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The Life and Contributions of Emile Letournel, MD, 1927–1994

Johnson, Eric Egan, MD, FRCSI (Hon)

doi: 10.1097/BOT.0000000000001393
Dedication
Free
SDC

CHS David Geffen School of Medicine University of California Los Angeles, Los Angeles, CA.

Reprints: Eric Egan Johnson, MD, FRCSI (Hon), 76-138 CHS David Geffen School of Medicine University of California Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA 90095 (e-mail: ejohnson@mednet.ucla.edu).

The author reports no conflict of interest.

Support for this manuscript was provided by the Don Yoder Foundation Santa Rosa, California.

Accepted November 06, 2018

Professor Emile Letournel, at the peak of his career, was the leading pelvic and acetabular fracture surgeon in the world. His lifelong contributions to understanding the classification of fracture patterns, creation of the orthopaedic trauma specialty of pelvic and acetabular surgery, and the documentation of the long-term results of operative treatment of acetabular fracture surgery laid the groundwork for this specialty today. Each surgical subspecialty in the history of orthopaedic surgery has a singular individual who dramatically changed the course of the specialty in their lifetime. Through education and technique refinement, the process forges a singular physician who dramatically changed that specialty, enhancing patients' lives, bringing light and understanding to the surgical technique, and changes to the education of that specialty. Emile Letournel was the premier surgeon who changed acetabular fracture surgery worldwide. The importance of his monumental achievements in surgery of the pelvis and acetabulum is unrivaled in modern trauma surgery. His career experience in management of complex acetabular fractures allowed him to define the surgical principles of acetabular and pelvic fracture surgery for his generation and generations to come.

Emile Letournel was born on the island of St. Pierre et Miquelon, Republique Francais, situated southwest of Nova Scotia, on December 4, 1927. He never spoke English while growing up. His family emigrated to St. Pierre from the Manche and Rouen areas near Normandy, France. In his youth in St. Pierre, he would frequently be seen walking to his uncle's house on Saturdays with his red wagon, hammer, and saw to learn carpentry, a skill that served him well in his later life. After finishing secondary school in St. Pierre, he obtained a scholarship to the French Institute in England. Emile left St. Pierre et Miquelon alone at the age of 16 years on July 27, 1944, to cross the Atlantic and attend school in Scotland. At the time of his departure, he did not speak English and had never seen a train or a big city. He was admitted to the Faculty of Medicine of Paris from 1946 to 1960 and became a registrar in 1956. As he developed an interest in orthopaedic surgery, it became necessary for him to apply for a postgraduate position to continue his education. Being from St. Pierre, Emile had no letters of support to compete adequately for an orthopaedic position. A friend suggested he contact Professor Robert Judet, and he did this out of desperation without any hope of obtaining a position. The meeting with Robert Judet was very brief. Professor Judet asked Emile for his letters of recommendation, of which he had none, but Emile indicated his sincere desire to train with him. Professor Judet asked him where he was from and Emile responded “St. Pierre et Miquelon.” Judet looked in his agenda book and offered Emile a 6-month opening the following year. The 6-month position lasted 12 months and Emile subsequently became Judet's assistant.

Judet and Letournel became interested in understanding the complexity of acetabular fractures. On exposing what they believed was a posterior wall fracture and opening the posterior retro-acetabular space, they found no fracture. On re-examination of the radiographs, they became convinced that an anterior wall fracture was present and approached the fracture through an iliofemoral incision. Subsequently, Judet challenged Emile to create a fracture classification system that would encompass all fractures of the acetabulum. His now famous radiographic approach was to line areas of the pelvic bone edges, prominences, and confluent cortical bone with lead. Radiographs were then made using anterior–posterior and 45-degree oblique views of the pelvis to help identify the bony landmarks corresponding to the anterior and posterior anatomical structures of the intact pelvic bone (Figs. 1, 2). He then divided the innominate bone into posterior and anterior columns and walls using the radiographs to define corresponding anterior and posterior simple fracture patterns. This process was expanded to define a second group of more complex associated fracture patterns based on a combination of the original 5 simple fracture types. In this way, the Letournel Classification of Acetabular fractures was born, which remains the world standard today, and is taught at every acetabular fracture course worldwide.1 Emile became head of the Department of Orthopedic Surgery at the Centré Medico Chirurgical de la Port de Choisy in southeast Paris. He remained at the Choisy Hospital until his retirement from academic medicine in October 1993. In addition to his interest in acetabular and pelvic fractures, he performed more than 5000 total hip arthroplasties, developed implant designs and surgical techniques for management of calcaneal fractures, and had extensive expertise in the surgical treatment of bone infection. He developed a scapulo-thoracic arthrodesis technique for patients with fascio-scapulohumeral myopathy. He was the first to implant a knee prosthesis in France in 1968 and he became legendary in managing the most difficult cases. After his death in 1994, the elected officials of St. Pierre et Miquelon passed a resolution naming a street on the island of his birth, “Emile Letournel,” and a school was similarly renamed.

