Q: From Several visitors

General Topic:

Do you know of a surgeon in my area

Submitted:

Numerous Times

I live in an area where you don't have any surgeons listed on your web site?  Are their any near me?

A: From Webmaster:

We currently have listed most all the surgeons as performing complete Ertl Procedures, or variations thereof, as opposed to  modified or partial procedures.  

The Barr Foundation does have  DVDs available through their donation site that could be obtained and shared with surgeons in your area for them to review.  Many surgeons, whom were not previously familiar with the "Ertl",  have reported that they were efficiently able to perform the procedure upon reviewing the film beforehand and or while, viewing the dvd in the operating room.

New surgeons are being added to the Ertl Surgeon  link every day.

Q: From Kimberly:
 
General Topic:
Bursa Sack

Submitted:

August 2005

Hey Dan and everyone else, I have yet another question to throw out there at all of you experts. I had my BKA in May 2004, I am up and walking, running and other things that I probably shouldn't do... However, I have been seeing my ortho doc, I guess that I have developed a bursa sack at the tip of my Tibia, at the amputation site. My doc says that I am the only person he has ever seen that has had this happen, through thousands of amputations. Well I guess these sacks should go away over time but mine seems to like me and has, over time, increased to the size of a golf ball and getting bigger. So, when you look at my leg, it looks fine , till you hit the end of the stump, then there is this HUGE lump at the end, that is fluid filled, sounds attractive doesn't it? Anyways, they are going to go in this Friday, 10-01, and remove it and re sew up the muscles that have loosened because of this. I guess what I really want to know, am I just the freak of nature that I think I am, or has anyone else experienced this? Any help would be appreciated.

A: From Dr. W.Ertl:

Kim, I am William Ertl MD, Tony Barr had forwarded you inquiry from Dan to Jan Ertl and myself. I hope I can provide some insight into your question(s).

A bursa sac can develop over the end of a prominent object after it gets irritated. This can occur in natural, uninjured, non-amputated joints. In amputees, sometimes the distal end of the tibia gets very prominent, irritated and the bodies response can be to form something, anything, to protect that area. At times, a bursal sac will develop. This is essentially a fluid filled area are inflammatory fluid from chronic irritation of that area. The exact mechanism, to my knowledge, is not entirely understood. But the end result is a frustrating situation for the patient.

A possibility of why this occurs is the chronic movement between the tibia and fibula when these are not stabilized. Bridging the tibia and fibula can prevent this chronic movement and hopefully diminish or remove a source of irritation. Further, the end of the limb can now become end-bearing allowing the amputee bear weight on the end of their limb and utilize the remainder of their residual limb to support the prosthesis. Essentially, the prosthesis can then become an extension of the residual limb instead of some place to put a prosthesis.

When there are no complications, the recovery from the Ertl procedure can be about 6-7 weeks until you get into your first socket and most likely a prepatory prosthesis. Of course, pain can be multi-factorial, such as in decreased bone density, neuromas, poor soft tissue balancing, etc. So the surgeon has to be sure of all causes of pain.

I hope that this has been helpful or at least a start of answering some questions.

Q: From Rachel:

General Topic:

Bone Growth in the muscle

Submitted:

December 2005

My son lost his leg from severe crush syndrome from a motorcycle accident. He has an above knee amputation. The top of his leg looks good but he lost alot of the back of his leg. There is alot of calcification which causes the the thin skin grafts to be unstable. He can't get a prosthetic until this is resolved.

The doctors we have seen don't really know what to do. One plastic surgeon said he might be able to do some reconstructive surgery but alot of the calcification would need to be shaved off first.

Can you give me any information on possible ways to correct this problem or who the best doctors to evaluate his problem?

A: From Dr. W.Ertl:

Rachel, sorry to hear that your son had a horrible injury. It sounds as if he has developed heterotopic ossification (bone growth in the muscle). I would suggest that he undergo an CT scan to determine the extent of the heterotopic ossification. It is not uncommon for traumatic amputees to develop this in their traumatized limb. If the heterotopic ossification is not allowing him to use a prosthesis, then it should be excised/removed. His limb will require a reconstruction. With an Ertl procedure, his limb would hopefully be end-bearing and allow him to apply a prosthesis giving him the ability to ambulate. Without seeing X-rays, CT scan and the limb, it would be hard to assess the extent of the surgery.

This is just a brief answer to a complicated situation. Ideally, he will require a complete evaluation to determine the extent of surgery.

Q: From Adam:

      (CP)

General Topic:

Rehab Protocol

Submitted:

January 2006

I am trying to provide the physicians in my area with a rehab protocol.  There seems

to be a grey area regarding immediate post operative procedure.  Since immediate weight bearing

is contra-indicated for the Ertl Procedure, is a rigid cast the recommended post op procedure

or can a protective device such as the Flotector be implemented?  Is complete isolation of the

residual limb required for control of adema or can the same results be achieved with a removable

device?  What are most prosthetists providing and why?

A: From Raymond Francis, L.C.P.

There are generally three schools of thought. One school of thought described and used mostly by Dr. Jan Ertl is to use soft dressings and "ace"  bandage type of compression on the residual limb for six weeks before any weight bearing.  I have had the privilege of attending some lectures with Dr. Jan Ertl and have been a co-speaker with him in presenting the rehabilitation protocol, I covering the Prosthetists' responsibilities. In my practice I use what we could call the second school of thought. I always use an Immediate Post Operative Prosthesis made of synthetic casting material with a pylon and prosthetic foot attached.  I do not allow any weight bearing on the newly amputated limb.  However,  I will allow the patient to "touch down" on the prosthetic side when standing still just to give a little extra balance to the patient.  The patient continues using an "I.P.O.P." as described above, for six weeks.  I change the "cast"  weekly to maintain a good snug containment especially of the distal end.  The purpose is to keep a good alignment and relationship of the Tibia and Fibula while the bone bridge is forming callous and/or healing. At the end of the six week post operative time frame and if good callous formation is confirmed by x-ray, I fit the patient in a standard total surface weight bearing socket type of transtibial prosthesis and start weight bearing as comfortably tolerated.  If Physical Therapy is needed for gait training it is initiated at this time.  Dr. Jan Ertl has said that if he had at his disposal a Prosthetist that was available to provide what I am calling the second school of thought, he would consider using that approach. The third school of thought is to use something like the "Flotec" type of prosthesis and allow the patient to remain in such a device for six weeks.  My concern is that while it allows the patient and others to remove the prosthesis and/or dressings for continued inspection it also allows the Fibula and Tibia to move without any restriction, thereby allowing the possibility of movement of the newly forming bridge.  In my opinion, this opens the door to possible damage and/or undo stress on the bridge.

