Dear colleagues,
Thank you to all of you who showed an interest and replied to my request
for information and opinions on the Gritti-Stokes amputation technique. A
special thank you to Rebeca Guajardo for being prepared to type as much as
she did:-)
On considering the thoughts and opinions of all who contributed it seems to
me that I have to be able to present *facts* to this sort of surgeon and so
may have to carry out some sort of audit of outcomes as suggested by
Richard Hirons (thanks Richard). This of course has its own problems not
least of which being that as we try our damdest to rehabilitate these
patients and most do end up walking – albeit in an un-cosmetic, tuber
bearing socket with a belt – how do I demonstrate that an alternative
procedure would have been better for that patient? The small numbers
involved are also a problem for this sort of endeavour.
Once again, thank you all for your interest. If you have any thoughts to
share (on or off the record) then I will be only too happy to receive them
in the future.
The following is my original post then I have compiled the replies below:
————————
Dear Colleagues,
As a prosthetist working in a clinic in the South of England I receive
referrals from a variety of surgical centres. There is one particular
centre which has been sending us a fair number of primary amputees where
the papers accompanying them claim they have had a knee disarticulation but
examination reveals that they have had a Gritti-Stokes procedure. There
seems to be one surgeon at that hospital who believes very firmly that this
is a worthwhile procedure.
As yet, I have been unable to find any prosthetist who thinks this is a
good amputation technique or who sees any advantages of this over a simple
disarticulation or a trans femoral amputation. It seems to me that with the
Gritti-Stokes we have all the disadvantages of the disarticulation
(principally lack of cosmesis) and none of the advantages (self suspension,
proper end bearing, quick healing etc.)
The general opinion I have found here is that a Gritti-Stokes is the sort
of amputation which should be reserved for those not expected to be ambulant
I would be glad to hear the opinions of the subscribers to this list both
medics and prosthetists on the merits and demerits of this procedure.
Thanking you in anticipation,
Grant Crosthwaite
—————————————-
From: [email protected]
Very interesting!
My limited experience (2)was with the patella placed on the distal end of the
femur-no shaving of condyles or other trauma to the femur. I will look into it
further.
-mark
—————————————–
From: “Ted A. Trower”
I’m in full agreement with your assessment of this dreadful procedure.
—————————————–
From: “P&H Goldberg”
Dear Grant,
Without going into any detail, I strongly agree with you on your views of a
Gritti-Stokes amputation. I have been a clinical arena for the last 10
years and ever since I can remember, I’ve never heard or seen the
advantages of this amputation.
I can only suggest that the surgeon be introduced without delay to both the
fittings and biomechanics of prosthetics.
I would welcome any thoughts on the advantages of the amputation.
Lots of luck
Peter
———-
Richard Hirons@OSSUR
08.06.98 08:55
Grant, Hello.
‘Outcome’ and ‘Clinical Audit’ are the tools you need to evaluate this
properly. If you are suggesting there is a problem with this type of
procedure, then you have to demonstrate this in a formal and recognised
manner. This would be a really interesting audit project. You can then
present the results as evidence to your group of surgeons. But you have to
be able to demonstrate that there is a significant difference in measurable
outcome between patients with Gritti-Stokes amputation and knee
disarticulation/trans femoral amputations. This would need to include
parameters that surgeons would include in their decision making regarding
the procedure they choose to perform. Otherwise it’s just your opinion
against theirs!
Richard
—————–
From: [email protected]
I am sending information that is taken from : Lower limb Amputations by Gloria
T. Sanders.
Advantages of Gritti – Stokes
1. Mortality is less than with mid-thigh amputations, probably because the
operation can be performed rapidly, blood loss is minimal, and the muscle mass
is uninjured.
2.The superior genicular artery is preserved, so blood supply to the skin flap
is good.
