syme’ samputation

Syme’ s Amputation

A l”on�i�ow’-u� S’runY OF FnFTY-0NE ADULTS AN!) THIRTY-TWO (1HILnaEN �

BY ROBERT �1AZET, JR., M.I).t, LOS ANGELES, CALIFORNIA

Fro,,i the Orthopaedic Serriee of the Veterans .ldrninistration Hospital, the University of

California Medical Center, and the Orthopaedic Hospital, Los Angeles

The anskle (lisarticulationi nsow klsowni as Syme’s amputation was described by

James Svme in 1843. Subsequeist modificationss have beds introduced ; amonsg them,

those of Pirogoff ansd Boyd (placing a portions of the calcanseus aisd its adjacent skin

and subcut.anseous tissue uisder the cut ensd of the tibia) have enjoyed limited

l)oPillaritY . None has withstood the test of time as satisfactorily as Syme’s amputa-lions.

Prior to the Second World War, surgeonss ins the Unsited States evinced little

init.erest. ins end-bearinig stumps, largely because of the prosthetic fittinig problems

involved. The bulbous stumps produced by ankle disarticulation cans be hidden by

trousers hut not by a skirt . However, Scottish ansd especially Canadians surgeons

have beens aware of the practical value of ankle disarticulations. The thick heel pad

of the stump provides an ideal weight-bearinsg surface which rarely breaks dow-n.

The skins is not plagued by cysts or furuncles, does not become maccrated, and

rarely develops verrucous or hyperkeratotic chansges.

Wilson, Warren anud associates, ansd several stansdard texts 2 4,12 described

cutting the tibia above, rather thans at, the ankle level.

Ins 1946, Alldredge ansd Thompson described their experienice with Syme’s

Procedure 115 the United States Army. They reported on seventy-five cases ins which

no reamput.ations were required but ins which there s�’as iso follow-up. The operative

technnique which they described so well is more or less st.ansdard today. They

emi)hasized the advantages of the long, ensd-bearing stump, its freedom from skins

troubles, anid the advantage to the patient of being able to walk about the house

without arsv prosthesis when desirable.

Ii. I. Harris was the most prolific and ensthusiastic writer ons amputation at this

level. In his erudite paper, ins 1961, he reviewed the history of this amputatiols and

its various modifications and re-emphasized several poinsts which Syme had insisted

were important.. These were as follows.

1. Preservation of blood supply to the flap by beinsg careful nsot to sever the

l)osteriOr tibial artery above its bifurcation;2. Keepinig close to the bonse to avoid buttonholinng the skins while dissecting

out the calcanseus;

3. Disarticulationi through the anskle, nsot i)roximal to it;

4. The importansce of keepinsg the heel pad from migratinsg during the im-

mediate postoperative period (it must be firmly held uisder the ensd of the tibia);

3. The importansce of transsecting the tibia parallel to the grouisd, nsot nseces-

sarilv perpendicular to the shaft of tibia.

Follow-up reports after Syme’s amputationss are scarce. In 1954, Shelswell

reported that of the 302 Syme’s amputees treated at the Roehampton Censter two-

* Head at the Annual Meeting of The American Orthopaedic Association, Boca Raton,

Florida, April 24, 1968.t Veteranss Administration Cemnter, Wilshire alid Sawtelle Boulevards, Los Angeles, California

90073.

VOl.. 50-A, NO. 8. I)ECEMBER 1968 1549

1550 ROBERT MAZET, JR.

thirds had good results, and 23 per cent iseeded reamputations. No details were

provided. Warrens ansd associates, in 1955, reviewed the cases of six patients w’lso

had had amputations one censtimeter above the anskle for peripheral vascular disease.

The follow-up period was from six mouths to three years. All had good ensd-bearing

stumps despite absensce of pedal pulses. The most signsificant follow-up study was

that of Dale in 1961. After twenty-two Syme’s amputationss for i)eriPheral vascular

disease, six stumps required reamputationi, ansd sixteens did w’ell. In this n’epon’t

seventy-six amputees were follow-ed for as lonsg as twensty-tw’o years, and the results

were geiserally good � ‘ � 13 14

For a descriptions of the technique of amputations, the reader is’ referred to the

articles by Alidredge ansd Thompson and by R. I. Harris 5,9,16,11,

Material

This study iiscludes fifty-one adults and thirty-two childrens w’ho had Syme’s

amputations and were follow-ed for one year or lonsger. Thirty-three of the adults

had their amputationus performed at the Los Ansgeles Veteranss Adminiistrationi

Hospital ; the others were treated or followed at the Los Anigeles Ort.hopaedic

Hospital or Veterans Administration Regional Office. The childrels w’ere treated or

followed at Los Angeles Ort.hopaedic Hospital or at the Child Amputee Prosthetic

Clinic of the University of California, Los Angeles. The eighty-three amputations

were performed by many surgeons. All ages, unless otherw’ise specified, are those at.

the time of amputation. The results of amputations in childrems are, of counse, very

different from those in adults. Children almost insvariably do w’ell with nuinninsum

complications. For this reason, the childrens and adults in this study were analyzed

separately.