Additional information from Jan & Will Ertl:

Q: From Jerry:

General Topic:

Blood Supply and possible revision

Submitted:

January 2006

Dear Sir,   I have read alot of articles about your procedures.  I have PAD. I had my right leg amputated on July 2003 the first time half way between knee and ankle. The bone kept deteriorating causing 3 more amputations. The last one was Oct 2004.  I was constantly in pain on an 8 scale. The last surgery a different doctor took it off at the knee. He was afraid to cut the knee bones so the knee is in tact including the knee cap. The bones before completely deteriorated before. I still have so much pain in the soft tissue under the knee cap, especially when sitting or moving around. I have a C leg but can't wear it because of pain when I sit or stand. Looking and talking with others on chat line finally this past month, I wonder if it the nerves and tendons now in let thats causing all the pain. When I scratch my outer skin under my leg from hip to the stump I can feel the tingle in my stump. When I push in on the soft tissue under the knee I get alot of pain. I am neurotin and methadon for 1 on half years now.  Some this week said the new medicine Lyrica was much better.  I did not know about you until two weeks ago.  Duke Hospital has been doing all this surgery until the last surgery . Did the bone in the leg keep decaying because no veins or arteries were attached?  Like now I have no blood arteries going to end of stump. MRA shows main artery stops 6 inches from end of stump. Doctor  at Duke said it can;t fix,  Said there might be on injection out now that might make blood cells grow at end of stump. I am really confused.  He said he didn't know where to have this done. Please give me some answers. Thank You Jerry Poston  I also have tubes in my left leg do to clogging. And in my Grion and a tube off my Aorta leading to my right leg. No one can find out why my blood clogs up. I am not a diabetic they say. Blood has been tested, sent away and tested and more test. No answer yet. HELP

A: From Jan Ertl & Will Ertl

The problem appears to be vascular occlusion. A bypass has been attempted and appears to have failed. There is apparent collateral circulation maintaining viability of the extremity.

The pain source is multifactorial. 1) nerve pain 2) vascular pain.

Surgery is not without risk in this patient as he has already experienced difficulty in healing due the decreased blood supply. pain may not be completely resolved through surgery, and the alternatives are already known, ie medications, inability to wear prosthesis and persistent pain. 

I believe that the nerve pain can be addressed surgically with excision. Osteomyoplastic reconstruction can be performed depending on the condition of the soft tissue. This may lead to improved vascularity and possible improvement in function. The kneecap may also be a source of pain depending on the location, and may also be removed. Prosthetist input, evaluation and recommendation is also very important and should be incorporated into the treatment plan.

The risks of surgery are necrosis and possible loss of further limb and persistent pain.

jan & will ertl

Q: From Alan

General Topic:

Recent "long flap" amputee with pain

Submitted:

January 2006

I had a below the knee limb removed on 5/22/05 (question posted on 18 Jan 2006). The procedure took all of 40 minutes. There has always been pain and discomfort even with the requisite number of stockings. Constant use of the prosthesis created a painful protrusion approximately 1/2" high, measured, above the skin which appears likely to burst through the skin should I continue to wear the prosthesis. It is immediately below the tibia. My attending surgeon suggested a pad below the stump.

A: From Dr J.Ertl

From the description, it sounds as though Alan has atrophy and retraction of his posterior muscle group, or even detachment from the bone. This would expose the distal end of the residual tibia , leading to  prominence and pressure against the prosthesis and subsequent bursa formation, irritation and swelling...and pain. Pain is multifactorial and my feeling is that neuromas and exposed bone are an additional source of pain.

The pain sound like a potential neuroma. The protrusion almost sounds like a blister. Again, a thorough exam looking at the stability of soft tissues, length of the limb, X-rays, would be important to determine how this should be approached.

Q: From Tim

General Topic:
Symes to BKA

Submitted:

January 2006

I have been a symes amputee with much success and no problems for the past seventeen years.  I am a very active person.  At present I am facing further amputation( BKA) due to soft tissue ulceration issues. The Ertl procedure was recommended to me by a person who has had it done by your office in California. My question is therefore should I have this procedure done at the time of my new amputation and are there any surgeons in the Northeast ( I live in Maine ) that perform this?  Any information or suggestion would be greatly appreciated!

A: From Dr W.Ertl

Certainly, revising your amputation to an Ertl BKA is an appropriate alternative. Yes, it can be done at the time of  your conversion from a Syme’s to a BKA. My brother, Chris Ertl is in Connecticut. There are other surgeons who are listed on the web-site who in New York. The goal is to provide you with an end-bearing residual limb the can improve your daily quality of life.

Q: From Dan

General Topic:
Studies on Volume Change

Submitted:

January 2006

Has there been a study done yet to the effects of the procedure in regards to Volume change? I experience zero volume change and know that I am unusual in this regard. Other than weight loss and training I have after the first year always maintained the same volume during the day. Are other ertls the same? I was casting a bk that also is on  Dialysis and see big daily changes and it got me thinking. Also to what that I never used a shrinker Per Will's instructions has to do with my stability of volume?

A: From Dr. J Ertl

What we have noticed with traditional/posterior flap amputations with open medullary canals, is the significant amount of volume changes that occur in the first post operative year.  The size of the post-operative limb is due to the bleeding from the medullary canal and post-operative soft tissue manipulation.  The volume changes that occur are due to resorption of the blood and atrophy of the muscle group aided by the stump shrinker.  The Ertl osteomyoplastic reconstruction closes the medullary canal (Bone Bridge) and the myoplasty stretches the muscles over the bone bridge and gives them an attachment site, reestablishing and maintaining a length tension relationship. By doing this the muscles are able to generate force/ power and can maintain contour and volume and in some instances increase volume. Therefore we do not like using the shrinker as it works against what we are trying to achieve.

The shape of the extremity is also important and adds to volume issues.  A cylindrical residual extremity is broader than the conical residual amputation extremity and allows for a broader surface area for weight bearing.  Jan Stokosa  CP  has performed volume measurements and demonstrated an actual increase in residual extremity volume.

Hence the diagnosis of the Inactive Residual Extremity Syndrome (IRES), for which we operate, in attempts to reverse this atrophying trend and allow the extremity to actively participate in ambulation.

