高端訪問：Joel Matta和Jeffrey Mast心目中的Emile Letournel（下）

河南省洛陽正骨醫院（河南省骨科醫院） 髖中心

河南省骨科微創工程技術中心

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高端訪問

Joel Matta和Jeffrey Mast心目中的Emile Letournel

譯者按：

數年前，我在收集關於Joel Matta老師資料的過程中，不經意間，於一個法國網站搜得此採訪稿。簡單閱讀後封塵至今。隨著臨床經驗的逐漸豐富、對骨盆髖臼興趣的逐漸濃厚、對創傷骨科認識的逐漸加深以及對醫學教育事業的逐漸熱衷，我重新打開塵封已久的這篇稿件，細細品讀之後，決定翻譯出來與大家共享。倍受感動、鼓舞、洗禮之餘，我不免有些遺憾，自責於當時的輕浮。

由於當時閱歷極其有限更兼缺乏敏感性，我沒能做到把相關信息（如網址、採訪者M.O.的履歷、採訪時間地點、是否有其他延伸內容等等）精細化地保存。反過頭來再想瀏覽網站以補全卻難以覓見。

通讀全文加以推斷，採訪應該發生在Joel Matta和Jeffrey Mast師從Emile Letournel學藝歸美的17年之後，也就是1998年。彼時，Emile Letournel已仙逝四載。縱悉全文，沒有絲毫悲傷氣息而洋溢的全是感懷、思索與承繼，他們已然完全走出痛失師尊的感傷，繼承遺志並發揚光大。師生情誼純粹，短短一季的相處，換來的是13載的相伴和一生的緬懷！師者，傳道授業解惑；徒者，不必不如師；情誼者，崇山邃海未及其右。真乃骨之美談矣！

蔡鴻敏（Miles Stone）

河南省洛陽正骨醫院（河南省骨科醫院）髖中心

河南省骨科微創工程技術中心

2017-07-19

TOP

INTERVIEW

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.

Joel Matta和Jeffery Mast受業於Emile Letournel。去年九月，他們在巴黎主持AFOR的骨盆與髖臼骨折手術課程。在此次採訪中，他們述說了如何邂逅宗師Emile Letournel以及在他那裡的所學所得。他們言語之間所流露的是我們所能想像到的絕佳的讚譽之詞！

10

M.O.: Jeffrey - do you remove the screws?

M.O.: Jeffrey，你也取這些釘子嗎？

J. MAST: I haven t so far, but probablywill do so from now on.

J. MAST:到目前為止，我還沒有取過。不過，將來很可能也這樣做。

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M.O.: How long did it take you to secureyour position as acetabular and pelvic surgeons?

M.O.:你們耗費了多長時間而立志成為髖臼和骨盆醫生的？

J. MATTA: There wasn t really a problem.When I came and said that I wanted to treat all the displaced pelvic andacetabular fractures, all my colleagues sent me their cases. I think nobody wasinterested 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 theresults were far from poor, and better, in fact, than what they could achievewith simple traction, that things started changing by and by. However, we hadby then secured a position, and become "the experts."

J. MATTA:這並沒有什麼難的。我來的時候就說過我要做所有移位的骨盆與髖臼骨折的手術，我的同事們把這樣的病例都給了我。我認為，除了像我們這樣一些瘋狂的傢伙之外，沒有人會對這感興趣。就像我前面說的，他們最先想到的是我們瘋了。事實上，直到他們見識到髖臼骨折手術的療效並非差得可憐，而是比他們通過簡單牽引所得到的結果要好得多的時候，情況才逐漸開始改善。然而，那時候，我們已然確立了這個領域的地位，成為了這方面的「專家」。

12

M.O.: How many acetabular surgeries haveyou done?

M.O.:到目前為止，你們一共做了多少例髖臼骨折手術？

J. MATTA: I must have done somewhere around750 with full documentation; and a grand total of nearly 1000 cases.

J. MATTA:有完善資料記錄的有750例左右。粗略地估算，總共大概將近1000例。

J. MAST: My follow-up is not as extensiveas Joel s, because I have worked at three different centers; but I must haveoperated on between 600 and 700 patients.

