The Ertl Controversy: Discussion
Prior articles have looked at the best of the limited body of written information available regarding the Ertl method of lower limb amputation, starting with the historical accounts and post-war experience of the 1960s and 70s. The only peer-reviewed article that I am aware of, by Dougherty, has been briefly summarized. And, Drs. Jan and Will Ertl were kind enough to contribute a Guest Article last month clarifying their viewpoint on a number of important details.
This article continues the focus on sorting out what we know with some assurance from what is more speculative. Next month's Corner will propose some thoughts on what can be done to bring more science into this debate.
The Facts, Continued:
As has always been the case historically, many contradictory opinions regarding the Ertl procedure and its advantages or limitations have been expressed, based on very few hard facts. From my perspective, the following statements seem to be defensible from the available evidence:
4] There is little independent objective evidence supporting the claims surrounding the Ertl amputation.
It is quite disconcerting to find that, after more than a century of advocacy, there is only one peer-reviewed article on the Ertl technique, and it is very limited in scope and did not identify any marked advantage among the outcomes evaluated. This is a very serious shortcoming that the proponents need to address much more effectively. Otherwise, critical observers will be justified in dismissing the hypothetical benefits as having no more credibility than those ascribed to untested herbal remedies. If my instincts are right, and there is genuine and lasting value here, it will be tragedy to see interest fade as the Ertl is dismissed once more as "just a passing fad".
I understand full well how difficult it is to conduct effective scientific research on clinical matters, and realize that it takes years to amass sufficient evidence to be able to draw really "bullet-proof" conclusions. But, there is no excuse for failing to start the arduous task. The longer the proponents avoid rising to this challenge, the more it will appear that the Ertl method will not withstand serious scrutiny.
5] Dysvascularity, wound contamination, and pre-existing infection significantly increase the risks associated with more complex procedures.
The reluctance of many surgeons to attempt an Ertl in the presence of contaminated wounds from the battlefield or traumatic causes is realistic, and does not justify some of the shrill criticisms leveled by enthusiastic supporters of the method. Furthermore, the case for using the Ertl method for dysvascular cases is much shakier than when there is a good blood supply. Even the results from the Ertl's reported series showed that the majority of the poor outcomes were from this population. It is highly unlikely that surgeons less experienced with the technique will have superior results!
Implying that the Ertl is the only effective alternative for all lower limb amputees, and "brow-beating" surgeons who choose a different technique, is coercive but not persuasive. A far more successful strategy would be to expend the same energy on clearly and objectively measuring the tangible benefits for the strongest candidates: transtibial amputation candidates who are not dysvascular. Once the Ertl has been shown conclusively to benefit this population, then controlled studies with less ideal candidates can be undertaken, and those results measured. In other words, the case for the Ertl method can be built up systematically.
It may well be that the evidence will ultimately support the viewpoint that "the Ertl is the best". At this time, we simply cannot determine if that is correct or not, so the decision to use or not use this method winds up being an individual decision.
6] There is growing sentiment that, to obtain maximum advantage from the Ertl method, specific prosthetic management protocols and socket design principles need to be followed.
For me, this is probably the least understood aspect of the "Ertl results" and it could potentially be one of the major contributors to the positive results reported by patients and prosthetists. Jan Stokosa CP undoubtedly has the largest personal experience fitting post-Ertl amputees, and he has developed a comprehensive and systematic protocol that gradually increases distal end weight bearing to simultaneously protect the bone bridge while encouraging solid consolidation. Jan is a very astute observer, and his attention to even the smallest details is legendary among his peers. How much this meticulous prosthetic technique contributes to the positive results attributed to the "Ertl Procedure" has never been investigated. The Ertl Reconstruction site has a detailed summary of Jan's protocol posted at www.ertlreconstruction.com/Programs%20and%20Papers.htm .
This too is fertile ground for study. For example, post-Ertl amputees could be randomized into two treatment groups who received different socket designs: one that emphasized progressive end bearing and one that did not. If their overall functional performance was measurably different after one year [for example], we would then begin to understand the importance of this aspect of the socket design. In another experiment, patients with meticulous, non-Ertl surgery could be randomized into the same two socket groups. If the results showed that, even with an end bearing socket design they were not as functional as those with a consolidated bone bridge, then we would have some concrete evidence of the value of that part of the surgical procedure.
Next month: Where do we go from here?
