SYME`S AMPUTATION The Technical Details Essential for Success

SYME’S
The
AMPUTATION
Technical
Details
R. I. HARRIS,
There
is considerable
In some
countries
condemned.
In
above
the
to
present
the
Canada
foot
Syme’s
has
day.
because
the
Syme’s
amputation
is not
was
not
and
Toronto
highly
States
Amputation
March
technique
of
to
to
this
the
since
as
technical
Conference
to
1843,
is
and
interesting
twenty-two
experiments
years
in
must
performed
details
before
antiseptic
Massachusetts
General
every
Pensions
Syme’s
Syme’s
amputation
held
amputation
the
stump
of
Amputations
in Ottawa
in
satisfaction
the
of
fundamental
countries.
have
United
American
found
difference
It is the
to be essential
in the
purpose
factors
of
for
this
success.
REVIEW
revert
to Syme’s
His first publication
son-in-law,
years
four
original
relating
Joseph
three
and
to some
different
we
to
I).
and
Hospital,
is an
almost
Netherlands
war
Syme’s
record
be due
in
which
his
surgery
that
war
there
amputation.
informative
surgery
(Fig.
in amputation
for
(Ministry
the
recent
on
in
extremity
1914-1918
to a below-knee
in
the
the
states
respects
before
interest
HISTORICAL
It
landmark
it and
is roundly
lower
different,
converted
Nijmegen
amputation.
it even
before
been
various
appeared
special
have
Syme’s
others
of the
since
to
in
of
; in
amputations
to be
States
renewed
of opinion
amputation
forth
set
International
led
merits
condemns
had
in
United
the
differences
the
which
but
with
striking
seems
has
1944
have
of all
Centre
the
the
success
unsatisfactory
In
papers
surgeons
Such
paper
was
best
Britain
war
stump
the
the
opinion
In
regarded,
several
orthopaedic
of
about
consistent
Great
1914-1918
performed.
in
and
body
of the
1939).
with
CANADA
it is neglected
some
to be
in
experienced
opinion
; in
used
Experience
amputation
publication
been
for Success
TORONTO,
of
regarded
it is thought
and
and
influential
divergence
it is highly
Essential
years
Lister,
before
before
record
of
to it was
first
embarked
Morton
first
Simpson
this historic
published
in
first
upon
used
ether
recorded
his
at
the
the
use
of
chloroform.
Syme’s
pre-antiseptic
amputation,
surgery
an infected
was developed
was to achieve
in
the period
a simple
and
1843
records
the
successful
of
the
and
removal
was
deliberately
the
incision.
The
man
and
any
the
of
the
left
degree
malleoli
and
with
was
healed
three
or
lower
to
after
be born
an
in
his
(sic)
artificial
the
spite
of
an
operation
and
of
of
the
with
is strongly
at
tibia.
but
which
has
Edinburgh
In this he
of suppurative
foot
the
“the
which
the
tibia
abscess
stump
and
Joint.”
of a case
of
surface
end
London
Ankle
previously,
articular
by the
foot
year
at the
disarticulation
cover
gradually
can
a boot
one
by
the
used
months
of pressure
of
treatment,
tuberculosis)
flush
wound
hospital
adaption
Syme’s
of his
(probably
preserved
The
by its thick
outcome
tarsus
of pre-anaesthetic
and
safe means
of removing
in the
Journal
disease
the
The
without
of
drainage.
wounds
soundly
a round
end
from
flap
suture
required
protected
ankle
heel
healed
well
suited
external
injury
integuments.”
interest
disarticulation
was
a valuable
with
a minimum
614
therefore,
his concern
or damaged
foot.
His first report
in February
of Medical
Sciences
was entitled”
Amputation
Monthly
for
and
in this
which
he
procedure
of risk
disarticulation-amputation
was
the
which
to the
first
to
permitted
patient.
grew
employ
the
By its
in
Great
the
his
Britain.
removal
use
from
of
He
a crushed
dangerous
THE
enthusiasm
JOURNAL
Chopart’s
had
learned
that
and
infected
forefoot
amputation
OF
for
BONE
through
AND
JOINT
this
the
SURGERY
leg
SYME’S
was
rendered
which
is
unnecessary
afforded
disarticulation
By 1846
able
perfect
success.”
and
to
state:
of
details
Syme
smaller;
the
have
the
the
left
Such
with
a support
success
led
“not
upon
more
technique
together
with
and
the
been
advantages
of the
stump
the
were
heel
operation
will
two
were,
one
and
were
“
be afforded;
than
that
consideration
of
involved
in disease.
In the last of these
dozen
of
cases
perfected.
removed
flap
useful
to
than
modified
malleoli
separating
comfortable
nearly
had
less
naturally
when the calcaneum
and talus were
five articles
on this new amputation.
operated
tibia
a more
was
tarsus.”
fashioning
that
that
patient
whole
operative
for
stated
2d,
“I
The
surface
precise
the
at the ankle joint
Syme had published
he was
articular
and
by
615
AMPUTATION
with
with
The
a single
lower
sawcut,
given.
1st, that
3d, that
the risk
the limb
of life
will
will
be
be
more
r
‘1
“k
4’
./
FIG.
James
Syme
(1799-1870),
University
of Edinburgh.
