Ankle Disarticulation Research Articles

Syme Ankle Disarticulation in Diabetic Dysvascular Disease and Trauma

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Pirogoff ankle disarticulation as an option for ankle disarticulation.

Eleven patients (12 ankles) who had Pirogoff ankle disarticulation were followed up for an average of 5.6 years (range, 2.1-8.9 years). After disarticulation of the Chopart joint, the talus was removed and the calcaneus was cut off in the coronal plane. The heel then was rotated 90 degrees to the tibial plafond. The postoperative result was evaluated using a scoring sheet. Excellent results were seen in four feet: two in patients with trauma, one in a patient with a metastatic tumor, and one in a patient with osteomyelitis. Good results were seen in two feet: one in a patient with trauma and one in a patient with diabetes mellitus. A fair result was seen in one foot in a patient with diabetes mellitus. Poor results were seen in four feet in three patients with arteriosclerosis and one foot in a patient with diabetes mellitus. In Pirogoff ankle disarticulation, the leg-length discrepancy is compensated for by using the calcaneus. The patients only had a leg-length discrepancy of 2.8 cm on average, which enabled them to walk outdoors wearing only a shoe orthosis. The postoperative results were unfavorable in patients with vascular diseases and were satisfying in patients without vascular diseases.

Syme ankle disarticulation in patients with diabetes.

Syme ankle disarticulation is an amputation level that minimizes disability and preserves function, but it has been used sparingly in patients with diabetes mellitus. Surgeons have avoided this level because of the perceived high risk for wound failure, wound infection, or migration of the heel pad, which makes prosthesis use difficult. Ninety-seven adult patients with diabetes mellitus who underwent Syme ankle disarticulation because of a neuropathic foot with an infection or gangrene, or both, during an eleven-year period were studied retrospectively. Selection of the amputation level was made on the basis of clinical examination and an assessment of the wound-healing parameters, i.e., vascular inflow, tissue nutrition, and immunocompetence. The average age of the patients was 53.2 +/- 17.5 years. Eighty-two patients (84.5%) ultimately achieved wound-healing. When threshold levels for vascular inflow (ultrasound Doppler ischemic index of 0.5 or transcutaneous partial pressure of oxygen between 20 and 30 mm Hg) and tissue nutrition (serum albumin of 2.5 g/dL) were met, an overall success rate of 88% was achieved. Total lymphocyte count (an absolute lymphocyte count of 1500) and the smoking of cigarettes during the study period did not appear to impact wound-healing rates. The overall infection rate was 23%, and it was three times greater in smokers. Most infections were managed with local wound care and antibiotic therapy. At a minimum follow-up of two years, all but two patients were able to walk with a prosthesis. Thirty of the ninety-seven patients died at an average of 57.1 months following surgery. The results of this retrospective review support the value of Syme ankle disarticulation in diabetic patients with infection or gangrene. This function-sparing amputation can be successfully performed with a reasonable risk. Patients managed with a Syme ankle disarticulation appeared to remain able to walk better and to survive longer than similar patients who had a transtibial amputation and served as historical controls. In diabetic patients with dysvascular disease who have adequate vascular inflow to support wound-healing (an ultrasound Doppler ischemic index of 0.5 or a transcutaneous partial pressure of oxygen between 20 and 30 mm Hg), the threshold for the wound-healing parameter of serum albumin appears to be as low as 2.5 g/dL.

Treatment of Longitudinal Deficiency Affecting the Femur: Comparing Patient Mobility and Satisfaction Outcomes of Syme Amputation Against Extension Prosthesis

Patients with proximal focal femoral deficiency or longitudinal deficiency affecting the femur were selected from a large regional center. Twenty-eight such patients were identified and were divided into two groups depending on how their condition was managed. Group 1 had opted for the surgical approach of ankle disarticulation (Syme amputation) and the fitting of an above-the-knee prosthesis. The patients in group 2 had been managed in a nonsurgical fashion using an extension prosthesis. They were asked about their level of mobility using the recognized Locomotor Index and their overall satisfaction using self-designed questions. The two groups' scores were similar for mobility whether using their prosthesis or not, but group 1 had lower satisfaction scores than group 2. Current opinion advocates the use of surgery in the management of proximal focal femoral deficiency because it is believed to have better cosmetic and functional results, but in the authors' comparison similar scores for mobility were shown. The nonsurgical extension prosthesis was associated with fewer musculoskeletal and residual limb problems, fewer problems with public transport, and greater satisfaction than Syme amputation. Overall, this small study suggests that the nonsurgical approach is preferable.

