JFAS 33(4): 355-364, 1994

The Syme's Amputation: A Correlation of Surgical Technique and Prosthetic

Management with an Historical Perspective

In 1843, James Syme introduced an amputation which he believed had numerous

advantages over more proximal amputations. Despite these claims, utilization of the
Syme's amputation has been limited due to a less than ideal compatibility of the surgical
result with prosthetic design and function. In this article, the history of the Syme's
amputation is reviewed along with indications and surgical technique. Modifications to
the original surgical procedure are discussed as well as advantages and disadvantages
inherent to the Syme's amputation. A description of the biomechanical function of the
residual limb/ prosthesis and management of the Syme's amputee is provided
emphasizing the quest for an ideal prosthesis which is found, could very well allow Dr.
Syme's amputation to reach the potential as he had originally envisioned.

Valarie Cottrell-Ikerd, DPM1

Frank Ikerd, BA2
David W. Jenkins, DPM, FACFAS3

Podiatric physicians are frequently involved in the care of vascularly compromised

patients. As the patient population ages, more vascularly compromised patients will
probably be seen. In order to provide optimum patient care, the physician should become
familiar with available amputation levels and their prosthetic management. The following
is a discussion of the Syme's amputation, as well as the history and current status of
prosthetic management.

History of the Syme's Amputation

On September 8, 1842, James Syme performed the first Syme's amputation on a

16-year-old male. In 1843, this procedure with its successful outcome was published (1,
2). Syme did not meet his eventual son-in-law, Joseph Lister, until 1853; therefore, this
procedure was performed without many of the aseptic techniques pioneered by Lister.
Many of the amputations done at that time failed due to high infection rates; however,
Syme felt that the cartilage left intact during his newly developed procedure helped to
lessen the chance of infection. Syme also believed that other significant advantages
existed for this surgery, such as lower risk mortality, a comfortable and functional
residual limb, better cosmesis, and a better chance for healing due to lack of exfoliation
(1, 2).
The classic Syme's procedure consisted of disarticulating the foot from the leg
and cutting off the malleoli with cutting pliers (11, 2). Today, the Syme's amputation
consists of either a one-stage procedure with primary closure or a two-stage procedure in
which the definitive amputation is performed separately form the initial disarticulation.
Further modifications have been made to these surgical procedures in an effort to
improve the surgical technique of the amputation itself, as well as to aid the prosthetist in
providing a more comfortable, functional and cosmetically appealing prosthesis.

Indications

Possible indications for a Syme's procedure include the following: severe trauma
of the foot, congenital anomalies, acquired deformities, malignant tumors, ischemia,
gangrene of the forefoot, frostbite, and specific neurological pathologies (3-6). The two-
stage Syme's procedure is indicated over the one-stage whenever gangrene of the forefoot
is present (3-7). The two-stage Syme's is also preferred in dysvascular and diabetic
patients. By staging the surgery, the limb has had time to revascularize as well as be
eradicated of infection. Some physicians believe that this amputation level should not be
performed on diabetic and dysvascular patients (8-10), while other clinicians have shown
a high success rate, especially with the two-stage Syme's procedure (11).
_____________________________________________________________
1067-25 16/94/3304-0355$3.00/0 Copyright © 1994
by the American College of Foot and Ankle Surgeons

