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Trans-USA Hip Disarticulation/Transpelvic Prostheses Tour:Part Three = Suwanee, Georgia
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Our second visit was to Stephen Schulte's facility in Suwanee, Georgia.
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As noted in prior Corners, I spent two solid weeks this summer criss-crossing the United States with a colleague from England, Steve Taylor. The purpose of our travels was to meet with a convenience sample of US prosthetists who had a special interest in high-level amputations to share information and learn from their collective experience.
The second stop on our whirlwind tour was in a small town outside Atlanta, Georgia to visit Stephen Schulte CP and his staff. Stephen and I have exchanged ideas and discussed difficult cases via telephone or email for many years, so I knew he had a number of active patients in his practice who had hip disarticulation and higher level fittings. He extended that gracious hospitality that the South is noted for, and welcomed us into his busy facility.
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Steve Taylor prefers to use elastic webbing straps to better define key anatomical landmarks, including the ascending ischiopubic ramus.
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Stephen had even contacted for a patient who was due for a replacement prosthesis who was interested in meeting with us. With the patient's permission, Steve Taylor conducted a clinical evaluation of her existing prosthesis and discussed the benefits and limitations of a number of prosthetic options based on his European experience. Since her present prosthesis no longer fitted due to changes in her residual limb contours, he also volunteered to take the plaster impression and rectify the positive model that would be used to form the initial test socket. This would allow Steve to demonstrate some of the details of his technique in more detail, while Stephen Schulte would still make the final decisions about the fitting since the test socket procedure and dynamic alignment trials were scheduled for the following week. With the patient's permission, that is precisely what transpired.
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Steve's impression method works best with an assistant, and is similar to other European techniques for casting transfemoral amputees.
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Steve emphasizes full containment of the ascending ischiopubic ramus, particular for patients with a mature residual limb. His experience parallels mine, which is that this approach seems to improve rotary stability of the residual limb within the socket and to offer the patient better control of the limb in the sagittal plane. It is possible that this contour results in a more energy efficient gait, and that it might account for the improvement in the PCI index that Steve's research has consistently demonstrated when IC is added to the design of an HD socket.
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Modified positive model demonstrating complete encasement of the ascending ischiopubic ramus. The region surrounding the distal pelvis will be reinforced internally with a rigid acrylic lamination while the shaded region will gradually transition to a completely flexible laminated mini-socket. The anterior lace closure will permit the amputee to "cinch" the socket snugly so that most of it can be laminated only with fabric-reinforced flexible silicone elastomer.
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Stephen Schulte later emailed me a note reporting that the test socket fit quite well, and would be suitable for a definitive socket after some selective remolding to improve patient comfort. Most patients who transition to a flexible silicone socket from a more rigid thermoplastic or laminated design report increased comfort, particularly when sitting. Lacing the socket snugly has a "girdle-like" effect that some patients report makes the socket seem less bulky under clothing. Hopefully this young lady will experience similar benefits from her new prosthesis, which will include a micro-hydraulic knee and dynamic response foot.
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Ante: Dynamic test socket proved comfortable, offered excellent control of the prosthesis, and fully contained the medial pelvis to the midline.
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Post: Dynamic test socket proved comfortable, offered excellent control of the prosthesis, and fully contained the medial pelvis to the midline.
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The Ertl Procedure: Part 2 A Challenge to John Michael
One of the Barr Foundation's goals is to educate the public, the patient, the surgeons and the O&P industry as to the advantages and advances of the Ertl procedure.
"It's a social crime that amputees are forced to make do without mdern s... read more
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Re: The Ertl Procedure: Part 2 A Challenge to John Michael
As promised, Tony, I did meet with the Academy folks to carry forward your proposal. As I thought, the upcoming Academy Annual Meeting is packed solid already so there was really no good time or even meeting room available at this late dat... read more
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Re: Re: The Ertl Procedure: Part 2 A Challenge to John Michael
Thank you John for making the attempt to have the Academy schedule a Amputation Surgery Symposium in 3 months, for the next annual meeting in New Orleans Feb 25-29th and for your successfull effort for the Ertls to provide a quest column in... read more
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The Ertl Procedure: From a Surgeon's Perspective Part 1
Drs. Jan and William Ertl have posted an excellent response, that comes from three generations of respected surgeons, as to the benefits and advances of this optional amputation surgical procedure that is for the most part being overlooked ... read more
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Re: The Ertl Procedure: From a Surgeon
Hi Tony- I've been travelling constantly the past few weeks in connection with my consulting business, so today is the first I've had a chance to log on to my Corner. I've just now scanned the Dr. Ertl's comments, and they seem very helpf... read more
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Ertl procedure: Part 6
Pain in an amputee can be mutli-factorial in etiology and potentially can be neurogenic, psychogenic, osteogenic, angiogenic, infectious, and prosthetic in nature. In the series we reported on, several patients with a vascular etiology had ... read more
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Ertl procedure: Part 5
In the November corner, you review the paper that was presented in 1997 at the American Academy of Orthopaedic surgeons meeting in San Francisco. To date, this is the largest review of patients who had undergone an above knee osteomyoplasti... read more
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Ertl procedure: Part 4
Recently, Paul Dougherty, M.D., has published an article reviewing the outcomes of Vietnam War veterans from the Valley Forge Center amputee center in Pennsylvania. His goal was to assess long-term follow-up of patients who required an ampu... read more
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Ertl procedure: Part 3
The socket of choice for an osteomyoplastic amputation is an end-bearing, total surface bearing socket. This allows greater axial loading negating the need for flexion to be built into the socket. A long posterior flap amputee cannot be end... read more
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Ertl procedure: Part 2
The caption under the picture in October’s corner states the primary difference between the Ertl procedure and other techniques is the bone bridge. This is incorrect. The Ertl procedure incorporates soft tissue coverage via a myoplasty. A m... read more
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Ertl procedure: Part 1
Dr. Johann Ertl developed the osteomyoplastic amputation, the Ertl procedure, based on his observations of the regenerative ability of periosteum. The technique combines an osteoplasty and a myoplasty to obtain an optimal residual extremity... read more
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