Modified Syme Amputation

Milton J. Wilder, M.D.


When amputation is being considered, the ideal operation would be one that affords a weight-bearing stump. The most useful of all amputations of the lower extremity is the one first advocated by Sir James Syme of Edinburgh in 1843. In his procedure, the tibia and fibula are transected 5 cm. to 6 cm. proximal to the articular surfaces.

Modifications

We have modified the Syme amputation by retaining the articular surface of the tibia. In some instances the protruding tibial and fibular malleoli are removed. The cartilaginous weight-bearing surfaces provided by this modification have proven to be invaluable to the amputee.

In 1843, the "Syme" amputation was performed primarily for conditions arising from trauma and very occasionally for disease. In our experience the indications for amputation have been entirely different; all of the procedures presented in this paper were elective.

Advantages

The end-bearing stump provided by the Syme procedure, as modified, is so superior to that obtained by conventional surgery that its use, we believe, is almost mandatory. Advantages are: (1) A stump which can tolerate end pressure; (2) A long lever arm providing increased control of the prosthesis; (3) Some patients can walk without the prosthesis (this applies also to the routine Syme at normal levels), a particular advantage when patients live long distances from limb shops; (4) The stump is usually less painful than non-weight-bearing ones, regardless of level; (5) The skin is more durable and there is less irritation of the stump; (6) A better selection of sites is available if re-amputation is necessary at a later date.

Disadvantages

Since the Syme amputation has not been universally accepted, there are obviously disadvantages to the procedure, although we believe that many of these are due to lack of experience of the surgeon and/or the prosthetist. Possible disadvantages which can be cited are: (1) It is not successful unless good pros-thetists are available; (2) The procedure is surgically more difficult than a routine amputation and may present more chance of infection; (3) End bearing may be painful; (4) The stump may be bulbous and/or be esthetically unacceptable to some women: (5) The stump may have redundant distal tissue which is unsightly and unstable (permits too much motion).

Five Cases

Our report presents a sample of five cases whose amputations essentially involved disarticulation at the ankle joint. Three of the five had undergone numerous previous procedures and none was considered a routine case.

In order to avoid token surgery, we have for many years attempted to analyze the amputee in his entirety before beginning treatment. It is our opinion that function is more important than cosmesis, although we strive for both. Hence, we believe that consideration of improved function should be primary.

Case No. 1

(W.R.) 4-year-old Negro male

Classification: Intercalary Longitudinal Complete Paraxial Hemimelia, Fibular, left lower extremity; leg length discrepancy, 8.7 cm. (Fig. 1 and Fig. 2 ).

Syme amputation performed: 7/23/64, (Fig. 3 , Fig. 4 , Fig. 5 , and Fig. 6 ).

Prescription: 9/14/64, Canadian Syme Prosthesis, delivered 10/5/64 (Fig. 7 and Fig. 8 ).

Discussion: As is apparent in the photographs (Fig. 7 and Fig. 8 ), there is a discrepancy in the knee centers which will certainly be a disadvantage. However, since amputation and the application of the prosthesis the resultant equalization in overall leg length has apparently made the child and his family much happier.

Case No. 2

(C.S.) 8-year-old Negro female

Classification: Intercalary Longitudinal Incomplete Paraxial Hemimelia, tibial, right lower extremity (Fig. 9 ).

Syme amputation performed: 7/12/60, following unsuccessful surgical procedures previously performed; and bracing to correct varus deformity of right ankle (Fig. 10 and Fig. 11 ).

Prescription: 1. 11/2/60, Patellar tendon bearing type prosthesis with side bars and corset necessary for support of laxity in collateral ligaments of right knee.

2. 12/7/64, Patellar tendon bearing, cuff suspension prosthesis .

Discussion: Result, satisfactory. No problems.

Case No. 3

(G.S.) 17-year-old Negro female

Diagnosis : Juvenile fibromatosis with metastatic potential of right forefoot.

Syme amputation performed: 6/3/63 (Fig. 12 , Fig. 13 , and Fig. 14 ).

Prescription: 7/13/64, Canadian Syme Prosthesis; delivered 10/19/64 (Fig. 15 ).

Discussion : The choice of a Syme procedure was based in part upon the fact that this patient lives in the country at a considerable distance from a limb shop. She will have to work as a domestic or a menial, and will have a better chance of employment with an amputation with which she can ambulate either with or without an artificial limb.

Case No. 4

(P.W.) 5-year-old Negro female

Diagnosis : Arthrogryposis multiplex congenita with the following sequelae (Fig. 16 and Fig. 17 ):

  1. Flexion deformities of knee joints bilaterally.

  2. Talipes equino varus bilaterally.

  3. Forefoot adductus bilaterally.

Syme amputation performed: 9/15/64, bilaterally (Fig. 18 , Fig. 19 , and Fig. 20 ). Previous surgery:

  1. 10/22/62 - Medial release left foot.

  2. 11/16/62 - Medial release left foot.

  3. 6/29/64 - Fusion of right knee.

Prescription: 10/19/64, Bilateral Canadian Syme prostheses; delivered 12/7/64 (Fig. 21 ).

Discussion: Despite the foot procedures previously performed, this patient was unable to walk. Since the bilateral Syme amputations and the fitting of prostheses, the patient is able to walk with the aid of canes.

Case No. 5

(S.W.) 17-year-old white male

Classification: Proximal Femoral Focal Deficiency, left lower extremity (Fig. 22 and Fig. 23 ).

Syme amputation performed: 6/11/62, (Fig. 24 ).

Prescription: 10/2/62, non-standard above knee prosthesis; delivered 1/16/63.

Discussion: This patient is a college student. He is impressed with the results achieved by the amputation. It is his opinion and ours, that the operation should have been done much earlier.

Summary

We have presented five cases in which a modified Syme amputation was performed. The important modification of the original Syme procedure involved retention of the articular cartilage. In some instances, the procedure provided equal leg length, so that the patient could ambulate even without a prosthesis. Others were done even when the resulting leg lengths were unequal. Since the weight-bearing stumps obtained in these cases have proven so superior for prosthesis fitting, it is our intention to perform this modified Syme amputation whenever it is feasible.

Milton Wilder is Chief of the Amputee Clinic Kernan Hospital and University Hospital, Baltimore, Maryland