Emile Letournel

The treatment of acetabular fractures through the ilioinguinal approach.

The ilioinguinal approach was developed in 1965 as an anterior approach to the pelvis and acetabulum. Before this date, the Smith-Petersen incision or a modification of it called the iliofemoral approach provided the only access to the upper part of the anterior column of the acetabulum. In the current study of 195 acetabular fractures, the ilioinguinal approach was used alone in 178 cases (90%) and in combination with the Kocker-Langenbeck as a double incision in 17 cases (10%). There were 39 simple and 156 complex associated fracture patterns. There were two large groups of associated fractures: anterior column posterior hemitransverse (39 fractures) and both column fractures (98 cases). Of these fracture patterns stabilized through the ilioinguinal approach, there was a rate of perfect reduction of 85% and 73%, respectively. Of 70 fractures involving the anterior column, anterior wall, and anterior column posterior hemitransverse, there were 61 perfect reductions (87%). The complication rate was extremely low, without any evidence of external iliac fossa heterotopic ossification. The ilioinguinal approach provides total and complete access to the anterior column from the sacroiliac joint to the pubic symphysis. An experienced acetabular surgeon may achieve excellent results even with complex fracture patterns.

Open treatment of acute calcaneal fractures.

Displaced intraarticular fractures of the calcaneus require operative intervention to restore the anatomy of the bone, which in turn is the requirement for recovery of subtalar joint mobility. Surgery through a lateral incision, without opening the sheath of the peroneal tendons, and the use of lag screws and a “Y-plate,” must restore not only the respective positions of the “three poles” of the calcaneus but also the respective orientations of the articular surfaces. Stable internal fixation allows early active and passive mobilization of the subtalar and ankle joints. If this is not achieved, the functional outcome will be poor.

Delayed reconstruction of acetabular fractures 21-120 days following injury.

A retrospective review was performed of 207 patients treated by delayed reconstruction of acetabular fracture between 21 and 120 days following injury. Nineteen patients were lost to followup. One hundred eighty seven patients had 188 fractures classified as follows; 35 posterior wall, 9 posterior column, 5 anterior wall, 4 anterior column, 13 transverse, 49 transverse/posterior wall, 21 T shape, 8 posterior column/posterior wall, 8 anterior column posterior hemitransverse, and 34 both column fractures. The average preoperative delay was 43 days. Followup averaged 6.5 years (range, 9 months-30 years). Overall good to excellent results were achieved in 65% of patients, fair in 9%, and poor in 26%. Good to excellent results by fracture type were; posterior wall (51%), posterior column (89%), anterior wall (60%), anterior column (100%), transverse (69%), transverse/posterior wall (59%), T shape (62%), posterior column/posterior wall (88%), anterior column/posterior hemitransverse (75%), and both column (72%). Heterotopic ossification developed in 49 of 168 patients without prophylactic treatment, in 6 of 12 treated prophylactically with diphosphonate, and in 2 of 27 receiving prophylactic indomethacin therapy. There were 20 postoperative sciatic nerve palsies, 3 immediate and 5 delayed infections, 5 cases of pulmonary embolism, and 26 cases of avascular necrosis. Delayed management of acetabular fractures increases the difficulty of operative treatment and may result in a significant reduction in good to excellent results. Simple anterior or posterior wall fractures, associated transverse + posterior wall fractures, and T shape fractures have an increased risk of failure when treated within this time period.

Fractures of the Acetabulum A Study of a Series of 75 Cases

Emile Letournel was born on December 4, 1927 in the St. Pierre et Miquelon islands, a French possession in the mouth of the Gulf of St. Lawrence. After his preliminary schooling, he was awarded a scholarship to the French Institute in London. He left his home and family at the age of sixteen, travelling to England on a troop ship in 1944. At the end of the war he was able to go to Paris where he completed his education, receiving his medical degree from the Paris Faculty. Letournel became a protege of Professor Robert Judet at the Hospital Raymond Poincare and this association became the most important factor in the development of his professional life. Because of Judets interest in the management of pelvic fractures, Letournel focused his attention on this problem also. As a result of his work in this area, major advances have occurred in the surgical techniques used to reduce and fix difficult fractures of the acetabulum. The paper chosen as a classic article is based on his thesis which was completed in 1960. It represents one of the first steps in using the diagnostic radiographs to classify and define the type of acetabular fracture and to determine the proper surgical approach to be used in reducing and fixing the fracture. Letournel continued to expand on this early work and through his numerous lectures, publications and books has become the major authority on the difficult problems posed by fractures of the acetabulum. He is presently a Professor of Surgery of the Hospitals of Paris and has a private practice in Courbevoie, France.

Surgical revision of malreduced acetabular fractures.

Early failure of open reduction and internal fixation of fractures of the acetabulum presents a treatment challenge even more difficult than that of the primary injury. This study evaluates the success of reoperation for 64 patients with surgical malreduction or secondary loss of reduction. In 36 patients (56%) the reconstruction achieved was within 2 mm of being anatomic as judged by plain radiography. Overall, 27 patients (42%) had excellent or good outcomes at an average 4.2 year followup. Delay to reoperation appeared to have an adverse affect on the result of surgery. At followup 57% of patients reoperated on within 3 weeks of injury were rated good or excellent. This figure dropped to 29% when the delay exceeded 12 weeks. These data do not compare favorably with results obtained in large series of singly operated fractures; however, they do indicate that it is possible to salvage a significant number of failed open reductions by reoperation.

Mechanics of Acetabular Fractures

Fractures of the acetabulum occur as a result of force acting between this part and the head of the femur, the last link of a chain of transmission from the greater trochanter, the knee or the foot. Alternatively, a blow on the back of the pelvis can have the same effect.

Early Complications of Operative Treatment Within Three Weeks of Injury

Four of the 569 patients with fractures of the acetabulum operated upon within 21 days after the accident developed pseudarthroses (0.7%). These occurred in two both-column fractures and in two associated transverse and posterior wall fractures. All four cases had a slightly imperfect reduction.

Radiology of the Normal Acetabulum

Since the first edition of this book, the use of CT scanning has become widespread and is now almost routine. At present only a few centres have access to 3-D CT reconstruction; when this is available everywhere, the understanding of acetabular fractures will be much easier. With good 3-D analysis, one just needs to know the classification to be able to link the case being treated to one of the fracture types described. It made us very happy to see that the 3-D images fully confirm the descriptions we gave of the different types of acetabular fracture.

Surgical Approaches to the Acetabulum

During so many years of operative management of acetabular fractures, we have pursued a dream of finding a method of approach which would permit us to cope with all problems of reduction, whatever type of fracture was involved. This approach would have to enable us to reach at the same time, and with the same degree of ease, both columns of the acetabulum and also to allow access to the inside of the pelvis. The latter is indispensable in the control of some fracture fragments, and sometimes necessary in order to explore nerves and vessels included in the fracture line or lacerated thereby.

Operative Treatment of Specific Types of Fracture

Table 22.1 shows the types of internal fixation used in 560 cases (for various reasons, nine cases did not need fixation) operated on within 21 days after injury.