Elective Syme's Amputation In Selected Congenital Anomalies
E. Reese Owens, M.D.
The conversion of a congenital deformity to a form better adapted for prosthetic fitting is occasionally necessary to facilitate rehabilitation. A type of conversion frequently employed involves ablation of a part of the limb. In cases of multiple deformities of the lower leg and foot, we have elected to do a Syme's amputation when feasible. In some instances this procedure is employed to provide these children with a functional limb without prosthesis; in others it is used to preserve the growth potential of the distal tibia and to aid prosthetic cosmesis.
In our experience, attaining a weight-bearing limb in the congenital juvenile amputee requires a longer period of time than in the adult amputee. This time lag appears to be based on circulatory differences unrelated to surgery. This paper discusses three selected cases on whom Syme's amputations were performed.
L.W. was born with a right terminal paraxial hemimelia involving the fibula and the two lateral rays of the foot (Fig. 1 and 2 ). A congenital fibular band with resultant talipes valgus had been previously corrected by surgery at another institution. Mensuration revealed 1-inch shortening of the leg.
L.W. was initially provided with a long leg brace with extension caliper. However, she did not have a functional foot, and a Syme's amputation was decided upon to provide her with an end-bearing stump and effective cosmesis (Fig. 2 Fig. 3 ). L.W. was fitted with a patellar-tendon-bearing prosthesis (Fig. 4 ). Because of the absent fibula she experienced initial difficulty in controlling rotation of the prosthesis. This problem was solved by modification of the socket and additional gait training. Growth at the distal epiphysis of the tibia has ceased.
R.M. was born with a right terminal hemimelia involving the fibula, tarsal bones, and second ray of the foot (Fig. 5 ). Congenital shortening of the femur and tibia was present with a consequent 2 1/2-inch deficit in the length of the leg. R.M. was initially ambulated in an ischial weight-bearing brace with an extension caliper. The anomalous tarsal development presented a foot maladapted for weight bearing, and a Syme's amputation was performed to modify the leg for better cosmesis and function (Fig. 6 and 7 ). The patient was fitted with a patellar-tendon-bearing prosthesis incorporating partial end bearing. Suspension was by means of a pelvic strap (Fig. 8). An initial vaulting problem subsided with further gait-training sessions. In this child the distal tibial epiphysis has remained open.
D.D. was born in June, 1950, with a focal deficiency of the proximal left femur and a right coxa vara. Malrotation of the foot precluded fitting of the usual nonstandard prosthesis with foot support, and he walked in an ischial weight-bearing brace and caliper, with the short leg suspended between the uprights. Leg length discrepancy plus hip instability produced a useless foot, and a Syme's amputation was performed (Fig. 9 and 10 ) to provide a stump suitable for fitting with a conventional above-knee prosthesis (Fig. 11 ). D.D. walks without ancillary support.
A Syme's amputation is useful in the treatment of selected congenital deformities of the lower extremity. Where there is no gross inequality of leg length, it provides a functional limb without prosthesis and improves cosmes is.
E. Reese Owens, M.D. is associated with the Child Amputee Clinic Home for Crippled Children Pittsburgh, Pennsylvania