Syme Ankle Disarticulation: A Simplified Technique

Syme Ankle Disarticulation: A Simplified Technique

Restoration of walking ability with Syme's ankle disarticulation.

Ankle disarticulation is a function sparing amputation level used primarily in the treatment of diabetic foot infection and gangrene secondary to peripheral vascular disease. It also has a valuable role in amputation surgery because of trauma, when combined with a dynamic response, or energy-storing, prosthetic foot.

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<h3><b>Background</b></h3> People with lower limb amputations frequently have impaired balance ability. The Berg Balance Scale (BBS) has excellent psychometric properties for people with neurologic disorders and elderly people dwelling in...

Charcot ankle fusion with a retrograde locked intramedullary nail.

Twenty patients with severe neuropathic (Charcot) ankle deformities underwent 21 attempted ankle fusions with a retrograde locked intramedullary nail as an alternative to amputation. All had insensate heel pads and had failed at nonoperative methods of accommodative ambulatory bracing. In 11, the talus was either absent, or the deformity was of sufficient magnitude to require talectomy to align the calcaneus under the tibia for plantigrade weightbearing. Ages ranged from 28 to -68 (average 56.3) years. Nineteen were diabetic, 12 being insulin-dependent. Their average body weight was 102 kg, with 11 greater than 90 kg at the time of surgery. Eight had chronic large full thickness ulcers overlying, but not involving bone of the medial malleolus, medial midfoot, or proximal fifth metatarsal, at the time of surgery. At a follow-up of 12 to 31 months, 19 achieved bony fusion. In the 10 patients where talectomy was not required, fusion was achieved at an average of 5.3 months without complications. In the patients who required talectomy, six of the patients required eight additional operations to achieve fusion. Three achieved fusion following removal of the nail and prolonged bracing. One opted for ankle disarticulation for chronic persistent infection, rather than attempt reoperation. One died of unrelated causes during the early postoperative period. Retrograde locked intramedullary ankle fusion is a reasonable alternative to amputation in the neuropathic (Charcot) ankle that cannot be controlled with standard bracing techniques. The potential for morbidity requiring reoperation is greatly increased when the deformity is of sufficient magnitude to require talectomy to achieve alignment of the calcaneus in a plantigrade weight-bearing position under the tibia or when there are large open ulcers.

Walking pattern of midfoot and ankle disarticulation amputees.

Measurements of the vertical component of ground reaction force (ORF) and dynamic center of pressure (COP) were recorded for five subjects with midfoot level amputations and six with Syme's ankle disarticulation amputations. All of the subjects underwent amputation surgery as a consequence of peripheral vascular disease and diabetes. GRF measurement was accomplished with the F-Scan system (Tekscan, Boston, MA). Each group exhibited a consistent, reproducible pattern of gait. Subjects with Syme's ankle disarticulation initiated initial loading response, i.e., heel strike, with a concentration of GRF in the center of the anatomic heel. COP progressed along the midline to the center of the anatomic forefoot, where GRF was concentrated at push-off. Midfoot amputees initiated loading at the lateral-posterior heel. COP progressed medially to the midline, where it progressed distally to the level of the distal residual limb (proximal metatarsal metaphyses). It then shifted medially under the base of the first metatarsal, where a small concentration of GRF occurred at push-off, similar to the normal foot. These findings explain the decreased magnitude of propulsion seen in midfoot level amputees and may explain the seemingly paradoxical increased metabolic cost of walking observed in midfoot amputees as compared with Syme's ankle disarticulation amputees.

Prosthetic fitting of adult lower limb amputees following trauma and peripheral vascular disease

The reader should first study the text and articles on normal human locomotion which provide a basis for the systematic treatment and management of pathological gait, especially when prosthetic and orthotic devices are used? ,2,3 In this article, we will stress current prosthetic fitting of adult lower limb amputees, and describe the abnormalities of gait when reviewed in follow-up clinics. Because of the rarity of hip disarticulation and trans-pelvic amputations, we will restrict our attention to partial foot amputations, Syme ankle disarticulation, trans-tibial amputation, through-knee disarticulation and trans-femoral amputation. The decision on selection of level for lower limb amputation has previously been described in this journal?