355

Surgical Technique

The skin incision is placed from the medial malleolar tip to the lateral malleolar
tip in both an anterior and plantar-circumferential direction (Fig. 1). The plantar portion
of the incision is to bone, but before the anterior incision is deepened to the ankle joint,
firm distal traction is applied to the anterior tendons and nerves prior to their division so
as to ensure as proximnal a retraction as possible. Arteries must be transfixed, but veins
may be ligated or cauterized as necessary. Talar disarticulation is then accomplished by
incising the collateral ligaments, taking care to identify and protect the posterior tibial
artery and nerve. The calcaneus is then sharply dissected subperiosteally from its
surrounding soft tissue structures. The Achilles tendon is tenotomized at its insertion,
taking great care not to buttonhole the overlying skin, as this has been reported to result
in a failed procedure even with repair of the skin (6). With the calcaneus fully stripped,
removal of the foot is accomplished and attention is then directed to the distal malleoli,
which are osteotomized transversely so that their weightbearing surface is parallel to the
floor. The actual level is selected to preserve approximately 1.5 cm. of the tibial plafond
which ensures the broadest weightbearing surface possible. After ensuring that no bony
prominences or irregularities are present, the heel pad is anchored to the underlying bone
through osseous drill holes with nonabsorbable suture. Subcutaneous and skin closure is
followed by insertion of a modified Shirley drain4 as a moderate dead space results (3, 4,
6).
In the two-stage Syme's, two separate operations are performed. The first
operation consists of disarticulation of the foot as noted above, but with the incision more
distally and anteriorly placed (Fig. 1). A healing period of approximately 6 weeks is
needed before the second stage is performed. The second operation consists of the
malleolar osteotomies. During this procedure, the medial and lateral flares of the malleoli
are trimmed parallel with the shafts as well as flush with the weightbearing plane. The
one and two-stage Syme's operations are otherwise identical (4, 6).
When performing these procedures, special care must be given to certain details.
The adipose lobules of the heel pad must be kept intact. Damage to the heel pad could
result in inadequate shock absorption, as well as migration of the heel pad. As previously
noted, when dissecting the Achilles tendon, the skin is at risk of being perforated. If this
occurs, there is a high risk of failure even if the laceration is repaired. Finally, great care
must be given to avoid the posterior tibial artery during dissection as inadvertently
lacerating it could result in devascularization and failure of the heel pad. The dog-ears
formed by closure of the incision should not be trimmed due to the risk of vascular
compromise to the tissue. Rather, direct compression by the postoperative walking cast as
well as the temporary prosthesis will diminish the dog-ears (4, 6).
The extent of the injury or infection, as well as the vascular supply to the tissue
and its propensity to heal must be considered in determining the level of amputation.
Many methods are available to aid the surgeon in choosing an appropriate level of
amputation with good vascular supply. Some of the methods include the following:
physical examination, transcutaneous measurement of oxygen tension (12-15), skin
temperature determinations (12, 16), fluorescein dye angiography (12, 17, 18),
muscularpH (12, 19), xenon 133 clearance (12, 20, 21), segmental pressure studies (22-
24), photoplethysmography, infrared thermography (12, 17, 24, 25), a morphine puncture
test5 (12, 26), and free bleeding within 3 min. of tourniquet release (6).

Advantages and Disadvantages

The Syme's amputation has many advantages compared with more proximal
amputations, such as below-the-knee or above-the-knee amputations. There is
significantly increased morbidity and mortality associated with more proximal
amputations of the leg. Perhaps the most important factor involved is cardiovascular
disease (7, 24,27,28). In one study of 1028 amputations in 786 patients, the primary cause
of mortality was cardiac complications (12). As the level of the amputation becomes
more proximal, the risk of morbidity and mortality increases (7, 24, 27, 29). Patients with
occlusive arterial disease have been shown to have a high correlation with coronary heart
disease (27).

Figure 1. Syme's amputation incision placement; broken line, one stage Syme's;
solid line, two stage Syme's.

356
Because an amputee already requires more energy to do the same amount of work as a
person without an amputation, increased energy demands are placed on an already
stressed cardiovascular system
The long lever arm of the Syme's residual limb not only allows the patient to
maintain much of his normal gait, but also increases the area in contact between the
residual limb and the socket. This decreases the stump to socket pressure, as well as
provides the patient with better proprioception and prosthetic control (30, 31). Studies
have shown the Syme's amputation patient to have a greater stride length, faster cadence,
greater velocity, less oxygen consumption and overall better function than amputations
performed at more proximal levels (6, 32). By retaining the lower leg, the patient may
also have a better self-image.
The Syme's amputation provides a broadly padded distal end that is suitable for
weightbearing. This broad cross-section allows weight to be evenly distributed over M
large area. Because pressure equals force divided by area (P = F/A), this large area
decreases the pressure I caused by weightbearing (30). The weightbearing pressures are
further aided by the remaining heel pad, which is naturally suited for weightbearing and
some shock absorption. Due to the large circumference of the bulbous residual limb, the
prosthesis may be self-suspending, eliminating the need for external straps above the
knee (30).
The characteristics of the Syme's amputation that proved to be advantageous also
have disadvantages associated with them. The length of the residual limb leaves minimal
room for an ankle joint to be placed in the prosthesis. The bulbous distal end is
cosmetically, unappealing to many patients and causes problems in the design of the
prosthesis with regard to donning and doffing (application and removal) of the prosthesis.
The heel pad may migrate from its intended weightbearing position; although the risk of
this occurring can be reduced partially by a properly fitting prosthesis (30, 33, 34).

