Syme Amputation Research Articles

Effects of high-profile crossover feet on gait biomechanics in 2 individuals with Syme amputation.

Prosthetic treatment options for people with ankle disarticulation (i.e., Syme amputation) are limited. Prosthetic feet designed for people with Syme amputation are often low profile to accommodate build-height restrictions, resulting in decreased energy return during gait. High-profile crossover feet that attach to the posterior proximal aspect of the prosthetic socket can bypass these restrictions and may promote a more physiologic gait pattern. To compare level-ground gait biomechanics and patient-reported outcomes between crossover and traditional energy-storing feet in people with Syme amputation. Within-participant pilot study. Both participants were fit with energy-storing and crossover feet and were randomized to the order they used the feet. Participants used each foot for 2 weeks before assessment. Step length symmetry, prosthetic ankle range of motion, prosthetic-side energy return, and peak sound-side loading were determined from motion capture data obtained in a laboratory. Mobility and balance confidence were measured using standardized patient-reported outcome measures. Foot preference was assessed with an ad hoc survey. Two participants with Syme amputations completed the study. Prosthetic ankle peak dorsiflexion and push-off power increased with the crossover foot compared with the energy-storing foot for both participants. Both participants reported an overall preference of the crossover foot. Changes in patient-reported outcomes did not exceed published minimum detectable change values. Crossover feet increased prosthetic ankle range of motion and energy return compared with traditional energy-storing feet in this pilot investigation of 2 participants. Crossover feet seem to promote physiologic gait and may be a promising alternative to traditional low-profile feet for people with Syme amputation.

Surgical Options for Diabetic Toe Ulcers and Osteomyelitis Technical Tips and a Decision-Making Algorithm.

Diabetic foot ulcers (DFUs) reflect a pivotal event that could lead to serious complications such as amputation and death. Although conservative surgery was reported to have better outcomes when compared to nonsurgical standard of care of forefoot wounds, the surgical management of diabetic toe ulcers (DTUs) is hardly researched. The aim of this study is to describe the types and techniques of surgical procedures that could be needed when managing DTU. The proposed surgical techniques were based on their outcomes following an evidence-based search of the literature. Six major types of procedures could be used to treat DTUs; (1) interphalangeal joint resection arthroplasty, (2) phalangectomy or internal pedal amputation, (3) distal Syme amputation, (4) percutaneous toe flexor tenotomy, (5) toe fillet flap, and (6) toe amputation. Details on technical tips are described. Based on the location, ulcer grade of the ulcer and the status of the surrounding soft tissue, a surgical decision-making algorithm is proposed to assist surgeons when managing such prevalent conditions.Levels of Evidence: Level V: Expert review.

Cross-Cultural Adaptation and Validation of The Nepali Version of The Prosthetic Limb Users Survey of Mobility Short-Form (Plus-M™/Nepali-12Sf) In Lower Limb Prosthesis Users.

Objective mobility measurement of Nepali prosthesis users is lacking. The objective of this study was to cross-culturally adapt, translate and evaluate construct validity of the Prosthetic Limb Users Survey of Mobility (PLUS-M™/Nepali-12 Short Form (SF)) instrument in lower limb prosthesis users residing in Nepal. Two forward translations, review and reconciliation, back translation, expert review, developer review to create the PLUS-M™/Nepali-12SF. Psychometric testing for internal consistency, test-retest reliability and construct validity against the Two-Minute Walk Test (2MWT) and Amputee Mobility Predictor with Prosthesis (AMPPRO) were performed on sixty-six lower limb prosthesis users. The majority of populations were with transtibial amputation 45 (68%), with transfemoral amputation 15 (23%), with knee disarticulation 5 (7.5%) and with syme's amputation 1 (1.5%). The most common cause of amputation among the population was trauma and the least was tumor. Chronbach's alpha for the PLUS-M™/Nepali-12SF was 0.90, mean T-Score was 52.90, test-retest intraclass correlation coefficient (ICC) was 0.94 (95% confidence interval 0.90-0.96). Construct validity with the 2MWT was good (r = 0.62, p< 0.001) and moderately positive with the AMPPRO (r = 0.57, p< 0.001). Our research evidenced that the PLUS-M™/Nepali-12SF had excellent reproducibility. The significance of this work is that it may allow for the measurement of mobility in austere locations of Nepal.

Diabetic patients with inadequate flow of the posterior tibial artery and in dialysis are not good candidates for Syme amputation

Objective: There is a renewed interest in Syme amputation (SA) as it is considered a “lower limb salvage” procedure. The aim of this study was to describe the characteristics and evolution of diabetic patients who underwent SA to search for factors that would affect the outcome by comparing a group of patients who had a successful amputation against those who required a major amputation. Methods: Seventeen diabetic patients submitted to non-traumatic SA between 2008 and 2016 were analyzed retrospectively. Results: Eight patients required a higher level of amputation. In this group, six patients continued with the posterior tibial artery (PTA) occluded despite the revascularization, and seven were on dialysis. When assessing the permeability of PTA and dialysis as predictors of failure, they multiplied the risk by 20 (cOR of 24 and 21, respectively). However, after adjusting for both factors, there was only clinical significance. Conclusion: SA in diabetic patients may be an alternative in those with a preserved heel pad tissue vascularization and permeable posterior tibial artery at the time of surgery. Patients on dialysis are likely to fail with this level of amputation. Level of Evidence IV; Therapeutic Studies; Retrospective Cohort Study.