Children

The reason for amputation in the thirty-tw-o children was as follows : fibular

hemimelia in nineteens (of whom nine had some degree of femoral deficiency and one

had a Boyd amputation) ; congenital amputation at the Chopart level ins four;

transverse amelia at the ankle in one ; mid-femoral defect with all bones ins the

extremity present in one ; lymphanigioma in two ; purpura fulminsanss in one ; ansd

trauma in four.

A ssociated Congenital Deformities

Factors complicating the mansagement of childrens with Syme’s anuputations are

almost entirely related to the concomitant congenital deformities, such as’ other

amelias, dislocations, or contractures. There were no operative complication�s

associated with amputation in this series.

The common fibular hemimelia is invariably accompansied by kyphos of the

tibia and foot deformities of greater or lesser degree. There may be maldevelopmenst

of the femur and often dislocations of the hip or underdevelopment of the acetabuluns.

Not unscommon also are dislocation of the knee or ankle aisd flexions deformities of

the hip, knee, and anskle. Dislocations of the patella and constricting (Ainthuns-like)

bands are less commons.

Fibular Hemimelia

The largest group of children with Syme’s amputatioss was composed of the

eighteen with fibular hemimelias, eleven girls and sevens boys. Their amputations

had been performed when they were between eight months aisd sevens years old.

One boy in this group, when he was three years and eight months old, had had a

Boyd amputation in an attempt to gain length, but his stump was functionsally

THE JOURNAL OF BONE AND JOINT SURGERY

sY\IE’S AMI’U’I’A�I’ION 1331

von.. 50-A. NO. 8. 1)E(’EMr;Ert 1968

sinuilam’ to iliat of a Svnnu’ sttInlsl) (l’ig. 1). l�ecsunse of instability of the knee, his

pnostinesis was I)I’OVi(le(l �vitIi a knee joint ani(I a thigin lacer. \%hen last seens, threeyears after ansputationi, he was ven’v active arsd had had no trouble with mis stump.

l�esides providing tine cinild wino has fibular inemsuimelia wntin an alnisost. ur-

tiest ruct ihk, end-bearing stumup, the Synsue amputat ion offers additional dividensds.

FmG. 1

:� five-year-old-boy wit ii fibular iiemslinilelia. �\. l3ovd-tvpe aniiptmt at ion wrt_s perfor!ile(l in anellor’t tI I p) ivule maxilii(rnii Ienrgt ii when he was three years amid eight nnonrths old. This st umpfnmnrct ionrol as a Syme amput ation. Lonrgit nrrlinralgrowtin of tine t iI)ia was retarded. Absence of tire111e(liaI mmlall(’ollns trill frliimla (‘liniinrate(l i)IrlI)olmsmress at I he end 4)1 tine st (rriip.

I A’1) : ( � in gem) it ill iieniininelia ��‘it in niar’ke(l i)( n�’inrg of I he I ibia. 1� ight : ‘l’�’o Itnr(I on re-iialf yearsafer’ S\nrre’s a!ill)i)I:tt ion, I he I iiia is conrsideraiilv st m’aigirtem’.

After �tmlul)utationn, the kvphotic tibia gradually beconues straighter (l’ig. 2). I)e-

creased growth of the distal tibial epiphysis and absence of the fibula obviate any

bulbousniess of the stump end. This decreased growth of the distal end als(l the


THE JOURNAl, or’ BONE AND JOINT SURGERY

The legs of a seven-year-old girl with congenital absence of the i’ight foot distal to the talus andcalcamieus. Tine right calcanietrs has been pulled posteriorly amid laterally; tire talus is in a vertical

position. Note hypertr’ophv of the right fibula.

Roenitgemiogranu of a girl, one year arid six months old, showimig underdeveloped acetabulae,absence of tipper part of both fenuora, short tibiae, absent fibulae, amid deformed feet.

Fn. 5

I,)�d 1n(,. 6 Inn. 7

1”ig. 6 : I A’ft : 1�oen i I gemrogm’anir of a t �s’ )-veam’-( )l( I boy ‘t�’i I ii disloc:tt ion ( if I he left I r i p ai senr (‘e of

all i)ii) I ire dist:tl era! of t he left femur, anr(l fihinlam’ h(’!liinnelia. l�igiit : :�fIem’ S�’nnie’s :tmlil)iitat ion, at

t uI.’age of seven, anr(l after fit t inrg tvit Ii an i’(’lrial-i)eam’inrg pr’ost lie’is.

