Articles from John Michael's Corner

John Michael's Corner The Ertl Controversy: Follow-up of Patients by the Drs. Ertl in the USA

http://www.oandp.com/news/jmcorner/2003-11/1.asp

http://www.oandp.com/news/jmcorner/2003-08/1.asp

Response from Dr. Jan Ertl and Dr. William Ertl

http://www.oandp.com/news/jmcorner/2003-12/3.asp

Response to Ertl Article by John Michael in the O&P Edge

I have read the comments written by John Michael, CPO regarding the Ertl amputation procedure. I have known John Michael for many, many years and have a great deal of respect for his writings. I must differ somewhat with John’s opinion of the Ertl amputation procedure. I have had the wonderful opportunity over the past 40 years to work with some very, very talented physicians who performed the Ertl procedure on below the knee amputees either at the revision stage or initial amputation stage. Over that period of time, I certainly have been involved in no less than 50 cases and probably if my memory could serve me a little better and I could count up the names some more.

I was first introduced to it almost by accident in the late 1960s to early 1970s. When there were many, many veterans of the Vietnam War returning to this country with amputations, at that time. The military certainly was overloaded with a number of these people. My practice was in a ”military town“ where there was a large Naval Hospital who serviced all the armed services including the Army where the majority of these amputees came from. Certainly, there were a large amount of Marines, but the large bulk came from the Army. There was an Army surgeon in Valley Forge Army Hospital in Valley Forge, Pennsylvania who was doing this procedure routinely on many of the patients. Valley Forge Hospital was some distance from me and I came to see these patients because as soon as they were well enough post-surgically to be moved they would be moved out to smaller hospitals in the medical community that had room for them. The major military hospitals were so overloaded they hardly had any available space to take care of these people. Therefore, they would be amputated, rehabilitated to a point where they could be handled by less intense military hospitals and moved there. One of those type military hospitals was in my area and many of the veterans from the Army would be sent from Valley Forge to my area to one or two of the small military hospitals that had some space available.

As I started to work on these amputees, I found that most of them were very healthy, in their 20’s and in excellent physical condition other than battle injuries. I was amazed at how quickly they healed, which I’m sure was due to their excellent health. Not only did they heal quickly, but they had very little of the usual problems that we see with their residual limb as soon as they started walking. Routinely, we would start walking these people quite early in their rehabilitation phase. What I saw were patients who had nice, long residual limbs that were very broad across the bottom and very non-tender. In those days we were fitting routine patella tendon bearing type sockets with the principle of total contact applied. Mild pressure was put to the distal end of the residual limb of which the patients had no discomfort. As they would shrink and get loose in the socket, they would begin to bear more and more weight on the distal end and still at no distress. I would see these patients in the office from time to time for follow up and I would be surprised at how loose they were in their sockets from normal shrinkage. Even though they were extremely loose in the socket and carrying significant end bearing on their residual limb, they had no discomfort. They were able to run, participate in sports activities and pretty much do what they wanted and they never had any discomfort. I did not see the tender fibulas; I did not see the tender distal end of the tibias; I did not see tissue broken down from what amounts to a high level of abuse to the distal end of their residual limb.

Today, in my area in Columbus, Ohio, we are doing a great deal of Ertl amputation procedures on BK amputations. We have done traumatic patients who again are generally in good health as well as some diabetic patients. Our success with the diabetics has been good. We have not had a failure in any one of them. They do however, take much longer to heal and much longer for the bone to show callous. The prosthetist must be very careful in continued management of the diabetic patient in the early phases of post-operative rehabilitation is very critical.

I feel the prosthetist plays a major role in caring for the patient at that time. It is my practice to put all of these patients in rigid Immediate Fitting Prostheses in the operating room and to maintain good, close contact with the distal end of the residual limb in that prosthesis. It is my belief that the use of a cast on the residual limb is very important to keep pressure on the new bone bridge and be sure that it does not come out of place. The surgical procedure used by the surgeons that I work with, that I have had the absolute honor to influence, is to notch both the fibula and the tibia and to fit the bridge into that notch. A hole is drilled between the bridge and the tibia and the bridge and the fibula and a dissolvable suture is put in place to try and hold the bridge in the notch created by the surgeon. No screws are used in the people that I work with. I do all that I can to discourage surgeons from using any screws or hardware of this type. My experience is that those people who have had screws have all had to have them removed at a later date. Most surgeons don’t think that’s a serious issue, but nevertheless any time that you have to open the residual limb to take the screw out it’s just another time to invite infection. I am pleased to report that since I started to become involved with this procedure in 1968, I have never I say again never seen an infected case. I have read reports of other cases in other areas of the country that have had an unusually high infection rate. I find it interesting that most of those cases come from one section of the country where the procedure is being done with screws in place.