3. Division is through skin, tendons, ligaments, and cancellous bone rather
than through muscle: therefore, blood loss, shock, and hematoma formations are
minimal compared with above knee amputations. Circulation is better,
4. The major muscles that move the thigh are not divided and the limb is long,
thus assuring good control of the prosthesis.
5. The limb is partially end weight-bearing because the patella and pre-patella
skin are accustomed to weight bearing.
6. Shrinkage is not a problem
7.The marrow cavity is not opened surgically.
8. The anterior flap is shorter than in knee disarticulation:therefore, there
is less incidence of delayed healing.
9. Skin closure is easier than through the knee amp.
10. Healing is fast, by first intention usually, and re-amputation is rare,
thus
making it an especially good procedure for elderly patients who are prone to
respiratory , cardiac, or urinary complications if confined to bed.
11. Phantom limb sensation is minor.
12. The limb is not too bulbous thus can be introduced into a rigid socket
from above. Since the femur is sectioned within the flare of the condyles, the
slightly bulbous limb can be used for suspension.
Disadvantages :
1. The distal femoral epiphisys is not preserved: therefore, this procedure
should not be chosen for children if disarticulation through the knee joint
can be done.
2. The disarticulation limb is bulkier giving better rotational control of
prosthesis.
3. The limb cannot usually tolerate total end bearing because the patella
gives a small surface area compared to the through the knee
4. Complications associated with preserving patella are as follows:
-reduction of weight-transmitting surface
-non-union to the femur
-avascular necrosis
-pain; even if there is bony union between femur and patella, the
irregularity of patella can make end bearing uncomfortable
5. A posterior flap that is too short may result in suture line infection due
to too much tension
6. Joint sensation is lost
7. The operation itself is more severe that knee disarticulation, with greater
risk of interfering collateral circulation
8. End not bulbous enough to aid suspension
9. Length prevents use of standard knee units
I hope this helps.
Rebeca Guajardo
———————
From: “ecat”
Grant,
I have yet to find a Gritti-Stokes which has ended up satisfactorily in
terms of cosmesis or ultimately, function.
There was a local surgeon who insisted that these were ‘the duck’s nuts’
because (he said) the end bearing was preordained anatomically. He didn’t
answer my questions about joint centres and cosmesis and often grumbled
about why his patients didn’t get the good looking results that others’
did.
Nothing changed until I had another of my enlightened surgeons educate him;
it wouldn’t do for him to listen to a mere prosthetist.
And then he died.
Since then I have had only one G-S: a 24 stone congenital amp. who has tried
Four-bar knees and different sockets but always returns to side-iron joints
and thigh lacers. Richard Ziegeler.
———-
From: “Rhona Wilkie”
I currently teach the knee disarticulation programme at the National
Centre. Knee disarticulation is an extremely difficult area for
prosthetists as all to often we are not told, as in your case, the true
nature of the amputation. Very often fitting can be difficult as they
only come along every so often and the prosthetist is unable to become
expert in this level. It is a vicious circle with surgeons failing to
consider this level of amputation possibly due to the poor fitting results
ie with cosmesis and the choice of components. Any trans section of the
bone must lead to increased risks for the patient. The natural weight
bearing surface of the bone is lost, suspension is compromised if the
femoral condyles are interupted and the change of position of the patella
reduces the control of rotation. In Gritti Stokes the patella can often
become dislodged and painful leaving a patient who needs an alternative
area to transfer load, the ischial tuberosity. In effect we then have a
trans femoral stump of excessive length. I doubt that the patient would
be pleased. I have no idea what percentage of Gritti Stokes amputations
are deemed unsuccessful but they do not have a good reputation. I would be
interested to hear your surgeons comments on the reasoning behind his/her
choice of amputation. It may be that feedback from the prosthetist to
the surgeon in this case, with regard to the problems that we face, would
be welcomed with this amputation level and you never know, he/she may be
glad of your input. I look forward to hearing how you get on and what the
general consensus of opinion is with regard to replies that you get to
your Email. Rhona Wilkie
