TECHNIQUE

Use of the Arthrex Tightrope for Fixation of the Distal

Tibiofibular Bone-bridge in Transtibial Amputation
Vincent Y. Ng, MD and Gregory C. Berlet, MD

Abstract: The distal tibiofibular bone-bridge is the hallmark of the

modified Ertl procedure. Designed to improve end weight-bearing
capacity and reduce painful tibiofibular movement, the osteoplasty is
thought to restore a more physiologic residual limb in active amputees.
Fixation of the bone-bridge segment was typically performed with
screws or sutures, but can result in painful hardware or inadequate
compression. We present a novel technique using the Arthrex Tightrope
to stabilize the osteoplasty easily and effectively.
Key Words: tightrope, Ertl, osteomyoplasty, transtibial, below knee
(Tech Foot & Ankle 2010;9: 68--71)

HISTORICAL PERSPECTIVE
Transtibial amputation is the most common and one of the
oldest procedures resulting in major limb loss.1 Until recently
in the US, and still true in many third-world countries, warrelated injuries are the leading cause of limb loss. As many of
these patients are active members of the community, maximizing
the function of the residual limb is of utmost importance in
returning to the workforce. Despite significant advances in the
prosthetic industry over the last century, many transtibial
amputees experience residual limb pain and difficulty in fitting
their prostheses.
In 1920, Janos Ertl Sr et al2 recognized that often the
residual limb is an inactive participant in ambulation and is
simply used as a passive suspension for a prosthesis. The Ertl
procedure was developed to provide an end-bearing limb that
would improve proprioception and prosthetic fitting, decrease
pain, and allow more efficient ambulation. With traditional
transtibial amputations, the tibia and fibula often move discordantly, resulting in chopsticking and painful instability.
The lack of axial loading causes penciling or atrophy of the
stump necessitating multiple liner, socket, and prosthetic adjustments over time. The presence of a bone bridge allows the
fibula to participate in weight-bearing as normal (Fig. 1).
Although osteoplasty is the most recognizable and
unique feature of the Ertl procedure, to achieve full synergistic
action and restoration of a physiologic state, one must attend
meticulously to even skin closure, individual ligation of
arteries and veins, transection of all nerves while under tension
to allow for retraction, and myoplasty to assist venous return.
The osteoplasty first described by Ertl uses an osteoperiosteal
bone graft elevated from the distal tibia and fibula and sutured
From the Department of Orthopaedics, The Ohio State University,
Columbus, OH.
The authors have not received any benefits for personal or professional use
from a commercial party related directly or indirectly to the subject of
this article.
Address correspondence and reprint requests to Gregory Berlet, MD,
Department of Orthopaedics, The Ohio State University, 456 West 10th
Avenue, 4110 Cramblett Hall, Columbus, OH 43210-1228. E-mail:
gberlet@aol.com.
Copyright r 2010 by Lippincott Williams & Wilkins

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together in a tube-like fashion to seal the medullary canal of

both bones. Over time, a bony synostosis typically ossifies
within this osteoperiosteal sleeve.
Pinto and Harris3 modified the original technique by
actually creating a bone bridge using a segment of fibula
harvested distally and held between the tibia and fibula by
slowly absorbable sutures through drilled bone perforations.
The authors have experienced complications with the suture
fixation technique described by Pinto and Harris including
inadequate compression and breakage of the suture over the
sharp edges of the bone tunnel. Alternatively, stabilization of
the bone bridge with compression screws has resulted in
painful hardware and subsequent removal.
The Arthrex (Naples, FL) Tightrope is based on the suture
endobutton design and has been used for acromioclavicular
joint luxation, Lisfranc ligament reconstruction, and hallux
valgus correction. The authors have earlier published the
largest case series of reduction and stabilization of tibiofibular
syndesmotic disruptions using the Arthrex Tightrope.4 The
fixation of the distal tibiofibular bone bridge for transtibial
amputations using this implant is the natural extension of this
concept. It allows physiologic micromotion, resists diastasis,
and minimizes the potential for symptomatic hardware.

FIGURE 1. Anteroposterior radiographs of the modified Ertl

amputation with fixation of the distal tibiofibular bone bridge
with the Arthrex (Naples, FL) Tightrope.

Techniques in Foot & Ankle Surgery  Volume 9, Number 2, June 2010

Techniques in Foot & Ankle Surgery  Volume 9, Number 2, June 2010

Use of the Arthrex Tightrope

INDICATIONS AND CONTRAINDICATIONS

The authors generally select the modified Ertl transtibial
amputation with Arthrex Tightrope fixation for highly active
patients likely to benefit from an axially loaded residual limb.
For traditional transtibial amputees with symptoms from an
unstable fibula which often can be evident on examination, late
reconstruction with an Ertl osteoplasty can be performed. As
many transtibial amputations are performed for infection or
vascular complications, harvest of distal fibula for the bone
bridge or even elevation of a periosteal sleeve for the original
Ertl procedure may be contraindicated if there is not an
adequate margin. Nevertheless, diabetes itself should not be an
exclusion criterion for this procedure.