Q: From Mike

General Topic:
Phantom & Stump Pain

Submitted:

January 2006

I have a residual limb (2 1/2 inches) with phantom pain and stump pain.  I have very little range of motion in my knee which causes me a lot of problems.  Some of this is due to 4 inches of redundant tissue.  I have read about the Ertl surgery and it sounds like it would be of great benefit to me.  With this limited range of motion I can't bend down, walk up steps, get into a vehicle without a lot of problem, even walking to where you have to step over anything with my right leg is virtually impossible without tripping. I would like to know if anyone performs this surgery closer to N.C., if not I would like some information on what I need to do to get an appointment to come and talk this over with Dr. Ertl.

A: From Dr W.Ertl

Not sure if there are any surgeons in the North Carolina area who have done an Ertl procedure or are doing the procedure. In Virginia, at the naval hospital, Dan Unger MD and his staff are performing the procedure on active military personal but not sure if he has a civilian practice.

One concern I would have is the amount of scar tissue causing your limited range of motion. Also, if there is the presence of advanced arthritis in the knee. Pictures of the limb and X-rays would be helpful to further give an opinion. As have said, limited range of motion is not ideal for an amputee.

Q: From Thomas

       (CP, FAAOP)

General Topic:
Neuroma Formations - revision needed?

Submitted:

February 2006

I have a patient with a conventional BK amputation--no beveling of the anterior distal tibia--poor neural resections resulting in neuroma formations in the distal pretibial area--hypersensitivity, etc.

Patient suffers also from kidney failure secondary to the systemic infection that resulted in the loss of his leg and fingers.  Goes to dialysis three x per week.

I have x-rays to forward to you if you would consider giving this patient advise whether Ertl revision is an option for him at this time.

A: From Dr W.Ertl

I would be happy to review the X-rays and any pictures you have of the patient if you have the patient’s permission to send me those things.

Note from Webmaster: Dr W.Ertl's contact info can be found on the Surgeon's page

Q: From Brad

General Topic:
Donor bone location after chemotherapy

Submitted:

February 2006

I am a healthy athletic 58 year old man who had osteogenic sarcoma in my left distal tibia. In October 2003, after successful chemotherapy, I had an allograph that bonded well, but the ankle joint became painfully arthritic, so I had a fusion done in April 2005. The fusion is failing and screws are breaking.

If I get an Ertl will it be necessary to take bone from my upper femur, or will the tibia be an acceptable donor? Do you know any doctors in Hawaii (where I live) or Seattle (where I have family) who do it?  Is an Ertl a straight-forward surgery.....If I had an Ertl done here in Hawaii by a good experienced surgeon who had not had special training in doing an Ertl, are there significantly increased risks? How long is the hospital stay with an Ertl, if all goes well? If I had it done away from Hawaii, how soon after the operation could I return to Hawaii? 

A: From Dr. W Ertl

Brad,

I am sorry for your diagnosis of osteogenic sarcoma. You have provided some valuable information regarding your past medical history and some of your surgical history.

I have several questions and will then explain, hopefully with some clarity, what I would recommend. I will also forward this to my cousin Jan Ertl, MD, for any additional input that he may have.

It sounds like you have a tumor diagnosis that sounds like it underwent chemotherapy and then surgery with an allograft. Is that essentially correct? Did your surgeons tell you that you had clear margins or that the tumor was sufficiently killed by the chemotherapy? Have you had any work-up lately to determine if it had recurred? What were the exact terms used to describe the osteogenic sarcoma?

To answer your questions:

1) No it will not be necessary to take bone from your femur to do a below-knee-Ertl. However, a thorough work-up prior to surgery would be required to determine if a below-knee-amputation can be done. That would include a metastatic work-up for your sarcoma, tests to determine the oxygen content in your leg, and a complete physical exam.

2) I do not know of any surgeons in Hawaii who perform this procedure. One surgeon in Seattle has done some but do not know his case load.

3) An Ertl procedure is straight forward for those who perform them. The procedure takes a little longer than a standard amputation that is performed currently. Surgeons who perform the procedure have probably read and seen the procedure performed. I can not predict what the risks of surgery would be for any other surgeon. I will educate my patients in terms of risks of infection, failure of wound healing, failure of bridge formation, and, in your case, risk of recurrence of tumor.

4) Length of stay in the hospital varies from patient to patient. In general, I tell patients that it is around 3-5 days based on pain control and ability mobilize. This is a very reconstructive procedure that requires about 48hours of regular pain medication as we do manipulate nerves, bone, muscle, etc. So after surgery, you will need a concentrated effort for pain control. Now, that being said, every patient is different. I have had patients go home in 36 hours after surgery, and some needing up to 5-6 days in the hospital.

5) Patients who have come from out of state I ask to stay in town for a couple of extra days so that I can see their wounds prior to traveling back. When flying in an airplane, there are pressure changes with in the cabin and this can cause extra swelling of the limb. So I like to be able to see the patient prior to leaving the state to make sure their wounds are fine. In an ideal world, I would love for out of state patients to stay a week or two but that is probably not feasible in this day and age.

6) Timing of surgery is dependent on the surgeons schedule and the patients schedule. I try to accommodate patients as best as possible. When patients come from out of town, I try to gather as much information via mail, e-mail, fax, sent X-rays, etc, so that the consult goes smoothly and efficiently.

I know that this is a lot of information. What will help is a basic review of your medical history, current tumor status and recent X-rays for whomever will be taking care of you.

If there is anything else I can do, please let me know.

Dr.William Ertl

Q: From Steven

General Topic:
ERTL procedure and IPOP

Submitted:

February 2006

I am having a bka sometime within the next two months, left leg due to severe diabetic nueropathy.  I have been doing extensive research on aspects of the surgery, recovery and rehabilitation. I don't think my doctor is familiar with the Ertl.

My question is: I want to have the ERTL done and have a IPOP asap.  Are the two good choices together? Is there any information you could send my surgeon as to the surgery and benefits?  I live in CO, and feel really comfortable with my choice of surgeon, I would just like him to be aware of the Ertl.

A: From Dr. W.Ertl

In my practice, I do not employ the use of the IPOP. I have seen young and old patients struggle with it and I have not seen as much benefit with the use of the IPOP. I comprehensive post-operative plan is important for you the patient and the recovery of the limb.

In regards with the surgery, I would be happy to speak and/or write with your surgeon if needed. He can contact me via the web-master here.

Q: From Gabrielle

General Topic:
ERTL Candidate w/ short limb below knee?

