American Association of Plastic Surgeons

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The Contemporary “Ertl”: A Functional Transtibial Amputation For Nontraumatic Comorbid Populations
Daisy L. Spoer, M.S.1, Samuel S. Huffman, B.S.1, Lauren E. Berger, B.A.2, Arshan Goudarzi, B.S.1, Rachel N. Rohrich, B.S.3, Christian X. Lava, M.S.1, Kenneth L. Fan, M.D.3, Grant M. Kleiber, M.D.3, Christopher E. Attinger, M.D.3;
1Georgetown University School of Medicine, Washington DC, DC, USA, 2Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA, 3Georgetown University Hospital, Washington DC, DC, USA

PURPOSE: The osteomyoplastic (Ertl) approach to transtibial amputation (TTA) is an alternative to the “gold-standard” Burgess technique. This study aims to investigate the safety, efficacy, and functionality of Ertl performed in a highly comorbid patient population.
METHODS: Medical records of TTA (Ertl and Non-Ertl) performed by a single surgeon between January 2017 and October 2021 were retrospectively reviewed.
RESULTS: 287 patients underwent 294 TTA via Ertl (n=51/294, 17.3%) and Non-Ertl (n=243/294, 83%) techniques. Ertl patients were younger (50.1 vs. 60.6 years, P<0.001) and had fewer comorbidities (Charlson Comorbidity Index: 2.7 vs. 5.5, P<0.001). Ertl was frequently combined with targeted muscle reinnervation (94.1% vs.68%, P<0.001) and extended operative times by an average of 19.9 to 50.3 minutes depending on the combined nerve procedure. There were no significant differences in short-term complication (n=52/294, 18%) or reoperation (n=57/294, 19%) rate. Of those with postoperative imaging, 93% demonstrated bony union (n=38/41) at a median of 6.1 months. Ertl conferred shorter times to ambulation (2.29 IQR: 1.53 vs. 3.65 IQR: 3.13 months, P<0.001) with higher rates (90% vs. 75%, P=0.016) than Non-Ertl. The majority of participants were classified into the K-3 (out of 4) prosthesis class (68.2%), with Ertl being associated more with advanced prosthesis classes (p=0.002). By a median follow-up of 15.4 months, 1% required transfemoral amputation (n=3/294), and mortality was 18% (n=51/294), occurring at a lower rate in Ertl ( 2% vs. 20.6%, P=0.001).
CONCLUSION: This study underscores the safety and physiologic relevance of performing Ertl to achieve functional outcomes.
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