FIGURE 1

FIGURE 1

FIGURE 2

FIGURE 2

The Choisy Medical Center was a nonprofit hospital, and Professor Letournel never charged a surgeon's fee to any patient throughout his entire career for his services. He was admitted to the French Academie de Medicine et Chirurgie in 1981 and organized the first acetabular fracture educational course in Paris in 1984. His Paris courses were famous for the exposure participants received to his wealth of surgical knowledge and skill, his superb hands-on cadaveric dissection, and above all, his boundless enthusiasm and energy. Professor Letournel received the “Legion d'Honneur” from President Francois Mitterrand in 1988.

There are very few instances of a surgeon contributing to the specialty of orthopaedics and trauma surgery in the complete and lifelong manner realized by Emile Letournel. His logical classification of these injuries into elementary and associated fracture types, and the development of 2 of the 3 standard major surgical exposures for acetabular fractures, the Ilioinguinal and the Extended Iliofemoral approaches, solved the exposure issues of acetabular fracture surgery. He created reduction techniques, instruments, and implant designs that are used today in every operating theater in the world. Letournel's original description, diagnosis, classification, and surgical techniques have remained the universal standard of care of acetabular fractures for the past 40+ years. Furthermore, Professor Letournel developed the database for the statistical analysis of both immediate and long-term results of operative management of acetabular fractures.

Letournel published his initial thesis on acetabular fractures in 1961, Fractures du Cotyle. Etude d'une serie de 75 cas,2 which contained the initial description of the classification developed by Emile Letournel and Robert Judet and has achieved worldwide acceptance. He published 3 major textbooks on acetabular surgery, all with coauthor, Robert Judet.3–5 The first of these textbooks was in French, Fractures du Cotyle in 1974,3 the second was in English, Fractures of the Acetabulum in 1981,4 and the third and most comprehensive, Fractures of the Acetabulum was published in 1993,5 with Robert Judet as a posthumous author. These latter 2 textbooks are the primary sources of information on surgery of the acetabulum in the English literature and are considered the “Bibles” of acetabular surgery. His work has resulted in a complete transformation of our understanding and treatment of fractures of the acetabulum.

Professor Letournel's patient list read as a “Who's Who Directory” of French society, yet he would treat the most common citizen with the same respect and care as any high-profile patient. His personality was robust, rugged, and energetic, and he lived life with great eagerness and excitement. His mere presence in the operating theater created movement. As he would scrub for surgery, his intense preparation would bubble forth as he would review in his mind the preoperative plan of surgical approach and internal fixation. His voice was the only voice in the theater. He was the captain of the ship. Professor Emile Letournel unexpectedly died too young after a brief illness on August 16, 1994, at his home in Paris, France.

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REFERENCES

1. Letournel E. Acetabulum fractures: classification and management. Clin Orthop Rel Res 1980;151:81–106.
2. Letournel E. Les fractures du cotyle, etude d'une serie de 75 cas. J de Chirurgie 1961;82:47–87.
3. Le Fractures du Cotyle. Paris, France: Masson et Cie; 1974.
4. Letournel E, Judet R. Fractures of the Acetabulum. Elson RA, eds. Berlin, Heidelberg: Springer-Verlag; 1981.
5. Letournel E, Judet R. Fractures of the Acetabulum. Elson RA, eds. Berlin, Heidelberg: Springer-Verlag; 1993.
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