Submitted:

February 2006

I am a RBKA who is short limbed at 3 inches below the knee. I am also very small boned and little body fat.  I had the amputation two years ago and have had alot of bone pain when I walk very much. Also have a lot of nerve shocks and nerve sensitivity in several areas of the stump. After six prothetics, I am finally in one that seems to be the best. I am not getting sores or skin break down and am in the top of the line foot and rotator. I am also in a flex suspension socket. So I don't think its the prothetic causing the pain and so forth.

I have been reading up on the ertl procedure and have talked to a few amputee's who have had it. But I have been told that my being short limb may cause me not to be a candidate for the procedure. Is this accurate?

A: From Dr W.Ertl

The short answer is no.

I have been able to salvage numerous limbs that were amputated quite short and provide the patient with an end-bearing limb. A complete evaluation is necessary to provide you with an accurate opinion.v

Q: From William

General Topic:
Throbbing pain

Submitted:

February 2006

I am an AK secondary to a shotgun blast. I have a long residual limb.  I have terrible pain that pulses with my heartbeat.  It starts low then increases to a level that contracts my whole leg and sometimes curls up my whole body.  I take 130 mg of Methadone per day to combat this pain. 

Is it possible that my sciatic nerve is next to my artery and is causing this type of pain?  Also, I have a huge bone spur at the dystal, laterial portion of my femur.  Would this procedure likely reduce my pain and reduce the bone spur?

A: From Dr W.Ertl

Major trauma that results in loss of a limb can be a large generator of pain in an amputee. It does sound like that you have a neuroma most likely from your trauma. In patients with intense pain after a significant trauma, it is hard to predict the improvement they will receive from a revision. Further, in my experience, the improvement of pain is slower when compared to a non-trauma amputee. The bone spur does not help and the fact you have poor soft tissue stability does not help.

My first impression is that surgical revision may help, but a complete evaluation is necessary to give a concise opinion.v

Q: From John

General Topic:
Problems with prosthesis fitting non-Ertl limb

Submitted:

March 2006

I am a below the knee amputee operated on at the Palo Alto VA Hospital.

My Wife asked the orthopaedic surgeon if they did the Ertl Procedure and she was told " . . . our method is just as good! . . . " What I am asking is, is there any chance of having my leg redone using your technique. I am having all kinds of problems getting a prothesis to fit. I trust the prothetist as he has voluntarily told me of the many irregularities in my surgery results. I have Medicare.

A: From W.Ertl

As I tell all the patients that I see, the goal I have is to provide the patient with sound, stable, dynamic limb that can support a prosthesis and improve their quality of life. To give a complete opinion, pictures, a physical exam and a review of the X-rays are important. My hope is that yes a revision with the Ertl procedure would be beneficial but factors as length of the residual limb, integrity of the soft-tissue envelope, presence of neuromas, etc, are important to assess.

I hope we can provide with a complete answer.

Q: From Steven

General Topic:
Questions from an orthopaedic surgeon

Submitted:

March 2006

I am an orthopaedic surgeon and member of the Musculoskeletal Tumor Society and experienced with trans-tibial amputation.  I have been referred a patient with a poorly-done, painful BKA who, I believe will benefit from an Ertl procedure.  In my reading, I see that the Ertl procedure is appropriate for revision as well as primary amputation.  Although you state that a transtibial revision with Ertl can be done with about 2 cm bone loss, it is difficult for me how I can span the distance to the fibula without supplementary bone graft. 

In this situation, should I expect that bone-grafting will be necessary to bridge the gap between tibia and fibula?  Do you have any illustrations, drawings or case examples that I can draw from as I prepare for the procedure?

A: From W.Ertl

It all depends on the integrity of the remaining soft tissue envelope. If there is a fair residual length of the anterior, lateral, and superficial compartment, than you may only need to resect up to 2cm of bone to gain enough periosteum to create the osteoperiosteal tube between the tibia and fibula. I have harvested periosteum from the more proximal aspect of the medical side of the amputated limb to create the osteoperiosteal sleeve between the tibia and fibula. If you do not need to shorten the tibia an fibula much at all, I have also gone to the contralateral limb and harvested osteoperiosteal flaps from that limb to make up the bridge. Finally, the Graft Jacket from Wright medical is another option as a periosteal extender. I have used this on a few patients and it does seem to support bone in growth. I would be happy to provide you with examples of any of these scenarios.

Q: From Betty

General Topic:
Revision to AK due to bone spur

Submitted:

April 2006

I am an AK secondary to a shotgun wound 9 years ago which left me with little muscle and my femur appears to be free floating and I am not sure how much muscle remains to be attached.  I have a bone spur on the end of my femur which causes piercing pain with each step.

Would your procedure help me without shortening my residual very much?

A: From Dr W.Ertl

It does sound as if though you have an unstable residual limb. Your description is very common from an amputee who have an unstable soft tissue envelope. The fact you have a bone spur is most likely the result of your surgery and/or trauma. The goal of the Ertl procedure is to provide you with a stable, end-bearing limb so that you can support a prosthesis and improve your quality of life. A complete physical exam of the limb and a review of X-rays would be ideal to give you a complete opinion of whether you would benefit from a revision. I can not say without seeing your limb how much if any your limb may need to be shortened.

Q: From Roger

General Topic:
Long AK limb with limp

Submitted:

April 2006

I have a question, I am an AK almost 3 yrs now due to a motorcycle accident. I am 44 yrs old male and in average shape, My limb was left a little too long and I have problems fitting different components. But I have been going thru physical therapy to get more strength out of my limb. My physical therapist has told me I am at the point that I can not get any more strength due to the muscle will flop around the femur giving me pain when in flops back and forth.

When I walk I have a very noticeable limp due to the femur moving back and forth. My prosthetist has told me that I am at the top 10% of what an AK can do right now. My therapist has told me that I am at about 60% of where someone my age and health should be at. He has told me about the Ertl procedure and what he feels it will give me.

I work as an electrician in the shops doing maintenance work, getting up and down off the floor and climbing over the machines. My question will the Ertl reconstruction give me better control walking without a limp, and more strength due to the muscles are attached to the end of the femur. The big question is how much more gain will I get? And is it worth the time and effort to go thru the rehabilitating all over again?

I do not have any real pain in my limb or bone spurs. But I am concerned about how I will be in 10-15 yrs if I leave my limb as it is, or will it be a lot better for me in the long haul to have it done? Thank you for any information you could give me, or if you need any more information please feel free to ask.