Fig. 7: Tire same boy as sii( wnr in Fig. 6 one �‘ear after aniptmt at ion when r Ire was (‘igiiI years 01(1.�1he (list:tl (‘nr(l of tire tibia is almost at t he level of tine normal knee.

sY\IE’� AMI’U’IA’I’nox 1333

\‘or..50.A, NO. 8, 1)FX’EM BEEt !9(iS

Sairre girl siio�s’mr in F’ig. 4 �virenr she �‘:rs fount (‘(‘Jr �‘ears :tnr(1 six nironrths old. I Icr’ knices ha(1 be(’nr#{241}rse I i ni ext en rsiors niak i rig iner a bila t em’al :ri)Ov(’-t iie-kmnee aninput cc.

r(.’tal’(l(’(l gn’o�vth inn i(’ngtin of tibia pn’()du(’e a nuson’ pleasingly siial)c(l stunip, �vhichs

earn he fitted with a pr’ostlicsis that mirror’s the (‘onitour’ of the normal leg.

(‘on qen ital A inputatwn

rIil(,n.(,\Ver(’ fivt’ (‘iul(ln’(’mi ��‘it ii (‘ongeniitai anuput at torts. l”our’ girls 11:1(1 (‘( inigennital



TABLE I

Cnmr�mnnEs WITH FEMORAL l)Es’ncrExcrEs

Age at Amputatiorl

(Years)

46

6 1/2

7 1/26 1/2

124 8/126

3 4/12

Follow-up since Anuputatmonr

(Years)

9

4

13 1/2

0

3

11

absenice of the foot distal to the calca.nseus and talus. Onse of the four ha(l this (lef(’ct.

bilaterally. Although they did nsot have true Syme’� stumps, they w�’re tl’eate(l its it’

they did, ssIi(l all four childrens walked well ins Syme’s-type devices. rfiue calcanneus

its cads insstanice was pulled upward and posteriorly, givinsg the stinnull) a somewhat

bulbous elsd. One of the four showed definsite fibular hvpertrophv at the age of’

seven (Fig. 3).

nil othen’ child with a consgenital ansputation was a boy who had a tr�nnisven’se

amelia at the anskle and nso distal tibia! suid fibular epiphvsis. lie was i’egan’ded as a

Svme amputee and did well with a Syme device.

Fern oral Deficiencies

Bevan-Thomas anud \lillar recenstlv reviewed twenty-two insstansces of cons-.

gensital femoral deficienscies. They nsoted the multiplicity of problensus frequently

encountered, listimig the five niost importanst onses as: (1) ans ulsstable hip, (2)

Iimb-lengtls discrepanicy which increases with age, (3) lack of proper alignnlluerst. of’

Fig. 8: Because of the posterior dislocation of the calcanneus and shortening of tire heel con’(I inn :n,congenitally deformed foot, a posterior flap could riot be fashioned when Synse’s anrni)irtat ion was.performed at the age of mine months. Note anterior flap amid posterior suture line. \Vhenn the boywas last seen at the age of four years, he was fully active amid had had nno trouble witin mis stirmnnp.

Fig. 9: Hoemntgentograms of a stump showing posterior migration of tile heel 1)11(1 with bone

proliferation about the lower end of the fibula amid imnrder the adjacent tibia pro(llrced i�’ imitation.

SY\nE’s AMPUTATION 1535

the extreruuit.y unsder the pelvis, (4) instability of the knee, and (5) deformity of the

foot.

Treat menit should be designsed to provide the child with the best possible

weigint-bearinig extremity. A Syme amputations is oftens sins importanst step ins the

�rogrnsnuu of aidinsg these patiensts to walk.Nine of our l)atienst.s, six boys ansd three girls, had hip dysplasias (oftens dis-

locations) and onslv a portions of the femur (perhaps just a nsubbins) (Figs. 4, 3, 6, ansd

7), ins athlitions to tise usual absence of the fibula and partial absensce of the lateral

side of the foot. The knee was invariably higher thars the normal knee. Two girls

were bilaterally involved.

‘fhese niinse children had used ischial-bearing long braces prior to anuputations

and ischial-bearing prostheses afterward, although several were provided w’ith

partial end-bearing as w-ell irs ans effort to promote longitudinal bone grow-th. Insthree, there was sufficient lensgth of femur to be useful, and, in these, knee fusion

wa.s donse ins addition to amputation (Figs. 4 and 5). In all instances, loisgitudinsal

growth of the long bones of the irsvolved side w-as subnormal, so that the low-er

end of the tibia � near the level of tlse nsornsal knee, aisd the lower tibial epiphysis

ss.its snualler ins diameter thans that of the opposite side (Figs. 6 and 7). There si-as no

bulbousness of any of the stump ends. At follow-up from one to elevens years after

amputations, all were usinug an ischial-bearing above-the-knsee device w-ith the knee

joint of the prosthesis at or near the level of the normal knee.

