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Ertl Background

Literature Review

Comparison of Functional Outcomes Following Bridge Synostosis with Non-Bone-Bridging Transtibial Combat-Related Amputations.

Assessment of Pressures within the Prosthetic Socket of a Person with Osteomyoplastic Amputation During Varied Walking Tasks.

Procedure

Definition

Commuri S, Day J, Dionne CP, Ertl WJJ.

Keeling JJ, Shawen SB, Forsberg JA, Kirk KL, Gwinn DE, Potter BK.

JBJS 2013;95:888-893.

JPO 2010;22(2):127-137.

Ertl Procedure: A Review of the Best Published Literature

Background

Background and Methods

  • Purpose: document amb. forces upon the RL of unilateral TTA who had the Ertl procedure
  • 43 y/o m w/ Rt Ertl amp s/p 10 surg from limb salvage due to pilon fx
  • Used px since '04, px in study since '06
  • Purpose - Evaluate and Compare Functional Outcomes for Two Groups of Unilateral TTAs: Modified Ertl vs. Modified Burgess using PEQ and Short Form-36

  • Walter Reed Medical Center and National Naval Medical Center databases
  • 65 unilateral TTAs: 27 Modified Ertl, 38 Modified Burgess
  • Combat-related injury TTAs between June 2003 and Dec. 2010

Methods

  • Socket fit w/ 12 force sensors

  • Distributed proximal, middle, distal

  • 7 tests to study gait

Results

  • RL length sig. longer (24.9 mm)
  • Delayed Amp (>12 wks s/p injury)

  • No significant benefits
  • Not recommended
  • Proximal sensors: forces were equivalent
  • Middle sensors: ant = greatest P
  • Distal sensors: ant distal = greatest P

  • Wt bearing was transferred proximally
  • End bearing occured throughout testing

Ertl Technique - Osteomyoplasty

Synostosis Formation

Myoplasty

Presented by

1. Osteoperiosteal Flaps

2. Fibula Bone Block

3. Free Grafts - prox tib or iliac crest

  • Flexors sutured to extensors
  • Muscle Mass
  • Increased SA
  • Osteo: Bone
  • Myo: Muscle
  • Plasty: Surgical Formation

  • Invented post WWI in Hungary
  • Standardized 1939 Janos von Ertl

Evan Ross

Amputation Osteoplasty

CO, MSEng

image from Deol et al. Oper Tech Orthop 18:293-298, 2008.

Transtibial Amputees from the Vietnam War: Twenty-Eight Year Follow-Up.

Image from Taylor BC, Poka A 2011

DeCoster TA, Homedan S.

Iowa Ortho Journal 2006;26:54-59.

Background and Methods

Dougherty PJ.

JBJS 2001;83-A(3):383-389.

  • Purpose: series of 5 cases to show indications, techniques, and short-term outcomes of the Ertl procedure

  • Based off reported results from Ertl amp

Background

  • 4 unilateral TTAs, 1 unilateral TFA
  • 4 males, 1 female
  • 29 - 52 y/o (mean = 41.8)
  • s/p osteo, nonunion of tib fx, multi trauma, diabetes

Background and Methods

  • Purpose: long-term f/u pts treated w/ TTA at Valley Forge Army General Hospital during Vietnam War -- questionnaire and Short Form-36

  • 72 unilateral TTA, avg age at time of amp 21.7 y/o

  • Group 1 - amputation w/ no other major injury
  • 19 of 28 had Ertl amp (~68%)
  • Group 2 - amputation w/ at least one other major injury
  • 23 of 44 had Ertl amp (~52%)

Results

  • All pts "good healing" and fxn
  • X-rays 6 months s/p Ertl: sealed canal and syn.
  • All pts utilized end-bearing px

Results

  • No significant diff in questionnaires (PEQ or Short Form-36)
  • Sig diff. psych. support 21% Group 1 vs. 50% Group 2
  • No sig diff in # surg, time to temp or perm px, px wear time between groups
  • No sig. diff. in SF-36 scores w.r.t. Ertl procedure

Conclusion

Advantages

Disadvantages

  • Longer surgery
  • Complications
  • Rate and reliability of bony bridge
  • Benefits = theoretical
  • Distal End Bear
  • Reduce pain: > SA, < P
  • Improves sensation and blood flow
  • Improved ambulation
  • Px wear
  • Decreased atrophy
  • Better proprioception

References

Commuri S, Day J, Dionne CP, Ertl WJJ. Assessment of Pressures within the Prosthetic Socket of a Person with Osteomyoplastic Amputation During Varied Walking Tasks. JPO 2010;22(2):127-137.

Decoster TA, Homedan S. Amputation Osteoplasty. Iowa Orthopaedic Journal 2006;26:54-59.

Deol PS, Lee TH, Berlet GC. Evolution and Modification of the Ertl Osteomyoplastic Transtibial Amputation. Oper Tech Orthop 2008;18:293-298.

Dionne CR, Ertl WJJ, Day, JD. Rehabilitation for Those with Transtibial Osteomyoplastic Amputation. JPO 2009:21(1);64-69.

Dougherty PJ. Transtibial Amputees from the Vietnam War: Twenty-Eight Year Follow-Up. JBJS 2001;83-A(3):383-389. Ertl JW, Ertl JP, Ertl WJ, Stokosa J.

Keeling JJ, Shawen SB, Forsberg JA, Kirk KL, Gwinn DE, Potter BK. Comparison of Functional Outcomes Following Bridge Synostosis with Non-Bone-Bridging Transtibial Combat-Related Amputations. JBJS 2013;95:888-893.

Taylor BC, Poka A. Osteomyoplastic Transtibial Amputation: Technique and Tips. J Orthop Surg Res. 2011; 6: 13.

The Ertl Osteomyoplastic Transtibial Amputation Reconstruction: Description of Technique and Long Term Results.http://www.ertlreconstruction.com/documents/108.html

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