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Osteomyoplastic Transtibial Amputation: the Ertl Technique 2016;24: the American Academy of Orthopaedic Surgeons

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Osteomyoplastic Transtibial Amputation: the Ertl Technique 2016;24: the American Academy of Orthopaedic Surgeons Review Article Osteomyoplastic Transtibial Amputation: The Ertl Technique Abstract Benjamin C. Taylor, MD Amputation may be required for management of lower extremity Attila Poka, MD trauma and medical conditions, such as neoplasm, infection, and vascular compromise. The Ertl technique, an osteomyoplastic 05/12/2020 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3XGJiJSDa6kIqumJxkk0xkUYASC1z6fwGnZioo2oIf3GVIHpTPTSEuw== by https://journals.lww.com/jaaos from Downloaded procedure for transtibial amputation, can be used to create a highly Downloaded functional residual limb. Creation of a tibiofibular bone bridge provides a stable, broad tibiofibular articulation that may be capable of some from distal weight bearing. Several different modified techniques and https://journals.lww.com/jaaos fibular bridge fixation methods have been used; however, no current evidence exists regarding comparison of the different techniques. Additional research is needed to elucidate the optimal patient population, technique, and postoperative protocol for the Ertl by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3XGJiJSDa6kIqumJxkk0xkUYASC1z6fwGnZioo2oIf3GVIHpTPTSEuw== osteomyoplastic transtibial amputation technique. espite considerable advances in the use of a vascularized fibular strut, Dlimb salvage and revasculariza- the presence or lack of an osteoperi- tion techniques, amputation is still osteal sleeve, and the use of various performed because the creation of a fixation constructs and postoperative pain-free, functional residual extrem- regimens; these variations are major ity may not be possible owing to the confounding influences on patient clinical scenario or the salvage tech- outcomes and warrant further nique used.1 Advances in patient care investigation. and prosthetic design have increased From the Department of Orthopaedic Surgery, Grant Medical Center, patient function after amputation, Columbus, OH. and a large number of patients can History and Development return to many, if not all, of their Dr. Taylor or an immediate family 2 4 member has received royalties from preinjury activities. The impact of a As early as 1920, Janos Ertl recog- Zimmer Biomet; is a member of a lower-extremity amputation on nized that patients with transtibial speakers’ bureau or has made paid patients should not be minimized, amputations were having substantial presentations on behalf of Zimmer however. These patients will have Biomet and Depuy Synthes; and functional difficulties and were using serves as a paid consultant to Zimmer continued dysfunction throughout the amputated stump as a passive Biomet. Dr. Poka or an immediate their lifetime.3 Although somewhat attachment for a prosthetic. Ertl4 family member is a member of a controversial, the Ertl technique for believed that traditional transtibial on speakers’ bureau or has made paid 05/12/2020 presentations on behalf of Stryker and osteomyoplastic amputation has been amputation provided a nonphysiologic serves as a paid consultant to Zimmer proposed as a reconstructive method environment that was worsened by the Biomet. that can further improve the out- often discordant motions of the tibia J Am Acad Orthop Surg 2016;24: comes of transtibial amputation. and fibula after loss of the distal 259-265 Much of the current evidence articulations. In the initial description http://dx.doi.org/10.5435/ regarding the Ertl technique is con- of the Ertl technique, the osteoplasty JAAOS-D-15-00026 flicting, and the indications for this was performed with elevation of an procedure remain somewhat debated. osteoperiosteal sleeve from the distal Copyright 2016 by the American Academy of Orthopaedic Surgeons. Many different variations of the tech- tibia and fibula that was sutured at the nique have been described, including end of these two bones to seal the April 2016, Vol 24, No 4 259 Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Osteomyoplastic Transtibial Amputation: The Ertl Technique 11-13 Figure 1 (Arthrex). To date, no clinical studies have compared the use of various fixation constructs for the synostosis in transtibial amputation. Indications and Contraindications The osteoplastic component of the Ertl technique adds surgical time to the procedure; however, we consider this component to be indicated for active patients who are able to regain mobility postoperatively. Patients who have had a traditional transtibial amputation may also benefit from a A, AP radiograph of the lower extremity obtained immediately postoperatively revision surgery with the Ertl