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Operative Complications of Combat-Related Transtibial Amputations: A Comparison of the Modified Burgess and Modified Ertl Tibiofibular Synostosis Techniques
LT Scott M. Tintle, MD1; CDR John J. Keeling, MD1; LCDR Jonathan A. Forsberg, MD1; LTC Scott B. Shawen, MD1; LTC(P) Romney C. Andersen, MD1; MAJ Benjamin K. Potter, MD1
1 Orthopaedic Surgery Service, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, America Building (19) – 2nd Floor, Bethesda, MD 20889. E-mail address for B.K. Potter: kyle.potter@us.army.mil
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at Walter Reed National Military Medical Center, Bethesda, Maryland
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, Army, Department of Defense, nor the U.S. Government.

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Jun 01;93(11):1016-1021. doi: 10.2106/JBJS.J.01038
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Abstract

Background: 

The complications of bone-bridging amputations remain ill defined. The purpose of this study was to compare the early and intermediate-term complications leading to reoperation between the modified Burgess and modified Ertl tibiofibular synostosis in combat-related transtibial amputations.

Methods: 

We conducted a retrospective review of consecutive, contemporaneous cohorts of thirty-seven modified Ertl bone-bridge and 100 modified Burgess combat-related transtibial amputations. The primary outcome measure was the need for reoperation following definitive closure.

Results: 

At a mean follow-up of two years (range, nine to forty-eight months), there was a 53% overall reoperation rate. The overall complications included infection (34%), neuroma excision (18%), heterotopic ossification excision (15%), myodesis failure (4%), and scar revision (7%). A significantly higher rate of overall complications (p = 0.008) was noted in the bone-bridge group. Additionally, there was an increased rate of noninfectious complications in the bone-bridge group (p = 0.02). A positive selection bias was also noted for performing bone-bridge amputations late (p = 0.0002) and outside the zone of injury (p < 0.0001). Bone-bridge-specific complications occurred in 32% of the modified Ertl group. Delayed union or nonunion of the synostosis (11%) and implant-related complications (27%) predominated. Three bone bridges were ultimately removed.

Conclusions: 

Reoperations were needed at a significantly greater rate overall and for noninfectious complications following bone-bridge synostosis compared with modified Burgess transtibial amputations. Additionally, despite the positive selection bias favoring the bridge synostosis cohort, infection rates were not lower in that group. Detailed patient counseling and careful patient selection are indicated prior to performing modified Ertl amputations, particularly in the absence of convincing evidence regarding objective functional benefits from the procedure.

Level of Evidence: 

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

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    References

    Accreditation Statement
    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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