A: From Dr W.Ertl

Your description basically tells me you have an unstable soft tissue envelope. I am glad to hear that you may not have any nerve pain, ie neuroma. The goal of the Ertl procedure is to provide you with an end-bearing limb, stable soft tissue envelope, a dynamic and well shaped limb that can accept a prosthesis  and improve your quality of life.

As with all patients I counsel, a complete exam of you, the limb, and review of the radiographs are required. I hope this gives you some answers to your questions.

Q: From Tony

General Topic:
Veteran needing an Ertl procedure

Submitted:

April 2006

I am 27 years old and I had the unfortunate situation of having a chondroblastoma destroy my talus bone. The tumor was so large, I was told that it had shattered the bone like an egg shell. I was given an ankle fusion, almost two years ago. The surgery did not take.

I was then informed that I could either try to have another ankle fusion or have an amputation. I decided to have the amputation. In that decision I came along the "ERTL" procedure, and I have to say it seems like the best decision. I then posed the questions to my doctors (I say my DOCTORS because I am doing this through the V.A. hospitals) unfortunately no doctor knows how perform this surgery and only one has heard of this surgery. I would very much like you assistants in finding a doctor near Indianapolis, Indiana that performs this surgery. I understand that you gentlemen are the best at what you do but I am unable to have either of you do the surgery due to V.A. billing situation. I also have no other forms of insurance. Do you know of any doctors near my area that perform the procedure for or through the V.A. system?

A: From Dr W.Ertl

I do not know of anyone in Indiana who performs the surgery regularly. You may try the VA in Ohio, possibly if there is one in Columbus, as Dr. Attilla Polka is in Columbus. I have privileges at the Oklahoma City VA hospital as our residents do rotate there and I have teaching responsibilities there. This may be an option.

Q: From Arien

General Topic: Symes needing a revision

Submitted:

April 2006

I have a Symes amputation at the end of my tibia and fibula.  I had bone spurs removed.  They left the fibula longer and it has snapped and will need surgery.  Is the Ertl Procedure an option for me?

I will be going to Metrogeneral Hospital in Cleveland Ohio, are there any surgeons there familiar with this procedure?

A: From Dr W.Ertl

I would say yes that the Ertl procedure is an option. However, a surgeon would need to evaluate your limb and review your X-rays. It may be necessary to get periosteal tissue from your other leg to complete a bridge if necessary.

I personally do not know of anyone in Cleveland who does that procedure. Brendan Patterson, MD, chairman of orthopaedic surgery, is an excellent surgeon, he may know of someone. Dr Atilla Polka is in Columbus, Ohio, I believe.

Q: From Brian

General Topic: Type2 Diabetic with plates and screws in ankle

Submitted:

April 2006

I am  a 48 yr male that severely shattered my L ankle almost 3yr ago.  I am type2 diabetes 8yrs, I am now 100Lb overweight (50Lb since surgery)  there were 2 steel plates installed and several screws driven to hold my ankle joint together, IN Addition to the plates. 

I have a bad history of wounds that did not heal but finally they closed over after both surgeries. (6 months ea), I still cannot walk without heavy use of cane and unbearable pain. Doctor wants to fuse my ankle, he says its very arthritic.  My concern is I would rather get it done and over with an ertl procedure.  I also have been tested poss for nerve damage to my first 3 toes and across top and bottom of foot, neurontin does not do much to benefit.  First surgery did not work, bone did not fill in after 1st  surgery.  After phy. ther. x-ray showed all screws in front plate were sheared off,  prompting another surgery with what is called op1 installation where bone did not fill in.

1 yr 3mo later i am gradually becoming less mobile that 2yrs ago.  i am just trying to find some one to understand and help get out of what i feel is a waste of time and get me back on my feet again.  IF NOT I FEAR FOR MY WIFE AND KIDS FUTURES..

A: 

not yet answered

Q: From Walter

General Topic: BK with differing lengths of tibia and fibula

Submitted:

May 2006

Doctors,

I am a 30 yr Army retiree. Lost my left leg in auto accident. BK with aprox 3.5 " tibia, aprox 1.5 " fibula. Constant stump pain; burning with steady, deep pain.

Questions:

(1) Would spinal stimulus implant help mask the pain effectively?

(2) is there a way to sever the nerves that transmit the pain yet retain mobility of my knee?

(3) would your procedure be the better approach?

I am 60 years old and in excellent health; highly active. Stubborn, "can do" attitude.

A: From Dr J Ertl

This is considered a short transtibial (BKA) Even with this amount of length an Ertl procedure can be performed and function increased. The pain has multiple sources and can be addressed with one surgery, and the knee will  be maintained and functional with motion.

I am not a proponent of spinal stimulation as it doesn't address the source of the pain.

Q: From Joyce

General Topic: BK recommended by surgeon ... other medical issues

Submitted:

June 2006

My orthopedic doctor has recommended a below the knee amputation on my left leg.

I have suffered for years with osteomylitis, bone fractures and now deformity in both the foot and ankle. I wear an AFO full time, which gives me only a slight increase in mobility with little relief from the pain. Although I am not diabetic, I do have steriod dependant asthma. I am 54 and over the last 30 years, I have experienced thinning of the skin as a result of  the now daily steriod use.

I have great pulses in my feet, ankles and legs and heal quite normally. Would I be a candidate for the ERTL procedure?  Are there any physicians in Atlanta, GA that practice this technique?  Does insurance cover this procedure?

A: From Tony Barr,

President of the Barr Foundation

My suggestion is that you first review all the amputee testimonials available on the Ertl Amputee link at www.ErtlReconstruction.com ,order the video to show to your surgeon, talk with AJ Johnson a Ertl amputee from the Atlanta area, who I’ve cc above .You would have to be evaluated for the procedure by a competent surgeon familiar with the procedure.

Be sure to also provide him with the ’suggested ‘  Ertl procedure surgical reimbursement codes also avail on the web site when you hand him the video.

Tony Barr

Barr Foundation

Q: From Warren

General Topic: How does one become an "Ertl Prosthetist"?

Submitted:

June 2006

I see a number of prosthetists listed on your site as "Ertl Prosthetists". What special qualifications do these people have that other prosthetists do not? How does one become an "Ertl Prosthetist"?

A: From Raymond Francis, L.C.P. 

As promised here is my attempt to clarify the things that a Prosthetist needs to know that is working with patients who have the good fortune to have received surgery as described by Ertl from those who have not.  Since there is nothing being done in the schools that teach Prosthetists   how to care for and manage amputees that have had their surgery done as recommended by Ertl, it becomes incumbent for the Prosthetist to learn on his/her own about the principals involved with this procedure.