George
Richmond’s
1
Professor
This
is
drawing
of
Holl’s
of him “in the prime
age forty-four
Probably
this
was his appearance
at
he published
his first
paper,
“Amputation
Joint.”
At his death
he was memorialised
and friend,
John
Brown,”
Verax;
Capax;
Efficax
Clinical
engraving
Surgery,
from
of life.”
when
the Ankle
thus by his pupil
Perspicax;
Sagax;
at
et Tenax.”
seemly
and useful
for progressive
motion.”
Reading
between
the lines there can be no doubt
that in Syme’s
mind
the importance
of the first
advantage
transcended
the others.
This is
confirmed
by his modest
boast
of having
operated
upon
nearly
two dozen
cases with perfect
success
radical
election
at a time
measures.
(a hand’s
between
medullary
Since
25
to
of
VOL.
aseptic
38 B,
50
cavities
Syme’s
development
when injuries
and infections
The common
treatment
breadth
below
the knee)
cent
from
infection
in the widely
opened
of the tibia and fibula (Godlee
1924).
day the risk of infection
in surgery
has been
NO.
3,
tissue
per
of antiseptic
surgery
of the foot could
only be mastered
by the most
was amputation
through
the leg at the site of
though
the mortality
from
this amputation
was
and
AUGUST
surgery
finally
1956
by
by
his
son-in-law,
the
introduction
Joseph
of
greatly
Lister,
bacteriostatic
spaces
and
reduced,
later
and
by
the
first
the
antibiotic
open
by the
perfection
agents.
616
R.
To-day
the
smaller.”
stump
must
great
advantage
It remains
is provided,
be given
the
of Syme’s
the most
more
credit
useful
I. HARRIS
amputation
no
of all amputations
seemly
and useful
for bringing
to
in amputations
of the lower
extremity
the merit of end-bearing
was secondary
the functional
value
of end-bearing
every
effort
should
be made
to use
fortunately
situated
James
Syme
1
in that
.‘
#{149}.
,
,
is “that
the
risk
of life will
a more
comfortable
and progressive
of the surgical
motion.”
world
the
for support
the attention
end-bearing
he worked,
To-day
great
that
than
longer
of the leg because”
be
To Syme
value
of
even though,
in the surgical
era in which
in importance
to the saving
of life.
amputations
of the lower
extremity
is so
them
when
possible.
Since
we are more
we do not
have
to concern
ourselves
so greatly
_.#{149}
.,
T
FIG.
Be/ow-The
calcaneum
“stout,
from
the
the knife.
sharp
heel flap.
Museum,
with
infection,
we
can
concentrate
which
will
the
best
possible
give
FUNDAMENTAL
The
important
amputation
knife”
which
Syme
used
to
Above-Plaster
model
of Syme’s
right
hand
Royal
College
of Surgeons
of England.
our
attention
end-bearing
of
the
upon
the
free
the
grasping
development
of
the
technique
stump.
PRINCIPLES
functions
2
OF
lower
END-BEARING
extremity
are
AMPUTATIONS
weight
bearing
and
propulsion.
Amputation
stumps
of the lower
limb must
be designed
to suit these functions.
The more
perfectly
they bear the weight
of the body
and transmit
the forces
of locomotion
the more
competently
their prosthetic
appliances
will be used.
For purposes
of weight
bearing
nothing
equals
a stump
which
can bear weight
upon
its end.
Propulsion
is best performed
by the
stump
which
joints
above
nearly
lower
normal
preserves
the level
length,
extremity.
To provide
1) The
provide
of bearing
the
greatest
length
of limb
with normally
functioning
muscles
and
the amputation.
Syme’s
amputation,
being
end-bearing
and of
offers
the best possibilities
of good
function
in amputations
of the
of
an end-bearing
stump
in the
lower
extremity
certain
requisites
are
bone
must be divided
where
its cross-section
area is as great
as possible
a broad
area of support.
2) The whole
of the cut surface
of the bone must
weight.
This
can
be achieved
by
a strong
meshwork
THE
JOURNAL
of
cancellous
OF
BONE
AND
essential.
in order
to
be capable
bone
JOINT
across
SURGERY
SYME’S
617
AMPUTATION
the whole
area,
or in the case of the ankle joint
by the retention
of the subarticular
bone at the lower end of the tibia.
The tubular
cross-section
of the shaft of the tibia
levels
is unsuited
to weight
bearing.
3) The
skin
and
subcutaneous
tissue
covering
cortical
at higher
the
end
of the
stump
must be appropriate
for weight
bearing.
Only two levels in the lower extremity
meet
these requirements.
They are the lower end of the femur
with a covering
of prepatellar
skin, and the expanded
lower ends of the tibia and fibula covered
by the heel pad.
It is interesting
to learn
that Syme
attempted
to devise
an amputation
at the level of
Technique
the
of
Syme’s
amputation.
entry
FIG.
3
Skin
incisions
of the ankle
joint.
knee
joint
embodying
the principles
which
his first two cases
in 1845, two
years
Ankle
Joint.”
Both patients
seem to have
reported
the
joint.
which
In both, the femur
was transected
was carious.
