title: Operative complications of combat-related transtibial amputations: a comparison of the modified burgess and modified Ertl tibiofibular synostosis techniques.
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.
authors.affiliation: Orthopaedic Surgery Service, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, America Building (19)-2nd Floor, Bethesda, MD 20889, USA.
authors.forename: Scott M
authors.initials: SM
authors.lastname: Tintle
authors.forename: John J
authors.initials: JJ
authors.lastname: Keeling
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Forsberg
authors.forename: Scott B
authors.initials: SB
authors.lastname: Shawen
authors.forename: Romney C
authors.initials: RC
authors.lastname: Andersen
authors.forename: Benjamin K
authors.initials: BK
authors.lastname: Potter
mesh_terms: D000671:Amputation, Surgical / Q000009:adverse effects* / Q000379:methods*; D001753:Blast Injuries / Q000601:surgery*; D005360:Fibula / Q000601:surgery*; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D009999:Ossification, Heterotopic / Q000209:etiology* / Q000601:surgery; D011183:Postoperative Complications / Q000601:surgery; D012086:Reoperation; D012189:Retrospective Studies; D013530:Surgical Wound Infection / Q000209:etiology* / Q000601:surgery; D013977:Tibia / Q000601:surgery*; D016896:Treatment Outcome; D014857:Warfare; D014948:Wounds, Gunshot / Q000601:surgery*