Ertl below-knee amputation using a vascularized fibular strut in a nontrauma elderly population: a case series

Tibiofibular bone bridging (Ertl) during a below-knee amputation (BKA) is used to create a stable bony platform, granting the patient improved rotary stability, higher end bearing potential, and ultimately, more functional ambulatory ability. However, limited data are available in the literature on actual patient outcomes, despite numerous reports of the technique. The purpose of this study was to report our experience with distal tibiofibular bone bridging using a vascularized fibular bone graft in an elderly nontrauma population.

We performed an institutional review board-approved, retrospective review of BKAs performed by the senior author between 2004 and 2011. Surgical indications, complications, and outcomes were recorded. A subgroup analysis and comparison was performed among patients that had received vascularized bone bridging and those that had not.

A total of 294 BKAs were performed on 270 nontrauma patients. Of these, 30 (11%) were done on 29 patients with tibiofibular bone bridging. The mean clinical follow-up among the Ertl subgroup was 11 months (range, 1-42 months), and 17 months (range, 23 days-78 months) in the non-Ertl subgroup. The ambulation rate was 100% (29/29) in the Ertl group, and 78% (161/207) in the control group (P = 0.004). The overall rate of operative revision due to any etiology among groups did not differ significantly (P = 0.255).

Tibiofibular bone bridging with vascularized fibula leads to a significantly higher rate of ambulation without a significantly higher rate of complications in a nontrauma population. Although this technique has been widely described in trauma patients, clinical data are lacking for the nontrauma population. This is the largest reported series of Ertl amputations in nontraumatic population to date and our results demonstrate a significant benefit of the Ertl technique in this population.

Level IV.