A Reevaluation of the Gritti-Stokes (Above-Knee) Amputation for the Nonambulatory Patient

Abstract

Objective: To reevaluate the benefits of a Gritti-Stokes amputation (GSA), as an alternative to the traditional above-knee amputation (AKA), in patients who are nonambulatory or not a candidate for a below-knee amputation (BKA).

Technique: A fish-mouth incision is fashioned below the tibial tuberosity into the popliteal crease, resulting in an anterior soft tissue flap and smaller posterior soft tissue flap. Thus the incision line will be on the posterior thigh, instead of the end of the stump. The patellar tendon is detached from the anterior tibial tuberosity, then the dissection is carried proximally behind the patellar tendon and the adjoining tendons of the vastus medialis and vastus lateralis, until the patella can be flipped over to expose the posterior patellar surface and joint capsule. The patellar's posterior surface is shaved down flat to medulla bone, with an electric small-toothed bone saw and large bur. The femur is then cleared circumferentially at its base. The foot is then placed at 90°, creating a 45-degree angle between the femur and the tibia, and the femur is then transected with a Gigli saw near the base or just above the base, depending on the size of the patellar surface area. This creates a 45-degree angle to the femur posteriorly, which allows the shaved patella to be secured to the end of the femur, with less chance of shifting. The fascia is then circumferentially closed around the patella and femur. Then, the remnant patellar tendon is sutured to the tendons of the posterior compartment. The dermis and skin are then closed in the standard tension-free manner using 2-0 interrupted vicryl sutures, followed by interrupted 2-0 nylon vertical mattress sutures. The dressing consisted of a single layer of ADAPTIC Non-Adhering Dressing to allow drainage, gauze fluffs, 6-inch kerlix, and finally a 6-inch ACE wrap was applied. The dressings are left intact for 2-3 days and then replaced daily thereafter.

Methods: A retrospective chart review was performed to identify patients who had undergone a GSA from January 2016 to September 2017 by a single surgeon. Estimated blood loss (EBL), operative time, and perioperative and postoperative complications were assessed.

Results: A total of 16 GSAs were performed on 15 patients by a single surgeon between January 7, 2016 and September 19, 2017. In our series, intraoperative outcomes were notable for an average EBL of 114 mL, lower than the traditional AKA (average EBL: 300-500 mL) with comparable operative times as short as 90 min (skin incision to dressing). No transfusions were required in the GSA group (postop days: 1-4) compared with traditional AKA group which required an average of 2.1 units. Postoperative outcomes showed low complication rates. Postoperative complications were limited to 2 cases of a stump infection, which were treated with local wound care and subsequently healed completely. One patient died from septic shock secondary to pneumonia unrelated to the GSA surgery.

Conclusions: A reevaluation of the GSA in the nonambulatory patient population is warranted in the United States as an alternative to the traditional AKA whenever possible. Our experience with a small series of GSA's has yielded promising advantages including potential for decreased blood loss and fewer complications in the postoperative period when compared with the standard AKA. Retained muscle attachments facilitate increased limb function and allow use of slide joint prosthetics, which are gaining popularity for ambulatory patients. The thickened skin and subcutaneous tissues overlying the patella, and the posterior incision have the potential benefit of protection against trauma and osteomyelitis seen with traditional AKA, in which case the open ended medullary bone is deep to the incision. We believe that for these same reasons the GSA should be considered in the nonambulatory patient as well.