I would like to take a moment to point out that the Ertl procedure is much more and beyond a simple bone bridge that is placed between the tibia and the fibula. The procedure calls for the careful management of the muscle tissue and it being reattached at the distal end through either myodesis or myoplasty. It also involves the very, very careful management of the 5 nerves that are in the below knee residual limb. Great care must be taken to identify each one of them and treat them in such a manner that they do not present themselves post amputation as painful neuromas.

I am somewhat taken back by Mr. Michael’s statements regarding there is not sufficient data to support the benefit of the Ertl procedure on a below knee residual limb. It is true that most of my work is based on anecdotal experience with these patients. I can understand someone being involved in one or two maybe ideal cases having this procedure being done can jump into conclusions that it is a very good procedure. I can see other people standing on the sidelines saying two cases don’t tell us a lot. The truth is I have been involved in these cases for better than 40 years. I have been involved in 30-50 cases over that period of time and I’m really sorry I have not kept better account of all the ones that were done and that I was involved in. As a prosthetist I can tell you with all my heart I believe those cases that have received the Ertl procedure that has been done in the manner in which I have described, experience far less pain and are able to participate in a far higher level of activity than those patients I have seen over the years that have not had the benefit of such treatment. I have talked to the surgeons I have worked with and asked them time and time again if they will publish a paper on their work and on the results of that work. Always the answer seems to be the same—yes, we need to do that, but it takes a great deal of time and I’m really, really busy at this point. I spoke to a surgeon whom I have done many of these with in the military only yesterday and our closing conversation is ”I really need to do a paper on the work that’s been done and present it“. What I have also found is that those good surgeons who are willing to reach out and go one step farther to provide patients with a better end result are usually the same surgeons who are very busy and have very little time in life to do documented research studies. I find it interesting that those people, both prosthetists and doctors, who have written articles saying that they’re just not sure there’s any real advantage to the procedure, have never really done one. In that light, I offer you John first my most highest and sincere respect; and secondly an open door invitation to you to come visit with me, participate in 2 or 3 of these patients through the surgical procedure and their rehabilitation to a point that they are well established into their temporary prosthesis and see first hand whether you think there is a difference.

When talking to some of the physicians I have worked with who are doing the procedure and literally begging them to publish a paper, one of the comments they make is that we should really take half a dozen trauma cases that are ideal for the Ertl procedure and then we should do half a dozen cases without the procedure and see the end results of both groups. The problem with that is I cannot bring myself, and frankly I do not think the surgeon can either, to perform a non-Ertl type amputation just to see how they fare. The issue at hand is that how then in good conscience and good responsibility to the people that we all take care of can you look at an amputee who in your heart and soul you believe would benefit doing the Ertl style amputation, and not do it just to see how well he would do. I’ve heard the argument that after a period of time, in fact, if it became obvious and documented that the group with the Ertl type amputation is doing better; you could always go back and revise the non-Ertl type to an Ertl style of amputation. Subjecting a patient to that I think falls into the category of something I would call unreasonable. So then it is suggested that we simply review a half a dozen amputees who have had their surgery done in the conventional manner and see how well their doing. There is some argument that is not a fair comparison or good research. It would depend upon who did the amputation, that surgeon’s personal hand skills and would they in fact differ from the individual doing the Ertl style procedure. I had pointed out to me by an orthopedic surgeon who is ”not convinced“ that the Ertl style amputation is of that much benefit. His argument is that most of the surgeons who do the Ertl are very skilled not only with their understanding of amputation, but also possess significant hand skills to perform that surgery. His argument continues that if the same skilled surgeons were to do a conventional type amputation the patient would fare just as well without having the Ertl style procedure as a result of the surgeon’s skill. While, once again I point out very clearly, I am not a surgeon; I am not a doctor; I am a prosthetist. After many years of seeing Ertl type amputations done, one after the other by different skilled surgeons, it is my experience that the ones with the Ertl style amputation do far better. The point being made is that in a study the same qualified and skilled level of surgeon should do the Ertl procedure as well as the non-Ertl procedure cases to compare. This brings us full circle and back to the issue of looking the patient squarely in the eye and saying you’re going to get a standard amputation because we need to do a study. I must be honest with you----I cannot bring myself to do that.

So then, in summing up, I personally invite you, John Michael, and for that matter any other prosthetist that is willing to spend the time and travel to our facility to personally partake in the prosthetist’s responsibility in surgery as I have, they may be right along side me in doing 3 or 4 of these cases. After these people have healed and in about 6-8 weeks when these patients have produced callous at the distal site of their tibia and fibula then to draw your own conclusions and then write what you have personally seen and experienced.

Most Respectfully Submitted,

Raymond Francis, C.P.