FIGURE 2. Skin incision for long posterior flap. The corner

between the posterior flap and anterior incision is less than 90
degrees to prevent the formation of dog ears after closure.

PREOPERATIVE PLANNING
A successful amputation requires careful planning. As with
traditional transtibial amputations, multidisciplinary preoperative assessments by a vascular surgeon, physical therapist,
prosthetist, psychologist, and social worker can optimize
ultimate functional status. It is important for the surgeon to
examine and understand patient expectations to provide
education and maximize satisfaction. Standard orthogonal
radiographs should be obtained, and for all malignancies and
infections, further studies such as magnetic resonance imaging
and computed tomography are important to assure adequate
margins of resection. Wound-healing potential can be
predicted with preoperative laboratory and vascular perfusion
studies. Threshold predictors include an ultrasound Doppler
ankle-brachial index greater than 0.5, transcutaneous oxygen
tension on room air greater than 20 to 30 mm Hg, albumin
level greater than 2.5 g/dL, and absolute lymphocyte count
greater than 1500/mL.5

TECHNIQUE
The patient is positioned supine on a standard operating room
table. General anesthesia is induced and prophylactic antibiotics are infused. Spinal anesthesia is typically used to
reduce the risk of phantom limb pain. A bump is placed under
the ipsilateral hip if necessary to prevent excessive external
rotation of the limb. A well-padded tourniquet is placed on the
upper thigh and inflated to 300 to 350 mm Hg. Both limbs are
prepped and draped if the patient has a contralateral below
knee amputation to allow intraoperative comparison and
achieve symmetry.
A long posterior flap skin incision is always used and the
desired final leg length is one-half the original distance
between the ankle and knee if the underlying pathology allows.
The corner between the posterior flap and anterior incision
should be less than 90 degrees to prevent the formation of dog
ears after closure (Fig. 2). The skin and subcutaneous tissue is
dissected off the anterior aspect of the distal limb exposing the
underlying bone. Using a small osteotome, a flap of periosteum
is carefully raised off the medial aspect of the tibia and
preserved for eventual creation of a bone graft pocket (Fig. 3).
The rest of the tibia and fibula are dissected free from the
anterior and lateral compartment musculature.
Using an oscillating saw and a Cobb elevator placed
posteriorly, the tibia and fibula are osteotomized at the same
level. The foot and ankle are removed by beveling free the
posterior soft tissues and the amputated limb is passed to a
sterile back table. Although the surgeon continues preparing
the stump, an assistant harvests bone marrow from the distal
tibial metaphysis and osteotomizes a 3 cm segment of fibula
for the bone bridge.
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2010 Lippincott Williams & Wilkins

To prevent the formation of a bulbous stump, the deep

posterior compartment musculature is excised. All vessels are
clamped with hemostats and ligated with double silk ties. The
tibial nerve is transected as proximally as possible under
gentle tension (Fig. 4). Forceful traction is not used to avoid
traction neuritis. All sharp osseous edges are rounded off
and a notch is created in the lateral cortex of the tibia and
medial cortex of the fibula with a power burr. The fibular
segment is further shaped with a rasp to comfortably fit in this
trough (Fig. 5).
After trialing the osteoplasty and confirming that the
posterior flap is long enough to provide easy closure of the
wound, the surgeon removes the fibular segment and drills a
3.5 mm hole through the tibia, fibula, and the canal of the bone
bridge. Using a Beath needle, the Arthrex Tightrope is passed
medial to lateral through each component of the osteoplasty.
With metal buttons on either side, the Tightrope is pulled taut
and at least 6 knots are tied on the medial aspect to secure the
fixation (Fig. 6).
The medial tibial periosteal flap is wrapped over the end
of the distal bone-bridge and secured with absorbable suture.
Bone marrow harvested from the amputated limb is placed in
this pocket to help osseous union (Fig. 7). After the pocket is
sealed, the posterior soft tissue flap is then folded over the
wound and the fascia sutured together. Using silk or nylon
suture, the skin is reapproximated with a tension-free closure.

FIGURE 3. The skin and subcutaneous tissue are peeled distally

and a proximally based periosteal flap is raised (shown here
under a Senn retractor).
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Ng and Berlet

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Volume 9, Number 2, June 2010

FIGURE 6. The Arthrex Tightrope is threaded through the

osteoplasty from medial to lateral and secured with knots on
the medial aspect. A power rasp or burr is used to smooth sharp
edges.

POSTOPERATIVE MANAGEMENT

FIGURE 4. The tibial nerve is gently retracted and transected as

proximal as possible. The deep posterior compartment musculature has been removed to prevent an overly bulbous stump. The
tibia and fibula have been osteotomized at the same level.

RESULTS AND COMPLICATIONS

This procedure has been highly successful in the senior
authors (G.C.B.) experience and these results have been
published elsewhere.6 A strong familiarity with the proper
indications for an Ertl amputation helps to prevent complications. Patients unlikely to tolerate a longer operative time
because of medical reasons or a more involved rehabilitation
protocol due to psychosocial factors will do poorly. Use of a
fibular bone segment that is too long may distract the tibiofibular
space and theoretically cause discomfort, although the authors
have not personally experienced this complication. As with any
amputation, infection remains a concern and the metal button of
the Tightrope may marginally increase this risk.

