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Table 3. Technical Pitfalls.
** Avoid transection of the adductor magnus at or proximal to
the level of the skin incision as this will not permit myodesis
to the anterolateral femur.
** Do not under- or overtension the adductors during
insertion. First provisionally check the adductor length across
the end of the femur and adjust as needed prior to Krackow
suture placement.
** Prevent anchor breakage during insertion by drilling and
powertapping the anterolateral drill holes twice to ensure no
bony blocks to anchor insertion.
** Avoid residual abduction deformity by holding the leg in an
adducted position during insertion of both anchors with the
adductor centered over the distal femur.

young patients with hard bone, it is necessary to
power-tap the drill holes twice prior to anchor insertion in order to prevent subsequent anchor breakage
(Table 3).
8. The thigh is held in neutral flexion-extension and
approximately 10 degrees of adduction by an assistant. The adductor is then brought over the distal end
of the femur, and the FiberTape tensioned to the
anterolateral drill holes. The distal eyelet at the tip
of the anchor is made flush with the bone and 2 mm
of slack is placed on the FiberTape to allow for complete anchor insertion. Avoid overtensioning and
pulling too much of the tendon into the drill hole
which can block insertion.
9. Holding the appropriate adductor tension, two
4.75×19-mm SwiveLock anchors are inserted one at
a time into the distal femur beginning with mallet
taps and then final hand tightening. Suture and tendon is directly fixed to bone in a tenodesis fashion.
There is often an audible squeak as the anchor is
seated flush with bone. A small freer can be used to
ensure that the anchor is flush with bone before
completely removing the anchor insertion handle.
10. The remaining core sutures from the anchor can be
used to tack down the remaining edges of the
adductor using a free needle or can be removed
from the anchor completely. The leftover FiberTape
is cut flush with the anchor and the final adductor
transfer is checked (Figure 3). Fixation is tested
with gentle abduction and adduction of the thigh.
To prevent the adductor from sliding anterior or
posterior over the end of the femur, the remaining
quadriceps and hamstrings muscles are sutured to
the adductor tendon along the distal aspect of the
wound.
11. The medial fascia is sutured to the lateral fascia lata,
and the remainder of the wound is closed in a layered
fashion with absorbable sutures for deep and subcutaneous tissue and nylon sutures and staples for skin.

Foot & Ankle International 39(7)
12. A well-padded soft dressing is placed over the
amputation stump and secured to the skin with tape
to avoid the dressing from rolling off distally.

Postoperative Protocol
0-4 weeks: Patients are immobilized in a non-weight
bearing soft dressing. Sutures are removed at 3 to 4
weeks depending on the degree of skin healing.
4-8 weeks: Patients are fitted with a stump shrinker to
reduce thigh swelling.
8-12 weeks: Patients are fitted for a femoral amputation
prosthesis and begin physical therapy working on gait
training, balance, and thigh muscle strengthening.

Complications
There are few reported complications with transfemoral
adductor myodesis in the literature.3,5,6,8 We have found
that the main complications are iatrogenic and include (1)
excessive shortening of the adductor tendon during initial
dissection, thus limiting excursion across the end of the
femur; (2) under- or overtensioning the adductor into the
anterolateral drill holes; and (3) loss of fixation in the distal
femur due to inadequate bony preparation, suture knot
loosening (traditional technique), or improper anchor
insertion (current technique).

Results and Discussion
In a series of 20 patients who underwent transfemoral
amputation with traditional adductor myodesis, Gottschalk
reported that all patients were able to be fit with prosthetics.6 One patient had an acute postoperative infection and
another had a late infection develop. No stump breakdown
occurred and there were no complications related to the
adductor myodesis. Strength testing showed improved
strength and stump control on isokinetic testing and
decreased lurch compared to nonmyodesis amputees.
In our preliminary series of 8 patients treated with transfemoral amputation and adductor myodesis using FiberTape
and knotless anchors, we have found that all patients maintained neutral femoral alignment and were able to be fit with
a prosthetic on final follow-up. No complications were noted
and there were no cases of stump or socket pain. Compared
with traditional techniques, we have found our knotless technique to be faster, easier, and more reproducible, with solid
tendon-bone fixation. We have also successfully used this
same technique in transtibial amputations to secure the gastrocnemius aponeurosis versus Achilles tendon to the anterior
aspect of the tibia to improved soft tissue stump coverage.
Further large clinical series and comparative studies are
required to determine the long-term clinical and functional
differences between adductor myodesis techniques in transfemoral amputation patients.

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