Postoperative Care

The first stage of prosthetic fitting for the Syme's amputee is the temporary
walking cast constructed of plaster or fiberglass bandage. This is usually applied
immediately postoperatively, with ambulation beginning as soon as the patient's
condition permits, usually within 1 or 2 weeks (35, 36). Advantages to fitting in this
manner include: reduction of edema at the surgical site, promotion of the venous pump
which aids in healing, a shaping effect on the residual limb to optimize prosthetic fitting,
mobilization of the patient, protection of the wound and positional stability of the heel
pad (6). Provisions should be made for donning and doffing the temporary walking cast
so that wound inspection and hygiene are possible and yet allow the bulbous distal end to
pass through the narrow portion of the cast immediately proximal to the flare of the tibia
and fibula.
At approximately 8 weeks, the residual limb will have matured sufficiently to be
fit with a preparatory prosthesis (6). Although the patient is allowed to wear the
prosthesis home at this time, it is not cosmetically finished to allow any realignment
necessary as the gait pattern of the amputee matures. The preparatory prosthesis allows
for ambulation during the maturation process of the residual limb and is usually worn for
3 to 6 months or until the limb is volumetrically stable. This period of time also allows
the prosthetist to identify problem areas and correct them before fabricating the definitive
prosthesis, which will be cosmetically finished. This ensures that the fit of the definitive
prosthesis will last as long as possible; however, it will need to be replaced periodically
due to mechanical failure or more commonly due to atrophy, weight gain, or weight loss
The average life span for a definitive prosthesis is generally 3 to 5 years, depending on
the activity level of the amputee (35).

Biomechanics

Excessive forces generated on the residual limb by the prosthesis have been and
continue to be a major source of prosthetic fitting problems. These forces become critical
during the periods from heel strike to midstance and from midstance to toe off (37-39).
Midstance is a transitional period in which the forces are concentrated throughout the
distal end of the residual limb. The amputee who has retained an adequate heel pad
should not experience any excessive pressures as a result of this type of weightbearing.
During heel strike to midstance, the ground reactive force is posterior to the ankle
joint axis, resulting in a plantarflexory moment at the ankle. Because ankle joint motion
is not available in the Syme's prosthesis, weightbearing at heel strike results in a sagittal
plane motion of the socket against the residual limb, such that excessive forces occur
posterior-proximal and anterior-distal (Fig. 2) (38, 39).
Similar circumstances are responsible for the pressure areas experienced between
midstance and toe off. During this period, the ground reactive force is anterior to the
ankle joint axis, resulting in a dorsiflexory moment. The lack of ankle motion results in a
sagittal plane motion of the socket against the residual limb, causing excessive forces
anterior-proximal and posterior-distal (Fig. 2) (38, 39).

