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The Ertl Controversy: Long Term Follow-up of Transtibial Amputations from Valley Forge Army General Hospital

[Grateful appreciation is extended to Jan Stokosa CP who kindly provided a bibliography and reprints of most of the articles discussed in this series of commentaries. To read the entire series and to follow all the commentary threads on this topic, click on the June 2003 and subsequent Archives.]

Paul J. Dougherty is a surgeon and Lieutenant Colonel in the United States Army Medical Corps with a strong interest in amputation surgery and prosthetic rehabilitation. I had the opportunity to chat with him at Walter Reed last year, following a meeting to help the military ramp up for the anticipated casualties from the looming war in the Middle East. Last year, Dr. Dougherty published the results of a follow-up study of the majority of those veterans who received Ertl amputations under the direction of Phillip Deffer MD and associates [as discussed in last month's Corner].

His article in the Journal of Bone and Joint Surgery [Dougherty PJ, Transtibial amputees from the Vietnam war, JBJS 83A[3]:383-389, March 2001] is one of very few published follow-up studies of Americans who have sustained a battlefield amputation. All surviving unilateral transtibial amputees who underwent amputation at that hospital during the post-Vietnam era were contacted and invited to participate in a two-part questionnaire review. A total of 72 individuals agreed to participate. Their average age at the time of amputation was 21.7 years; at follow-up, the average age was 48.4 years.

The respondents were stratified into two groups. Group One include the 28 individuals with only the transtibial amputation, while Group Two included the 44 people who had at least one additional major injury in addition to the amputation. "Major injuries" were defined as long bone fractures, burns involving more than 20% of the body surface, and/or a face or head wound. At the time of the study, both groups were wearing their prostheses an average of 16 hours daily, virtually all were employed, more than 90% had married, and more than 80% had children. So, overall this was a group of very active and successful prosthetic wearers.

They had worn an average of 8 definitive prostheses over the 30 years since the initial amputation. All had received early prosthetic fittings with plaster sockets and simple pylons to encourage weight bearing as soon as possible after the final amputation. One major difference between the two groups on the survey instrument was that half of those with poly-trauma had received psychological counseling since the amputation while 21% of those with a transtibial amputation only reported receiving counseling. This difference was statistically significant.

Both groups also took the SF-36 test, a well-accepted and validated health survey that measures such factors as physical function, bodily pain, general health, vitality, social function, and mental health. The poly-trauma group scored substantially lower than the TTA-only group on all SF-36 subscales, indicating lower physical function, more pain, poorer health, and so on. These differences were all statistically significant.

Dougherty then performed a separate analysis that divided the subjects into two new groups: one with all Ertl amputations, and the other with no Ertl amputations. Given Deffer's enthusiasm for the Ertl osteomyoplasty and the anecdotal advantages expressed by many of the amputees shortly after the surgery, the hypothesis was that those individuals with the Ertl would have done better long term than those with a 'conventional' amputation.

The results were quite clear: there were no significant differences between the Ertl group and the non-Ertl group for any of the SF-36 scores. These data suggest that, whatever the benefits of the Ertl surgery were for these veterans, they were not of sufficient magnitude to make a significant difference on any of the factors measured by the SF-36. The most significant event in these veterans' medical care was not the amputation technique but rather whether or not they had additional major injuries beyond the transtibial amputation. Those with poly-trauma were less functional in all measured scales and needed more psychological care.

This study is noteworthy because it was well crafted and conducted and yet failed to demonstrate any of the expected advantages to the Ertl method. That fact should make all of us who believe that the Ertl method is optimal scratch out heads and try to understand what these results show.