The Ertl Controversy: Introduction
Just after June's Corner went to press, a flurry of reader comments erupted about the Ertl procedure. To reread these threads, go to www.oandp.com/news and www.oandp.com/news.
My take on this discussion is that there is plenty of heat being generated on this topic but not nearly as much light. As Yogi Berra is credited with saying, "This is déjà vu all over again!" The Ertl controversies have waxed and waned in various decades since the initial flurry of interest in the US following World War II. By the time I first entered the field in the 1970s, interest in the Ertl procedure had largely faded and most surgeons worldwide ignored this technique.
By sheer coincidence, I happened to be practicing in the Chicago area, and encountered a small number of transtibial and transfemoral amputees who demonstrated unusually high distal end bearing capabilities. As has always been my custom, I evaluate the end-bearing potential of every residual limb by having the patient gently push with progressively more force into the palm of my hand, which is cupped around the distal soft tissues. I was quite surprised by the tremendous force a few amputees could comfortably tolerate, and ultimately asked those individuals to "stand on my hand": to bear weight through the end of the residual limb while it was cradled in my palm, with the back of my hand resting on the seat of a padded office chair. These transtibial amputees could all place their full body weight onto the residual limb in this manner; the transfemoral folks could all load my hand at least until my metacarpals hurt! This was substantially more distal end bearing that other amputees I had examined could comfortably tolerate.
I therefore designed the sockets for these patients to emphasize peripheral loading and significant distal end bearing rather than the focused proximal weight bearing that was fashionable in those days of the PTB theory. As anticipated, shifting a significant percentage of the weight bearing forces to the distal end resulted in a very comfortable socket in these cases, and appeared to offer control advantages similar to other end bearing amputations. In other words, these transtibial amputees could be fitted almost as if they had Syme ankle disarticulations; the transfemoral amputees almost as if they had knee disarticulations. Although there was no practical method to quantify the amount of end bearing in those days, I would estimate that all those patients tolerated 50% or greater end bearing long term.
In addition, these residual limbs were well muscled and remained so over the several years that I followed these cases. One transtibial amputee, who initially weighed well over 300 pounds and often did heavy lifting in his work, was able to lose over 100 pounds yet continue to wear the same socket comfortably by simply adding dozens of sock plies. Another noteworthy transfemoral amputee was able to suspend his socket securely by contracting his muscles, and elected to wear a thin pull sock inside his suction socket long term since he did not need full "skin-tight" suction.
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These patients were so functional with their prostheses, compared to other cases with similar-looking residual limbs, that I kept trying to figure out why they had done so well long term. Eventually, one patient remarked that he "had a revision a few years ago by a Dr. Ertl in Hinsdale, Illinois" and the mystery was solved. When I called the other patients who had demonstrated full end bearing capabilities, they too remembered having their amputation performed by "a doctor Ertl", although none apparently realized at the time that the name of the person who performed their surgery might be significant. So, my anecdotal observations support the notion that the surgery performed by the Drs. Ertl in Hinsdale 30 years ago created highly functional residual limbs.
By the late 1970s, the merits of the Ertl procedure were once again being debated, thanks in large part to a book written about Illinois Senator William Barr titled "Whole Again". It recounted his ongoing problems with residual limb pain that were ultimately resolved following revision surgery by the doctors Ertl. With support from Senator Barr and the Illinois P&O Society, State licensure for prosthetists was twice passed by the Illinois legislature, but vetoed by the Governor on both occasions and never enacted into law.
In the 1980s, interest in both licensure for P&O and in the Ertl amputation methods faded, and lay dormant for nearly 20 years. During those decades, I spoke with many orthopedic surgeons around the world, asking about the Ertl approach and their personal experience with such amputations. Some were aware of the concept and a few had used the method for selected transtibial revisions, but none were sufficiently impressed with their personal results to adopt the Ertl approach for primary amputations.
All of these surgeons [from the US, Canada, Europe, and Australia] were concerned with the greater morbidity associated with more complex bony procedures, and most were aware of cases where attempts to make a bony bridge between the fibula and tibia had resulted delayed healing, infection, non-unions, or chronic pain. So, I learned that whatever merits I thought I observed when fitting such patients had to outweigh the added risks of a more complex amputation method. That is a difficult judgment to make when almost all the evidence available is based on subjective personal experience.
Interest in the Ertl approach is once again on the rise, initiated by a lecture Dr. Jan Ertl gave at the Flex-Foot-sponsored International Conference on Advanced Prosthetics in 2000. Click here [www.oandp.com/news] for a brief summary of this talk and related ICAP topics. Earlier this year, the Barr Foundation released two videotapes advocating the Ertl method for various lower limb amputations. Combined with ongoing lectures by Jan Ertl MD and Will Ertl MD, this exposure has rekindled debate about this technique in the rehabilitation community.
My hope is that this decade will not simply repeat the experience of prior eras, dividing the world into "pro" and "con" partisans who base their viewpoints about the Ertl exclusively on personal observation. Such an approach has historically failed to have any lasting effect on how surgery is performed. Some well-conceived prospective studies might produce statistically significant results that would go a long way toward resolving some of the key controversies.
Next month: History and key elements of the transtibial Ertl procedure.
