Foot & Ankle International - July 2018 - 875

875

Hsu
Table 1. Indications.

Table 2. Technical Pearls.

Patients with the following conditions involving or extending
proximal to the knee:
** Severe vascular disease
** Chronic osteomyelitis
** Soft-tissue and bone loss from trauma
** Malignant tumors

** Careful dissection of the adductor magnus distal to the skin
incision off of the adductor tubercle.
** Leave as much femoral length as possible for improved
postoperative gait mechanics.
** Secure the adductor with a locked Krackow FiberTape
suture, being sure to pull out all the slack after each locking
pass and making sure the thickest portion of the suture is in
tendon.
** Drill and powertap 2 holes spaced 1.5-2 cm apart in the
anterolateral distal femur.
** Hold the leg in neutral flexion and 10 degrees of adduction
prior to tensioning the adductors and insertion of the 4.75mm knotless anchors with a small amount of slack (2 mm) to
allow for complete anchor insertion.
** Check to make sure anchors are seated flush with bone prior
to inserter removal.
** Suture the remaining anterior and posterior musculature
to the adductor myodesis to hold it in place followed by
meticulous layered closure.

bridge with the femur held in neutral flexion and 5 to 10
degrees of adduction.6 Although this myodesis technique
has shown favorable results in the literature,6 it is often
time-consuming, difficult to pass sutures through drill
holes, and fixation to bone can be inconsistent because of
reliance on suture knots.
In this report, we describe a novel adductor myodesis
technique that uses locking Krackow sutures with
FiberTape combined with two 4.75-mm knotless
SwiveLock anchors (Arthrex, Inc, Naples, FL). Although
this technique was originally described for repair of quadriceps tendon and proximal patella tendon ruptures, we
have found that this procedure applied to adductor myodesis is easier, faster, stronger, and more reproducible than a
traditional drill hole technique in our series of transfemoral amputation patients.

Indications
Primary indications for transfemoral amputation include
severe vascular disease, chronic osteomyelitis, soft-tissue and
bone loss from trauma, and malignant tumors (Table 1).3,6,8,10,11
Chronic leg ischemia is the most common cause of all major
lower extremity amputations, with 45% of those patients also
having diabetes.7 Patients with poorly controlled diabetes and
vascular disease are the most common patients to undergo
transfemoral amputation because of poor healing potential
and concurrent comorbidities such as end-stage renal disease.
Trauma patients with severe soft tissue, vascular, neurologic,
and bone loss tend to be younger and are more likely to receive
a postoperative prosthesis with return to ambulation (Figure
1).4 Adductor myodesis is indicated in all of these patient
groups in order to avoid postoperative limb deformity and
pain and improve the likelihood of success with prosthetic
fitting and use.

Contraindications
Transfemoral amputation is contraindicated in patients
who can be successfully treated with a more distal level of
amputation such as a transtibial or through-knee amputation as there is substantial morbidity and increased oxygen
consumption (68%-100%) associated with a femoral
amputation.9 Adductor myodesis is also contraindicated if

there is loss of the adductor tendons due to soft tissue damage from trauma, tendon necrosis due to infection or vascular disease, or spread of malignant tumor requiring adductor
excision.

Operative Technique
1.

Surgery is performed under general anesthesia with
the patient supine and a small bump under the ipsilateral hip to internally rotate the leg to a neutral
position and allow for hip extension and adduction.
A sterile thigh tourniquet is used as high into the
groin as possible to avoid interference with soft tissue dissection.
The transfemoral amputation should be performed
as distal as possible to preserve femoral length
(Table 2). Kinematic gait outcomes have been
shown to improve with increased residual femoral
length after amputation.2 A fish-mouth-shaped incision is typically used with equal anterior and posterior soft tissue flap lengths. Alternatively, a longer
posterior flap incision can be used similar to a transtibial amputation. In trauma and vascular cases, the
incision shape is often dictated by areas of soft tissue loss and/or previous attempted vascular repair.
The adductor magnus is dissected sharply from the
adductor tubercle and tagged distal to the skin incision to preserve as much length as possible for later
myodesis. Thigh muscles should not be sectioned
until they have been individually identified in order
to prevent accidental shortening or excision of the
adductors.

Table of Contents for the Digital Edition of Foot & Ankle International - July 2018