Background: The Gritti-Stokes amputation procedure is a modification of the traditional transfemoral amputation, with resection of the bone at a supracondylar femoral level and fixation of the patella to the distal part of the femur as an end-cap. Although well-established in patients with vascular compromise, no evidence exists on its use in the trauma setting.
Methods: Fourteen consecutive patients who underwent Gritti-Stokes amputation and fifteen consecutive patients who underwent traditional transfemoral amputation by fellowship-trained orthopaedic traumatologists at a level-I trauma center were evaluated at more than fourteen months postoperatively. The Sickness Impact Profile (SIP) questionnaire was also administered to both patient groups at more than thirty-six months postoperatively to assess patient-reported functional outcomes.
Results: Despite the two groups not having significant differences in preoperative variables or demographics, the Gritti-Stokes group had significantly improved SIP questionnaire overall and domain scores. This procedure also left the patients with a significantly longer residual limb (an average of 46.1 cm of residual femoral length versus 34.6 cm for the transfemoral group). The Gritti-Stokes group also had a significantly increased rate of walking without assistive devices (five patients versus none in the transfemoral amputation group).
Conclusions: The Gritti-Stokes amputation appears to be safe and beneficial when utilized in the trauma population.
Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
1Department of Orthopedic Surgery, Grant Medical Center, 285 East State Street, Suite 500, Columbus, OH 43215. E-mail address for B.C. Taylor: email@example.com
2Department of Orthopedic Surgery, Mount Carmel Medical Center, 793 West State Street, Columbus, OH 43222
Lower-extremity amputation as a sequela of trauma, vascular compromise, or other etiologies remains commonplace; an estimated 133,735 lower-extremity amputations are done each year in the United States alone1. Patient mobility and overall function are related to the remaining length of the limb, and there is general agreement about maintenance of the knee joint to optimize final patient outcome2,3. Therefore, transtibial amputation techniques, such as those described by Burgess and Zettl4 or Ertl5, are typically utilized when the clinical situation allows. However, an amputation at such a distal level is occasionally impossible or undesirable in a trauma patient. In these instances, a more proximal resection is indicated, with the transfemoral amputation being most commonly performed6. This procedure requires substantial muscle transection and, specifically, myodesis of the adductor magnus for optimal outcomes. Despite careful attention to technical and patient factors, the number of stump wounds not healing continues to be relevant, with reported incidences of 2% to 10%7. This procedure leaves the patient with a short femoral stump, which is not beneficial for patient positioning and transfer as well as leading to increased energy requirements for mobilization. In fact, successful rehabilitation and use of a prosthesis are limited, with some investigators reporting an ambulatory rate of <50%7,8.
Alternative options are available for proximal resection, including a knee disarticulation amputation. In this procedure, the patella is maintained and the patellar tendon is sutured to the cruciate ligaments of the knee9,10. The large remaining bulbous femoral condyles allow excellent weight-bearing, but unless they are surgically modified, prosthetic fitting and skin breakdown over this area can become an issue11. Major reamputation rates of 9% to 17% have been reported in the literature12-15. The Gritti-Stokes procedure is a modification of the traditional transfemoral amputation, with resection of the bone at a supracondylar level of the femur and fixation of the patella to the distal part of the femur as an end-cap16,17. There is controversy regarding the proper indication for this procedure, with the strongest evidence supporting this technique demonstrated in patients with substantial peripheral vascular disease11,15-17.
We present a retrospective review of the results of this procedure in our trauma patients, with comparisons with a similar group of patients with a traditional transfemoral amputation. We hypothesized that the patients treated with the Gritti-Stokes procedure would have a longer residual limb, improved wound-healing rates, an earlier time to prosthetic fitting, and a decreased revision rate as compared with the patients who had a standard transfemoral amputation. In addition, we hypothesized that patient-reported outcomes would be better in the Gritti-Stokes patient population.
Materials and Methods
After institutional review board approval was obtained, prospectively collected trauma registry data were used to identify fourteen patients who had undergone Gritti-Stokes amputation by fellowship-trained trauma orthopaedic surgeons at our institution, a level-I trauma center, between 2006 and 2010. An identical review of the trauma registry data identified fifteen patients who had undergone a traditional transfemoral amputation over the same time period. With the exception of one surgeon who always performed the transfemoral amputation, the Gritti-Stokes procedure was performed on all patients in whom distal part of the femur and patella could be maintained. Patient demographic information is shown in Table I.