J. MAST:因為我在三個不同的中心工作，所以病例隨訪做得不像Joel那麼地完善。我的病例數量在600到700之間。

13

M.O.: Do you operate on them yourselves, ordo you let your younger surgeons do this surgery?

M.O.:對於髖臼骨折的手術，你們是親力親為呢，還是讓你們手下的年輕醫生做呢？

J. MATTA: I do the cases pretty muchmyself. I have a fellow who is with me, but I m not that anxious for him tohold all the instruments and do the job. This is difficult surgery, and most ofthe patients come to you and want you to do the job, and not somebody else. Ishudder to think what would happen if anything went wrong, and the lawyersfound out that someone else had been doing the operation.

J. MATTA:這些手術幾乎全都是我做。我手下有一個fellow，但是我並不急於讓他主導手術。這些手術都頗具難度，而且絕大多數病人是專程找你並希望你而非他人做手術的。一想到術中出錯以並且律師發現手術是其他人做的後果，就會令人不寒而慄。

14

M.O.: How did Emile Letournel react afteryou had become recognized in theUnited States?

M.O.:當你們在美國得到認可的時候，Emile Letournel是什麼樣的反應？

J. MAST: He was very proud of us. He waslike a great father who supports his sons; he was absolutely great. It allworked very well: we had made his name famous in theUS, and he supported us wherever hecould.

J. MAST:他很以我們為傲，就像一個非常偉大的父親支持他們的孩子那樣。我們兩下里相得益彰：我們使他名揚全美，而他隨時隨地給我們支持與鼓勵。

15

M.O.: Jeff - what did you do after goinginto practice in Nevada?

M.O.: Jeff，你在赴內華達開展業務之後都做了些什麼？

J. MAST: I went to Tampa,Florida, where I was offered a post in the University Hospital. I was able to run a traumacenter for several years. There was a large case volume, and it was there thatI started specializing in complex injuries and in acetabular surgery.

J. MAST:我在佛羅里達Tampa的大學醫院獲得一個職位，所以去了那裡，並且得以在數年間執掌一個創傷中心。那裡的病例量很大，也正因為此，我開始專長於複雜創傷的處理和髖臼骨折的手術。

I did between five and eight cases a month.That way, one can gain experience quickly.

我一月做5到8台手術。這樣的話，經驗方可以快速提升。

16

M.O.: Has it been your policy to operate onall acetabular fractures? And do you not think that you may have been tooaggressive?

M.O.:對所有髖臼骨折進行手術是你的一貫原則嗎？你難道就不覺得這樣太過於激進了嗎？

J. MAST: I believe very much in surgery foracetabular fractures. Of course, sometimes the injuries are huge, andassociated with other injuries - nerve injuries, or ruptures of muscles andligaments - that will compromise the result.

J. MAST:我對髖臼骨折的手術信念堅定。當然，有時髖臼骨折過於嚴重，而且合併有諸如神經損傷、肌肉肌腱斷裂此類的傷害，這些將會損害最終療效。

17

M.O.: Do you think that acetabular surgeryis difficult, and should be left to a few highly skilled surgeons?

M.O.:你認為髖臼骨折的手術富有難度而必須由少數經驗老練的醫生操刀嗎？

J. MAST: Obviously, acetabular surgery isdifficult, but it is not impossible. It just needs longer training than othertrauma work. If one is lucky enough to be taught by an expert, that is betteryet. One saves time, and, above all, one saves the patient s time.

J. MAST:很顯然，髖臼骨折手術是有難度的，但並非遙不可及。它只是比起其他創傷手術需要更長時間的訓練。如果有誰足夠幸運能受教於一個這方面的專家，那就再好不過了。一個人充分地利用自己的時間學習了並進步了，那麼最終，他就會為病人爭取時間。

18

M.O.: There was a time when acetabularfractures were not operated on; do you not think that, now, they are operatingtoo much?

