The Long posterior flap method (Burgess)
The long posterior flap method, which is most common, leaves open the medullary
canal. As a result of this, although the amputees generally can successfully wear a prosthesis, they often experience sores and severe pain (Dederich, 1963). Furthermore, the open canal leads to a higher risk for venous stasis and bone spurs. The stump has been shown to be, in some cases, 7 ºC cooler than the rest of leg due to poor blood flow (Dederich, 1963). Aside from physical complications, functional complications also arise. Because tissue and muscle degeneration and venous stasis occur, the limb often does not fit properly for optimal function (Dionne, 2009). Pain is also a common side effect of an amputation which leads to decreases in walking and further disrupts lives. The pain can be so severe that some patients have gone through as many as 35 operations seeking pain relief alone (Dederich, 1963). Bone spurs, a common source of postoperative pain, can be surgically removed, but often grow back.
The ostemyoplastic amputation method (Ertl)
The osteomyoplastic reconstruction method, also known as the Ertl, was first used on World War I veterans by Dr. Janos von Ertl of Hungary and is much less common. In this method of amputation, the tibia and fibula are fused together to make a bone bridge which closes the medullary canal. (Dionne, 2009) Opposing muscle groups are attached as to cover the entirety of the bone bridge followed by covering the stump with the soft tissue and applying sutures. After the surgery, bone spurs and scarring are much less of a problem. (Dionne, 2009) The synostosis of the tibia and fibula has shown to have many benefits. By closing the medullary canal, normal pressure is returned to the canal and normal venous activity returns which leads to increased blood flow, and overall, a healthier residual limb. (Loon, 1962) This method also gives the stump a cylindrical shape, allowing for the prosthesis to fit more optimally, leading to better postoperative function. Furthermore, the closure of the medullary canal through a bone bridge may provide the amputee with a more stable weight bearing structure than does the open ended canal of the long posterior flap method. (Dionne, 2009) Since the synostosis provides a significantly larger surface for weight bearing, pressure points on the residual limb decreases, thereby also decreasing the risk of skin deterioration. (Dionne, 2009) Despite these benefits, the Ertl is a longer operation and requires higher technical ability of the surgeon. (Ertl, 2013)