The transfemoral procedure was performed as described by Gottschalk6,18, with careful attention to soft-tissue handling, reattachment of the adductor magnus to the lateral aspect of the femur via suture and small drill holes, and myoplasty of the anterior and posterior musculature. Neurovascular structures were individually identified and were carefully ligated in isolation. The Gritti-Stokes amputation was performed in a manner similar to that described by Beacock et al.16 (Fig. 1). In this technique, asymmetric larger anterior and smaller posterior fish-mouth flaps are utilized, with the medial and lateral apices at the level of the femoral epicondyles. The hamstring muscle tendons are sharply released from their distal insertions for later repair; no posterior muscle transection is performed. Dissection is largely avoided in the prepatellar region to minimize scarring and devitalization of the future weight-bearing tissue. The synovium is removed in its entirety, and the posterior half of the patella is transected. The femur is then transected at the distal aspect of the adductor tubercle, providing a flat surface to match the size of the patella. The femur is amputated with the angle of cut approximately 15° proximal-posterior to distal-anterior, in order to help provide resistance against late patellar displacement. Patellofemoral fixation is performed with large nonabsorbable suture through 2.0-mm drill holes. The hamstring tendons are trimmed and are sutured to the patellar tendon and deep anterior fascia. Closure is done in a layered manner, with suction drains utilized for the first forty-eight hours after surgery. Postoperative care in both groups included use of an immediate postoperative cast prosthesis or soft compressive dressing, as decided by the operating surgeon.
Involvement of a licensed prosthetist was often initiated prior to amputation, when clinical scenarios and operative timing allowed. Compressive stump shrinkers were routinely utilized; weight-bearing through a temporary prosthesis was permitted when stump soft-tissue healing allowed. All prostheses in this study utilized a total contact surface-bearing socket. The temporary prostheses were fit with a tight, supportive proximal socket initially, to limit contact pressures at the distal part of the stump during initial healing. This proximal fit was relaxed for the final prosthesis, as the final socket is designed to assume the shape of the distal end of the limb, creating a total surface-bearing construct with limited end-bearing. A thin protective socket insert/liner was utilized to provide protection to the limb while minimizing the distance between the end of the patient’s stump and the top of the prosthetic knee component. All patients were fit with the Mauch prosthetic knee unit (Össur, Manchester, United Kingdom), a hydraulic style component that allows the knee to be attached directly into the prosthetic socket with minimal clearance.
Electronic and written charts were reviewed to collect demographic data, information regarding the patient’s injury (Table II), perioperative data, and follow-up data points. Radiographs of the Gritti-Stokes patient group were also evaluated for healing of the patellofemoral arthrodesis site.
All patients were contacted and asked to complete the Sickness Impact Profile (SIP) questionnaire. The SIP is a comprehensive validated health measurement instrument that evaluates 136 limitations across physical and psychosocial domains, including sleep, eating, work, home management, recreation, ambulation, mobility, body care, social interaction, alertness, emotions, and communication19. Scores for the SIP range from 0 to 100, with a lower score indicating a better result; scores of >20 represent severe disability. This particular instrument was chosen to allow comparisons with similar studies, such as the Lower Extremity Assessment Project (LEAP) study20.
Statistical analysis was performed, with means, ranges, and confidence intervals calculated for continuous variables and compared by using the Student t test. Frequencies were calculated for continuous variables and compared by using the Fisher exact test for increased accuracy in small proportion analysis. A level of p < 0.05 was set as significant, with a trend defined as a p value between 0.05 and 0.1. Because this study had a small sample and multiple comparisons, unadjusted p values are given.
Source of Funding
No outside funding was utilized in the creation of this article.
Few significant perioperative differences were seen between the two patient populations (Table III). As expected, operative time was increased with the Gritti-Stokes procedure as compared with the traditional transfemoral amputation (140.5 and 108.8 minutes, respectively), but a significant difference was not seen with the number of subjects available. On average, the remaining femur was significantly longer in the Gritti-Stokes population, as hypothesized. Interestingly, the postoperative comparisons also revealed several significant differences between the two groups after more than fifteen months of follow-up (Table IV). A significantly increased proportion of the Gritti-Stokes population did not require mobilization aids (five versus no patients , p = 0.04). A trend was noted for a decreased time to final prosthesis wear (2.3 versus 3.5 months, p = 0.08) in the Gritti-Stokes group. No differences were noted between amputation groups with regard to the percentages of patients employed, disabled, or using narcotics at the time of final follow-up. No differences were noted in the rates of subsequent surgical procedures or revision amputations.