The ages at the time of amputations and the length of time these children were

followed after amputation are given in Table I.

Ablation of nuns ugly arid almost useless foot and fitting with ans artificial foot,

which permitted facile locomotion, made daily living more pleasant for several

poorly adjusted children. Their social adjustment and their school w-ork showed

striking improvement after amputation.

Relaxed collateral ligaments of the knee may necessitate the addition of a knee

joinst and a thigh lacer to the prosthesis for several years. Usually by the time

tise child becomes adolescent, the kisee is stable enough so that these unprepossessing

appendages can be discarded.

Rarely, the skins flap may have to be modified. In a nine-month-old boy with

fibular hemimelia, the foot was dislocated posteriorly with the result that the heel

cord was retracted and the calcanseus was displaced upward. A good heel flap could

not be fashioned so a long anterior flap ��‘as used to cover the Syme stump (Fig. 8).

Whens lie s�’ns.s last seeni at the age of four years, his stump was excellent, and he was

walking anid runsninsg without difficulty.

Trauma in Childhood

I”our of the Syme amputatiorss ins cisildrens were necessitated by trauma. One

w’a.s ins a girl, fifteen and a half years old, who had lost her foot follow’insg a crushing

injury ins nils automobile accidenst ; ansother, in a ten-year-old boy who had had

amputations of onse foot arsd of the other extremity above the knee as the result of a

trains accidenst; the third, ins a boy elevens years old who Isad to have Syme’s amputa-

tions after his foot had beens insjured by a power mower; ansd the fourtis, ins a seven-

teds-year-old boy ss-ho had lost his foot followinsg an hsjury in an automobile ac-

cidenst.. All four stumps healed without complications, and none of these children

had any stunip trouble w-hen last seens onse ansd a half to five years later. All led

active lives ansd participated ins most school activities.

Results

The follow-up period of observations of these thirty-two children w-as from one

VOL. 50-A, NO. 8, 1)ECEMBER 1968


TABLE II

LENGTH OF FoLww-un’-YEAnIs

Cause ofAmputation 1-2 3-4 5-9 10-14 15-19 20+ Failures Total

Adults 51

Trauma and infection 4 1 2 6 4 7 5 29

Diabetes 4 1 6 11

Arteriosclerosis 1 1

Other �3 1 1 3 2 10

Children 32Trauma 2 1 1 4

Congenitaldeformities 9 7 3 5 1 25

Other 1 1 1 3

to two years in twelve, from three to four years ins nine, from five to nine years ins

five, and from ten years or more in six.

All of them used their stumps hard as children insvariably do, ansd not one of

them had a stump breakdowns or serious trouble of any nature.

Postoperative complications ins children are rare, especially ins those whose

amputations were performed for congenital deformity.

Ins patients whose foot deformity is a transverse amelia, grow-th of the distal

tibial epiphysis is usually slow-ed, and longitudinal growth is, therefore, lessuied.

There may be hypertrophy of the fibula if the calcaneus moves laterally unsder this

boise (Fig. 3).

Advits

There were fifty-onse adults eighteeni to sevensty-four years old. All were male

except for one diabetic woman forty-one years old.

The reasonss for the Synse amputations in these patients were as follows: pen-

pheral vascular disease in seventeens (Buerger’s disease ins five, arteriosclerosis’ ins

one, and arteriosclerosis with diabetes in elevens) ; trauma ins twenty-four; frostbite

(bilateral in one) ins two; trophic ulcers of undeterminied etiology ins onse; chronsic

osteomyelitis in five; ansd recurrenst vensous thrombosis ins tw’o.

Of these fifty-one patients, thirty�eight had serviceable stumps ansd thirteens

required reamputation at a higher level. The length of follow--up and the incidence

of failure are given in Table II.

These patients were divided into two large groups:

1. Those w’hose amputations were caused by peripheral circulatory embar-

rassment including those with long-standing infections and much scarring and

those with frostbite- the majority of these amputees were over forty years old;

2. Those who were in good health but w-ho had lost tise foot because of severe

trauma including war ss’ounds-the majority of these patiensts were unsder forty

years old.

