Technique selection in transfemoral amputation surgery: an interview study among surgeons

Background: In transfemoral amputation surgery, two surgical techniques can be used to secure the transected muscles in the residual limb: myodesis and myoplasty. A scientific basis for determining which surgical technique to use is still lacking. Furthermore, little is known about the circumstances in which surgeons select one technique over the other and the reasons behind their choices. Therefore, this qualitative interview study aims to explore the current practices, influencing factors and decision-making in surgical technique selection in transfemoral amputation surgery. 

Methods: Individual, semi-structured interviews were conducted with vascular, orthopedic, and trauma surgeons. Recruitment was purposefully aiming to include surgeons with varying age, gender, surgical specialism, workplace and nationality. Data was analyzed using the Applied Thematic Analysis approach. 

Results: Twenty-three surgeons were interviewed. Variation was found in the way surgeons described and applied myodesis and myoplasty. Differences existed for example in which muscles were reattached, how these muscles were reattached, and the position of the hip during muscle fixation. Myodesis was mainly chosen for its potential favorable outcomes, like preventing femur deviation and improving function, while myoplasty was often chosen for practical reasons, like sticking to what was learned, reducing the number of surgical actions involved and minimizing operation time. Moreover, conflicting perspectives existed about the possible advantages and disadvantages of both techniques and whether or not to use a myodesis in the older, more fragile patients. The lack of research and patient follow-ups were mentioned to influence technique selection, along with factors such as the personal experience and training of the surgeon, surgical practices of peers, observed outcomes and patient feedback, and the characteristics of the treated patient population. 

Conclusion: This research reveals great variation in technique descriptions and surgical practices in transfemoral amputation surgery. Surgeons have diverse opinions and rationales for the use of myodesis and myoplasty, reflecting varying approaches and preferences in their clinical practice. The findings underscore the lack of evidence to support current choices in surgical technique selection in transfemoral amputation surgery and highlight the need for further research on the advantages and disadvantages of both techniques to provide surgeons with evidence-based recommendations.