The end of the
derived
some
the
from
time
to
calf.
wounds
down
to
bone
and
proved
so successful
at the ankle joint.
after
his first publication,
“Amputation
been suffering
from
tuberculosis
of the
He
at
knee
through
the condyles
just above
the articular
surface,
stump
was covered
with a long posterior
flap of skin
healed
without
serious
complication
though
they
took
do so.
with
It is evident
from
devising
a safer
VOL.
38 B,
NO.
Both
carried
3,
AUGUST
Syme’s
operation
1956
presentation
than
of
amputation
these
two
through
cases
the
that he was chiefly
mid-shaft
of the
concerned
femur
and
618
R. I. HARRIS
believed
that section
of the bone
took
no pains
to cover
the end
where
of the
it was
stump
cancellous
involved
with weight-bearing
that the achievement
of a healed
stump
without
life was all that was necessary
to ensure
good
Twenty-one
years later,
in 1866, he wrote
femur.
His interest
this level using
an
had
been
anterior
renewed
flap
by Carden’s
after
removing
sepsis
function
again
of
Syme’s
dislocated
from
completely
separated
been
dissection.
amputation,
which
could
additional
advantage
that
bone,
instead
of becoming
The
be
tendo
performed
amputation,
the ankle.
report
of his method
of amputating
at
Syme warmly
commended
Carden’s
4
continued.
The
The calcaneum
the heel flap by
calcaneus
is about
to be
insertion.
with
little
risk
eminently
additional
rest upon
it just
as they
do after
amputation
acknowledged
that his earlier
attempt
to perfect
through
the femur
had failed and had fallen into
calf of the leg “proved
very inconvenient.”
talus
has
nearly
subperiosteal
divided
at its
has been
from
“the
stump
proved
thinner,
acquired
sepsis.
He
believing
and without
serious
risk to the patient’s
and even weight
bearing.
about
transcondylar
amputation
of the
(1864)
the patella.
FIG.
Technique
less risk from
skin, evidently
to the
patient
serviceable,
thickness,
at the ankle.”
the technique
disuse
because
THE
from
sepsis
with
the
since the skin over the
so that the patients
could
In this publication
Syme
of transcondylar
amputation
the skin flap derived
from the
JOURNAL
OF
BONE
AND
JOINT
SURGERY
SYME’S
FIG.
Technique
the tarsus
of Syme’s
has been
amputation,
continued.
removed
from
the heel
VOL.
38 B,
NO.
3,
AUGUST
of Syme’s
amputation,
flap to the leg to ensure
will
1956
5
Left-The
anatomy
flap.
Right-Closure
FIG.
Technique
the heel
619
AMPUTATION
of the field of operation
after
of the wound
with
drainage.
6
continued.
The method
that its position
is exactly
remain
so.
of strapping
correct
and
620
R.
Syme,
therefore,
nearly
level.
and because
weight-bearing
sepsis,
with
achieved
success
He failed
because
he did not appreciate
skin, though
in the
transcondylar
HARRIS
I.
in
devising
an
end-bearing
stump
at
the
his attention
was focused
upon
the avoidance
of
the importance
of covering
the end of the stump
case of the ankle
joint he seems
to have been aware
of its value.
ADVANTAGES
The
the
incomparable
end
of the
merit
stump.
OF
of Syme’s
Canadian
SYME’S
AMPUTATION
amputation
experience
is that
indicates
end of the patient’s
life.
The stump
is nearly
as long
quality
of end-bearing,
gives
the patient
a stump
which
foot.
The patient
can stand
and walk upon
it without
heaviest
useful
and
kind of work.
He can even walk
most serviceable
of all amputations
upon
it permits
that
this
full
quality
as a normal
approaches
limitations
weight
bearing
on
until
the
is retained
leg.
This, added
to the
the function
of a normal
and can undertake
the
it without
a prosthesis.
It is by far the most
of the leg and should
be used whenever
possible.
It is much
more
valuable
than a below-knee
amputation.
Few below-knee
amputees
can walk
on their prosthesis
all day without
damaging
the stump,
because
weight
is borne,
not upon
the end but upon
the side of the stump,
where
there is no specialised
weight-bearing
skin and
subcutaneous
tissue and where
the thrust
is not end-bearing
but is oblique,
and is a shearing
force.
STRUCTURE
Many
detail
factors
most
combine
essential
for
to
make
success
OF
a
Syme’s
is the
THE
HEEL
PAD
amputation
a
preservation
heel
of
flap.
good
the
end-bearing
This
function
but
the
of
the
from
the
stump,
weight-bearing
function
derives
partly
thickened
structure
skin but chiefly
from the
of the elastic
adipose
tissue
between
calcaneum
the
specialised
interposed
skin
on the one hand
and
plantar
aponeurosis
other.
Kuhns
(1949)
reviewed
of elastic
adipose
tissue
and
attention
the detailed
studies
and
on
the
the
our knowledge
brought
to our
of Tietze
(1921)
and Blechschmidt
(1933).
Wherever
pressure
or weight
bearing
is applied
to localised
points
on the
body
(heels,
fingertips,
thenar
and
hypothenar
eminences,
ischial
tuberosities
and
prepatellar
adipose
pressure.
of
presence
enclosing
separate
tissue
a
is
This
quality
dense
septa
specialised
form
In the heel pad the fibrous
the dermis
below
and are
septa
closed
and posteriorly
by the inferior
surface
calcaneum
and
anteriorly
by
the
FIG.
