Prosthetic Categories

5 Misconceptions About the Ertl Procedure

    Since its development in the early 1900s, numerous misconceptions, as well as misapplications, on the Ertl procedure have sprung up. The procedure was born in Hungary, shortly after World War I, because of the need to return numerous amputees back into the workforce. The primary goal of the procedure was prioritizing the ability of the amputee to go back to having an active lifestyle, become physically fit, and have a pleasant psychological outlook.

    A BK amputee standing on his residual limb after ertl procedure

    Image by Superior Prosthetic Solutions, Newport, KY

    Before heading on to the misconceptions about the Ertl procedure, let's discuss what it actually does. The procedure combines different surgical procedures that should result in a functional and dynamic limb that is contoured well for prosthetic fitting and allows end weight bearing.

    The procedure utilizes bone grafting that covers the end of the bone, thereafter sealing the bone cavity or where the bone marrow resides with a flexible bone graft. For transtibial patients, it aims to create a bony bridge that would increase the surface area for the end bearing's potential. Myoplasty would then help antagonistic muscle groups to recreate a muscle-length tension relationship that would promote muscle growth. This also balances the muscle structures surrounding the bone and pad on the distal end. The closing of arteries and veins is done, as well as resecting nerves or neuromas to prevent future issues. 

    Now, here are common misconceptions and misapplications of the Ertl procedure:

    1.) The bony bridge is the sole thing that defines this surgery. 

    Many people tend to think that the only difference between this procedure and a regular amputation is the bony bridge, which is not the case. The Ertl procedure makes it a priority to seal the central cavity of the bone shafts thereby recreating internal pressure and improving blood circulation.

    2.) Closing the Bone Cavity doesn't matter.

    There is a misconception that sealing the bone cavity is irrelevant because bone tends to scar inward. By foregoing a sealed bone cavity, bone spurs can develop along the bottom end of the bone and without distal end weight loading this can progress into something more crippling for some amputees. The Ertl procedure removes bone scarring and closes the bone cavity to reestablish appropriate internal pressure and allow for end weight bearing. The boney bridge also helps stabilize the smaller bone of the below-knee limb secondarily creating a greater surface area for weight-bearing. 

    3.) Sacrificing 10cm of distal residual bone.

    This misconception is not credible nor accurate. Bone is not sacrificed and the length of the amputation is determined by the patient's goals, clinical exams and circulation results. There is no standard residual limb length and each length should be customized to the person's needs. It is preferred to leave as much length as clinically appropriate. Additional bone, if required, can be sourced from other areas of the body.

    4.) Diabetes should bar people from getting the Ertl procedure.

    With proper evaluation and undergoing various tests, diabetic people could still benefit from the procedure, especially since it would help them maintain an active lifestyle.

    5.) The procedure cannot be performed on children.

    The concern with children is that you're capping bone growth. It's been said that any terminal overgrowth or capping can be easily corrected with another procedure. And the benefits of the Ertl procedure are maintained and outweigh the alternative standard amputation procedure.


    While these five misconceptions may seem harmless, the widespread belief in them creates misinformation for those who are trying to make an informed decision about the benefits of the procedure. And the erroneous discredit has tainted a method that has been designed to improve the lives of the amputee population. 

    Instead, the Ertl procedure should be viewed as a reconstructive surgery that creates an optimal healing environment for the residual limb. The procedure’s philosophy and process—one that is meant to draw on the body’s natural regenerative powers—aims to bring the amputated limb to a state that is as close to a normal biologic and physiologic state as possible. And let's not forget this procedure believes in the holistic approach involving the entire rehabilitation team.  

    What about you? Have you undergone the Ertl procedure? Let us know what your experiences are in the comments section below.

    5 misconceptions about the Ertl procedure