tech- demonstrating an osteomyoplastic transtibial amputation. Note the placement of nique to treat symptomatic instability an autogenous fibular strut across the distal aspect of the amputated tibia and of the residual tibia and fibula, also fibula. AP (B) and lateral (C) radiographs of the extremity obtained 36 months “ ” postoperatively. known as chopsticking. Contraindications for the procedure include inadequate distal margins medullary canal and form a solid bony attention to appropriate, tension-free from an infection or neoplasm because synostosis at the distal amputation skin closure is crucial to minimize harvest of the fibula and/or periosteal stump.4 wound healing complications. sleeve requires a longer healthy limb The bone bridging (ie, osteoplastic) Later investigation on the effect of than that typically required for a tra- component remains the most recog- sealing the medullary canal revealed ditional transtibial amputation. In nizable aspect of the Ertl technique, that this closure led to a prompt early reports, the procedure was con- but descriptions of the procedure recovery of the intramedullary pressure traindicated in patients with diabetes focus equally on the evaluation and of the tibia, which was shown in several mellitus or vascular insufficiency; treatment of the soft tissues. Individ- angiographic evaluations to improve however, larger case series that ual ligation of each component of the medullary blood flow such that it included these patients revealed that neurovascular bundles is required to was comparable to that of uninjured they can undergo the procedure suc- recreate a residual limb that is as limbs.10 In addition, this closure has cessfully but may not achieve the same physiologically similar to the native been shown to increase blood flow to level of function as do patients without 9,12,14 limb as possible, with transection of the residual limb, which may have these comorbidities. all nerves done while under tension to important implications in healing.7,10 allow for proximal retraction. A The Ertl technique has continued to ’ meticulous myoplasty also is essential evolve, with the most notable alteration Authors Preferred to create a well-balanced, stable limb of the original procedure described by Technique with minimal muscle-related com- Pinto and Harris.8 Theyreportedona plaints; in fact, the myoplastic com- series of patients who underwent the Preoperative Evaluation ponent of the procedure may be just procedure with the addition of an Multimodal evaluation and treat- as important as the bony aspects. The autogenous fibular strut placed across ment is often critical for patients who myoplasty or myodesis recreates the the distal aspect of the remaining tibia are candidates for the Ertl technique, tension of muscles of normal length, and fibula (Figure 1). Pinto and Har- and the involvement of a psychologist, increases and stabilizes the surface area ris8 used heavy, nonabsorbable suture physical therapist, social worker, available for prosthetic fitting, normal- for fixation of the synostosis, but prosthetist, vascular surgeon, and izes muscle function as viewed on elec- several different fixation methods have family physician may be necessary. tromyographic testing, and improves since been described, including small Preoperative workup may also include both the arterial and venous circulation fragment screws, headless com- laboratory or vascular perfusion stud- of the residual stump.5-9 Careful pression screws, and the TightRope ies; wound healing potential can be 260 Journal of the American Academy of Orthopaedic Surgeons Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Benjamin C. Taylor, MD, and Attila Poka, MD predicted with an ankle-brachial procedure. We recommend the use of and division of the neurovascular index .0.5, transcutaneous oxygen general anesthesia and a well-padded bundle in the lateral compartment. levels .20 mm Hg, a serum albumin tourniquet on the ipsilateral thigh. The deep posterior compartment is level .2.5g/dL,andanabsolute A long posterior flap is created unless transected at the level of the tibial cut, lymphocyte count .1,500/mL.15 previous scars, wounds, or other fac- and the superficial posterior com- Finally, the surgeon should have an tors require an alteration of the flap partment is then sharply beveled honest and candid discussion with the design. In these cases, vascular-based from the tibial cut to the level of the patient and his or her family regarding skew flaps, fish mouth flaps, long skin incision for the posterior flap. the procedure, its inherent limitations, medial flaps, or sagittal flaps may be The posterior neurovascular bundle and the inability to eliminate all pain; used. To create a long posterior flap, the is identified and carefully separated, the value of fostering realistic patient
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