357

These pressures are significantly greater than those generated between heel strike
and midstance, and may cause difficulty during fitting (38). The pressures applied to the
residual limb are a result of the force divided by the area over which this force is being
applied (P = F/A). Since the forces generated are constant, the only manner to decrease
the pressure is to increase the area over which they are applied. For this reason, the socket
of the prosthesis is extended as far proximally as possible to maximize the area available
to dissipate these pressures (31, 38, 39). Because the tibial crest is a very prominent bony
structure, it is unable to accept these high repetitive pressures without pain and tissue
breakdown. The patellar tendon, however, is a durable, pressure tolerant area that can
readily accept concentrated pressures; therefore, the socket is extended to this level
utilizing these characteristics.
During various phases of the gait cycle, transverse rotation will tend to occur
between the residual limb and the prosthesis. This unwanted motion is prevented by
either shaping the distal tibia and fibula during surgery to provide a bony lock or by
achieving threepoint stabilization by flattening the positive model posteriorly over the
gastrocnemius and against the medial and lateral flares of the tibia (40). Rotation will
also tend to occur coronally between the residual limb and the prosthesis as the patient
shifts his weight laterally during midstance. With this shift, the weight line tends to fall
laterally to the foot and an excessive varus moment is placed on the knee by the varus
rotation of the prosthesis. Consequently, excessive proximal-medial and distal-lateral
pressures develop on the residual limb. These problems are alleviated by positioning the
foot laterally to provide stability and decrease the varus moment (39).
Through clinical experience and the biomechanical principles previously
discussed, a standard prosthetic alignment has been determined. The foot is placed as far
posteriorly as cosmetically possible to shorten the anterior lever arm of the foot and
reduce the forces generated from midstance to toe off. It is also placed as far laterally as
cosmetically possible to provide lateral stabilization and prevent rotation in the coronal
plane. Adding the appropriate amount of toe out to the prosthetic foot contributes to
lateral stabilization and also provides an easier rollover by shortening the anterior lever
arm. Finally, the foot is dorsiflexed 5 to 7 degrees to provide a smoother rollover and
everted slightly so that the foot is flat on the floor during midstance. Both of these
adjustments also assist in toe clearance during swing phase. Slight modifications may be
necessary to accommodate for the functional characteristics of the type of foot utilized
and gait pattern of the individual amputee.

The Ideal Prosthesis

Historically, the Syme's amputation has not been widely accepted largely because
of complications with prosthetic fitting. While many physicians have reported
satisfactory experiences with the Syme's amputation (10, 41-43), the inherent shape of
the residual limb has', posed problems for the prosthetist in the fabrication of \ a
functionally and cosmetically acceptable prosthesis. The lack of space below the
amputation places limitations on the components available to restore normal function
while the bulbous distal end poses problems for donning and doffing of the prosthesis. A
satisfactory prosthesis must provide comfortable transmission of forces to the residual
limb, restore the equivalent of foot and ankle function, restore length lost due to the
removal of the talus and calcaneus, provide adequate suspension during swing phase,
allow easy donning and doffing and be cosmetically acceptable to the patient. Despite the
advantages mentioned previously for this level of amputation, the ideal Syme's prosthesis
has yet to be developed (40).

History of Prosthetic Types

Very early prosthetic designs consisted of a molded leather socket reinforced with
steel uprights along the medial and lateral sides, and a lacer with a soft leather tongue
along the anterior aspect (Fig. 3). Until 1955, this design was routinely fitted for the
Syme's level amputee, but was unhygienic, extremely heavy, and very cosmetically
unappealing (33, 44). The introduction of thermosetting plastics into the prosthetics
profession has been an important advancement for improving the prosthetic care of all
amputees. These intimate total contact sockets are easily modified, lightweight, and more
cosmetic than previous designs. In addition, thermosetting plastics allow a wider, more
even distribution of pressure, better control of edema, and increased proprioception for
the amputee (37).

Figure 2. A, socket forces on leg, heel strike to mid-stance. B, socket forces on

leg, midstance to toe off.

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The application of thermosetting plastics has produced several socket design variations
which are currently utilized. The physician should be aware of these prosthetic options
and utilize this knowledge during the amputation surgery to provide the amputee with a
reconstructive procedure conducive to optimum prosthetic fit.
A bi-valve socket with a posterior opening extending upward to the brim of the
socket was developed by the Canadian Department of Veterans Affairs and is referred to
as the Posterior Opening Syme's or Canadian Syme's prosthesis (Figs. 4, 5). Because the
entire posterior portion is removable, it allows a residual limb with a large bulbous end to
be fit. Suspension of the prosthesis during swing phase is achieved by the narrow portion
of the socket immediately proximal to the bulbous distal end. Straps necessary to hold the
two sections together add an undesirable element to the overall appearance. A
circumferential measurement is taken at the largest portion of the distal end of the limb. If
there is not an equal corresponding circumference below the patellar tendon level, the
posterior opening or Canadian Syme's prosthesis is the only prosthetic option available
(34).

Figure 3. Leather and metal Syme's prosthesis.

Figure 4. Posterior-opening or Canadian Syme's prosthesis.

Figure 5. Posterior-opening or Canadian Syme's prosthesis with posterior panel

removed.

