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Case Report

Retained Internal Fixation as a Cause for Late Prosthetic Fitting Problems in Ertl Transtibial Amputation

A Case Series

Grannis, Kimberly A. BS; Cox, Joseph T. MD; Graham, Mark A. CO; Laughlin, Richard T. MD

Author Information
JPO Journal of Prosthetics and Orthotics: October 2013 - Volume 25 - Issue 4 - p 184-187
doi: 10.1097/JPO.0000000000000004
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Janos von Ertl was a Hungarian surgeon who used his understanding of bone biology and physiology to develop a corticoperiosteal graft for reconstructing bony facial defects of war veterans during World War I.1–3 He expanded his technique to several areas of the body, and in 1949, he described the technique to create a periosteal sleeve between the tibia and the fibula in transtibial amputees that would ossify with time.1,4,5 Several modifications have been described, but all have the common goal of creating a solid arthrodesis/bony bridge between the tibia and the fibula that improves function and pain in active patients with transtibial amputations.1,3–6 Today, the fibular bone block technique developed by Pinto and Harris4 is an accepted and commonly used method for creating a stable fusion of the distal tibia and fibula.1,2,6–9 This method can be used for amputations due to trauma, residual limb revisions, tumors, diabetes mellitus, and other dysvascular issues in the lower limbs.

In brief, the fibular bone-block technique includes exposing the tibia to the level of amputation and making the appropriate transection. The fibula is exposed and transected at a level 2–4 cm below the tibia while maintaining the soft tissue attachments to the fibula to preserve periosteal blood supply. The fibula is then transected at the level of the tibia, taking care to preserve the medial periosteum, and it is then rotated toward the tibia. After notching the tibia to receive the fibula, a screw is placed laterally to medially through the fibula and the tibia for fixation of the bony bridge.1,4,10 The soft tissue is reconstructed with gentle tension on the muscles, and the skin is closed. Although there are slight variations in technique, the creation of this distal bony bridge along with the soft tissue reconstruction are generally referred to as the Ertl osteomyoplastic amputation.1 Today’s proponents of the Ertl technique cite the increased bony surface area of the residual limb that decreases the mechanical load on the soft tissues, which improves stability, pain, and functional results for amputee patients.1,11

Complications after the Ertl procedure do exist. Similar to other surgical procedures, these patients can experience infection, neuroma formation, heterotopic bone formation, wound healing problems, and other complications. However, they also experience complications not seen in other types of amputations including delayed union, nonunion, bone bridge failure or dislocation, and hardware complications.2

Prominent or painful hardware is a relatively common late complication, occurring in some studies in up to 19% of the time.2 Soft tissue irritation often results but is often attributed to malfitting prosthesis due to volume change of the residual limb. Unaware of the prominent hardware, patients return to their prosthetist requesting a modification of the prosthesis rather than the orthopedic surgeon for removal of the hardware. This may cause a delay in diagnosis of the primary problem. The purposes of this case report were to improve healthcare providers’ suspicion of prominent hardware in patients who have undergone Ertl transtibial amputation and to avoid unnecessary medical costs and risks by obtaining a simple and inexpensive set of radiographs.


A 38-year-old man presented with complaints of a chronic diabetic foot ulcer. Interestingly, this patient had previously received a kidney and pancreas transplant, which returned him to non–insulin-dependent status. Unfortunately, he still had diabetic complications and eventually developed chronic foot ulcers due to diabetic neuropathy. During several months of conservative treatment, his left neuropathic foot slowly worsened and eventually developed infection. A thorough discussion about the treatment options occurred, including fusion of the ankle or transtibial amputation. Because of the patient wanting to get back to an active lifestyle, he decided to proceed with the transtibial amputation rather than pursue a lengthy reconstruction. He had a modified Ertl transtibial amputation in August 2007. Postsurgically, his left transtibial amputation healed well, and he was fit with a transtibial prosthesis in September 2007.

