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What is an ERTL Bonebridge? |
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(Caution: This page contains graphic photos) |
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To understand what a bone bridge is, and why it is important, it helps to first understand a bit about a typical person’s lower extremity anatomy. In the lower leg, there are two bones jointed together just below the knee called the tibia and the fibula. They run fairly parallel down the leg and are stabilized again just above the ankle. Because of nature of this construction, the relationship between these two bones is fairly solid in design and there tends to be very little to no motion that occur between them at any given time when a leg is in it’s God given state. When a person undergoes a conventional below the knee amputation, the lower leg is generally cut directly across both the tibia and the fibula. In most cases, the cut ends of the bones are left open allowing intramedullary pressure and the bone’s blood supply to flow out. Once transected, the underlying musculature is allowed to retract as they have loss of any kind of length-tension relationship from their opposing muscles. The bones may atrophy in time, loosing strength and integrity due to lack of loading. Often, arteries and veins are tied off together, but this can lead painful fistulas and added stress on the heart. The nerves are transected and rarely given any special treatment. |
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The previously mentioned motionless relationship between the tibia and fibula diminishes from an extremely stable design to a something that may allow significant motion to occur, especially while in a prosthesis. Generally, when someone wears a below the knee prosthesis, their residual limb is held up off the bottom of the socket by circumferential tension that is built into the socket. As a day progresses, most amputees have a slight tissue volume change and their prosthetic fit may become loose. As well, the tension that was incorporated in the socket design is no longer a tight enough fit to hold a person up off the end of the socket. Consequently, as this happens, the amputee’s limb will sink down into the socket squeezing the fibula and tibia together. Often, underlying nerves are compressed when the tibia and fibula are squeezed together resulting in pain. This feeling is often describe as “chop sticking” in the socket. | ||||
| This is only one source of pain amputees often endure. A secondary issue may occur as the end of the tibia is now likely forced to bear too much weight due to loss of muscle volume. Now that there is a clear understanding of a typical conventional method for a below the knee amputation, it should be much easier to understand a what make the Ertl bone bridge so different, and why it is such beneficial reconstructive alternative to consider. | |||||
(Ertl Bonebridge) |
(Sponteneous growth of a natural Bonebridge) |
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But first, a bit of history! Like many advancements in medicine, the history of the Ertl bone bridge really started with a single physician that had a sincere passion for helping his patients. In 1920 Professor Janos Ertl, Sr., MD, of Hungary, developed the Ertl procedure in order to return a high number of amputees to the work force. During this time, amputees had significant problems with pain and difficulty with prosthetic wear. Dr. Ertl noticed in months follow-up after an amputation, often there was a natural tendency for the cut end of the tibia to grow towards the cut end of the fibula. This gave Dr. Ertl the idea to assist this natural phenomenon by precipitating the bone growth between the cut end of the tibia and fibula. This was done by harvesting an osteoperiosteal graft from a portion of the tibia that traditionally discarded after amputation and use it as a connection between the tibia and the fibula. |
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John Ertl, M.D.
William Ertl, M.D. |
Jan Ertl, M.D. |
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Originally conceived as a "flexible bone graft," the Ertl reconstruction amputation procedure itself has evolved during the course of its 83-year history and implementation by three generations: patriarch Janos, son John, and grandsons Jan and William. Use of a osteoperiosteal graph was the original method described by Dr.s Ertl. Over the past few years there have been acceptable variation to this procedure, which incorporate a portion of the fibula cortex along with the osteoperiosteal sleeves as the bridging graph. Once the fibular graft is sutured in place, this offers a fairly rigid relationship between the tibia and fibula from the moment of post-op. This being the case, it appears to offer the opportunity for a less painful, and possibly more progressive rehabilitation process. |
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Click on image for photos of the Creation of the Ertl Bonebridge |
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| Above all, it is IMPERATIVE to remember there is more to this procedure than just the, (1. Creation of the Bonebridge!) All together there are five facets of the Ertl Osteomyoplastic Lower Extremity Amputation Reconstruction Technique that are equally important. Unlike a conventional amputation where the arteries and veins are often tied off together, (2. the vessels are individually suture-ligated) to prevent the formation of a painful fistulas or hematoma. (3.The nerves are identified, distracted, injected with a pain reducing medication, transected, and allowed to retract up into the soft tissue area) that has not been traumatize allowing less opportunity for neuromas to form. (4. A myoplasty is performed between the agonist and antagonist muscle groups) reestablishing a muscle pumping action, giving greater control to the limb and add a muscle padding over the end of the limb. (5. Even the skin is given special attention to allow for a smooth even closure) that should aid in providing a good prosthetic fit. |
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 Individual suture ligation of vessels |
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 Treatment of the 5 nerves |
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 Myoplasty of the muscles |
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 Smooth skin closure free of Dog Ears |
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For more information about the Ertl procedure and the Ertl bonebridge you may contact us, or go to the following link at  . |
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Both the Ertl Reconstructive amputation procedure and MAS ramus containment socket are examples of technological advances that generally offer superior outcomes for amputees. Unfortunately, they are also extremely time consuming when compared to more conventionally accepted techniques that offer no extra reimbursement for either prosthetist or surgeon. Knowing this, one must ask why would we spend the extra time and money on something that is so much more trouble than other more conventionally accepted techniques, especially when there is no extra reimbursement? Our answer is simple. “ Jesus Christ laid down his life for us. And we ought to lay down our lives for our brothers.” (1 John 3:10) Keeping this in mind, our first ethic will always be to the patient. That being the case, we believe in taking our time, with every opportunity, to give our clients our very best. |
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| Special thanks to:
Attila Poka, M.D. |
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And two very special ABC certified prosthetist: Raymond Francis, CP/L and Kenneth M. Berman, CPO/L. For with out the patience of these two very talented educators, and their heart for the profession, I would not be the practitioner I am today. |
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Superior Prosthetic Solutions Inc. 901 Monmouth Street Newport, Ky 41071 Office (859)491-0257 Fax (859)491-4042 Please contact Robert at jrp@bonebridge.com |
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