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Comparison of Functional Outcomes Following Bridge Synostosis with Non-Bone-Bridging Transtibial Combat-Related Amputations
CDR(Ret.) John J. Keeling, MD, MC, USN1; LTC(P) Scott B. Shawen, MD, MC, USA1; CDR Jonathan A. Forsberg, MD, MC, USN1; LTC Kevin L. Kirk, DO, MC, USA2; LTC Joseph R. Hsu, MD, MC, USA2; CDR David E. Gwinn, MD, MC, USN1; MAJ(P) Benjamin K. Potter, MD, MC, USA1
1 Department of Orthopaedics, Walter Reed National Military Medical Center, America Building (Bldg 19), 8901 Wisconsin Avenue, Bethesda, MD 20889. E-mail address for B.K. Potter: kyle.potter@us.army.mil
2 Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234
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Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Army, Department of Defense, or the U.S. Government. We certify that all individuals who qualify as authors have been listed; each has participated in the conception and design of this work, the analysis of data, the writing of the document, and the approval of the submission of this version; that the document represents valid work; that if we used information derived from another source, we obtained all necessary approvals to use it and made appropriate acknowledgements in the document; and that each takes public responsibility for it. Nothing in the presentation implies any Federal/Department of Defense/Department of the Navy endorsement.

Investigation performed at Walter Reed National Military Medical Center, Bethesda, Maryland, and San Antonio Military Medical Center, Fort Sam Houston, Texas

Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 May 15;95(10):888-893. doi: 10.2106/JBJS.L.00423
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The prevalence of penetrating wartime trauma to the extremities has increased in recent military conflicts. Substantial controversy remains in the orthopaedic and prosthetic literature regarding which surgical technique should be performed to obtain the most functional transtibial amputation. We compared self-reported functional outcomes associated with two surgical techniques for transtibial amputation: bridge synostosis (modified Ertl) and non-bone-bridging (modified Burgess).


A review of the prospective military amputee database was performed to identify patients who had undergone transtibial amputation between June 2003 and December 2010 at three military institutions receiving the majority of casualties from the most recent military conflicts; two of those institutions, Walter Reed Army Medical Center and National Naval Medical Center, have since been consolidated. Short Form-36, Prosthesis Evaluation Questionnaire, and functional data questions were completed by twenty-seven modified Ertl and thirty-eight modified Burgess isolated transtibial amputees.


The average duration of follow-up after amputation (and standard deviation) was 32 ± 22.7 months, which was similar between groups. Residual limb length was significantly longer in the modified Ertl cohort by 2.5 cm (p < 0.005), and significantly more modified Ertl patients had delayed amputations (p < 0.005). There were no significant differences between groups with regard to any of the Short Form-36 domains or Prosthesis Evaluation Questionnaire subsections.


The modified Ertl and Burgess techniques offer similar functional outcomes in the young, active-duty military population managed with transtibial amputation.

Level of Evidence: 

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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