359

A variation of the posterior opening or Canadian Syme's prosthesis is the medial

opening Syme's prosthesis (Figs. 6, 7). The opening, needed for passage of the bulbous
distal end through the narrow portion of the socket, resembles a small door. Because of
the medial malleolar prominence and the overall varum curvature of the leg, the opening
is placed medially for ease of donning and doffing (34). Suspension is also a result of
narrowing the socket above the bulbous distal end, as in the posterior design.
 This design is indicated for patients with a small distal end, in which the proximal
measurement corresponding to the largest distal circumference is 3 inches or more below
the level of the patellar tendon (37). The 3-inch distance is necessary for the structural
integrity of the prosthesis, which is superior to the Canadian Syme's design. Although
this style has generally been acceptable to patients, the straps necessary to secure the door
detract from the cosmetic appearance.
Another available design is the socket with a removable insert. This prosthesis
utilizes a liner of pelite (a closed-cell foam), which is vacuum-formed to the residual
limb. The liner is built up externally from the largest dimension of the distal end to the
corresponding dimension proximally to facilitate donning and doffing. Allowing the
socket to be uninterrupted by a removable section results in a more durable and
structurally sound prosthesis. Suspension in this design is a result of the build-up around
the narrow portion of the residual limb proximal to the bulbous distal end. This design is
appropriate for patients with an atrophied residual limb or small distal end (34). In these
cases, the prosthesis tends to be more cosmetic than the previous designs because no
straps are required.
The hidden panel Syme's prosthesis (Figs. 8, 9) was developed at the University
of Miami Prosthetic-Orthotic Laboratory in 1965. This design was developed in
conjunction with a modified surgical technique in which the distal bony residual limb is
only slightly wider than the diaphyseal portion of the leg (35). By reducing the bulkiness
of the distal end during the amputation surgery, the limb is able to pass through an inner
expandable panel and the need for an opening in the socket is eliminated (35, 36). Socket
construction is composed of a rigid proximal brim, an expandable sleeve (usually silicone
based), a rigid distal cap and an outer socket lamination wall. An air space between the
flexible inner sleeve and the outer rigid lamination allows the bulbous distal end to pass,
providing for donning and doffing. Once the distal end has passed through the
expandable sleeve, the sleeve returns to its original shape and provides suspension of the
prosthesis.

Figure 6. Medial-opening Syme's prosthesis and solid ankle, cushion heel

(SACH) foot.

Figure 7. Medial-opening Syme's prosthesis with medial panel removed.

360

A hidden panel Syme's prosthesis is indicated only for patients who have the distal end
appropriately narrowed during the amputation procedure. This prosthetic design and
modified surgical technique provides superior cosmesis.
Because various flaws still exist in the prostheses currently available, new ideas
and designs continue to be developed. New materials have been introduced recently and
have been successfully utilized in the prosthetic fitting of other amputation levels. These
materials will likely provide similar progress of Syme's levels fittings and result in
continued improvement of socket designs.
The hidden panel variation developed by Hanger Orthopedics6 is referred to as
the air chamber Syme's prosthesis. After the patient dons the prosthesis, the air space
around the expandable sleeve is inflated utilizing a hand pump. This design allows patient
control of suspension pressure and accommodates volumetric changes. This should be
considered for extremely active patients or volumetrically unstable patients.
The introduction of soft, flexible thermoplastics such as Optiflex,7 Endoflex,8 or
Flexilene9 allows for an improved transmission of forces to the residual limb, providing a
more natural comfortable fit. An inner socket of this soft material sets in a carbon fiber
rigid outer frame which has opened windows along the medial and lateral sides. A foam
cosmetic cover is applied over the prosthesis which provides a more natural look and feel
to the prosthesis. The flexible plastic and carbon fiber combination is the current state of
the art in the field of prosthetics and will likely allow for the development of designs that
are a dramatic improvement over current standards.

Prosthetic Feet

Early prosthetic feet for the Syme's level amputation were often comprised of
wood, felt or rubber and most utilized some type of articulated joint. Because the
components required were so small, the articulated mechanisms usually failed due to high
stresses, resulting in their abandonment (44). The introduction of thermosetting plastics
allowed for the utilization of new foot designs.

Figure 8. Hidden panel Syme's prosthesis with solid ankle, cushion heel (SACH)
foot.