Early
(two
weeks)
a Syme’s
fibrous
tissue
and
change
normal
their
shape
form
(Figs.
extend
above
of the
plantar
They enclose
flask-shaped
spaces
filled with fat lobules.
Each space is reinforced
by oblique
and spirally
arranged
bands.
These
compartments,
bounded
by sheets
of elastic
aponeurosis.
7
post-operative
amputation
of
developed
which
resists
is obtained
by the
of elastic
fibrous
tissue
spaces
filled with fat. Each loculus
is
from its neighbour
and the fat lobules
it are
isolated
from
the surrounding
within
loculi.
from
pads)
fat
elastic
appearance
stump.
of
filled with semi-fluid
fat,
but not their
content.
8 to 13).
act as
When
hydraulic
pressure
THE
buffers.
is released
JOURNAL
OF
Under
they
BONE
AND
pressure
they
resume
their
JOINT
SURGERY
SYME’S
A lateral
structure
seen
radiograph
of the
running
more
anteriorly
heel,
tissue.
from
the skin
(Fig. 14).
It is important
amputation.
and their
of the
subcutaneous
below
to
this
to preserve
if not
The
over-exposed,
vertical
the
will
septa
calcaneum
specialised
If the heel flap is dissected
content
of fat is forced
out
621
AMPUTATION
often
of elastic
above,
subcutaneous
reveal
this
connective
or
to
tissue
the
in the
through
the subcutaneous
by pressure
because
they
plane,
are no
fundamental
tissue
plantar
heel
are
readily
aponeurosis
flap
of a Syme’s
the loculi are opened
longer
closed
spaces.
FIG. 8
Vertical
transverse
Section through
foot, the
plane of which corresponds
approximately
to the incision
for Syme’s amputation.
Fat
has been stained
red to contrast
with the
white
septa
of fibro-elastic
tissue
which
enclose the loculi of the heel pad.
In order
that the
to preserve
intact
plantar
aponeurosis
removed
intact
THE
with
the
this specialised
weight-bearing
and the periosteum
of the
heel
IMPORTANCE
OF
the
elaborated
tissue
it is necessary
of the calcaneum
be
flap.
SUBPERIOSTEAL
IN
Syme
subcutaneous
inferior
surface
technique
DISSECTION
SYME’S
of his
OF
THE
HEEL
FLAP
AMPUTATION
amputation
with
great
care.
Two
incisions,
the
the ankle joint
and the plantar
incision
carried
directly
through
to
the bones of the tarsus,
outlined
the extent
of the heel flap. The talus was dislocated
downwards
and
forwards
from
the mortise
of the ankle
joint
and
the calcaneum
was freed
from
the
tendo
calcaneus
and
the heel pad by dissection
with a sharp,
stout
knife
in a plane
which
hugged
the bone
(i.e., in the subperiosteal
plane).
In advocating
this plane
Syme
was attempting
dorsal
to
VOL.
one
avoid
38B,
to
open
injury
to
NO.
3,
into
the
AUGUST
calcaneal
1956
branches
of
the
posterior
tibial
artery.
That
is important,
622
R. I. HARRIS
but a greater
weight-bearing
is the assurance
be included
intact
that the subcutaneous
in the heel flap (Figs.
Such a flap contains
the stumps
of origin
of the
flap and every
meticulous
surgeon
instinctively
untidy
bulky
muscle
in the
removal
and
accomplishment
qualities
will
the
stumps
(Alldredge
of the
plantar
fat is squeezed
out.
and
Thompson
aponeurosis.
They
can
If this
no longer
short
plantar
muscles.
desires
to tidy it up
1946).
is done
with
tissue
its
special
3 to 7).
It is a clumsy,
by removing
the
But to do so is likely to result
also
the subcutaneous
loculi are opened
function
as hydraulic
buffers.
#{149}
/
FIG.
9
amputation
to show especially
the position
and structure
of the heel pad. This figure is based on
Figure 8. Insert shows the plane of section.
The anatomy
Subperiosteal
It leaves
the heel
of the tibia,
of the heel
dissection
flap lined
of the field of Syme’s
of the calcaneum
with periosteum
and more firmly.
Sometimes,
flap and this ensures
very firm
from
the
which
more
indeed,
fixation
heel flap has
readily
adheres
new bone forms
of the heel flap
another
to the
advantage.
cut surface
from this periosteal
to the tibia and an
lining
intact
mechanism
(Figs.
15 and 16).
It is of interest
to quote
an observation
of Jacobson’s
(1889)
which
confirms
this point.
He described
the technique
of removal
of the calcaneum
from the heel flap by an approach
from
above.
“The
foot being
still more
pressed”
(i.e., downwards
to dislocate
the talus
weight-bearing
from
then
the ankle
the tendo
joint),
achillis.
“the
upper
nonarticular
This is severed
and
the
surface
of the os calcis
heel flap next dissected
THE
JOURNAL
OF
comes
off the
BONE
AND
into
view
os calcis
JOINT
and
from
SURGERY
SYME’S
above
623
AMPUTATION
special
care
being
taken
to cut this flap as thick
as possible;
not to score
it, but rather
to peel it off the bone
with
the left thumbnail
kept
in front
of the
by touches
of this.”