Tss-ersty-onse of the fifty-one adults had lost a foot because of arterial disease:

seventeen from peripheral vascular disease, two from frostbite, ansd tw’o from vensous

thronibosis. Their ages ranged from forty-onse to sevensty-four, the average age

beinig fifty-five years (Table II). Included in the tss-ersty-one patients were two

diabetics, fifty-one and sixty-nine years old, who had excellent stumps, as well as

seven of the thirteen failures. Of these seven, t’wo became above-the-knsee amputees

within two weeks of primary amputation (one of these became a bilateral above-

the-knee amputee seven months after reamputations); another had two subsequent


SYME’S AMPUTATION 1557

arnpintationis (the first below, the second above, the knee) ; and four had reamputa-

tionis below’ the knee (two bilaterally).

Ins conitrast to the relatively high failure rate among mers with arterial disease,

those whose Svme’s amputations followed trauma were far more often good i)rOS-

thesis users. Of the twenty-nine patiennts who comprised this group, only five whose

injury had beeni follow’ed by chronic osteomyelit.is ansd niuch scarring failed to use

th(’ir prosthesis. �Fh ages of these twenity-niine men ranged from eighteen to fifty-

()nie; the average age was tw’enity-niine. Sevens of the twenty-nine patients had been

followed more thars tens years.

Complications in A (lulls

Complicationns of Syme’s amputations ins adults usually stem from inssufficient

blood supply to flap, infection, and imperfections irs technsique. The complicationss

commonly encountered its adults s�’ere the following:

1 . Dehiscence of the w’ound arid nsecrosis of skins flap from inssufficienst circula-

tioni, infection, or, ins onie instanice, failure to mairstainn constant. stuns!) compression

nifter immediate fitting of the prosthesis;

2. Migrations of the heel flap, buttonholing of skin, ansd sloping of the unsder

surface of the tibia due to technsical errors;

3. overgrowth of the end of the tibia;

4. A nerve or tensdon caught. ins the scar;

5. Painiful nieuroma;

6. ilypertrophy of the skins or callosities under enid of tibia.

Tine commonest complications are wound dehiscenice arid necrosis of heel flap.

These may be cause(l by infection, poor blood supply, or poor operative technsique.

In the presenice of gross inifectioni, a two-stage procedure should be done. At the

first stage, the caicanneus is removed, but the leg bonses are niot t.ranssected, and the

wounid is left openi with traction on the skins flaps. The procedure is completed when

Iie�tlthy graniuiationns are present tens to fourteens days later.

If there is Iso gross infection, but. dirty or nsecrotie tissue is founnd ins the ankle

regionr, leavinig rubber drains in place for from five to sevens (lays is advisable to

allow tlet ritu s to escape postoperatively.

Necrosis of skini edges because of PeriPheral vascular inisufficienscy, if nsot

extensive, m�t�’ be self-limitinsg amid permit litter secondary closure. If during the

open’ationn the Posterior tibial artery is divided above its bifurcations, the flap will

be ir’r(’parably damaged. (�fh ss’as onse such complications ins this series.) Failure to

niainitaini coml)resiions postoperatively and migrations of the flap posteriorly cans

cause circulatory embarrassmenit and loss of heel flap.

Buttoniholinig the flap by not keeping all the soft tissue instact anid peelinsg it

5l.IbI)(’riost(’ntllV off the calcanseus disrupts the septst of the flap, openis fat. loculi, arid

�tllows fat to C5Citl)C. A defective l)ntd, which may be painnful, is the result.

‘nligrationi of the heel flap is a frequent cause of pain, and breakdowns of the skims

froni tenisioni niav lead to posterior migration. Displacement of the heel pad produces

a shili(’lagh-like stunisp with ann oblique weight-bearinsg surface, which is prone to

inlcerationi because the enid of the tibia is inssufficierstly padded ons the high side.

Overgrowth of the cut. enid of the tibia is occasionally produced by periosteal

irritations, usually from infections (l’ig. 9).

Nerve enn(linngs or tenicloni eni(ls are rarely caught in scar tissue. Ordinarily,

Iresstnre from the prosthesis cans be relieved over such areas, with disappearance of

I)nunn. Surgery should be reserved for resistanst cases.

Sloping of the weight-bearing surface of the tibia produces migration of the

heel flap, excessive pressure over the lower cornier of the tibia, pain, and ulceration.

�‘OI.. 50-A, NO. S. n)E(r:MBER i968

FIG. 10


THE JOURNAL OF BONE AN1) JOINT SURGERY

A diabeti(’ heavv-eqtmiprnenrt operator, forty-four �‘ears old, wino ina(1 had a mo(lified Svme

arill)tttIttiOnl at aniot her iu)spital because of breakdown of iris heel amid mit emnnit t emit drainage fortWo years. lie (li(l riot rensainr for a fitting of a prosthesis. \\‘hemr he was seen at our ix)spital threerisoniths later, there was considerable ex(’ess soft tissire distal to tine boric ends amid an (ml(’er overthe anterior aspect of the tii)ia above the site of anspirtationr. Tine ulcer healed slowly, and, fivennomnths after aniputatiomi, the bulboins mass of soft I issue on tine (list al end of tine st immp hadnnigrated medially.

