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Procedure

Syme Amputation & Prosthesis

Syme Amputation (Ankle Disarticulation) is performed at the level of the ankle joint, where the heel pad is preserved. It offers the best possibilities of good function in amputations of the lower extremity.

Syme amputation was first described in 1843 by Sir James Syme of Edinburgh, Scotland

Syme Amputation Procedure Steps

The procedure involves using a single long posterior heel flap. The incision begins at the distal tip of the lateral malleolus, crosses the front of the ankle joint at the level of the distal end of the tibia, and reaches a point just below the tip of the medial malleolus. From there, it extends downwards across the sole of the foot to the lateral side and ends at the starting point.

See Also: Ankle Anatomy
Syme Amputation Procedure Steps

All structures are divided down to the bone. To remove the tarsus, the foot is positioned in marked equinus, and the anterior capsule of the ankle joint is cut. A knife is inserted into the joint space between the medial malleolus and the talus, then drawn downward to section the deltoid ligament, while ensuring protection of the posterior tibial artery. The same maneuver is repeated on the lateral side to section the calcaneofibular ligament.

A bone hook is placed in the posterior aspect of the talus to further increase equinus, and dissection is carried out posteriorly, dividing the posterior capsule of the ankle joint. The dissection continues near the upper surface of the calcaneus. The Achilles tendon is identified and exposed, and it is divided at its insertion on the calcaneus, being cautious not to damage the overlying skin to prevent flap necrosis.

Using a periosteal elevator, the soft tissues are dissected from the lateral and medial surfaces of the calcaneus, pulling the bone into more equinus. Subperiosteal dissection is then performed on the inferior surface of the calcaneus until reaching the distal end of the plantar skin flap.

Syme Amputation Procedure Steps

The entire foot, except for the heel flap, is removed. The flap is retracted posteriorly, and the soft tissue around the tibia and malleoli is dissected. The periosteum is incised circumferentially 0.6 cm proximal to the joint line, and the tibia and fibula are divided at this level, ensuring that the transection line passes through the center of the ankle joint dome. The cut surfaces of the tibia and fibula should be parallel to the ground when the patient is standing. Sharp corners of the bone are rounded and smoothed.

The medial and lateral plantar nerves are dissected and divided proximal to the bone end. Tendons are sectioned and pulled downward, retracting them proximally into the leg. The posterior tibial artery and vein are isolated and ligated just above the cut distal edge of the heel flap, while the anterior tibial artery in the anterior flap is also ligated.

Minimal debridement is performed on any soft tissue tags of plantar muscle and fascia along the inner surface of the heel flap, while preserving the intact subcutaneous fat and its septa, which are specialized pressure-tolerant tissue.

To prevent migration of the heel pad on the stump, various techniques have been used. One effective technique, known as the Wagner technique, involves drilling holes through the anterior edge of the tibia and fibula, and suturing the deep fascia lining the heel flap to the bones through these holes.

Syme Amputation Procedure Steps

The skin edge of the heel flap is then approximated to the skin edge of the anterior flap using interrupted nonabsorbable sutures, ensuring there is no tension. At each end of the suture line, there may be protruding tags of skin called “dog ears,” which should not be removed as they contribute to the blood supply of the heel flap and eventually disappear under bandaging.

A cast is applied, extending above the knee, and a drain is inserted. The drain is removed 24 to 48 hours after the surgery.

Syme Amputation Procedure Steps

Aftercare

A soft dressing can be applied and treatment continued. A preferable approach is to apply a properly padded rigid dressing in the operating room at the conclusion of surgery. If ambulation is to be delayed until wound healing is assured, a simple well-padded cast is adequate. If early ambulation is preferred, or when subsequent prosthetic ambulation is to be instituted in the postoperative period, a true prosthetic cast should be applied as follows.

Apply a light sterile dressing to the wound, and apply a sterile stump sock. Sterile felt pads are appropriately fashioned and skived by the prosthetist to relieve pressure over the tibial crest and the edges of the transected bones; the prosthetist glues these pads to the stump sock with medical adhesive and applies the plaster cast.

Use elastic plaster of Paris in the initial wrap to provide good control of tension; reinforce this with conventional plaster. Gentle compression should be maximal over the end of the stump and gradually decrease proximally. The cast need not extend above the knee because the shape of the stump and the intimate fit between the stump and the rigid dressing provide sufficient suspension.

The end of the rigid dressing is flattened for weight bearing by pressing a board against the wet plaster. The proximal part of the dressing is molded to create a patellar bar and a popliteal bulge, as in a patellar tendon-bearing prosthesis, to allow partial weight bearing by the patellar tendon and tibial condyles.

A filler block is added if needed to correct leg-length discrepancy, and a Syme Prosthesis foot or a rubber walking heel is attached to the cast. A waist belt and suspension straps are used for additional suspension.

Gait training and further postoperative Syme amputation care proceed.

Syme Prosthetic

A Symes prosthesis may use a suspension sleeve or a total contact socket and a prosthetic foot with the socket being the most important part of the prosthesis.

Syme Prosthetic
Syme Prosthetic

References & More

  1. Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, page 93.
  2. Syme, J., Amputation at the ankle, London and Edinburgh Monthly Journal of Medical Science, Vol. 6, No. LXVII, Aug. 1846, pg. 81.
  3. Diveley RL, Kiene RH. An improved prosthesis for a syme amputation : Rex L. Diveley MD (1893-1980), Richard H. Kiene MD. Clin Orthop Relat Res. 2008 Jan;466(1):127-9. doi: 10.1007/s11999-007-0027-0. PMID: 18196383; PMCID: PMC2505294. Pubmed
  4. Morrison SG, Thomson P, Lenze U, Donnan LT. Syme Amputation: Function, Satisfaction, and Prostheses. J Pediatr Orthop. 2020 Jul;40(6):e532-e536. doi: 10.1097/BPO.0000000000001430. PMID: 32501929. Pubmed
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