M.O.:髖臼骨折曾一度進行保守治療。而現在，你不覺得手術做的太多了嗎？

J. MAST: It s not, as a whole, that peopleare being operated too much, but that they are being operated on by too manydifferent surgeons. Maybe we should have fewer centers that do this surgery,and those centers should have highly trained people.

J. MAST:從整體來看，髖臼骨折的手術並非做得太多，而是，這些手術是由太多不同的醫生來做。或許，我們僅僅需要少數聚集有訓練有素的醫生的中心來做就好。

19

M.O.: Given the progress made injoint replacement, do you think that there is an age limit to surgery? Forexample, should one still be doing surgery after fifty?

M.O.:鑒於關節置換領域的進步，你認為髖臼骨折手術有年齡限制嗎？例如，50歲以後還要做手術嗎？

J. MAST: Are we talking surgeon s age orpatient s age?

J. MAST:你說的是醫生還是病人的年齡？

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M.O.: Patient s age, of course.

M.O.:當然是病人的。

J. MAST: The patient s age is not thatcritical; what matters is the premorbid activity level. The life span of thehuman being is getting ever longer. People want to be active again, they wantto have an excellent quality of life. So, 65- or 70-year-old patients willoften be better off having their fractures treated aggressively with surgery,with the right principles, as opposed to being treated nonoperatively.

J. MAST:病人的年齡因素並非至關重要，重要的是傷前的活動水平。人的壽命正在逐漸延長。人們想重新活躍起來，想有非凡的生活質量。所以，與保守治療相比，在正確原則指導下，對65歲或者70歲的髖臼骨折的病人進行手術，他們通常會得到更好的康復。

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M.O.: However, it is well known that themuscles and the cartilage will respond less well at sixty than at twenty.Should these elderly patients not be treated nonoperatively, and given a hipreplacement afterwards?

M.O.:但是，總所周知，60歲與20歲相比，肌肉、軟骨的反應要弱。對這些老年病人不進行保守治療而隨後進行關節置換如何？

J. MAST: In my opinion, in an activeperson, the indications remain the same.

J. MAST:在我看來，對於比較活躍的老年人來說，他們具有同樣的手術適應症。

J. MATTA: I could comment a little on whatthe statistics show in that regard. As patients get older, the result ofacetabular surgery is not dramatically different: we lose the excellent andgood results in the older patient by maybe 10 or 15 per cent. The main problemin 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 arate of excellent clinical results as younger patients who have a perfectreduction.

J. MATTA:關於這個問題，我想就統計學內容進行些許評價。隨著病人的老化，髖臼骨折的手術效果並沒有顯著性的差別：老年病人的優良率的降低程度大概在10%或15%。主要問題在於老年人的骨折複位並不像年輕人的那樣好。然而，有著完美複位的老年人與同樣有著完美複位的年輕人的臨床療效一樣優異。

There are various reasons why the qualityof reduction should be less good in older patients. One is quality of bone, sothere is some difficulty in repositioning of the fragments and in maintainingfixation. Also, there is a higher rate of impaction in the acetabularcartilage.

老年人的骨折複位不良的原因有許多。一個是骨的質量，因此，在骨折的複位和固定的維持方面均有難度。當然，髖臼軟骨壓縮骨折的幾率也相對較高。

As the patient gets older, I tend to modifythe surgical approach. I would avoid the extended iliofemoral. If I have a25-year-old patient, I would readily do such an extended approach in order toreduce the joint perfectly. In an older patient, I make a compromise: I do theilioinguinal, even if that means slightly less perfect reduction. I think inthe older patient we can accept post-traumatic hip arthritis much more easilythan one can in a younger patient.

隨著病人的老齡化，我傾向於改換手術入路。我會避免使用擴大的髂股入路。假如是一個25歲的病人，我自然會做這樣一個擴大入路以獲得關節的完美複位。然而，對於一個老年病人來說，我會進行折中，做一個髂腹股溝入路，即使這樣意味著複位的些許不完美。我以為，老年人相比於年輕人更易於承受髖關節創傷性關節炎。

There are, however, older patients with afracture of the posterior wall of the acetabulum with posterior dislocation ofthe hip, and in those patients the result of conservative treatment is probablygoing to be terrible. So we have to decide: either to repair the posteriorwall, or to do a primary total hip with maybe some grafting of the posteriorwall. I think most of the time we can repair the posterior wall accurately.

