Foot & Ankle International - July 2018 - 874

776041
research-article2018

FAIXXX10.1177/1071100718776041Foot & Ankle InternationalHsu

Surgical Strategies

Transfemoral Amputation Adductor
Myodesis Using FiberTape and Knotless
Anchors

Foot & Ankle International®
2018, Vol. 39(7) 874-879
© The Author(s) 2018
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https://doi.org/10.1177/1071100718776041
DOI: 10.1177/1071100718776041
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Andrew R. Hsu, MD1

Abstract
Transfemoral amputation is considered the last treatment option for severe infection, vascular disease, trauma, and malignant
tumors of the lower extremity that have failed limb salvage. Unopposed pull of the hip abductors causes a flexion-abduction
thigh deformity that results in abnormal biomechanics and increased oxygen consumption during ambulation. Myodesis of
the adductor tendons is a critical component of transfemoral amputation that creates dynamic muscle balance, enhances
prosthetic fitting and function, and improves clinical outcomes. Traditional adductor myodesis uses locking sutures passed
through cortical drill holes along the anterolateral aspect of the distal femur that are tensioned and tied by hand. In this
report we describe a novel technique for adductor myodesis using FiberTape suture and knotless anchors that we have
found to be quick, easy, and reproducible with strong tendon-bone fixation.
Level of Evidence: Level V, expert opinion.
Keywords: amputation, above the knee, trauma, mangled, dysvascular, diabetes, limb deformity

Introduction
For the foot and ankle surgeon, transfemoral amputation is
often a salvage treatment option for cases of severe infection
that involve or extend past the knee joint.1 Although there
has been an overall decline in the use of lower extremity
amputation over the past decade with a concurrent increase
in the use of limb-sparing techniques, transfemoral amputation remains a standard procedure in cases of nonsalvageable tissue in patients with diabetes, peripheral vascular
disease, and trauma.1,4,8,10 In 2010, 36.4 transfemoral amputations were performed per 100 000 Medicare beneficiaries,
with the most common indication being chronic leg ischemia after previous failed distal extremity amputation.1,11
The level of function after transfemoral amputation is
affected by several factors including operative reattachment
of the remaining thigh musculature, orientation of the femur,
limb length, and prosthetic fit.2
Prior to the late 1980s, techniques for transfemoral amputation often sacrificed the hip adductor muscles, resulting in
unopposed abductor pull and a thigh flexion-abduction
deformity. Loss of the normal adductor musculature with an
abducted femur causes an increase in side lurch and higher
energy consumption during ambulation. Research into muscle stabilization and gait biomechanics has shown that

preservation of the adductor magnus and myodesis to the
distal femur can maintain the normal femoral shaft axis and
improve prosthetic fitting.6 The adductor magnus is ideal for
myodesis as it has 2 nerve innervations (sciatic and obturator), allows for hip adduction and extension, and is 3 to 4
times larger in cross sectional area and volume compared to
the adductor longus and brevis.5,6
Overall benefits of adductor myodesis include (1) creation of a dynamic muscle balance of the amputated femur,
(2) improved position of the femur to allow for more efficient ambulation, (3) increased soft tissue cushion beneath
the distal femur for padding, and (4) improved prosthetic fit
by preventing adductor atrophy.2,3,5,6 Traditional adductor
myodesis is performed using Krackow sutures through the
distal adductor tendon that are passed across the end of the
femur and through a series of drill holes made along the
anterolateral femur. Sutures are passed from outside the
cortex into the medullary canal and then tied over a bony
1

Department of Orthopaedic Surgery, University of California-Irvine,
Orange, CA, USA
Corresponding Author:
Andrew R. Hsu, MD, University of California-Irvine, 101 The City Drive
South, Pavilion 3, Building 29A, Orange, CA 92868, USA.
Email: hsuar@uci.edu
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Table of Contents for the Digital Edition of Foot & Ankle International - July 2018