First the Prosthetist must have a very clear understanding of the principles of a Total Surface Weight Bearing Socket.  It does not matter if the patient is a Transtibial or Transfemoral amputee. The very strict principals of Total Surface Weight Bearing must be adhered to.  I would like to point out as a lecturer to many Prosthetists that have come to our facility to attend seminars here there is a vast amount of confusion over the difference between the definition of Total Contact and Total Surface Weight Bearing.   Let me try and clear up that point right now.  The difference between the two terms is that a ”Total Contact socket“ touches the residual limb in all places but still indicates that there are areas of ”weight bearing“ and areas where there is skin contact but NO weight bearing. The ”Total Surface Weight Bearing socket“ is designed to distribute the patient’s weight EVENLY throughout the entire socket. There should be no areas that carry more of the patient’s weight then any other area.  This is very important to the transtibial amputee.

In prosthetics that are made for traditional amputations where the Ertl recommendations are not followed there is significantly more ”weight bearing“ carried at the proximal portion of the socket.  The attempt is to prevent the patient’s residual limb from bearing any weight against the distal circumference as well as directly on the end of the tibia or fibula.  These areas are usually very sensitive and painful to any type of compression.  The fibula does not respond well to any pressure that tends to direct the bone medially causing pain from the squeezing of the muscles and nerves that are between the tibia and the fibula. All Prosthetists are taught during their training years about this issue and the best way to manage it.  In transtibial amputations that are done following the Ertl recommendations this problem does not exists.  Since the tibia and fibula are joined at the distal end by an osteomyoplastic reconstruction procedure the distance between the two bones does not change and therefore does not impinge on the muscles and nerves. It is important for the Prosthetist to know and understand this principle of surgical reconstruction.  It is the Prosthetist that is going to design the socket for this patient and in fact he needs to establish a stabilizing force along side the reconstructed fibula.  This is exactly the opposite of what would normally be done for the traditional non-Ertl case.

Prosthetists should follow the example of surgeons.  If a surgical procedure is developed that is different from what is traditionally taught and practiced in the mainstream of surgery the surgeon wishing to use the new procedure will read any and all published information on the subject.  In the interest of providing no harm to the patient as well as desiring to have the most successful outcome for the patient, the non-experienced surgeon will usually contact the surgeon performing the procedure and they will communicate back and forth on a professional level.  If there are very intricate and technical procedures involved the experienced surgeon will often invite the non-experienced surgeon to observe the procedure being done so he can see first hand some of the subtleties of the surgical techniques. 

The Prosthetist that is designing a socket for an amputee that has undergone a procedure described by Drs. Ertl should have current x-rays of the patient’s residual limb.  It is important to see the finished shape of the tibia and fibula.  It is important to see if the edges of both bones are rounded or if the callous formation may have produced an ”irregularity“ in the healing process.  If there are any irregular callous shapes present they need to be accommodated for the socket design and fabrication.  Since the end goal in mind is for the patient to be able to bear weight equally on the distal end of the residual limb as they do throughout the entire socket the design of the shape of the distal portion of the prosthesis is quite critical. It usually is more ”square“ than is seen in the non-Ertl amputee’s socket.  Being familiar with the use of x-rays and the information that they offer the Prosthetist in socket design is often something that is best learned through instruction from someone that has ”been there before“.

It is highly desirable for the Prosthetist to observe an amputation preformed using the methods described by Drs. Ertl.  This gives insight to the care that is needed in the first six weeks post surgery.  The Prosthetist plays a very important role in guiding the patient during this healing process.  He/she sees the patient more than any other member of the rehabilitation team.  Whether a rigid or soft dressing is used, the Prosthetist is really the one who guides the patient during this time of healing. In that light, the Prosthetist has a serious obligation to ensure that he/she has gained all the knowledge that is available to assure the patient is going to have a successful outcome from the surgical/prosthetic experience.  Experienced Prosthetists that have been involved with this procedure have the same obligation to share and teach other Prosthetist about their experiences for the benefit of all amputee patients. 

Respectfully,

Raymond Francis, L.C.P. 

=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=

To be eligible to be listed on the Ertl Prosthetic Providers link at ErtlReconstruction.com, I must be able to have a brief telephone interview with at least one Ertl amputee you have successfully fitted. Because of confidentiality laws ,you as a the prosthetist, must ask the patient to contact me by telephone at 561-394-6514.

It would be ideal, but not mandatory, that the Ertl Amp be at least 30 days post fitting, be active and have access to e-mail.

Subsequent to a satisfactory interview and qualification, the prosthetist will submit, upon my direction, his company contact information and web site address for the listing.Unlicensed /non-certified prosthetists need not apply.

Tony Barr

Barr Foundation

Q: From Sherri

General Topic: Ertl procedure on a small child?

Submitted:

June 2006

Can the Ertl procedure be done on a young child? 

Does growth have any impact on the planning or execution of the procedure? 

Thank you.

A: From Dr W Ertl

Can the Ertl procedure be done on a young child?  Yes

Does growth have any impact on the planning or execution of the procedure? 

Not as far as we have seen when performed according to the principles laid out by Janos Ertl, MD.

Q: From Van

General Topic: Knee Disartic. with constant ache

Submitted:

Aug 2006

I am an AK with through the knee disarticulation, for three years.  I have contance stump pain. It is a constance ache. have tried all kinds of drugs, pain pills. from lortabs to nurotin, not found any thing that works, I have great socket fit and a c-leg, can't sleep, and just hurts , do you have any suggestions????

A: From Dr J Ertl

Depending on the level of the transfemoral (AKA) amputation, it sounds as though the pain is neurogenic in nature. Most likely the sciatic nerve, although there are the some smaller nerves at varying levels.

This could be addressed through surgical reconstruction with the Ertl procedure. Many patients, with similar symptoms, have obtained significant improvement and  discontinued their pain medication requirements.

Q: From Chris

General Topic: Ertl Procedure in London?

Submitted:

Aug 2006

Are you aware of any surgeons in London, UK that are qualified to perform the ERTL procedure?

A: From Dr J Ertl

I do not know of any surgeons in London whom have experience performing the Ertl Procedure but

I could perform the procedure there if the appropriate arrangements were made.

Perhaps you can consult with your orthopedic surgeon in London on that possibility.

Jan Ertl MD

Q: From Betty, RN

General Topic: Questions from a nurse

Submitted:

Aug 2006

Would this procedure be beneficial for a double amputee. i.e. aka and bka client ?