The SIP questionnaire was administered at a mean of 36.5 months after the amputation, with no significant difference in the time from surgery to questionnaire completion between the groups. The questionnaire was completed by ten patients in the Gritti-Stokes subset and nine of those in the transfemoral amputation subset. The Gritti-Stokes group had a significantly lower (improved) overall score as well as physical dimension subset score; they also had significantly lower scores in the body care and movement, home management, and mobility domains. Trends for lower overall scores in the Gritti-Stokes group were seen in the sleep and work domains. The complete questionnaire results are shown in Table V.
The Gritti-Stokes technique has several proven as well as theoretical advantages over a traditional transfemoral amputation. In this investigation, we compared these amputation methods in the perioperative period and at the time of final follow-up; patient-reported outcomes were also collected and evaluated.
There are several important study limitations. The retrospective nature of the study may have invoked recall and selection and detection bias, decreasing study quality. The retrospective nature of the study also prevented an a priori power analysis to be completed, and therefore the significance of the p values is opportunistic in nature. The limited number of patients with either of these procedures further diminishes the ability to draw conclusions on the basis of this study because of limited statistical power and small sample sizes. The limited sample size may not fully capture the data variability or secular trends seen with this patient population, and therefore errant conclusions could be made. Finally, the results from this evaluation are not necessarily generalizable; the patients in this study, who had injuries resulting from high-energy trauma, were treated at a level-I trauma center, where thorough multidisciplinary patient care is available. Such high-level patient-care settings are not always accessible, and the results of these techniques may differ according to treatment teams and available resources.
Nearly all of the literature concerning Gritti-Stokes amputation pertains to its place in the management of peripheral vascular disease, and that literature has shown improved soft-tissue-healing rates compared with those following transfemoral amputations15,17,21. This finding has been attributed to the preservation of the collateral circulation around the knee, including the superior genicular system, which helps to preserve the soft-tissue flaps21,22. We did not observe any differences in healing rates between the two groups in our study, which may be due to limited patient numbers or potentially a decreased dependence of soft-tissue flaps on a well-developed collateral vascular supply in the trauma patient population.
We observed a significantly decreased need for assistive devices for mobilization and a nonsignificant decrease in wheelchair dependence in the Gritti-Stokes population. Unfortunately, no comparable studies have dealt with those factors; several investigators evaluated them to a limited extent, but the studies were burdened by limitation to vasculopathy-induced amputations, inclusion of bilateral amputees, or poorly characterized mobility status and use of assistive devices8,15-17,23. However, multiple studies have confirmed the finding that only a minority of patients with a dysvascularity-induced amputation have successful rehabilitation and/or achieve prosthesis use8,15,24.
Patient-reported outcomes in the overall and physical dimensions of the SIP were significantly improved in the Gritti-Stokes group, with scores revealing less dysfunction in nearly all of the remainder of the subcategories (Table V). There is little corresponding literature to enable us to compare our SIP scores with those in other patient cohorts. An attempt at such a comparison was recently made with the LEAP study, in which transtibial amputations, knee disarticulations, and transfemoral amputations were compared at two years postinjury20. Regarding the SIP questionnaire, the only difference discovered in the LEAP study population was an increased physical domain score in the knee disarticulation group as compared with that in the transtibial amputation group, thereby revealing more physical dysfunction in the disarticulation group. No differences were seen when transfemoral amputations were compared with more distal amputations. Our SIP results revealed slightly more dysfunction overall (scores of 16.9 in the Gritti-Stokes group and 26.2 in the transfemoral group compared with 15.9 in the knee disarticulation group and 10.2 in the transfemoral group in the LEAP study), which may be attributed to one or a combination of factors. The time from injury to questionnaire administration was significantly longer in our series, which may more accurately reveal the equilibrium of the trauma patients’ overall condition or may demonstrate deterioration of the results over time.
The Gritti-Stokes amputation technique has several advantages compared with transfemoral amputation in trauma patients. First, the limb length is significantly longer with the Gritti-Stokes technique, which can help in balance for transfers and sitting, particularly in bilateral amputees. Second, the superior genicular arterial system is maintained, improving blood supply to the soft tissue flaps and potentially leading to increased healing rates. Lastly, the need for mobilization aids appears to be decreased with this technique, with improved patient-reported outcomes. Further work remains to be done in assessing Gritti-Stokes amputation, including determining appropriate indications and patient selection, patellar fixation methods, and postoperative rehabilitation protocols.
Investigation performed at Grant Medical Center, Columbus, Ohio
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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.Copyright 2012 by The Journal of Bone and Joint Surgery, Incorporated