To this is appended
a footnote:
“If,
in a young
subject,
the
downwards,
or puncture
knife
aided
epiphysis
comes
away
in the
heel
flap,
it may
remain
if the
there
parts
are
healthy.
Anterior
The
same
Posterior
10
FIG.
Sagittal
section through
the heel of a seventeen
years old girl to show
the structure
of the heel pad. Fat has been stained
red in contrast
to
the white septa of dense elastic connective
tissue which run from the
dermis below to the plantar
aponeurosis
and the tuberosity
of the
calcaneum
above.
Calcaneum
Short
Heel
FIG. 11
Vertical
transverse
section through
patient
to show the structure
course
be followed
may
Smith,
Johnston
on the other
harder
VOL.
and
38 B,
no
more
NO.
3,
when
attempt
with
was
rounded;
AUGUST
the
periosteum,
amputating
made
more
1956
if it is found
feet
for
frost
to save
it.
The
first
that
of foot
pad
the heel of a young
of the heel pad.
both
like
muscles
of a Pirogoff’s
loose
bite,
stump
and
peels
left the periosteum
was much larger
amputation.”
easily
away.
Mr
on one side,
than the other,
624
R. I. HARRIS
This
and
quotation
hence
picture,
flap
the
from
may
is
important
and for the
the stump.
conclude,
1889
American
firm
This
that
then,
the
for
edition
subperiosteal
maintenance
anchorage
of the
may damage
the
will remove
certainly
the
of Jacobson’s
ray.
The
In all respects,
of subperiosteal
Operations
of Szirgery
save the radiographic
separation
of the heel
calcaneum.
We
flap
is from
antedates
the introduction
of the Roentgen
his description
indicates
clearly
the advantages
of
separation
an
flap to the
weight-bearing
the periosteal
lining
intact
lower
of the
heel
of
the
calcaneum
weight-bearing
end of the tibia.
mechanism
of the
flap
and
from
covering
invite
of
the
the
It is unwise
subcutaneous
an unstable
end
heel
stump
to tidy up
tissue
and
to the stump.
FIG. 12
II.
Ii
Figure
12-Horizontal
section
through
heel (parallel
to the sole of the foot and below the level of
the calcaneum)
to show the structure
of the heel pad. The septa and the loculi they enclose
have
been cut across at right angles to their vertical axis. The skin of the heel bounds
this section medially.
posteriorly
and laterally.
Figure
13-Thick
frozen transverse
vertical
section
of heel pad. ( . 2.)
Stained
with Oil Red 0 for fat and counterstained
with light green.
From
above
downwardsA--bellies
of short muscles of foot; B-plantar
aponeurosis;
C-specialised
elastic adipose
tissue:
D-skin.
IMPERFECTIONS
WHICH
MAR
AND
Not
all
eliminated
Syme’s
by
stumps
meticulous
compensated
by the
the following
result.
are
Misplaced
manner
of the
the
are
perfect.
attention
fitting
and
most
heel flap-Care
that the plantar
tibia, and it must
Nevertheless
most
the technique
of the prosthesis.
important
faults
which
AMPUTATION
the
of
STUMP
imperfections
of
the operation
and
some
In addition
to damage
to the
to
use
must
THE
FUNCTION
OF A SYME’S
HOW
TO AVOID
THEM
may
prevent
the
achievement
can
be
can
be
flap
heel
of a perfect
be
taken
to place
the heel flap beneath
the tibia in such a
the flap is exactly
beneath
the centre
of the cut lower end
be maintained
there until sound
healing
has occurred.
This requires
surface
of
painstaking
care because
the heel flap is a large
deep cup which
fits loosely
over the lower
end of the tibia.
At the end of the operation
the correct
position
can best be secured
by
adhesive
strips
(Fig.
6). These
should
be inspected
frequently
during
the first two weeks
after operation
to ensure
that the correct
position
is maintained.
If necessary
they should
be
adjusted
the end
the
skin
to keep the heel flap
of the tibia the margin
against
the
inside
in its proper
position.
If the
of the cut surface
of the lower
of the
prosthesis
and
cause
heel flap is improperly
placed
on
end of the tibia will press through
discomfort
THE
JOURNAL
(Fig.
OF
17).
BONE
AND
JOINT
SURGERY
SYME’S
VOL.
Lateral
FIG. 14
radiographs
of the foot to show the fibro-elastic
septa of the heel pad when no weight
borne on the heel (top), and when the patient’s
weight is transmitted
through
the heel.
38 B,
NO.
3,
AUGUST
1956
625
AMPUTATION
is
626
R. I. HARRIS
Sloping
cut surface
of the tibia which
side of the slope.
ground,
mean
at
of the lower end of the tibia-When
weight
is borne
upon
the cut surface
is not parallel
to the ground
the heel flap tends
to be pushed
to the high
To avoid
this the lower end of the tibia must be transected
parallel
to the
both
in the
right
angles
transverse
to
the
and
long
in the
axis
of
antero-posterior
the
shaft
plane.
of
the
is bowed,
the plane
of section
of the lower
end of the
not at right angles
to the long axis of the lower
half of
Too small
cross-section
to cut end of tibia-The
largest
end of the tibia and fibula
is desirable.