Please advise.

A: From Dr W. Ertl

I have treated several patients who were aka and bka bilateral amputees. These were "younger" patients, meaning that they maintained their motivation and persistence to participate in rehab and prosthetic care. The relative success will depend on the goals desired, the capability of the surgeon, the motivation of the patient and the overall clinical health of the patient. A thorough exam of the patient will be required. I can not speak for the insurance company but with proper surgical indications, the surgery can be justified. Amputees can still develop dvts. To answer the question of graft material would depend on the state of the limb. We have employed some allograft material and have been successful in constructing a bridge in BKA patients.

Q: From Chad, CPO

General Topic: Questions from a CPO regarding nerve pain

Submitted:

Aug 2006

I have a transfemoral patient - trauma post 3 years with remarkable nerve pain and unstable tissue routing in the residuum.  The local Ortho's want him to undergo a series of injections to the nerve (in the spine) and eventually an electrical stim unit surgically placed.  I am very skeptical that this will solve the true problem.  I think an Ertl revision may be of some assistance.  Please advise, and thank you. 

Note: J. Ertl performed an excellent revision on a transtibial patient of mine, now he is a member of the US paraolympic standing volleyball team.  Thank you in advance for all that you all do in this capactiy.

A: From Dr W. Ertl

It does sound as if at this time the patient has neurogenic pain, possibly from a neuroma and also may have a component of centrally mediated pain. A thorough clinical exam will be of help. An MRI can be done to assess the limb to determine the presence of a large sciatic neuroma. Post-traumatic amputees will have a higher incidence of chronic pain, therefore it is important to determine the exact etiology of this pain. Centrally mediated pain is a chronic condition requiring the expertise of chronic pain specialists skilled in the clinical area. A revision may be of help, but does require a complete exam, x-rays, possbibly and MRI.

Q: From Kay

General Topic: Approximate cost of an Ertl Procedure

Submitted:

Aug 2006

What is the estimated cost of performing the Ertl procedure as reconstruction of a transfemoral amputation?

A: From Tony Barr

The 'suggested'  reimbursement surgical codes for performing the Ertl procedure are listed at www.ErtlReconstruction.com

These are only 'suggested' codes which the Barr Foundation consolidated and which we are suggesting as possibilities for review.

The responsibility for accurate coding lies with the patient care facility and surgeon (office manager) to confirm the codes for their own use prior to submitting appropriate billing paperwork. These recommendations are open to revision and are provided as a starting point for research/determination of codes to use. They are also subject to changes to the alpha-numeric system. The above are "suggested" billing codes. Every case is unique and different.  There in not one exact pre-operative ICD-9 code for all amputees. All appropriate pre-operative codes should be verified by the appropriate coding department and link the diagnoses to the surgical codes.

The cost will vary from hospital to hospital, surgeon to suregon. Its been reported to me, from several patients recieving the Ertl, that the cost can range from $12,000 to $40,000 depending on the complexity of indivisual cases, whether it is reconstruction or primary, transfemoral or transtibial, complications re: neuromas, bone, nerve ending, reconstruction, etc.

Thats also the approximate range for the cost of a new prosthesis !

Ask your surgeon to research the codes for your specific case.

Anthony T. Barr

President

Barr Foundation

www.oandp.com/barr

Q: From Kristi

General Topic:

Special Instructions to CPs fitting Ertl Amputees?

Submitted:

Sept 2006

I don't find any documents on the website of the proper method of fitting an Ertl amputee with a socket.

Unfortunately, I don't have the luxury of traveling to see an experienced Ertl prosthetist, and am having a real problem with my socket fitting comfortably. I have constant swelling and pain at the knee, the bone on the outside of my leg (tibia head?), and my shin bone.

Jonathan Day, Prosthetist in Oklahoma, gave my prosthetist specific directions to put pressure at the end of my limb when making the mold for my socket. My prosthetist did this for the first "test" socket. Now, he just puts the plaster on, smooths it down and lets it dry. He hasn't put pressure at the end the last 3-4 sockets. Is putting pressure at the end of my limb and pushing it up an important step in making a socket for an Ertl amputee? If so, why?

Also, my prosthetist makes my sockets so that I'm bearing a lot of weight under my knee, which causes pain. I'm bearing some weight at the end, but I don't think it's enough. I told him I got the Ertl amputation so that I could bear weight. Everytime I go in to see him, I ask him to shave down the socket at the knee, because the pain it causes is unbearable for me. He balks at it, but does it for me anyway.  Because of this, I believe my limb sinks down deeper into the socket, which is what I want and it feels fine at the end of my limb, but the rest of my leg seems to be suffering. Could it be that  when my leg sinks down, it's causing my shin, tibia head and knee to fall into a different position in the socket than what was originally molded for these bones, causing pressure, swelling and pain in these areas, because he did not form fit the socket to allow for weight bearing?

I just paid $11,500 for a new prosthesis, which has a Renegade foot.  Unfortunately, I can't wear it much due to my socket discomfort. Not only that, I'm having pain in my sound foot, due to overcompensation. So, I need to do something to correct this problem, but can't seem to get it done.

Just wondering if someone can offer some advice I can pass on to my prosthetist. I'm ready to get on with my life and my sockets are keeping me from that. My limb is long, about 7 inches from the knee and I'm wearing a hard plastic socket.

Thank you for any help and advice and I hope this makes sense!

A: From Dr W. Ertl

and

Raymond Francis

Dr Ertl:
The goal of fitting an Ertl amputee, in general, is to provide them with an end-bearing, maximal surface bearing socket to maximize the capabilities of end-bearing that the residual limb can sustain. Every patient is unique in terms of shape of the limb, volume of the limb and stability of the soft tissues. It will take some experimenting, trial/error, with an inexperienced prosthetist to obtain this. I would defer specific instructions to prosthetists who a significant experience with Ertl amputees.

Raymond Francis:

A socket designed for a patient who has had the benefit of an Ertl style of amputation should be, and in my opinion, "must be" of a total surface weight bearing design.  Dr. William Ertl wisely makes mention of this in his comments below. The length of the socket as measured from the Patella Tendon "bar" to the distal end of the socket is quite critical. While I use a mild  (straight not "smiley face" shape) Patella Tendon bar in the socket I do not rely on, or intend the "bar" to be a major weight bearing area.  Nor do I expect the "bar" to prevent the patient from going lower in the socket as they experience volume loss. In a total surface weight bearing socket the residual limb is supported evenly throughout the entire socket.  As the patient experiences some volume changes in their daily activities, they just begin to have a little more weight bearing on the distal end. This is not distressful to the patient as their surgery was designed to accommodate this and most of them will tell you that they just feel a little looser in their socket and a little firmer on the distal end towards the end of the day.  Because there is no place in the socket for them to go, the shape of their residual limb continues to match the shape of the socket.  If they do not have good distal contact and they begin to have some volume loss throughout the day then their skeletal structure begins to be forced down into a part of the socket that does not match their anatomical shape.  The following result is usually pain.  I suspect that may be happening to this patient.  However, without seeing the patient, this is only my best GUESS.