但是，有些老年病人罹患髖臼後壁骨摺合並後脫位，對這些病人進行保守治療將可能得到災難性的後果。所以，我們必須做出抉擇：要麼對後壁進行修復，要麼進行全髖關節置換的同時或許還需進行後壁植骨。我認為，我們有絕大多數的機會對後壁進行精確重建。

Another injury in the older patient is awidely displaced transverse fracture. We need to restore the innominate bone inthis case, else we will have a non-union or a malunion of the innominate bonethat one can t do an arthroplasty for later. Older people may also fall ontheir side and get an acetabular fracture; and the common pattern is ananterior column fracture or a both-column fracture. If either of these arepresent and the patient is treated nonoperatively, the bone will heal and theaccuracy of the innominate bone will be adequate for doing a good total hiplater on, if that needs to be done. What must be borne in mind, though, is thatpatients that are to be managed in this way will need to be kept at bedrest fora long time, with all the risks that that entails. This is why, if the case isat all suitable, I would offer surgical treatment with internal fixation. Thisway, they can regain their independence in a short space of time. Nobody woulddream of allowing malunion to occur at the proximal end of the femur so as toallow a femoral stem to be inserted later on.

老年人的另一個損傷是明顯移位的髖臼橫形骨折。對於這樣的病例，我們需要重建無名骨，否則，我們將面臨骨折不癒合或畸形癒合，以至於後期無法進行關節置換。老年人還可能因為摔倒而出現髖臼骨折，常見的類型是前柱或雙柱骨折。假如病人罹患了兩種骨折類型中的一種並且得到有效的保守治療的話，骨折將得以癒合，而且，一旦需要的話，無名骨的對位將足以進行後期的關節置換手術。不過，我們需要謹記的是，這樣一來，病人需要長期卧床並承擔所有相關的風險。這也是一旦病人情況允許我將為之提供內固定手術治療的原因所在。這樣做，病人在較短時間內就可以恢復獨立性。同樣道理，沒有任何醫生可以容忍在股骨近端骨折畸形癒合之後再插入股骨柄的。

J. MAST: As Joel has pointed out, in manyof the fracture patterns the instability is so great that not to do somethingabout fixing the fracture will compromise the stability of a prosthesis andlead to a bad result. So, it s a matter of diagnosis, and assessing the patientas an individual, and applying an individual treatment to each older person.

J. MAST:如Joel剛才所說，對於很多類型的髖臼骨折來說，骨折端極其不穩定，以至於不進行複位固定的話將會影響後期關節假體的穩定性而導致不良結局。所以，這是對每一個老年病人進行診斷、個體化評估和治療方面的問題。

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M.O.: How old was the oldest patient thatyou have operated on?

M.O.:你們所做過的最高齡的病人的年齡是多大？

J. MATTA: Ninety.

J. MATTA: 90歲。

J. MAST: I win this one! I have a93-year-old. He was well and living alone a year after his surgery. He had ananterior wall fracture that was quite extensive, with a medial dislocation ofthe 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. MAST:這一輪我贏了。我做過手術的病人的最高齡是93歲。他術後恢復得很好並且健在了一年。他的髖臼前壁骨折範圍非常大，合併髖關節中心性脫位，也就是所謂的股骨頭脫入真骨盆內。醫生將會為他做點什麼？我們就讓他卧床不起靜等時日無多？

J. MATTA: If there is intrapelvicdislocation, one must operate as soon as possible, either to do a primary totalhip - 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 "seehow it goes," the functional outcome is bound to be disastrous. There aresome patients whom I have operated on, and who have been worse off than withconservative treatment. Those patients are the ones who have hadintra-articular infection. Currently, the infection rate is 3 per cent. That isalways a disaster, because it limits the possibilities for later reconstructivesurgery. In my series, I have had a 15 per cent incidence of poor results. Thisincludes, of course, the 3 per cent infections. There were, of course, patientswho had lesions that could not possibly be treated, but also patients whom Ishould not have operated.