Clubfeet and tarsal coalition.

Tarsal coalition was noted in 18 cases of rigid equinovarus deformity. Sixteen cases were encountered at surgery and two at morbid dissection. There were 14 patients in the series; six had associated pathologic conditions that might have caused their clubfeet to be deemed "teratologic," whereas eight did not and were considered to have congenital clubfeet. Four patients in the series had bilateral coalitions. Preoperative radiographs demonstrated the coalition in only one case. A presurgical magnetic resonance image (MRI) clearly showed the coalition in another case. Nonoperative treatment was unsuccessful. Two patients with tibial dysplasia had ankle disarticulations. The remaining 16 feet required extensive soft-tissue releases, internal fixation, and coalition excision. The vast majority of cases showed cartilaginous subtalar coalition at the medial facet. The patients were followed for an average of 6 years, and two recurrences were noted. Remaining feet were painless and plantargrade, but were rather stiff. This anomaly may be more common than previously described. It is usually not suspected preoperatively and may likewise be difficult to recognize at surgery. A preoperative MRI scan may also be helpful.

A Volume-Adaptable Prosthesis for Ankle Disarticulation

Ankle disarticulation amputation in patients with peripheral vascular disease is sometimes complicated by delayed healing or residual limb volume fluctuation. This change in shape and contour presents several challenges to the prosthetist charged with producing a static prosthesis that must meet the demands of a constantly changing residual limb. This article describes a method of producing a preparatory ankle disarticulation prosthesis that can be quickly and inexpensively fabricated, and can adapt to changing residual limb size and shape.

A Treatment Algorithm for Neuropathic (Charcot) Midfoot Deformity

Forty-nine feet in 47 patients with midfoot neuropathic foot deformity were referred for care to a comprehensive foot salvage clinic and followed for an average of 3.6 years. Twenty-three initially presented without open ulcers. Two underwent elective Syme's ankle disarticulation amputation, and the others were kept ambulatory with a combination of periods of nonweightbearing cast immobilization, accommodative extra-depth shoes with custom orthotics, and ankle-foot orthoses. Twenty-six of the feet initially presented for care with open ulcers and/or chronic osteomyelitis. Twenty-two of these patients underwent 32 surgical procedures. Sixteen underwent debridement of the infected bone and surrounding soft tissues. Excision of large, nonaccommodative boney prominence, termed exostectomy, was performed in eight. Partial excision of the deformed midfoot combined with boney stabilization and attempted arthrodesis, termed partial tarsectomy, were performed in seven. All surgical patients were managed postoperatively with long-term custom accommodative bracing. Follow-up at an average of 3.6 years revealed that all but one of the patients remained ambulatory. Six walk with accommodative shoe gear and persistent stable chronic open ulcers. None required below-knee amputation. Five amputations were performed, three at the Syme's ankle disarticulation level, one at the Chopart's hind-foot level, and one at the mid-foot level.(ABSTRACT TRUNCATED AT 250 WORDS)

Technique of childhood ankle disarticulation

Surgical Principles James Syme first recorded the technique of ankle disarticulation in the adult in 1843 [5]. It included the creation of anterior and posterior flaps, a subperiosteal dissection with preservation of the heel pad and bony contouring of the distal tibia and fibula to reduce the bulbous appearance and to facilitate prosthetic fitting. Although an analogous procedure is done for children, there are substantial differences between the two techniques which are related to the presence of growth plates, and the potential problem of stump overgrowth and pencilling. Fortunately, a true ankle disarticulation can usually be performed in children without the need for extensive surgical bony reshaping due to the excellent potential for remodelling with future growth.

Local Anesthesia for Surgery on the Foot: Efficacy in the Ischemic or Diabetic Extremity

The efficacy, risks, and benefits of the use of local anesthesia for surgery on the foot were assessed in 75 patients who underwent 127 procedures with lower calf, ankle, metatarsal-ray, and digital blocks. There were 23 procedures on digits alone, 97 forefoot operations (transmetatarsal amputations, wound debridements, closures, osteotomies, joint resections), six ankle or hind-foot amputations, and one open ankle disarticulation. There were no complications directly related to the use of local anesthesia; specifically, no extension of preexisting infection or ischemia due to injection in the foot. There were three deaths (30-day mortality 4%). The procedures were uniformly well tolerated, even in patients with ongoing myocardial ischemia or severe metabolic disorders. Local anesthesia is a safe and effective method to perform local debridement or amputation of the foot in an ischemic or diabetic extremity.

