World War I was a savage, brutish war, where pitched battles were fought from trenches at close range. Equipment was crude by today’s standards, and often soldiers had to do the most dangerous thing of all to enact their grisly task—they had to poke their heads up out of a trench, or run across a blasted battleground to rescue a comrade. The injuries from such wars were profound.
Dr. William John Ertl sat at a conference table in a spotless white doctor’s coat, and opened a 1939 surgical textbook. The yellowing pages showed soldiers with missing pieces of their lower jaws, or massive trenches in their skulls gouged out by bullets. Photos document human lives taken from catastrophic wound to, miraculously, near-restoration. Over months, the photographs show bodies regaining healthier form and function. It’s freaky, frankly, and almost unbelievable. But these results are quite real, and tested over the last three generations.
The author of the textbook: Dr. Janos Ertl, William’s grandfather and a WWI combat surgeon for Hungary. Janos pioneered what’s now known as the Ertl Procedure, a bone-grafting technique. Now a standard of care worldwide, the Ertl Procedure chisels off periosteum, and grafts it onto damaged bones. The graft actually regenerates new bone mass.
“Patients not only cosmetically would look better, but they would function better,” explained William, an orthopedic surgery professor and surgeon at University of Oklahoma Health Sciences Center (OUHSC). “Sometimes from their injury they would lose their teeth, but they could eat, or there was a defect and (it) all grew back in.”
This generation’s Dr. Ertl takes care of traumatic amputations as part of the Level 1 Trauma team at OUHSC. Such emergencies hold intense challenges since many patients have multiple, serious injuries, and more than one surgeon is needed to save life and limb. Dr. Ertl researches and works collaboratively across OU teams to enact and evolve his grandfather’s time-honored techniques.
Surgeons look at amputation as a failure; as a surgery of failure. (It’s) the pink elephant in the room. I see amputation as an opportunity to get rid of what is dysfunctional.
Dr. Ertl is currently focused on improving outcomes for above-knee amputation. He’s also dedicated to maintaining the integrity of how the original Ertl techniques are deployed, and expresses concern with protocols within the military. An improperly done amputation, he explained, makes it much harder to have success with prosthetics and physical therapy. Such profoundly affects quality of life.
Start with a good foundation, do it properly, and keep learning. These were fundamental ideals the Ertl family brought from Hungary when they emigrated to the United States after WWII.
Tell me about growing up in a family with such a big legacy. My mom wanted to be a nurse, and my parents met (when) my dad did his residency, after he came to the United States. He was basically drafted into the Korean War before he was made a citizen. I remember seeing a picture in his office of him in his naval uniform, being sworn into (citizenship). The story I remember is he got this draft notice and he said. “How can I be drafted, I’m not a citizen?” And they said, “Well, put your uniform on and raise your right hand.’ He spent two years in the Korean War on a naval ship.
I grew up in Chicago. I had to do a science paper in grade school, and I learned quickly not to leave it to the last minute. My father said, “Who do you want to write on?” And I said, Opa, or Grandfather. This was on Saturday night. At five (the next) morning, my dad knocks on the door. It was in the middle of winter, about 30 degrees outside, and we sat in his office and talked. Then I wrote and he read it, and then I had to correct it. Then he said, “Well, you got it wrong” and we would talk more, and he would explain to me things about his father.
His family members were hikers and we are hikers. When we would go walking, he would tell us stories. Right before he passed away, he was starting to tell us what he went through during WWII. My cousin, when he graduated, had a candlelit graduation. I leaned over to my dad and said, “This is romantic.” I was 16 or something, and he goes, “Oh, I graduated by candlelight, too…we had to do it because there was a bombing raid. The Allies were bombing Budapest.” (He) pretty much escaped through the underground, from Budapest to Germany.
In a way, you’re the inheritor of epic struggles. You come into people’s lives at an incredibly difficult time, too. The hardest part to take care of is the acute trauma, because nobody desires to wake up and get in the car and get hit by a bus, or they get hurt on their job—let alone have a limb-threatening injury that may resolve in amputation. Last night, there was a guy just working an engine and the engine block fell over and he probably will need an amputation for his arm. So those are the challenging patients because their life changes in an instant.
But what I try to do is be supportive with them and show them that, even with a missing limb, they can still have a very high quality of life. What we have seen with our patient surveys is that it takes about two years (to) emotionally and mentally accept the fact that they are an amputee. They go through all the stages of grief. Anger is one of the things that stays with them a little bit longer—anger they ended up with an amputation because of someone else's poor judgement, or their arm got ripped off because of the oil well.
You also deal with emotional trauma, not just trauma to the body. Some people don't get over that mountain that they're climbing and I’ve seen it also absolutely (go) 180 degrees in the other direction, where they take control of their life. That's the one thing (my dad) always pressed on me when I was little: it's not called plastic surgery, it’s reconstructive surgery. Amputations are reconstructive. He always looked at surgery as restoring some function. So, getting those patients over that mountain is important. I try to empower the patient. Are you going to do your rehab? If you do, you can see other patients in the clinic doing better than they ever thought they would. Amputation is a disability, it’s a void, a loss. But…why not reach for those goals?
How did you end up in Oklahoma? I walked into my mentor’s operating room—he’s from Texas and he had that Texas drawl. He was doing a unique approach to a fracture and I wanted to see. He just stopped and looked at me and said, “If you don’t go work for (OU), I will.” (OU was building) the trauma program. They needed more trauma surgeons and when I heard my mentor say that, I was like, ‘I better call.’
I hear you saying, ‘get it right’ a lot, kind of like your dad said to you when you were writing that paper. We (hosted) three amputation symposiums in three years and only two surgeons showed up, though a lot of (related fields) came. We educated a lot of people, but a lot of surgeons don't put stock in doing a quality amputation.
The surgeon creates a limb that is the foundation, and if you don’t do that, how can you expect a patient to successfully use a prosthesis, and to then go to a therapist and get their functional capabilities back? If you have a poorly done amputation, then they're going to be frustrated because they are going to be spending so much money on prostheses. And when they can't use the prosthesis, they’ll sit in their wheelchair.
Being Jonas Ertl’s grandson, what do you hope to add to the legacy of the Ertl Method? Through the research, (I’m) trying to re-educate people on really the fundamentals of the Ertl procedure…. My hope is before I leave this planet, to have that impact, or at least to try to educate people…. Surgeons look at amputation as a failure; as a surgery of failure. (It’s) the pink elephant in the room. I see amputation as an opportunity to get rid of what is dysfunctional. What we have seen in some of our research studies is that when amputees get a sound amputation with functional prosthetics, they can pretty much do work-simulated tasks just as well as a non-amputee. They just do it a little slower.
I felt like I knew my grandfather, but I never met him. He passed away after he came to the United States, six months later, because of renal failure. He was given an appointment at the University of Chicago and you always wonder, what if he had done that? I guess existentially I'm trying to do now what maybe my grandfather would have done in the ’50s, before the end of his career.
Maybe in the back of my mind, subconsciously, I have been trying to extend that legacy to modern-day science, studying at the tissue, cellular and functional level.
Sophia Massad assisted with this story. Archival photo courtesy of the Ertl family.