Smaller
areas
weight
bearing
be just
above
area
“
for
the
Wobbly
from
use
then
presses
dissection
“
and
consequent
formation.
For
does
not
example,
necessarily
when
the
tibia must
be parallel
the tibial
shaft.
to the
possible
area
may
cross-section
result
Therefore
in localised
the
plane
of
of
upon
the
the
heel
may
wipe
it to one
or other
side
adipose
subcutaneous
An unstable
heel
technique.
by further
minimised
should
The
end
tibia
their
function
operation.
it cannot
be corrected
its shortcomings
can be
lacing
of the prosthesis
if the
is small
cross-section
or has
of the
projecting
spurs.
restored
by
the
cut
It can
heel
flap
structures
the
operation
any
subsequent
out and divide
it at a higher
level lest this cause damage
to the weight-bearing
qualities
of the heel pad.
If the
neuroma
which
inevitably
develops
on its end becomes
painful,
late transection
of the nerve
at a level above
15
Small mass of bone laid down in the heel
flap of a Syme’s amputation,
the result of
subperiosteal
removal
of the calcaneum.
Useful
in ensuring
firm fixation
of the
heel flap to the tibia.
to faulty
operative
technique.
flap by injury
to the posterior
occurs
beneath
the adhesive
be
always
adipose
Neuroma
of
the
posterior
tibial
nerve-Careful
preservation
of the full thickness
of the heel flap leaves
the posterior
tibial
nerve
in the flap.
At the primary
operation
no attempt
should
be made
to dissect
this
\,.
FIG.
cannot
edge
by subperiosteal
itself firmly
to the
firm
intact
pad of
be prevented
by proper
fashioning
of
during
the operation.
If the weight-bearing
of the heel flap have
been damaged
by
- :.
pressure
bone
flap with calluses-This
is almost
to preserve
the specialised
elastic
It is accentuated
of the
possible
tissue
resists changes
in its shape.
can be avoided
only
by proper
Once it has occurred
operation,
though
by modifying
the
(Fig.
17).
Tender
heel
due to failure
tissue.
flap
cut
from
transection
or backwards.
scar.
A flaccid,
loose
heel flap can be prevented
flap.
The deep surface
of the heel flap then attaches
cut surface
of the bone
and
the
the
pressure
cartilage
of the lower end of the tibia, to ensure
the greatest
support
of the heel flap.
or unstable
heel flap-If
the heel flap is loose
and easily
displaced
the
prosthesis
leg
ground,
the articular
of the
of
callus
This
tibia.
.
.
the
ankle
cures
the
joint
without
condition.
Margmal
gangrene
peripheral
vascular
removal
of the heel
disease
of the
flap-Except
this is nearly
distal
segment
in cases of
always
due
Either
the blood
supply
is impaired
in the preparation
of the
tibial artery
or the dressings
are put on too tightly,
or swelling
strips
and they are not removed
soon enough.
With
care in
operating
there
is little danger
of necrosis
of the flap.
Should
necrosis
occur,
the stump
is
not necessarily
ruined
unless
the loss of tissue
is very great.
Vascular
insufficiency
in the heel flap-It
has been said that the great length
of a Syme’s
stump
results
in vascular
insufficiency
which
is manifested
by a cold,
THE
blue,
JOURNAL
painful
OF
BONE
end
AND
to the
stump,
JOINT
SURGERY
SYME’S
FIG.
16
Unusually
large mass of bone laid down in the heel flap of a Syme’s amputation
A) Four months
after operation.
B) One year after operation.
This cloud
bone
is unusually
large and heavy
because
osteogenesis
was stimulated
inflammatory
reaction
to tuberculosis
of the tarsus
for which the amputation
undertaken.
VOL.
38 B,
B
NO.
3,
AUGUST
stump.
of new
by the
was
17
FIG.
18
unstable
heel pad on Syme’s stump of left leg, the result of tidying
up the heel
of the short plantar
muscles,
and with them the plantar
aponeurosis
and the
The result is a heel pad imperfectly
fused to the end of the tibia and in
the muscles
at rest and the heel pad held in place under the tibia by elastic
peroneal
muscles contract
they drag the heel flap to the outer side of the stump.
the poor Syme’s stump illustrated
in Figure
17. In addition
to the unstable
transection
of the tibia provides
a small area of support.
In spite of these
the stump has functioned
reasonably
well for nine years.
FIG.
Figure
17-Misplaced
and
flap by removing
the stumps
periosteum
of the calcaneum.
bad position.
Left-With
traction.
Right-When
the
Figure 18-Radiograph
of
heel pad, the high level of
defects
627
AMPUTATION
1956
628
R.
I. HARRIS
FIG.
1..
FIG.
20
Figure
19-A functionally
good Syme’s stump.
The heel pad is firmly fixed to the
lower end of the tibia in good position.
The area of support
is broad.
This
amputation
was undertaken
to remove
a foot much distorted
after many attempts
to correct
recurrent
club foot.
Figure 20-Radiograph
of the satisfactory
Syme’s
stump shown
in Figure
19.
Standard
Syme’s prosthesis.