During the next 2½ years, the patient had his prosthesis revised once because of volume changes in the residual limb but otherwise had no complications. At the 2½-year mark, however, he began to have some irritation on the distal lateral aspect of his left residual limb. The patient again presented to the prosthetist for revision of his prosthetic socket, which was accomplished and relieved much of his pain. This scenario occurred a total of four times for approximately 1½ years, with the last time resulting in cellulitis. Because of the infection, he was referred to the orthopedic surgeon for reevaluation.

Radiographs in the office at that time showed a healed distal tibiofibular bone bridge with prominent screw fixation on the lateral fibula. The patient was given antibiotics and scheduled for removal of the internal fixation screw. Once the screw was removed, the wound healed uneventfully, and the patient returned to his normal functioning status without further complications.


The second case is a 71-year-old woman with long-standing diabetes and a right neuropathic ankle. She developed a nonhealing ulcer 1 × 2 cm in size over the medial aspect of her right ankle after a minor injury and presented with an unstable ankle and open wound. At the time of presentation, she was the primary healthcare provider for her husband, and her main concern was avoiding lengthy reconstruction of her ankle. She elected to have an Ertl transtibial amputation, which was performed in May 2005, and she healed without complications. Radiographs at the 6-week time point indicated osseous healing between the distal tibia and fibula.

She was fitted with a right transtibial prosthesis 1 month after her soft tissues healed. She did well until the 6-month time point, at which time she began having superficial irritation at the distal lateral aspect of her right residual limb. During the next 2 years, she presented to her prosthetist four times for evaluation of her prosthesis, which was believed to be causing the irritation. Despite multiple attempts to improve her irritation by increasing the liner thickness and revising her prosthesis, she developed a large painful subcutaneous bursa and was eventually referred back to the orthopedic surgeon for reevaluation.

Radiographs obtained showed resorption of the distal end of the fibular strut graft and a floating screw (Figures 1A, B). The patient underwent excision of the bursa and removal of painful hardware in her right residual limb in 2008 (Figures 2A, B). She healed uneventfully and went on to function well with her right transtibial amputation prosthesis until her death in 2011.

Figure 1:
Anterior-posterior (A) and lateral (B) radiographs showing the right residual limb 3 years after an Ertl transtibial amputation in case 2. These radiographs illustrate the healed synostosis between the tibia and the fibula. Resorption of the distal fibular strut graft has occurred, and the screw used for fixation is now floating free of the bone.
Figure 2:
Clinical appearance of case 2. A, Clinic examination appearance of the right transtibial amputation residual limb. Gross appearance does not show any superficial skin irritation. B, Intraoperative photograph demonstrating removal of the subcutaneous bursa before removal of the internal fixation screw.


Case 3 is a 46-year-old man who had severe open fractures to the left distal tibia, fibula, and talus. He had a reverse sural artery pedicle flap for definitive soft tissue coverage of his open wound. Unfortunately, because of the serious nature of his injuries, he developed painful chronic osteomyelitis. Although he went through several months of pain control and attempted eradication of his infection, he eventually elected to proceed with modified Ertl transtibial amputation, which was performed in May 2004.

The patient was very active before his injury, and postsurgically, he returned to construction work with his prosthesis. Approximately 3 months after his surgery, however, he began having irritation at the distal lateral aspect of his left residual limb. He continued with this pain and irritation for 19 months and had his left prosthesis revised three times in an attempt to remove the perceived external irritating area in his prosthesis. Upon presentation to the orthopedic surgeon, physical examination was significant for a painful ulceration located over the distal lateral aspect of his residual limb, and the area appeared to be infected. Radiographs showed prominent hardware at the distal lateral aspect of the tibia. In December 2005, he underwent debridement and removal of the internal fixation screw at the distal lateral aspect of his fibula. His wound healed without incident at this time, and he returned to the use of his prosthesis without pain until his death in 2011.


Case 4 is a 36-year-old man who sustained isolated left lower-limb trauma in 2007. Because of his young age, salvage of the limb was attempted but failed, and he underwent modified Ertl transtibial amputation (Figure 3). The patient healed uneventfully and had a left lower-leg prosthesis fitted 1 month postoperatively. He functioned with this for several years without difficulty.