Figure 9. Sagittal cross-section of the hidden panel Syme's prosthesis with

flexible inner liner.

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The solid ankle, cushion heel (SACH) foot (Fig. 10) is comprised of a solid
wooden, aluminum or plastic keel (solid, structural component) which extends to the ball
of the foot and a cushioned heel wedge available in different densities. In order to adapt
this foot for use in the Syme's prosthesis, material must be removed from the heel
cushion area. Reducing the amount of material in the heel cushion diminishes the amount
of shock absorption available from the foot, thereby compromising its function. This
design offers adequate results to most amputees and remains the single most
recommended prosthetic foot for all levels of amputations.
The rigid keel of the SACH foot acts as a rigid lever arm and adds significant
stresses to the prosthesis, which are transferred to the residual limb. This problem of
rigidity with resultant force transfer combined with the patient's demands for a prosthetic
foot that allowed them to return to high activity levels and smoother gait, resulted in the
development of many new prosthetic foot options.
Several types of dynamic or energy storing feet have recently become available
for the Syme's amputee. In general, dynamic feet use high strength materials which allow
the keel to be flexible and distort during forefoot loading. By distorting, energy is
absorbed and released during the propulsive portion of the gait cycle when the keel
returns to its original shape. Dynamic feet are usually recommended for active patients
who will receive full benefit of the flexible keel, but it may also be indicated for patients
where ambulation may be increased by utilizing these energy returning features. Current
dynamic feet available for the Syme's level include the Seattle Lightfoot10 (Fig. 11),
which utilizes a plastic spring keel; the Carbon Copy II 11 (Fig. 12); the Flex Foot12
(Fig. 13); and Springlite13 (Fig. 14), all composed of a carbon composite material; and
the Quantum foot,14 which uses fiberglass-reinforced spring keels and heels. Advantages
of the dynamic or energy storing feet are decreased weight, and the ability to return
energy for propulsion which results in a smoother and more efficient gait for the
amputee. All feet are finished with some type of cosmetic foam cover, although the
degree of cosmesis varies among the various manufacturers. Cosmesis may also be a
consideration when recommending a foot type because it may be of more importance to
certain patients.

Clinical Evaluation

Dermatological disorders, which are detrimental to the amputee, are usually a

result of improper fit, malalignment, underlying physiological conditions or poor
hygiene. It is essential that the clinical team identify and correct these factors if they
appear. Because healthy skin is essential to the success of a prosthesis, hygiene of the
residual limb cannot be stressed enough to the patient. A proper hygienic regimen should
involve cleansing the residual limb nightly with a mild antibacterial soap, cleaning the
socket nightly with rubbing alcohol, witch hazel or an antiseptic, changing the prosthetic
socks as necessary to keep the limb dry, and washing the socks after each use (45). By
following this routine, complications that could interfere with the use of the prosthesis
can be avoided.
To evaluate the prosthesis for proper fit several areas must be critiqued. In
general, the prosthesis should be comfortable, function well and should be cosmetically
acceptable to the patient. Specifically, the prosthesis must be the proper height with the
pelvis level during normal stance. Proximal trimlines should not impinge on a functional
range of motion at the knee. The correct amount of toe out should be present on the
prosthesis to provide lateral stability and enhance roll over.

Figure 10. Solid ankle cushion heel (SACH) foot with hidden panel Syme's
prosthesis.

362
There should be a smooth transition throughout stance phase and adequate suspension
provided during swing phase. Finally, the foot should be flat on the floor during
midstance. If all of these criteria are met, a satisfactory prosthetic fitting has been
achieved.

Summary

Communication and cooperation between the physician and the prosthetist has
brought about earlier rehabilitation and improvements in the shaping of the residual limb,
leading to improved prosthetic fitting. These advancements combined with the
development of new materials and components in the field of prosthetics have enabled
the fitting of a prosthesis that is functionally and cosmetically superior to previous
designs. The continuation of these processes will ultimately lead to the overall
improvement of patient care rendered by the rehabilitation team.

Figure 11. The Seattle Lightfoot dynamic foot.

Figure 12. The Carbon Copy II dynamic foot.

Figure 13. The Flex foot dynamic foot.

Figure 14. The Springlite dynamic foot.

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Additional References

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