DAY TWO of a 3-day series
THE WAY THERE
Published July 15, 2002
With the second surgery behind him, Jim Miller was ready to begin the process of getting artificial legs. Bill Copeland wrapped plaster around Jims stumps to create the molds for the leg sockets.
The surgeon drew a scalpel along the scar at the end of Jim Miller's left leg. A thin red seam unfolded in an oval field of umber antiseptic.
The operating room was frigid. The nurses wore extra gowns for warmth. Dr. Jan Ertl, in short sleeves, was flushed with concentration.
Jim's body, everything except for the stump of one leg, was concealed under a tent of pale blue sheets. It was as if all Jim had ever been or might ever be was located in this exposed patch of skin and bone.
After the first surgery, in December 1999, Jim had developed bone spurs on the ends of his legs that needed to be removed before he could walk without pain. Generally, patients who need follow-up surgery get it from the same doctor. Jim knew the first doctor had saved his life, but now, more than a year after the accident, he was depending on Ertl to help him walk. In effect, Jim was about to be amputated for the second time.
The procedure was known as the Ertl Osteomyoplastic Lower Extremity Amputation Reconstruction. Ertl had learned it from his father, John W. Ertl. He had learned it from his father, Janos Ertl Sr., who had developed the method in Hungary in 1920 to help veterans who lost limbs in World War I.
Many surgeons remained unconvinced Ertl's longer, costlier procedure was necessary. But prosthetists, who saw the work of different surgeons every day, believed it improved the odds their patients would walk. Bill Copeland, the man who would fit Jim with artificial legs, had flown to Sacramento at Jim's expense to learn more about Ertl's technique. He stood over the doctor's shoulder as he worked.
A nurse put a Van Halen compact disc in the CD player as Ertl used a hot-tipped electric scalpel to burn through tissue -- pebbly yellow fat and hard white scar. The faint smell of seared flesh rose into the overhead lights on tiny wisps of smoke.
Probing inside the leg with his fingers, Ertl found one of the strongest muscles in the body, the one that runs along the interior of the thigh. The muscle was slack, like a broken guitar string.
"This is about the way it's usually done," Ertl said, assessing the work of the original surgeon. "Most people do it straight out of the book."
Ertl continued to poke inside Jim's thigh, searching for the sciatic nerve, a neural trunk line running the length of the leg. After several minutes he withdrew his gloved hand, the fat white nerve looped around his blood-slicked forefinger. Jim's sciatic had embedded its severed end in the scar tissue of his stump. Every time something pressed on that area of his leg, Jim felt jabbing pain.
Ertl pulled the nerve taut from the end of the leg. He cut off about 41/2 inches and allowed it to snap back deep into the thigh. This way it wouldn't bind into the new scar tissue.
Gradually, Ertl separated the muscles and other soft tissue, revealing the bone spur. It looked like the head of a small pickax.
A nurse handed Ertl a chisel with his name branded on the wood handle. Ertl cut into the periosteum, the sturdy membrane of connective tissue that surrounds all healthy bone.
"Oh, no," he said.
Peeling back the periosteum, he discovered that the hole at the end of the femur had been capped with a wad of surgical wax. The instinct to close the end of the bone was a good one, Ertl said, but wax would never work as well as a natural substance such as the periosteum. He quickly scraped away the wax.
With a pneumatic chisel, Ertl removed a little less than half an inch of bone -- enough to get rid of the spur without significantly shortening Jim's leg. Ertl sewed the periosteum back over the opening of the femur.
Then he separated the thigh muscles into four sections -- front, back and sides. He sewed the medialis to the periosteum. He sewed the lateralis to the medialis. Then he sutured the hamstring to the lateralis and, finally, the quadriceps to the hamstring. When he was done, the muscles looked like the neatly wrapped end of a Christmas present.
Closing the wound, Ertl trimmed the skin like a dressmaker. He wanted to avoid the "dog ears" of leftover skin that poke out at the corners of the incision when surgeons rush. Any irregularity on the skin would prevent a tight fit of the prosthetic leg.
He repeated the process on the second leg. Four and a half hours after he began, with Bon Jovi's Lay Your Hands On Me echoing in the room, Ertl tugged the last stitch tight. He inserted two pieces of soft surgical tubing into the corners of the incision to drain fluid from inside. They looked like whiskers on a catfish.
The anesthesia nurse leaned over and whispered in his ear, "Time to wake up, honey."
In the recovery room, Jim pushed through the fog of the anesthesia. He smiled when he saw Bill standing next to the bed. Bill clasped his hand.
"Did you learn anything?" Jim said.
"You bet," Bill said.
Jim smiled and gave him a thumbs up.
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