Figure 3:
Immediate postoperative anterior-posterior (A) and lateral (B) radiographs of the left lower limb in case 4. The fibular strut graft is properly fixed with a transosseous screw placed from lateral to medial.

This patient started having irritation to his distal lateral residual limb in 2013. Similar to the previous cases described, he presented to his prosthetist for evaluation and refitting of his prosthesis; the prosthetist then referred him to the orthopedic surgeon for evaluation. Physical examination was significant for painful bursa formation over the distal lateral fibula, and office radiographs showed distal resorption of the fibular strut graft (Figure 4). The patient was scheduled for excision of the bursa and removal of hardware, which occurred in March 2013.

Figure 4:
Anterior-posterior (A) and lateral (B) radiographs of case 4, five years after modified Ertl with internal fixation. There is solid osseous incorporation of the fibular strut graft bridging the tibia and the fibula. Resorption of the most distal aspect the fibular strut graft has occurred, and the screw head is prominent at the distal lateral aspect of the residual limb.


The Ertl transtibial amputation modified with a fibular bone block and internal fixation is an established and accepted method of creating a stable arthrodesis between the tibia and the fibula.2,4,8,9,11 Postoperatively, a patient is usually followed closely for the first several months, during which time most complications occur.12 Once osseous and soft tissue healing are obtained, patients are referred to the prosthetist for fitting of a prosthesis. At this point, patients often have only intermittent follow-up with the orthopedic surgeon. Soft tissue breakdown and pain can occur during this time, but these complications are generally relieved with modifications to the prosthesis.13 However, late complications specific to the Ertl procedure exist, and all healthcare providers involved in the care of these patients should be aware of these problems.

We presented four patients who underwent modified Ertl amputation with internal fixation of the fibular bone block (Table 1). Many months to years after the operation, the hardware became prominent and resulted in soft tissue irritation in all four patients. At presentation, the only healthcare providers following up on the patients were their prosthetist and primary care physicians. Initially, the prosthetists believed it to be caused by a badly fitting prosthesis. Despite repeated attempts at relieving external pressure on the area, one patient developed an infected bursa and one patient developed an enlarging painful bursa. In reality, the primary problem was internal and due to prominent hardware.

Table 1:
Reason for amputation and time course from amputation to presentation with soft tissue irritation from hardware

Generally, patients with diabetic neuropathy will present with irritated or ulcerated soft tissues but not necessarily pain. This poses a risk for infection, prolonged wound care, and prolonged time in which they are unable to use the prosthesis. In the case of amputation done for late sequelae of trauma, the patient is more likely to have sensation and will present with pain over the hardware. In both types of presentation, a plain radiograph should be obtained as part of the evaluation.

Every patient is a dynamic individual, and after their surgical wounds heal, these patients will likely interact with numerous healthcare providers such as their family physician, prosthetist, physiatrist, and physical therapist on a more frequent basis than the orthopedic surgeon. For patients who underwent the Ertl transtibial amputation and experienced distolateral residual limb irritation, a plain radiograph should be obtained as part of the evaluation. The delay in diagnosis in these cases resulted in prolonged attempts at socket adjustment, higher costs associated with repeated visits to the prosthetist, and the increased health risks related to infection and antibiotic use. Obtaining radiographs in these instances will prevent a delay in diagnosis and possibly provide a solution to the problem.


Healthcare providers should be aware that many transtibial amputations with distal tibiofibular fusion are performed with internal fixation. This technique is known as the modified Ertl transtibial amputation. Patients who have undergone the modified Ertl amputation may present far after their transtibial amputation to any one of the many healthcare professionals involved in an amputee’s care. Late prosthetic socket-fitting problems including painful bursa, skin irritation, or ulceration at the distal lateral aspect of the residual limb can occur as the limb matures and the hardware becomes more prominent. These patients should be referred to the orthopedic surgeon for evaluation and radiographs of the limb as a first step in evaluating the source of the soft tissue irritation because removing the hardware provides a potential solution to this problem.


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Ertl; transtibial; amputation; complication; irritation; residual limb

© 2013 by the American Academy of Orthotists and Prosthetists.