Combat-related bridge synostosis versus traditional transtibial amputation: comparison of military-specific outcomes.

Benjamin F Plucknette,Joseph C Wenke,Jessica C Rivera,Chad A Krueger

doi:10.1007/s11751-015-0240-4

Abstract

The aim of our study was to determine military-specific outcomes for transtibial amputations of US Service members using either the traditional technique (Burgess) or the Ertl technique. All US Service members sustaining transtibial, combat-related amputation from September 2001 through July 2011 were reviewed. Amputation type, mechanism of injury, time interval to amputation, age, sex, branch of service, rank, force, nature, and injury severity score were recorded. Outcomes were determined by analyzing military-specific medical review results, to include the following: Physical Evaluation Board Liaison Office (PEBLO) rating (0–100), PEBLO outcome (permanent retirement, temporary disability retirement, separation without benefits, continuation of active duty, or fit for redeployment), and the rate of redeployment. Amputation type (Ertl vs. Burgess) was determined by reviewing postoperative radiographs and radiology reports. Data from all of the above categories were compared for both Ertl and Burgess amputees. Of 512 subjects identified, 478 had radiographs or radiology reports distinguishing between Ertl or Burgess transtibial amputation. A total of 406 subjects underwent the Burgess procedure, and 72 subjects underwent the Ertl procedure. There was not a significant difference between the two groups in review board rating (p = 0.858), review board outcome (p = 0.102), or ability to deploy (p = 0.106); however, subjects that underwent the Ertl procedure remained on active duty at a significantly higher rate (p = 0.021). There is a higher rate of remaining on active duty using the Ertl technique. This study suggests that there is an improvement in functional outcome with the Ertl technique.Electronic supplementary materialThe online version of this article (doi:10.1007/s11751-015-0240-4) contains supplementary material, which is available to authorized users.

Highlights

There is a high rate of lower extremity amputation within the combat-deployed population of the US military [1]
Thirty-four subjects were excluded for either lack of radiographs/reports or radiographs/reports that established that an Ertl or Burgess amputation was not present
Despite the changes in technique and seemingly logical improvement in distribution of weight-bearing forces associated with the Ertl amputation, there remains a paucity of evidence to support the superiority of the Ertl technique versus the Burgess technique as to functional outcome

Summary

Introduction

There is a high rate of lower extremity amputation within the combat-deployed population of the US military [1]. In comparison with the Burgess method, the Ertl technique utilizes either a section of fibula as a strut or a periosteal sleeve to bridge the distal aspect of the residual limb and create a platform synostosis on which to bear weight [4]. Proponents of the Ertl technique claim that the bone bridge provides a more stable platform for prosthetic weight bearing [5]. Some studies claim there is greater residual limb health, improved prosthetic fit and a higher health-related quality of life in patients with an Ertl amputation [5, 6]. A fluoroscopic evaluation of prosthetic fit related to residual limb displacement demonstrates no kinematic difference between the two amputation techniques, further disproving the theoretical benefit of the Ertl technique to improved fit of prosthesis [8]. Critics of the Ertl amputation cite an increased operative time and complications as contraindications to creating a bone bridge in patients with an otherwise stable fibula [10, 11]

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