Ertl Procedure: Giving Amputees a New Beginning

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"Amputation should not be looked at as a failure. It should be looked at as a reconstructive procedure that will provide the patient with a functional residual limb that can be fitted well with a prosthesis and improve the patient's quality of life. I get frustrated with the idea that amputation is just amputationó'cut off the leg and get on with it.'"óWilliam J.J. Ertl, MD

William J.J. Ertl, MD
William J.J. Ertl, MD

Jan P. Ertl, MD
Jan P. Ertl, MD

William J.J., MD, and Jan P. Ertl, MD, are carrying on the pioneering work of their grandfather, Janos von Ertl, MD, and his sons, John Ertl, MD, and William Ertl, MD (deceased).

Although von Ertl's work in Hungary treating World War I casualties and others involved several aspects of reconstructive plastic surgery, in the United States probably the best-known aspect of his legacy is the Ertl amputation procedure.

Von Ertl and his family, including his two sons, moved to the United States in 1951 after he was offered a position in Illinois at the University of Chicago. Carrying on their grandfather's work, William Ertl is an assistant professor at the University of Oklahoma, Department of Orthopaedic Surgery, and Jan Ertl is a clinical assistant professor at the University of California, Davis. Von Ertl's son and Jan Ertl's father, John W. Ertl, MD, is professor emeritus at Loyola University/Stritch School of Medicine, Chicago, and a retired surgeon who promotes bioregenerative aspects of surgery.

Anecdotal evidence abounds that the Ertl procedure benefits amputees, generally enabling them to have more function and a higher quality of life than do traditional surgical techniques. However, as in other aspects of orthopedic surgery, as well as in the prosthetic field, outcomes-based research and quantifiable data have been lacking.

That is now changing.

A study funded by the Department of Veterans Affairs (VA) at the University of Oklahoma (OU) and the Oklahoma City VA Medical Center is comparing, at several levels, the outcomes of Ertl and non-Ertl amputations. "This is a study that people have been looking for and have been hoping would be done," says William Ertl. "If you talk to various surgeons or look in the literature, there is no prospective randomized study comparing one amputation technique to another, so hopefully this study will give us a lot of information."

William Ertl designed many of the clinical and surgical protocols for the research project, while Jonelle E. Wright, PhD, RN, an associate professor of research at OU, is the principal investigator and developed the physiologic protocols.

The study, which began in January 2006, is expected to be completed by December 2008. "We're getting early data back, and we're going to start analyzing early results by this spring or summer," says Ertl.

Designed to compare the effects of different lower-limb amputation surgical procedures on leg bone integrity and rehabilitation outcomes, the study will research outcomes in bone and muscle integrity, inflammatory response, weight bearing, residual-limb perfusion, activity level, prosthesis mobility and functional capacity, and quality of life measures within two weeks and again at six weeks and six months post-amputation surgery. The study will explore secondary outcomes: intra-operative tourniquet time, medullary perfusion, and blood loss measures during surgery. It will also look at post-operative healing and infections during a six-month follow-up and the cost of treatment at six months.

Besides transfemoral and transtibial surgery patients, William Ertl also has seen good results with the Ertl procedure on transhumeral amputees. "There's no objective data yet, but in early limb rehab, my patients seem to be able to get into a myoelectric prosthesis faster, easier, and with more control than with traditional surgery. This application of the Ertl procedure uses the same principles of bony closure, osteoperiosteal flaps, and local stabilization of the soft tissues."

To utilize the end-bearing capabilities of the limb and the large surface area, the Ertls recommend an end-bearing, maximal surface-bearing socket.

Ertl procedure amputees Dan Sheret (top), Russ Thomas (above and above right), and William Malmskog (right) are continuing their active lifestyles.

William Ertl emphasizes the need for careful patient evaluation before committing a patient to amputation. A vascular study reveals potential for wound healing. Other diagnostic tools have identified patients who could benefit from vascular bypass surgery and don't require amputation. Ertl has identified some patients whose potential for successful vascular bypass was missed by earlier medical examinations. "I have identified patients who needed an aortofemoral bypass. The vascular disease may be very proximal but affecting their limb very distally." Ertl notes that the majority of diabetic and vascular disease patients have diffuse dysvacularity that cannot be bypassed. "However, some patients have a lesion that can be treated by bypass, stenting, or angioplasty of the vessel."

Both William and Jan Ertl are strong proponents of a team rehabilitation approach, including physical therapists, prosthetists and others, with the patient at the center. They point out, too, that giving prosthetists a better limb to fit can make the prosthetist's job much easier, as well as making patients much happier and more functional with their prostheses.

Passionate About Benefits

Both are passionate about the benefits of the procedure. Jan Ertl has traveled the world, including developing countries, performing surgeries and teaching other physicians how to perform the procedure.

Anthony "Tony" Barr, president of the Barr Foundation, Boca Raton, Florida, which assists amputees with prosthetic care who otherwise could not afford it, is also passionate about the Ertl procedure, and has helped launch an informative website: www.ertlreconstruction.com . More than 30 surgeons are now listed on the site as routinely performing Ertl amputations.

Both Barr and his father, William G. Barr, suffered amputations that were greatly helped by Ertl reconstructive surgery, explains Barr. Barr's father suffered excruciating pain until he underwent the Ertl procedure in 1978, which freed him from pain and enabled him to lead an active life until his death in 1987.

"We need to change the attitudes of the general public, physicians, and patients," says Jan Ertl. "They need to regard amputation not as a failure, but as a new beginning. We want to provide a limb that will give them the best function possible for a healthier life and the ability to pursue their goals, whatever they may be."

The Ertl procedure is explained in detail in an article by John W. Ertl, William Ertl, and Jan Ertl in the Orthopedic Technology Review, September/October 2006.
Miki Fairley is a contributing editor for
The O&P EDGE and a freelance writer based in southwest Colorado. She can be contacted via e-mail at†miki@opedge.com

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