Modified Ertl Procedure for Terminal Overgrowth...

This paper was presented at the 2002 ACPOC Annual Meeting, April 10-13, Toronto, Ontario, Canada:

MODIFIED ERTL PROCEDURE FOR TERMINAL OVERGROWTH IN CHILDHOOD BELOW-KNEE LIMB DEFICIENCIES: COMPARISON WITH EXCISION AND PERIOSTEAL CLOSURE

Philip E. Gates, MD; J. Scott Bicknell, MD; Sheryl Ostendorff, RN

Shriners Hospital for Children, Shreveport, LA

Purpose:

Terminal overgrowth in childhood through-bone limb deficiencies is a common problem noted with growth. There have been numerous attempts at devising a method of residual limb revision to decrease repeated revisions. J.Ertl first documented in 1949 a distal tibiofibular synostosis in adults with transtibial amputations. Recently documented use of a modified Ertl procedure in childhood terminal overgrowth has noted questionable success. Our experience with the modified Ertl procedure, demonstrates improved revision rates with the modified Ertl distal tibiofibular synostosis compared to more traditional methods of revision surgery.

Methods:

All patients with below-knee limb deficiency revision surgery for terminal overgrowth since 1994, using the modified Ertl procedure have been followed a minimum of 2 years, with an average follow-up of 4.4 years. The rate of revision surgery in this group of consecutive patients is compared with the rate of revision surgery in all patients (consecutive) having revision surgeries for terminal overgrowth done in the ten years prior to 1994, using the traditional method of excision of bony prominence with periosteal closure. This is a retrospective cohort study.

Results:

Sixteen patients having traditional overgrowth surgery required 42 revision, for an average revision rate of 2.6 procedures per child. Average follow-up after the final revision was 3.4 years. All were followed to maturity, except three who were lost to follow-up; their data is included until they were lost to follow-up (two for two years, one for three years)

Seventeen patients having the modified Ertl procedure required no revision surgery (rate equal zero) for terminal overgrowth. One repeat surgery was done for screw removal from the residual limb, and a subsequent revision was done on the same patient for repeat soft-tissue closure over bone following muscle retraction. The only other noted complication was one broken Steinmann pin. Modified Ertl procedure follow-up average is 4.4 years, with a range of 2 to seven years. Twelve children have had at least a 4-year follow-up. Two children were lost to follow-up after two years (data included as successful for 2 years). Eight of the children with the modified Ertl procedure have been followed to maturity. Five children with previous traditional residual limb revision surgeries, when needing further surgery, were converted to the modified Ertl procedure, with no further revisions required.

Conclusions:

The modified Ertl method of distal tibiofibular synostosis for terminal overgrowth in below-knee childhood limb deficiencies is an effective treatment method.