The desire to provide amputees with pain-free residual limbs that are able to support substantial weight and give maximum flexibility led Dr Janos Ertl of Hungary to develop the procedure that bears his name.

The Ertl Procedure, developed in 1920, involves strengthening the remaining lower limb bones by connecting them with a bony ”bridge“ and covering them with a protective layer of muscle. The result is a residual limb that is able to bear substantial weight comfortably and function to the greatest degree.

The Barr Foundation, devoted to research and prosthetic assistance for amputees, recently completed a documentary videotape entitled ”The Ertl Procedure: Beyond the Bridge.“ According to Anthony T. Barr, Foundation president, the 72-minute surgical documentary is available to doctors, medical students, amputee support groups, and prosthetists.

Barr explained that many amputees who experience pain when wearing a below- or above-knee prosthesis are quick to blame the prosthetic socket or the practitioner for their discomfort. They aren’t aware that how the amputation surgery was performed has a major impact on the residual limb’s ability to accept weight/pressure and function comfortably.

Barr said, ”They believe the prosthesis is the problem, when often it’s a residual limb that is impossible to fit successfully.“

Enlightening surgeons as well as patients was a primary reason for undertaking the film project, Barr noted. ”Through its work, the Barr Foundation has discovered hundreds of documented cases of amputees suffering from painful neuromas, instability of the fibula and tibia, detached muscle tissue, etc. In most cases, these result from improper and antiquated surgical techniques. Such cases seem to be the norm more than exceptions, particularly in third-world countries...“

A. Jan Ertl, M.D., and John Ertl, M.D.

B. An x-ray of a soldier’s residual limb after he lost his leg in an Afghanistan land mine explosion. Although the Ertl procedure was not

performed, the fibula and tibia are attempting to grow toward each

other to form a natural bridge as in the Ertl procedure. Photo by Ohio

Willow Wood.

C. It may be the surgical technique, not the socket that accounts for

discomfort.

D. The Ertl procedure provides a pain-free residual limb that is able to bear substantial weight.

E. The Ertl procedure strengthens lower limb bones by connecting them with a bony bridge.

Articles about the procedure indicate it was initially designed so elite amputee athletes could put greater pressure on their residual limbs. Soon, however, it was agreed that such weight bearing ability was a boon to leg amputees of all ages. Barr noted that the Ertl procedure has been successfully performed on thousands of amputees, including his father, William G. Barr, a transfemoral amputee who experienced pain for eight years before undergoing a reconstruction surgery for his residual limb. He was then able to live many years with pain-free mobility.

The operation, as described in the 1980 book ”Whole Again“ by William G. Barr and Lee Whipple, consists of four main components: (1) excess nerves are removed from the residual limb; (2) arteries and veins are separated; (3) the periosteum is stretched down to cover the femur and tiny islands of bone from the upper femur are transplanted to create a protective bone flap on this weight-bearing point; and (4) the muscles are repositioned, stretched down, and joined, forming a cushion over the end of the femur.

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A number of professional journals and certified prosthetists have printed articles and made presentations concerning this approach over the past few decades. One issue raised is that the intricate bone-fusing procedure takes more than twice as long to perform as a simple surgical amputation — three hours versus one hour, according to one report.

Keeping the operation site open for that long a period invites the possibility of infection, notes a doubter. Some skeptics feel that not all surgeons are adequately skilled or well enough trained to complete the delicate operation correctly. Others simply prefer to stick to traditional methods. And those who want scientific backup by data say there haven’t been sufficient studies performed over a lengthy enough period to validate the long-term benefits of the method.

However, many surgeons and prosthetists familiar with the Ertl Procedure feel ample proof is demonstrated by patients who’ve enjoyed pain-free prosthetic use over the years. They stress, however, that a successful outcome requires the cooperation of surgeon and prosthetist since socket design must be in accord with weight bearing on the end of the prosthesis.