As a side bar, I would humbly suggest that the patient ask her prosthetist to either make her a socket that she can wear comfortably or return the fees that she paid him for those services.  It is like buying a new car.  If it doesn't work the place that you bought it needs to either fix it; replace it or give you your money back. It seems to me that this world not be an unreasonable request.

Respectfully,

Raymond Francis  LPO

Q: From Tanya

General Topic:

Will Medicaid cover an out-of-state Ertl procedure?

Submitted:

Sept 2006

Hi my name is Tanya. I am 32 years old and have a BKA I grew up with an amputated foot at the ankle and 3 years ago doctors convinced me to get a BKA. 

Since then I have not been able to run nor work,  I am very depressed and want to find a way of getting the Ertl procedure done but my insurance does not pay for it it is medicaid and no one in kentucky where i live does it.  Do medicaid wont pay for it out of state.  If you could send me some info I would appriciate it.

A: From Dr W. Ertl

Each state, to my knowledge, has different rules regulating out of state coverage by Medicaid and Medicare. I would suggest that the billing department for your group or department first identify the state that is providing the coverage and inquire whether they will cover it or not. If not, then you or the group may need to "apply" to be covered by that state's system.

Q: From Chris

General Topic:

Ertl Procedure with screws and plates?

Submitted:

Sept 2006

I have recently had an BK amputation of my left leg.  After the amputation the wound got infected, so I was sent to get an MRI.  Upon seeing the MRI, I found out that the Ertl procedure was performed on me, and was happy to hear that being that I’m 22 years old and very active. 

My question is, to bridge the fibula and tibia screws and a plate was used.  I have not seen anything about this in the ErtlReconstruction website.  Is it performed in this way often?

A: From Dr W Ertl

This is a very general question so I can only answer pretty specifically. I would not recommend regularly using plates and screws to accomplish bony stability for below knee amputees and creating a bridge. There is a risk with stress shielding and bony resorption. This said, there is a modificaiton utilizing screws to provide early stability to a bone block. I would still recommend utilizing periosteal tissue to encompass the bony block or bone graft. The screw should probably removed once there is radiographic evidence of bony healing.

Q: From Bennett

General Topic:

No body knows about the Ertl procedure?

Submitted:

Sept 2006

I have RSD of my right foot and I'm looking for a doctor that is fluent with the ERTL procedure.   

When I loose my leg I just want to be in comfort.  But it seems that no body knows what I'm talking about. 

Please contact me back.

A: From Tony Barr

The Ertl Procedure is not new.In fact its application has provided positive outcomes and benefits for amputees since World War 1 .

The obstacles, in gaining full acceptance is

    1) it  normally is a 3-4 hour procedure to perform correctly 

    2) approximate reimbursement for a standard amputation is less than $1200.00

    3) the lack of public awareness

We have provided on the ErtlReconstruction.com. web site 'suggested'  reimbursement codes that generate between $10,000 -$15,000 for surgeons reimbursement to perform the procedure and Ertl intro and surgical DVD videos as visual aides for both patients and physicians.

Many surgeons have reported that they have been able to perform the procedure successfully upon viewing the surgical video.

My suggestion is that you review all the links on ErtlReconstruction.com. share that information and the 'suggested' reimbursement codes with your physician, and order the videos (tax deductible donation).Most all the surgeons listed on the Ertl Physician list would be happy to discuss the benefits further with your surgeon.

There are approximately 30 physicians, (listed on ErtlReconstruction.com ) whom are routinely performing the procedure.That list is growing everyday as the Barr Foundation, patients, prosthetists and surgeons promote the benefits of the Ertl to achieving positive prosthetic rehabilitation outcomes. .

Anthony T. Barr

President

Barr Foundation

www.oandp.com/barr

Q: From Dr. NDR

General Topic:

Questions from another surgeon: age and fusion?

Submitted:

Nov 2006

I am a Trauma & Orthopaedic surgeon with a limb reconstruction interest who has been getting an increasing number of trans-tibial amputees referred for revision.  Have been doing your technique for a few years.  2 questions:

1.  What is the youngest patient you have done?  Any contra-indications to your methods for very young patients?  Any specific advice?  (Have been referred a 5 year old girl, bilateral TTA from meningococcal septicaemia aged 2.  Very mobile.)

2.  None of your technique papers describe your ideal level for "fusion" of the fibula to the tibia.  Any pearls of wisdom please?

Thank you

A: From Dr W Ertl

What is the youngest patient you have done?  Any contra-indications to your methods for very young patients?  The youngest child I have operated on was a congenital amputee born with a transtibial amputation. He continued to have terminal overgrowth after creating an "autobridge". I removed the terminal overgrowth and covered the end of the bridge with perioteum to effectively cap the bridge. He was two years old at the time of revision and at 2 years post op, has not recuured terminal overgrowth.

Any specific advice?  (Have been referred a 5 year old girl, bilateral TTA from meningococcal septicaemia aged  two .  Very mobile.) The specific advice would be to still adhere to the principles of utilizing periosteal tissue to form the foundation of the bridge. When possible, I will utilize portions of blocks of fibular incorporated into the periosteal sleeve as a source of autogenous bone graft, hopefully hinged on vascularized periosteum. Further, soft tissue reconstruction and stabilization using a myoplasty to provide distal coverage and anchorage of all muscle groups is still important. For the 5y/ogirl with meningococcal septicemia, she will frist need non-invasive studies to determine the potential of surgical wound healing. I would assume this far out from her sentinal event, the vascularity is probably fine. A good physical exam of the quality and quantity of the remaining soft tissue envelope is paramount as this will also guide you to the appropriate level of amputation. Quality radiographs, A/P, lateral, and internal oblique, are important to see what the quality quantity of the bony structures remain. Then a complete plan presenting all! options should be reviewed, including the potential for higher amputations to provide functional limbs for prosthetic fitting. What I can't tell from the question is the length of the residual limbs and