J. MATTA:假如病人有髖關節中心性脫位，那麼需要儘早手術，或者進行初次全髖關節置換（在過去的17年間，有不超過20次我不得不這樣做的經歷），或者進行複位內固定手術。假如有人將患髖置之不理而任由事態發展，那麼髖關節功能的結局一定是災難性的。我也有一些手術病人因為出現關節內感染而療效差於保守治療。目前，感染的幾率是3%。這往往也是個災難，因為它限制了後期重建手術的可能性。在我的病例系列中，差的手術結果佔15%，這當然包括那3%的感染，也包括合併無法修復的嚴重創傷的病人，而且還包括一些我本不應該做手術的病例。

There is a group of maybe 15 per cent ofpatients with displaced acetabular fractures of whom it is now known that theywill 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, Iwould not hesitate to operate, because I do not like to wait for the result ofnonoperative treatment and find that the result is bad, in which case thepatient doesn t have an option any more. In a 20-year-old, I would not want torun that risk.

目前得知，有一組約佔15%比重的髖臼移位骨折的病人，即使不做手術也會恢復得很好。我的一些有著良好手術效果的病人，經非手術治療，他們估計也會平安無事。對一些有疑問的病例，我將會毫不猶豫地進行手術，因為我不情願等到保守治療最後卻發現結果很糟糕，到那時，病人將沒有任何選擇的餘地（只有關節置換了）。對於一個20歲的病人，我不願冒那樣的風險。

J. MAST: Late surgery for malunion anddeformity of the pelvis and the acetabulum is one of the most difficult anddemanding surgeries, with an even more guarded prognosis as to outcome than inacute fractures.

J. MAST:由畸形癒合導致的骨盆髖臼畸形的矯正手術是最為困難和要求最高的手術之一，其治療結局也遠較急性骨折為差。

23

M.O.: Do you think that progress inacetabular surgery will come from better patient selection?

M.O.:你認為良好的病例篩選會促進髖臼外科的進展嗎？

J. MATTA: I think so. The future ofacetabular surgery is not only to improve the surgery but to continue to studythe indication also. Maybe it won t change too much from what it is now; but wemust analyze our cases very carefully, to get a better handle on patientselection.

J. MATTA:我同意這樣的看法。髖臼外科的未來不僅僅局限於手術的進步，也在於對手術適應症的持續不斷的研究。或許，相比於目前狀況來說，並不會有大的改變；但是，我們必須悉心研究我們的病例以更好地處理病例篩選（適應症）方面的問題。

24

M.O.: Jeff - 17 years on, have there beenany significant improvements in acetabular surgery?

M.O.: Jeff，17年來，髖臼外科出現過什麼重大進展嗎？

J. MAST: I don t think there is too muchnew that s of real importance. We now probably have better plates, and, at anyrate, the plates are now available. We also have better clamps. Otherwise, notvery much. Every time I went to Emile Letournel with a new clamp, which Ithought 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."

J. MAST:我不認為有什麼真正意義上的新進展。我們現在很可能有一些更好的鋼板，而且這些鋼板隨時可用。我們也有了一些更好的複位鉗。其他方面就不是太多了。每次當我攜帶一個新式的自認為能解決複位難題的鉗子去見Emile Letournel時，他會瞟上一眼，說：「我也有一個類似的。它正躺在抽屜裡面睡大頭覺呢。」

There is a French surgical approach thatmay be helpful, the digastric approach to the hip. This is a Kocher-Langenbeckincision plus the removal of the greater trochanter with the muscles attachedin continuity. This gives better exposure of the anterior column, withoutcompromising the stability of the gluteals. The Swiss and Ganz have worked alot on this.

