Rehabilitation for Those With Transtibial Osteomyoplastic Amputation

Abstract

Often encountered in traditional transtibial amputation is a condition that constitutes pain, swelling, sense of instability, bone and soft tissue atrophy, and prosthetic difficulties, resulting in decreased function. One innovative method for maximizing the rehabilitation capability after amputation surgical reconstruction is osteomyoplastic transtibial amputation, commonly called the "Ertl procedure" (Ertl and Ertl, Prosthetics and Patient Management: A Comprehensive Clinical Approach. 2006). A standard for physical therapy management of those with osteomyoplastic transtibial amputation needs to be described for future controlled study. To describe the typical clinical presentation and current physical therapy management practiced in patients with osteomyoplastic transtibial amputation. Standardized physical therapy management of primary and secondary osteomyoplastic transtibial amputation from initial status through discharge is described. During the rehabilitation process after the Ertl procedure, residual limb compression hose is usually not applied. Progressive residual limb end bearing is encouraged. Muscle hypertrophy of all residual limb muscles because of strengthening exercise can occur, thus permanent prosthesis use may be delayed. Patient goals for normal gait and return-to-previous function can be achieved. Patients, who undergo an osteomyoplastic transtibial procedure, the Ertl procedure, may benefit from standardized physical therapy management guidelines to facilitate recovery time and maximize function. Setting a standard for care will allow outcomes to be measured and generalized more broadly, allowing future study of the effectiveness of care for patients with transtibial Ertl procedure. (J Prosthet Orthot. 2009;21:64 -70.)

The effectiveness of the bone bridge transtibial amputation technique

“…Two studies reported evidence in favor of the bone bridge compared to the non–bone bridge TTA, in the topics of Subjective analysis and Function (patient-reported functional outcomes). 12,16 A favorable outcome is consistent with a large body of articles, 5,20–27 not considered in this review due to the screening process; primarily because they were level IV and V case studies or reports. These reports add to the reported benefits of the bone bridge technique compared to the non–bone bridge technique.…”

“…An alternative addition to transtibial amputation is a bone bridge, which considers limitations of traditional procedures. 5 A bone bridge technique described by Ertl 6 reportedly restores intraosseous pressure through canal obliteration while expanding the area of terminal support by creating a bony bridge between the distal tibia and fibula. 6 The stabilization of the tibia and fibula through this bone bridge eliminates potentially painful movement of the fibula while creating a blunt surface at the distal end of the RL.…”

Biomechanical analysis of curb ascent in persons with Ertl and non-Ertl transtibial amputations

“…11 This technique has been suggested to improve the overall physiology of the residual limb by maintaining the medullary canal pressures and improving vascularization of the remaining tissues. 12,13 Unlike a non-Ertl amputation, the Ertl creates a “bone bridge” to connect the tibia and fibula, seals the medullary canal, and sutures the anterior and posterior residual musculatures together. 12 The Ertl has been suggested to tolerate greater direct load bearing of the distal end of the residual limb (standing directly on the stump without a prosthetic socket) than the non-Ertl procedure.…”

“…12,13 Unlike a non-Ertl amputation, the Ertl creates a “bone bridge” to connect the tibia and fibula, seals the medullary canal, and sutures the anterior and posterior residual musculatures together. 12 The Ertl has been suggested to tolerate greater direct load bearing of the distal end of the residual limb (standing directly on the stump without a prosthetic socket) than the non-Ertl procedure. 12,14 Greater residual limb load bearing has the potential to positively impact long-term outcomes by increasing symmetrical loading between limbs, thereby reducing the increased risk of osteoarthritis in joint proximal to the site of amputation and the intact limb joints.…”

“…12 The Ertl has been suggested to tolerate greater direct load bearing of the distal end of the residual limb (standing directly on the stump without a prosthetic socket) than the non-Ertl procedure. 12,14 Greater residual limb load bearing has the potential to positively impact long-term outcomes by increasing symmetrical loading between limbs, thereby reducing the increased risk of osteoarthritis in joint proximal to the site of amputation and the intact limb joints. 15,16 Other factors may influence symmetrical loading such as rehabilitation, socket fit, and prosthetic foot design.…”