Dr. Dougherty responds

Dr. Dougherty responds:

30 December 2003

Paul J. Dougherty, M.D.,

orthopaedic surgeon

William Beaumont Army Medical Center

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The correspondents raise some interesting questions concerning the paper "Transtibial Amputees from the Vietnam War: Twenty-Eight Year Follow Up". I wish to answer some of their concerns and correct their misconceptions about the care of these wounded soldiers.

The age range of forty-five to fifty-four years allowed for the best follow up and data analysis. The vast majority of Vietnam Vets with amputations were in this age range at the time of the study. Follow up of those amputees outside of this age range (all older) included few patients who did not allow for proper analysis.

As per the correspondents' request, a comparison of SF-36 Health Survey scores of those with the Ertl procedure and those with a conventional transtibial amputation showed no significant difference within group 1 and group 2. This is consistent with the results presented in the paper and adds little to the conclusions(fig 1).

Fig 1. Mean scaled SF-36 Health Survey scores of isolated transtibial amputees (group 1) comparing those with the Ertl procedure to those with a conventional transtibial amputation.

	PF	RP	BP	GH	Vit	SF	RE	MH
Ertl	81.3	79.7	81.6	77.2	66	87.9	84.2	78.3
NonErtl	82.2	88.8	81	67.5	69.4	91.6	96.3	82
P value	0.898	0.488	0.950	0.098	0.690	0.624	0.207	0.531

Fig 2. Mean scaled SF-36 Health Survey scores of transtibial amputees whohave one other major injury (group 2) comparing those with the Ertl procedure tothose with a conventional transtibial amputation.

	PF	RP	BP	GH	Vit	SF	RE	MH
Ertl	61.3	36.9	49.4	61.4	55.7	71.75	67.3	69.3
NonErtl	55	28.9	52.4	57.6	48.0	61.28	50.8	59.2
P value	0.30	0.473	0.658	0.587	0.203	0.239	0.248	0.158

The terms used in the article (Ertl osteoplasty, Ertl procedure and Ertl transtibial amputation) are the terms synonymously used in English language publications, including the American Academy of Orthopaedic Surgeons volume on "Atlas of Limb Prosthetics"'. This refers to a transtibial amputation performed in creating a bone bridge via osteoperiosteal flaps or bone graft from another site, along with the use of a myoplasty. The correspondents' are incorrect in asserting that only a bone bridge was performed without myoplasty. Review of patient records, correspondence, and discussions with surgeons who worked at Valley Forge confirm that the Ertl procedure was performed as described above with the inclusion of a myoplasty. Only surgeons who were assigned to the amputee service did this procedure and a high level of proficiency was obtained by the surgeons. However, not all patients who had a conventional (non-Ertl) transtibial amputation had a myoplasty or myodesis.

The results section shows both the number of prosthesis used over time and the percentage of patients who changed their prescription. None report having "end bearing" prosthesis as described by the correspondents. I disagree with the correspondents' assertion that this would provide a better outcome. Rather, the quality of the prosthetic fitting appears to have the most influence on a patient's function. I am also unaware of a study that supports the correspondents' assertion.

I wish to thank the correspondents for providing an interesting historical background on the Ertl procedure. However, the well-known bias of the correspondents for the routine use of the Ertl procedure is not supported by the present study. Also, a review of the English language literature does not find a study of equal strength supporting the routine use of the Ertl procedure for transtibial amputees. Perhaps future research may further clarify this point.

The long-term outcome of these patients appears to be most influenced by the initial injury severity, proper surgery (Ertl or conventional), and high quality rehabilitation, prosthetic fitting and psychological support. I hope that the care provided to our soldiers during the present conflict is equal to that provided at Valley Forge during the Vietnam War.

1. Bowker JH, Goldberg B, and Poonekar PD. Transtibial Amputation CH 18 in Bowker JH and Michael JW (editors) Atlas of Limb Prosthetics: Surgical, Prosthetic and Rehabilitation Principals. American Academy of Orthopaedic Surgeons. Mosby Year Book, St Louis. 1992. pp 429-452.

2. Deffer PA, Moll JA, and LaNoue AM. The Ertl Osteoplastic Below-Knee Amputation. J Bone Joint Surg. 1971;53A:1028.

Sincerely,

Paul J. Dougherty MD

Lieutenant Colonel, United States Army

Chief, Department of Surgery

Orthopaedic Surgery Program Director

William Beaumont Army Medical Center

5005 N. Piedras

El Paso TX 79920

(915) 569-2288

paul.dougherty@amedd.army. mil