments - that will compromise the result.
J. MAST : Obviously, acetabular surgery is difficult, but it is not impossible. It just needs longer training than other trauma work. If one is lucky enough to be taught by an expert, that is better yet. One saves time, and, above all, one saves the patient's time.
J. MAST : It's not, as a whole, that people are being operated too much, but that they are being operated on by too many different surgeons. Maybe we should have fewer centers that do this surgery, and those centers should have highly trained people.
J. MAST : Are we talking surgeon's age or patient's age?
J. MAST : The patient's age is not that critical; what matters is the premorbid activity level. The life span of the human being is getting ever longer. People want to be active again, they want to have an excellent quality of life. So, 65- or 70-year-old patients will often be better off having their fractures treated aggressively with surgery, with the right principles, as opposed to being treated nonoperatively.
J. MAST : In my opinion, in an active person, the indications remain the same.
J. MATTA : I could comment a little on what the statistics show in that regard. As patients get older, the result of acetabular surgery is not dramatically different: we lose the excellent and good results in the older patient by maybe 10 or 15 per cent. The main problem in the older patient is that the reduction of the fracture is not as good. However, older patients who have perfect reduction of the joint have as high a rate of excellent clinical results as younger patients who have a perfect reduction.
There are various reasons why the quality of reduction should be less good in older patients. One is quality of bone, so there is some difficulty in repositioning of the fragments and in maintaining fixation. Also, there is a higher rate of impaction in the acetabular cartilage.
As the patient gets older, I tend to modify the surgical approach. I would avoid the extended iliofemoral. If I have a 25-year-old patient, I would readily do such an extended approach in order to reduce the joint perfectly. In an older patient, I make a compromise: I do the ilioinguinal, even if that means slightly less perfect reduction. I think in the older patient we can accept post-traumatic hip arthritis much more easily than one can in a younger patient.
There are, however, older patients with a fracture of the posterior wall of the acetabulum with posterior dislocation of the hip, and in those patients the result of conservative treatment is probably going to be terrible. So we have to decide: either to repair the posterior wall, or to do a primary total hip with maybe some grafting of the posterior wall. I think most of the time we can repair the posterior wall accurately.
Another injury in the older patient is a widely displaced transverse fracture. We need to restore the innominate bone in this case, else we will have a non-union or a malunion of the innominate bone that one can't do an arthroplasty for later. Older people may also fall on their side and get an acetabular fracture; and the common pattern is an anterior column fracture or a both-column fracture. If either of these are present and the patient is treated nonoperatively, the bone will heal and the accuracy of the innominate bone will be adequate for doing a good total hip later on, if that needs to be done. What must be borne in mind, though, is that patients that are to be managed in this way will need to be kept at bedrest for a long time, with all the risks that that entails. This is why, if the case is at all suitable, I would offer surgical treatment with internal fixation. This way, they can regain their independence in a short space of time. Nobody would dream of allowing malunion to occur at the proximal end of the femur so as to allow a femoral stem to be inserted later on.
J. MAST : As Joel has pointed out, in many of the fracture patterns the instability is so great that not to do something about fixing the fracture will compromise the stability of a prosthesis and lead to a bad result. So, it's a matter of diagnosis, and assessing the patient as an individual, and applying an individual treatment to each older person.
J. MATTA : Ninety.
J. MAST : I win this one! I have a 93-year-old. He was well and living alone a year after his surgery. He had an anterior wall fracture that was quite extensive, with a medial dislocation of the hip - the femoral head was literally intrapelvic. What was one going to do? Should we have left him in bed and wait for several months?
J. MATTA : If there is intrapelvic dislocation, one must operate as soon as possible, either to do a primary total hip - and I have had to do this less twenty times over a period of 17 years - or to do a reduction and internal fixation. If one leaves the hip to "see how it goes," the functional outcome is bound to be disastrous. There are some patients whom I have operated on, and who have been worse off than with conservative treatment. Those patients are the ones who have had intra-articular infection. Currently, the infection rate is 3 per cent. That is always a disaster, because it limits the possibilities for later reconstructive surgery. In my series, I have had a 15 per cent incidence of poor results. This includes, of course, the 3 per cent infections. There were, of course, patients who had lesions that could not possibly be treated, but also patients whom I should not have operated.
There is a group of maybe 15 per cent of patients with displaced acetabular fractures of whom it is now known that they will do well without surgery. I have operated on patients with a good outcome, who would equally have been all right without an operation. In case of doubt, I would not hesitate to operate, because I do not like to wait for the result of nonoperative treatment and find that the result is bad, in which case the patient doesn't have an option any more. In a 20-year-old, I would not want to run that risk.
J. MAST : Late surgery for malunion and deformity of the pelvis and the acetabulum is one of the most difficult and demanding surgeries, with an even more guarded prognosis as to outcome than in acute fractures.
J. MATTA : I think so. The future of acetabular surgery is not only to improve the surgery but to continue to study the indication also. Maybe it won't change too much from what it is now; but we must analyze our cases very carefully, to get a better handle on patient selection.
J. MAST : I don't think there is too much new that's of real importance. We now probably have better plates, and, at any rate, the plates are now available. We also have better clamps. Otherwise, not very much. Every time I went to Emile Letournel with a new clamp, which I thought was the answer to our problems, he would look at it, and say, "I've had one like that developed. It's sleeping in my box."
There is a French surgical approach that may be helpful, the digastric approach to the hip. This is a Kocher-Langenbeck incision plus the removal of the greater trochanter with the muscles attached in continuity. This gives better exposure of the anterior column, without compromising the stability of the gluteals. The Swiss and Ganz have worked a lot on this.
J. MATTA : I think the main new thing is that many more people operate acetabular fractures. The unfortunate thing is that many people with limited experience are creating new techniques, and getting inferior results because of it.
It's a bit like hip prostheses. Lots and lots of new patterns have been developed over the last 20 years: everybody has an answer to something; but nobody has been able to better the statistics of Charnley's prosthesis. I think we have to learn to live with the fact that very few surgeons can invent something truly novel. Most of us should accept that they need to learn the knowledge that's gone before, and to try to be as good as those who are achieving the excellent results. This may be hard to swallow, but that's how it is.
To give you an example: some surgeons have been worried about the extended iliofemoral approach. So they have tried other things - iliac crest and greater trochanter osteotomy (the Maryland approach), lesser approaches, two simultaneous incisionss, a percutaneous approach. There was perhaps just one thing they had overlooked: the reduction of the fracture. It's that which makes for good results, not the approach. Let's not forget that!
The protocol and techniques developed by Emile Letournel have the merit of being there, of being efficacious, but also of being the best supported by clinical follow-up and clinical data. Everything proposed by Emile Letournel is supported by very advanced statistics. These results have been confirmed by Jeff, by Keith Mayo, by Eric Johnson, by myself, and by many other surgeons.
It would be a shame if the surgery of acetabular fractures were to get overwhelmed by too many unproven novelties. It is one thing to devise a new technique; it is quite another to show that the technique is valid, and superior to the techniques currently available.
J. MAST : That reminds me of a cartoon: Two orthopaedic surgeons are looking at each other across the table at surgery, and the one says to the other, "Wow, what a wonderful technique!" And the other one says, "Yeah, it's modified."