A front lacing leather bucket moulded
to the stump is fastened
to a strong steel frame with an ankle block
at the lower end; anterior
and posterior
views.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
SYME’S
much
in cold
accentuated
of our
patients,
This
weather.
in winter,
are
subjected
629
AMPUTATION
has
not
to very
us to feel that vascular
stasis from exposure
it may be, however,
that long-continued
been
low
the
experience
in Canada
temperatures.
Our
where
experience
would
many
lead
to cold is not a problem
of any importance.
exposure
to damp
cold can produce
vascular
problems
with which
we are not familiar.
Certainly
chilblains
are almost
unknown
to us
while they are common
in Great
Britain.
If this is the explanation
of any vascular
problem
which
may arise in Syme’s
amputation
the cure may well be in sympathectomy
rather
than
re-amputation
at a higher
Laminated
synthetic
over a plaster
model
the
is often
and
source
sometimes
level.
A paralytic
lower
extremity
after
poliomyelitis
in Canada
resin bonded
prosthesis
for Syme’s amputation
made of layers of fibreglass
cloth moulded
of the stump and bonded
with a rigid epoxy resin.
The opening
for the insertion
of the
stump is posterior
and is closed by a plastic door buckled
into place.
of
much
discomfort
develops
trophic
in
skin
cold
weather.
This
lesions.
It becomes
problem
is
blue, cold,
completely
and painful
relieved
by
sympathectomy.
SUMMARY
The
the
details
provision
in technique
of a broad
as low as possible;
the
heel flap; and the proper
If these
VOL.
aims
38 B,
NO.
are
3,
achieved
AUGUST
which
area
are
most
of support
for
maintaining
intact
of the
placement
a good
1956
and
useful
essential
the
heel
to ensure
flap
by transecting
of the specialised
heel flap under
the
stump
is assured;
a perfect
Syme’s
the
weight-bearing
cut ends of the
if they
are
tibia
stump
and
qualities
tibia and
neglected
the
are
fibula
of the
fibula.
stump
630
will
of
be
imperfect
the
heel
flap
It must
often
can
If its
of
the
bony
been
those
flap
or there
nutrition
stumps
in which
of the
the
small;
in all
condition.
The
Severe
severe
of
or
that
flap
a Syme’s
With
antibiotics
More
open
the
wound
will
has
for
especially
war
that a two-stage
restore
the
of
serve
of the
the
well,
qualities
technically
of the
of the
though
not
that
heel
controlled;
or
heel
prosthesis.
perfectly,
as
an
re-amputation
the
flap
perfect
A loose
corset
is so high
tibia
be
not
as to necessitate
qualities
cannot
are
re-amputation.
lacing
it may
foot
such
area
have
there
supporting
been
damaged;
is impairment
of
be
lost
be
performed
the
amputation
necessitate
injuries,
the
operation
reduced
or
can
of the
performance
is
frequently
and
soft
of
to
that
the
sometimes
will
as
size.
become
the
risk
actual
amputation
as
In
following.
dealing
JOURNAL
of
is in good
the
to
tarsus
the
grossly
as a primary
a secondary
procedure
injuries
be
OF
BONE
and
measure.
infection
resort
is so
is eliminated.
or potential
with
and
foot
deformed
of infection
advantages
of Syme’s
amputation
should
can be performed
rather
than
immediate
THE
the
injury
be performed
plus
heel
fractures
the
amputation
of the
are
that
foot
Syme’s
skin
comminuted
tissues
a small
the
performed
as soon
the
stump,
that
If it is evident
foot.
will
contusion
AMPUTATION
end-bearing
provided
compound
the
should
severe
or
foot
it is most
of
foot
SYME’S
of the
as
injuries
the
FOR
a satisfactory
which
available
healed,
can
which
consider
unsatisfactory
which
lesions
amputation
frequently
wound
the
of
to
by firm
of transection
ensures
destructive
crushing
much
rigid,
operation
stumps
need
weight-bearing
heel
which
conditions
injuries
metatarsus
further
flap.
a technique
is indicated
Syme’s
large
INDICATIONS
With
no
so completely
plane
or the
of the
heel
that
is reasonably
Syme’s
is instability
and
there
has been no
the end of the bone
support
is too
unsatisfactory
however,
that
beneath
stump.
heel
be
lacking.
recorded,
held
end-bearing
have
are
so well
be
area
may
be
function
pad
and
which
HARRIS
I.
R.
of
borne
to
AND
in the
after
the
foot,
in mind
a mid-tibia!
JOINT
SURGERY
so
SYME’S
The
amputation.
heel
flap.
second
has
healed,
of the foot
intractable
an
infections
indication
will
will
be a formal
Syme’s
bones
even
acid
foot,
which
by resection
and
than
respond
and
the
formerly.
to deal
foot with intractable
cases of obliterative
with
some
cases
infections
infections
sympathetic
to conservative
of Buerger’s
disease
In
such
disease,
in
but
the
a higher
of
the
level,
and
cases
The
involved
the occasional
one
has
heavy
accomplished
the bulky
prosthesis,
by
OF
ankle
unattractive
but
Syme’s
capable
2. The
amputation
for
men
possible
area
patient
stands,
38 B,
NO.
of
AMPUTATION
a bulbous-ended
3,
b) The
necessarily
AUGUST
localised
pressure.
such conditions
as
1956
line
at right
feasible
of arteriosclerotic
or middle
a favourable
vascular
aged
man
response
followed
by
that
the
other
(Fig.
that
in obliterative
vascular
thrombosis
Such cases
stump
and
is unsightly.