Fm. 11

Roentgemrogm’am of the stump shown in Fig. 10. Note that the tii)ia had beemn tmanlsecte(l abovethe level of tire ankle joint.

Fn;. 12


vor. 50-A, No. 8, DECEMBER 1968

‘l’Ire st nnrrp of tire PII ienit sino%s’nr in l�’igs. I I) amid I I itft er n’evisiomr . l�r’ior’ t � r’eviiomi, ire 11:1(1 1 4)1

‘t�’alked. :�fier revisn)nr, he �‘a1ked %Vithi))nmt(hifhcirltV until ire died as tire result of chronic nrepirn’ilisanr(1 (hiai)etic coiria six nnorrths l�ttem.

Operative co rrec tioni is inniperative. rfin(, tibia should be cut Parallel to the floor.rflmn adherent skins under the end of the tibia, such as that 1)roduce(l by a

split graft, ��‘ili always break downs.

Irs tine present series, twelve patients had (lehiscence of the �voiinid 915(1 necrosis

of the ineel flap. The diagnosis inn th(’se patients w’as diabetes inn five, Buerger’s

(li5e�t5(’ ins onte, bilat{’I’Itl frostbite with breakdowns of both sttnmps inn one, traumatic

rul)tur(’ of tine fennion’al artery associated with fracture of the fenistir ann(l gangrense of

t he toes inn one, chroniic infection mi three, arid traumatic inijun-y of tine foot ins one.

I ni one of tii(’ diabetic I)itt ienits, a t(’cinnsicai error’, r(’suitinrg inn tearing of t he post(’rior

tibia! ar’t(’rv, s�’as I)n’obablY t he cause of the necrosis. Scar’rinng about the pen’Onie�tl

ni(’n-v(’ anal tendons caused disabling pains ins one ni�tnn, hut aften rele�ts(’of these

st ninet tines Isis st unn�i�) \\‘1ts s�tt isfactory. TF\�’() j)ttilsftnl st.unnps becanise asynuj)tonsat ic

after (‘xcisionl of nneuronsas. lour stunips \\‘ere unnsatisfactory because of niigrationi

of I he heel flaps. \%li(’ni th(� fl�tps ��‘ere surgically rel)laced benie�sth the end of the

tii)itt, these stilnups becanse s(’rvic(’able (l”igs. 10, 1 1, ttni(l 12).

One failure ()ccurn’ed inn a veteran, thint�’-four y(’ars 01(1, svitis a nnetnrotic

(lepenidenit. l)ersonnality. \Vheni he was eighteen year’s old, lie had sustained inns O�CI5

fracture of tine tibia w’inile on active duty. ‘l1his was followed by cinronnic osteomyelitis

anid tine (levelopnisentt of a stifi arid painful foot. A lumbar sympathectonsy anid

Larubriniudi st�thilizationi of the foot. failed to give relief. rf(�ni y(’itrs after mis inijinn�’,

itt tlE.� age of twenty-eight, a Syme amputation w’as i)erforrned at another hosl)ital,

but lie \�‘as never able to bear weigist. Sixteens years after isis innjury arid six years

after the Synise’s ansputationi, a below’-the-knnee amputations was i)erfornsed. There-

after, he got along ss’ell arid �vas working as a l)ost office clerk witls rio difficulty

from Isis stUnlsj) eight years later.

Balloon Prosthesis

l”or the piLst few’ years, w’e have trimmed the malleoli when doing Synsie’s

FIG. 13


THE JOURNAL OF’ BONE AN!) JOINT sl’RGF:RY

Synne’s arrnpintationn (left) and normal amrkle (right). The malleoli were trimmed at the time (If

amputation to decrease bulbousness. Note decrease inn transverse dianneter conrpared with tineopposite side.

Balloon prosthesis. The sagittal se(’tio!n (inn the left shows the inner silast ic wail (wirnte ) amid tineair space between it �tmid tine osnter plastic lanninrate shell. The complete pm’osthnesis on tine right.demonstrates that the limb is mnot unduly bulbous at the ankle.

