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Revision Transtibial Amputations: The Ertl Procedure
The Ertl procedure is a technique for transtibial amputation revision for problematic residual limbs. The procedure, also called bone bridge synostosis, calls for raising periosteum from the medial aspect of the fibula and anteromedial tibia, with attached cortical chips. Anteriorly and posteriorly, the edges of the two periosteal flaps are sutured together, forming a tube of periosteum with opposed cambial surfaces and viable bone chips. With time, a synostosis forms between the two bones, with a broad, generally smooth surface. Ertl suggested that this technique allowed end bearing in the socket, thus reducing pain and improving function. He also suggested that sealing the medullary canal restored “normal bone physiology.” The most consistent indication for the Ertl procedure is fibular instability caused by rupture of the interosseous membrane with or without concomitant overt proximal tibiofi bular joint instability. This injury can occur as an extension of the forces to injure the leg, with disruption of the interosseous membrane and either fracture of the proximal fibula or disruption of the proximal tibiofibular articulation. This chapter reviews the indications, contraindications, surgical steps, results, and potential complications of the Ertl procedure.