有一個法國手術入路——二腹肌截骨入路——或許會有所幫助。這是一個Kocher-Langenbeck切口附加保持肌肉連接的大轉子截骨的顯露方法。它可以更好地顯露髖臼前柱，而不損害臀肌的穩固性。包括Ganz在內的瑞士人在這方面做了大量的工作。

J. MATTA: I think the main new thing isthat many more people operate acetabular fractures. The unfortunate thing isthat many people with limited experience are creating new techniques, andgetting inferior results because of it.

J. MATTA:我認為最主要的新事物是越來越多的醫生在做髖臼骨折手術。然而不幸的是，很多經驗不足的人正熱衷於「創造新技術」，並且因此而蒙受不良治療結果。

It s a bit like hip prostheses. Lots andlots of new patterns have been developed over the last 20 years: everybody hasan answer to something; but nobody has been able to better the statistics ofCharnley s prosthesis. I think we have to learn to live with the fact that veryfew surgeons can invent something truly novel. Most of us should accept thatthey need to learn the knowledge that s gone before, and to try to be as goodas those who are achieving the excellent results. This may be hard to swallow,but that s how it is.

上述情況類似於髖關節假體的演變：在過去的20年間，越來越多的新型假體被研發出來，每個人只對某些個問題給出解決方案，但沒有任何人能超越Charnley假體的統計結果。我認為，我們需要在認清只有極少數醫生才能夠創造出一些真正新奇事物的事實上去學習和生活。我們中的大多數需要接受這樣的事實，也就是，學習現有的知識並努力嘗試與那些臨床水平卓著的醫者看齊。

To give you an example: some surgeons havebeen worried about the extended iliofemoral approach. So they have tried otherthings - iliac crest and greater trochanter osteotomy (the Maryland approach), lesser approaches, twosimultaneous incisions, a percutaneous approach. There was perhaps just onething they had overlooked: the reduction of the fracture. It s that which makesfor good results, not the approach. Let s not forget that!

我來舉個例子：一些醫生為擴大的髂股入路深感憂慮。所以，他們做了其他嘗試，諸如髂嵴和大轉子截骨（也就是Maryland入路），小切口，兩個聯合切口，經皮操作等等。他們可能恰恰忽略了一件事：骨折的複位。這才是取得良好治療效果的關鍵所在，而非手術入路。我們需要謹記於心！

The protocol and techniques developed by EmileLetournel have the merit of being there, of being efficacious, but also ofbeing the best supported by clinical follow-up and clinical data. Everythingproposed by Emile Letournel is supported by very advanced statistics. Theseresults have been confirmed by Jeff, by Keith Mayo, by Eric Johnson, by myself,and by many other surgeons.

Emile Letournel的診療規程和手術技術有著現實意義、有效性，並且被臨床隨訪和有關數據驗證是最為優越的。Emile Letournel所推薦的任何內容都有非常先進的統計學支持。這些結果得到了Jeff，Keith Mayo，Eric Johnson，我，以及其他眾多醫生的驗證。

It would be a shame if the surgery ofacetabular fractures were to get overwhelmed by too many unproven novelties. Itis one thing to devise a new technique; it is quite another to show that thetechnique is valid, and superior to the techniques currently available.

假如髖臼骨折手術被眾多未經驗證的所謂的創新所淹沒的話，那將是一件令人感到羞恥的事情。研發一項新技術是一回事，證明該技術有效且優於現有技術則是另一回事。

J. MAST: That reminds me of a cartoon: Twoorthopaedic surgeons are looking at each other across the table at surgery, andthe one says to the other, "Wow, what a wonderful technique!" And theother one says, "Yeah, it s modified."

J. MAST:這讓我想起一部動畫片：兩個骨科醫師在手術過程中隔台相望，其中一個向另一個說道：「哇，多麼漂亮的技術！」另一個回道：「是的，他是經過改良的。」（意為在未曾完全融會貫通的前提下，有輕率的「創新」者，更有無知的盲從者。還等什麼？乖乖地、踏實地、努力地學起來吧！）

感謝各位老師、同道的支持與厚愛！

讓我們攜手努力，共築美好！

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