OUTER PLASTICSHELL

SYME’S AMI’t”I’A’n’nON 1561

VOl.. 50-A, No. 8, r)F:(’EMr)ER 1968

:�:::� � 2 LAYERS

� SILAST1C

COMPRESSIBLEAIR SPACE

FI(t. is

l’ai)m’ic:tt 4 �i of iBtll( E)�i prost iresis.‘ I j�per left : ‘Fire Stimlini) is covered by two thicknesses of nylon stockinette inrnpregmrated witin

snlastit’,

I �pJ)(’r right : A su’ax build-imp is a�)plie(l over I he silast ic inn sufficient annoirni t to make the diameterof tine s))(’ket evervuu’here eqinivalemrt to t h:nt � f I lie st nmniip end. ()ver t inc silastic amrd wax, tine

I)la.St,iC laininiat e socket is tireni fabmicat ed.Lower left : ‘Fire wax ir:ns i)eenr renlove(l amid rej)laced uvit in air. ‘Fhis is (Ionic by drilling two

holes in tire socket I)) all)rnvtire uu’ax, nneite(1 in’ placing tir(’linini)in an oven, to rimnrout. ‘Fire holes

are I inert sealed leaving amr enrcl))se(I aim’ sp:tce.L))uu’(’r right : As I he arinpint ce’s st Imnip is inrserte(1, t ire silast ic inner’ uu:tll st ret (hes to inliow I Ire

i)lnlI)olrs enrd to i)it55 (k)%%’ni I lie so(’ket . ( )nrce t inc lirmni) rea(’hnes t lie 1)01 toni of I he socket , I he air is all(Iisj)ht(’e(i I)) simrrounn(i t mt.’ rrarro�v part of t Ire st imnip :rmr(I hold tine st tnrinp l)roPerI�’ seated.

aniputationns inn or(Ier to decrease tine bulbousnsess of the stuns1) end (l’ig. 13). The

less I)unlbOins stinnip has perniitt(’(I use of a nio(Iified type of l)rOstliesis irs �vliich no

5i(l(� ifi’ back winn(low’ is nneeded. The (levice is held firmly agaimnst the stump by a

ballooni-lil�’ air-fillet! cuff. As the stilmi) is iniserted into the socket., the air is dis-

l)l11c(�(l l)roxiniitllY its th(� sttnnil) conipresses tine sid(’s of tine cuff (1�ig. 14). Once tinesttnlnil) r(’acines tii(� bot.t.oni of the socket, the air fills the space above the bulbous ennd.

Ins fabricating this type of prosthesis, it is nsecessary to make tine shell of the

socket. everywhere large ennough for the end of the stump to pass through. This is

accomplish(’(l by inncreasinng the dianseter of the plaster mol(l of the stump wisere it

narrow’s above tine ankle. A double-thicklness of nivlon stockinette impregnnate(l with

sili.tst ic is itj)l)l1(�(l over tine cast of the stump to form a flexible covering. A wax

build-up is a�)plied over this to make the circumferenice of the area proximal to the

annkle tine 5�tnie size as tinat of the sttlnil) enntl. Tine outer I)lastic shell of the socket

is lansinated over this. After the laminsate has set, two holes are drilled in the outer

sh(’ll, and tin(’ socket is place(1 in an ovens. As the wax melts, it rums out ansd is

I’eplace(l by air. The holes are theni closed. Tue air-filled cavity bet.w-eens tise silastic

itIs(l the outer shell left by removal of the wax pernsits the bladder to collapse its

the stumi) ens(l passes downsw’ard anid thens to re-expanid above the stump ensd to

hold the socket in place. (Fig. 15).

We have fitted three patiennts with this device which they have worn for over a


year with complete satisfaction. They prefer it to the older type prosthesis because

it is lighter, and the nsuisansce of adjusting the winidow is obviated.

Comment

A well executed operations in a limb with good circulations anid a wound which

has healed without complication assure the patient a relatively indestructible stump

ons which he cans walk with or without a prosthesis.

The durability of the Syme stump of the adults who lost their foot because of

trauma ansd hence had a stump with an essenstially normal blood supply is attested

by the occupationss of these mens.

Of the sevensteers follow-ed tens years or longer after amputations, eight had

heavy laborinsg jobs ansd nine, w-hite collar jobs insvolvinsg conssiderable walking.

Nonse did sedentary work.

Furthermore, our patients with Syme’s stumps were rarely troubled by

ulceration, furunncles, infected cysts, ansd the dermatological nsuisances which so

frequently bedevil above and below--t.he-knsee amputees.

A long-term follow--up study of fifty-one adults and thirty-two childrens who

had Svme’s amputations has been presented. There w-ere onsly thirteens failures

w’hich necessitated reamputation-all in adults and usually associated with vascular

insufficiency. Of the eighty-three amputees, ten had used a prosthesis regularly for

from onne to twensty-tw-o years. The findings ins this study emphasize the necessity

for meticulous operative technique and the prevenstions of migrations of the flap un

the immediate j)ostoperative period. The complications seers in these amputees have

beers enumerated and the reasons for each complications discussed. There were no

failures ansong the childrers.

Conclusions

The results of this study confirm the conclusions ensumerated by Harris inn his

magnificent review- �.