Prevention of ligament and meniscus atrophy by active joint motion in a non-weight-bearing model.

This study describes the effect of active joint motion on the maintenance of ligament and meniscus mass in a non-weight-bearing model of disuse. Denervation and fixation models of immobilization have shown that resorption of isotope and atrophy of mass occurred for hard tissue (bone) and soft tissues (ligament, tendon, or meniscus). A unilateral ankle disarticulation model of disuse that maintains active knee motion without weight bearing was studied for 8 weeks in dogs that were chronically prelabeled with three different isotopes. The effects of non-weight-bearing without denervation or fixation were analyzed for the resorption of isotopes, and net atrophy of bone mass (femur or tibia) and soft-tissue mass (collateral or cruciate ligaments, menisci). A large and similar loss of all three isotopes, as well as collagen and calcium mass occurred for whole femur and tibia; this indicated that mass loss was equivalent to bone resorption and suggests little replacement with new bone. No loss of isotope or mass per whole tissue occurred for the collateral and cruciate ligaments or menisci. The strength of the femur-anterior cruciate ligament-tibia complex was analyzed by a tensile failure test when a fast rate of deformation was applied; the results did not differ qualitatively or quantitatively between control and experimental limbs. The absence of weight bearing for 8 weeks resulted in marked bone atrophy without resorption or atrophy of soft tissues, or decrease of the mechanical strength for the femur-ligament-tibia complex.

Hallux-to-Hand Transfer During Ankle Disarticulation for Multiple Limb Anomalies

FOR TRAUMATIC loss of the thumb, the techniques and results of hallux transfer for hand reconstruction are well established. In addition, there are several reports of toe-to-hand transfer for reconstruction of the congenitally deficient hand. Most of these cases involved transfer of a normal toe from a normal foot1; in several cases, abnormal toes from cleft feet were transferred.2,3This case report highlights the treatment of a child who was born with four anomalous limbs. He required an ankle disarticulation because of a severely unstable ankle. During the preoperative planning of amputation, the usefulness of the amputated foot tissues for hand reconstruction was discussed, and a microsurgical hallux-to-hand transfer was performed at the time of ankle disarticulation. Report of a Case The patient had four anomalous limbs at birth. No specific etiologic factor could be identified. The left upper limb had syndactylous ring and little fingers; the thumb,

Hallux-to-hand transfer during ankle disarticulation for multiple limb anomalies

Hallux-to-hand transfer during ankle disarticulation for multiple limb anomalies

Proximal Femoral Focal Deficiency

In patients with unilateral proximal femoral focal deficiency, the leg length inequality is almost always greater than five inches at skeletal maturity. Consequently, prosthetic management should be planned before the patient walks. A standard plan of treatment of the patient with unilateral PFFD is not possible at this time, primarily because of the varying percentage of femur missing and the controversy of management of the hip in patients with type A or B deformity. However, we found that ankle disarticulation with Syme flap closure combined with arthrodesis of the knee is a reasonable plan in many patients with unilateral PFFD. This allows correction of the knee and hip flexion contractures and gives the patient a functional, cosmetic stump. By the time he begins school, he is functioning as an above-knee amputee. This is not an undesirable goal, as one of us (E.G.R.) recently examined an above-knee amputee, a Captain in the United States Army, who continued his hobby of sky diving.

The Syme amputation in children

Twenty-three children had proportionate growth of bone and soft tissue between two and eleven years after a Syme ankle disarticulation. All walked with permanent prostheses within three months after operation. Ischemic necrosis occurred twice after inadvertent ligation of the posterior tibial artery. Suture of the extensor tendons into the heel pad eliminated its posterior migration. Prosthetic realignment compensated for progressive genu valgum in ten of fourteen amputees with fibular hemimelia. On the basis of these gratifying results, the Syme ankle disarticulation is suggested as early treatment for certain congenital anomalies of the lower extremity.