21).
Some
improvement
to resist
to a large
has
been
Even so
because
CONCLUSIONS
because
when
are
the
it provides
for
lower
transection
to the
end
must
long
an
end-bearing
stump
the stresses
of locomotion.
when the area of bone supporting
specialised
essential
at the
angles
need
amputation.
AND
of
who
to
Syme’s
leg may
the stump
and it must
be strong
it. Hence
the patient
is condemned
body weight
and of transmitting
well
in a Syme’s
stump
will be obtained
support.
not
was
from
tabes
and
syringomelia;
nerve injury;
spina bifida.
for Syme’s
amputation.
It gives
amputation
the heel flap is as broad
as possible
and
the heel flap is maintained
undamaged.
3. Technical
steps in the operation
which
and fibula just above
the articular
cartilage
VOL.
to
SYME’S
it is an excellent
is a valuable
of taking
full
best end-bearing
be effectively
operation
of resin-bonded
laminated
fabric
(Fig. 22).
It is not likely ever to be popular
with women
SUMMARY
I.
possibility
is similar
in appearance
making
the prosthesis
area is still obvious.
of its appearance,
and
but
sympathectomy
the
here
shortcoming.
most
which
will last for years.
Fifty per cent
disease
have been successful.
This is an
than would
have been the case had their
with
problem
case
often
master
still
original
case is in the young
of the forefoot
and
The prosthesis
must
be bulky
to accommodate
the great stresses
that are transmitted
through
and
is less
to
vascular
changes
in the foot induced
by cold cause
area
which
can result
in gangrene
of the forefoot.
SHORTCOMINGS
amputation
this
us
can
Syme’s
treated
by Syme’s
amputation.
neurological
problems
such
as neuropathic
joints
ulceration
of the forefoot
from irreparable
sciatic
disease of the forefoot
is an occasional
indication
Syme’s
wound
to streptomycin
and
such as blastomycosis
from rigidity
or infection,
a lumbar
especially
foot-The
difficult.
less
vessels
are well
Certain
intractable
Malignant
at
later.
immersion
the
the
deformity
can also be well treated
by Syme’s
amputation.
vascular
disease-Contrary
to expectation
it has proved
block.
been
to be amputated
Frost
bite and
well
tarsus
treatment,
stump.
amputation
will often give a good and useful
stump
of our Syme’s
amputations
for obliterative
vascular
important
group
in which
function
is much
greater
amputation
preserving
after
day
enable
respond
of the
of a Syme’s
disease
by Syme’s
amputation.
The most suitable
has obliterative
vascular
disease
with gangrene
lumbar
present
Antibiotics
for tuberculous
infection
of the talus and calcaneum.
Deformities
of the foot which
cause
serious
disablement
The chief cause
of such deformities
is previous
trauma
old club
Selected
foot,
or even
amputation.
well
development
infected
is controlled
of thefoot-At
tuberculous
A few unusual
do not
the
shattered
infection
andjoints
and
hydrazide.
Madura
the
after
amputation
infections
remove
performed
Syme’s
iso-nicotinic
treated
stage
stage,
of the
for
pyogenic
and
primary
The
631
AMPUTATION
weight-bearing
success
of the
are:
tibia.
be parallel
axis
of the
structure
a) Transect
This
to the
tibia.
gives
ground
c) The
of
the
the
tibia
largest
when
the
heel
flap
632
R.
must be separated
from the calcaneum
of the weight-bearing
elastic
adipose
to the lower
end of the tibia.
d) The
held there until it is soundly
healed.
I.
HARRIS
by subperiosteal
dissection.
This ensures
the preservation
tissue
in the heel and firm attachment
of the heel flap
heel flap must be precisely
placed
beneath
the tibia and
My thanks
are due to my friend and colleague,
Gordon
Maclntyre
Dale, who for thirty-five
years has been
an ardent
exponent
of the merits of Syme’s amputation.
He has freely shared
his experience
with me. I am
indebted
to the Royal College of Surgeons
of England
for the photographs
of Syme’s knife and of the cast of
his hand holding
the knife. These are in the Hunterian
Museum.
My appreciation
is due also to the Department
of Prosthetic
Services
of the Canadian
Department
of Veterans’
Affairs for their interest
and skill in developing
the specialised
prosthesis
for Syme’s
amputation
and for their permission
to include
illustrations
of the
prosthesis
in this paper.
Professor
J. C. Boileau
Grant of the Department
of Anatomy,
University
of Toronto,
prepared
in his Department
the splendid
specimens
which illustrate
the anatomy
of Syme’s
amputation
and
the structure
of the heel pad.
Dr W. B. Anderson
of the Department
of Surgical
Pathology,
Toronto
General
Hospital
perfected
the technique
which demonstrates
clearly
the histology
of the heel pad (Fig. 13). Their
assistance
has ensured
adequate
illustration
of this article.
For this I tender
them my grateful
thanks.
REFERENCES
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(1946):
The Technique
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Journal
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E. (1933): Die Architektur
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Morphologisches
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H. D. (1864):
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