1. The Syme stump is durable and almost trouble free. It withstansds the

stresses of weight-bearing for many years.

2. Productions of a satisfactory Syme stump nsecessitates strict adherennce to

the basic principles and operative technique described by Syme. Deviations from

these priniciples or from the technique frequently leads to complications ansd loss of

the flap, rec�uirinsg reamputation at a higher level.

3. Surgeonss who must ablate a foot because of disease or trauma should be

familiar with the advantages provided by this amputations and utilize it w’hens it is

insdicated.

References

1. ALLDREDGE, H. IL, and THOMPSON, T. C.: The Technique of the Syme Annpurtationn. J� Boneand Joint Surg., 28 : 415-426, July 1946.

2. BANCROFT, F. W., and MURRAY, C. H. : Surgical Treatment of the Motor-Skeletal Systennn,Part I, pp. 535-543, Philadelphia, J. B. Lipirncott Company, 1945.

3. BEVAN-THOMAS, W. H., alnd MILLAR, E. A. : A Heview of Proximal Femoral 1)eficierrcies. J.Bone amid Joimnt Surg., 49-A: 1376-1388, Oct. 1967.

4. CAMPBELL’S OPERATIVE OnlTHoPAEDncs. Edited by A. II. Crenshaw. Fourth Edition. $t.

Lotmis, C. V. Mosby, 1963.5. CATTERALL, H. C. F.: Syme’s Ampirtatiomn by Joseph Li.ster after Sixty-six Years. J. Boric arid

Joinit Surg., 49-B : 44, Feb. 1967.6. 1)ALE, C. M.: Syme’s Amputation for Ganngrerre from Peripheral \‘ascular I)isease. Artif.

Limbs, 6: 44-51, 1961.7. (iI�ADSTONE, H., and IULmUccm, L. : Some American Experiennce with Syme Prostheses. Artif.

Limbs, 6: 90-101, 1961.8. HARRIS, H. I. : Syme’s Ampuntatiorn. The Technical i)etails Essential for Success. J. Borne arid

Joint Surg., 38-B: 614-632, Aug. 1956.9. liAnInIns, H. I.: The History annd Developmennt of Syme’s Amputation. Art if. Linnbs, 6: 4-43,

1961.

THE JOURNAL OF BONE ANN) JOINT SURGERY


10. 1l,�itmtms, it. I.: � Annputatiomn. The Technique Essential to Secure a Satisfactory Fnrd-Bearing StiIln�np: Part I. Canadian J. Strrg., 6: 456-469, 1963.

1 1. IlArirIrs, H. I.: Syinne’s Amputation. ‘I’he Technique Essential to Secure a Satisfactory End-Bearinrg Stump. Part II. Carradiann J. Stmrg., 7 : 53-433, 1964.

12. I%.nrnK, N. ‘F.: Annputatiorrs. Operative Technrique-Fornnationr arid After-Treatnnemnt of theStimIli1)s from the Standpoint of Prostheses. A Study Based on Seveniteemi liruidred Cases ofA liilMmt at jones for I nj nmries arid 1 )isease occurring inn t Inc \Vorld \Var arid Sin (V I I s Ternninntt ionPirblished inmrder the authority arid with the approval of the Surgeon (enneral, U. S. Army, 1924.

13. LnNoQurs’n’, CA81’ons, arid HnsKA, E. B. : Chopart, Pirogoff amrd Syme Amputations. A Surveyof Svnne’s Amputatiomi. Twerity-orre Crises. Ada Orthop Scanrdimnavica, 37 : 1 10-1 16, 1966.

14. HATr.IF’F, A. Ii. C.: Synne’s Annnputationr: Hesirlt after Forty-four Year’s. Report (if R Case. J.Boric arid Joint Sirrg., 49-B : 142-143, Feb. 1967.

15. HOBEIIT5ON, J. Ii. Ii.: Orthopaedics arid the African. Clint. Orthop., 6: 202-207, 1955.16. SIiELss%’Er�r�, J. 11.: Syme’s Amputation. In Proceedings of tine British Orthopaedic Associa-

I ion. J. Bone arid Joint Surg., 36-B : 507, Aug. 1954.17. Ss’smE, JAMES Amputation at the Ankle-Joint. Lomrdomn arid Edinrbinrgh Monthly J. Med.

Sci., 3: 93-96, 1843.18. W’AuaEs, limcHAnw; THAYER, T. H.; ACHENBACH, ilArtTwrG; and KEsrmn�n�, L. .: The Syme’s

Annputationi in Peripheral \‘a.scular 1)isea.se. Sirrgery, 37: 156-164, 1955.19. \\mr.sox, P. I).: The Svme Amputation. Strrg. Chirn. North America, 1: 711-728, 1921.

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syme’ samputation

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