FIGURE 5. The fibular segment is placed between the tibia and

fibula in 2 notches created with a power burr.

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Postoperatively, a surgeons cast is applied over light sterile

dressings and padding for the patella (Fig. 8). The knee held in
extension to prevent a flexion contracture. Patients are
admitted to the hospital for observation, pain control, and
assistance with ambulation. All patients receive antineuropathic medications such as gabapentin or pregabalin. After 48
hours, the dressing and cast is removed and a rigid removable
dressing as described by Wu et al7 is made by the physical
therapist. Typically, patients are discharged after receiving
their rigid removable dressing.
Once the incision has healed, a clear plastic test socket is
used to allow the prosthetist to monitor for proper alignment
and areas of high pressure. At 6 weeks, the patient begins using
a total contact-specific weight-bearing socket prosthesis, similar
to that of a traditional amputee, and gradually progresses to fulltime wear. At 12 weeks, the bone bridge is healed and the patient
can transition to prosthesis with a total surface-bearing socket.
Patient motivation and physical therapy are integral parts of
a successful surgery. Early mobilization and reintegration of the
residual limb into the patients daily life can decrease phantom

FIGURE 7. Bone marrow harvested from the distal tibial metaphysis is placed within a pocket formed by wrapping the periosteal flap over the end of the bone bridge.
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Techniques in Foot & Ankle Surgery

Volume 9, Number 2, June 2010

Use of the Arthrex Tightrope

age-old procedure of transtibial amputation will help patients

to recover quicker and return to a higher quality of life.
REFERENCES
1. Bowker J, Goldberg B, Poonekar P. Atlas of Limb Prosthetics:
Surgical, Prosthetic and Rehabilitation Principles. 2nd ed. St. Louis,
MO: Mosby; 1992;429--452.
2. Ertl J, Ertl J, Ertl W, et al. The Ertl osteomyoplastic transtibial
amputation reconstruction. Medical Papers Page
[www.ertlreconstruction.com].
3. Pinto M, Harris W. Fibular segment bone bridging in trans-tibial
amputation. Prosthet Orthot Int. 2004;28:220--224.

FIGURE 8. A surgeons cast is applied postoperatively. Two layers

of elastic socks help to reduce edema, and a plaster shell protects
the distal stump and prevents flexion contractures.

limb pain and improve patient psyche. The distal tibiofibular

bone bridge, when healed, allows for accelerated rehabilitation.

FUTURE OF THE TECHNIQUE

Since the first amputations performed by Hippocrates (385
BC) and the early Babylonians (1700 BC), military medicine
has been on the forefront of research and advancement in this
field. As a result of current conflicts such as Operation Enduring Freedom, Operation Iraqi Freedom, and the global war on
terrorism, more than 1200 soldiers have sustained major limb
amputations as of January 2009.8 In the US, complications
related to diabetes have surpassed war-related amputations as
the leading cause of limb loss.
Although the distal tibiofibular bone-bridge concept for
transtibial amputation has theoretical advantages and has
succeeded in many series of patients, whether it offers a
clinically significant difference when compared with traditional techniques is still controversial based on the literature.913 As more long-term outcomes are published for both
civilians and military personnel, further refinements on the

2010 Lippincott Williams & Wilkins

4. Cottom J, Hyer C, Philbin T, et al. Treatment of syndesmotic

disruptions with the Arthrex Tightrope: a report of 25 cases.
Foot Ankle Int. 2008;29:773--780.
5. Pinzur M, Stuck R, Sage R, et al. Syme ankle disarticulation in patients
with diabetes. J Bone Joint Surg. 2003;85-A:1667--1672.
6. Berlet G, Pokabla C, Serynek P. An alternative technique for the Ertl
osteomyoplasty. Foot Ankle Int. 2009;30:443--446.
7. Wu Y, Keagy R, Krick H. An innovative removable rigid dressing
technique for below-the-knee amputation. J Bone Joint Surg. 1979;
61-A:724--729.
8. Fischer H. United States military casualty statistics: operation Iraqi
Freedom and Operation Enduring Freedom. Congress Res Serv.
2009:RS224--RS252.
9. Pinzur M, Gottschalk F, Pinto M, et al. Controversies in lower
extremity amputation. Instr Course Lect. 2008;57:663--672.
10. Pinzur M, Pinto M, Saltzman M, et al. Health-related quality of life in
patients with transtibial amputation and reconstruction with bone
bridging of the distal tibia and fibula. Foot Ankle Int. 2006;27:907--912.
11. Pinzur M, Beck J, Himes R, et al. Distal tibiofibular bone-bridging in
transtibial amputation. J Bone Joint Surg. 2008;90-A:2682--2687.
12. DeCoster T, Homedan S. Amputation osteoplasty. Iowa Orthop J.
2006;26:54--59.
13. Dougherty P. Transtibial amputees from the Vietnam War. Twentyeight-year follow-up. J Bone Joint Surg. 2001;83-A:383--389.

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