Fibular Hemimelia: A Case Series of Nine Patients Treated with Syme Amputation

Fibular Hemimelia: A Case Series of Nine Patients Treated with Syme Amputation

Multiple Continuous Y-to-V–Plasties for Excision and Reconstruction of Constriction Band Syndrome: Case Series and Description of Surgical Technique

Many patients with constriction band syndrome will seek treatment to improve limb function and cosmesis. Although several techniques for excision are reported, cosmetic and functional deficits can persist, including hourglass deformity, lymphedema, and inadequate band excision with resultant neurovascular compromise, which may lead to revision surgery, including amputation. The authors present a novel technique that uses multiple continuous opposing Y-to-V-plasties in a single or staged manner to correct extremity constriction bands. Seven patients with 10 involved extremities were included in this retrospective case series. Patient demographics, associated abnormalities, and operative indications were collected from medical records. The primary outcome measures were primary wound healing and release of the constriction band. Secondary outcomes measures were perioperative complications and the need for revision surgery. All patients achieved primary closure with excellent healing in one or two stages. No infections or scar complications occurred, and no revision surgery of the band was required. One patient had mild indentation of scar tissue after their second stage, which improved with scar massage. One patient who had preoperative sciatic compression neuropathy and an insensate foot secondary to band constriction developed chronic calcaneal osteomyelitis requiring a subsequent Syme amputation. Postoperative lymphedema occurred in two patients, which resolved with the use of compression bandages over several weeks. Use of multiple continuous opposing Y-to-V-plasties is a safe and effective technique for adequate constriction band excision without residual hourglass deformity and good functional outcomes for patients with partial or circumferential constriction bands. Therapeutic, IV.

Terminal Syme Amputation of the Great Toe in the Pediatric Population.

In the pediatric population, chronic ingrown toenails (onychocryptosis) can cause infection (paronychia), debilitating pain, and may be unresponsive to conservative treatments. Following multiple failed interventions, a terminal Syme amputation is one option for definitive treatment of chronic onychocryptosis. This procedure involves amputation of the distal aspect of the distal phalanx of the great toe with complete removal of the nail bed and germinal center, preventing further nail growth and recurrence. A retrospective review was performed to determine outcomes of a terminal Syme amputation in the pediatric population. Inclusion criteria included treatment of onychocryptosis involving terminal Syme amputation with a minimum follow-up of 1 year. The medical record was reviewed to assess previous failed treatment efforts, perioperative complications, radiographic outcomes, and the need for additional procedures. From 1984 to 2017, 11 patients (13 halluces) with onychocryptosis were treated with a terminal Syme amputation. There were no intraoperative complications. One hallux had a postoperative infection requiring antibiotics as well as partial nail regrowth following the terminal Syme procedure that required subsequent removal of the residual nail. Following partial nail ablation, the patient had no further nail growth. An additional patient also developed a postoperative infection requiring oral antibiotic treatment. All patients returned to full weight-bearing physical activities within 6 weeks of surgery. Terminal Syme amputation was successful in treating pediatric patients who have recalcitrant onychocryptosis and paronychia. There was little functional consequence following terminal Syme amputation of the great toe in this patient population, making it an effective salvage procedure. Level IV-retrospective comparative study.

Modified Syme Amputation Using Skin Flaps on the Side of the Heel

Modified Syme Amputation Using Skin Flaps on the Side of the Heel

Conservative Surgical Options for the Treatment of Forefoot Diabetic Ulcers and Osteomyelitis: An Evidence-Based Review and a Decision-Making Tool.

Diabetic foot ulcers cause higher rates of amputation and mortality; amputations yield even higher mortality rates than diabetic foot ulcers. Conservative excisional surgical procedures could be a suitable alternative to amputations, with comparable results with respect to wound-healing and infection control. Also, toe-sparing conservative surgical procedures offer good to excellent outcomes when compared with the nonoperative standard of care. Fourteen types of conservative surgical procedures were identified including bone excision with ulcerectomy, interphalangeal or metatarsophalangeal joint resection arthroplasty, internal pedal amputation of the phalangeal or metatarsal bone, distal Syme amputation, metatarsal osteotomy, metatarsal head resection, Achilles lengthening, gastrocnemius recession, selective plantar fascia release, percutaneous toe flexor tenotomy, and skin grafting. Depending on the location of the ulcer or osteomyelitis, a decision-making tree tool has been developed to assist surgeons for the indication of the different conservative operations. A striking underuse of the available conservative operations was noted. When indicated, the outcomes of conservative surgery were rated good to excellent; these procedures could be suitable alternatives to amputation.

Should Chopart Amputation be Performed in Diabetic Foot Ulcer Patients?

Category:Diabetes, Midfoot/ForefootIntroduction/Purpose:Diabetic foot ulcers (DFU) with deep infections and osteomyelitis often lead to partial or complete limb loss. Determination of the appropriate level for amputation is challenging, and is a complex decision based on the patient’s function at baseline, extent of infection, vascular patency and comorbidities. Although Chopart amputation preserves greater limb length than Syme amputation, additional procedures, such as Achilles tenectomy and tendon transfers are necessary to optimize residual foot function. Challenges with wound healing and prosthesis fitting have been reported. We aimed to investigate the functional and clinical outcomes including patient reported outcomes of Chopart and Syme amputations.Methods:A query utilizing current procedural terminology (CPT) codes was performed to identify patients who had undergone Syme or Chopart amputations for diabetic foot infections by an academic orthopaedic group between August 2013 and September 2018. Twenty-two patients with average age of 59.8 (range, 28-79) years, comprising 18 Chopart amputations and 4 Syme amputations were identified. Demographic characteristics, body mass index, hemoglobin A1c, medical comorbidities, major and minor post-operative complications, unplanned admission or return to OR, revision surgeries, and time to receiving a brace or prosthesis information were compiled. After informed consent was obtained, subjects completed three Patient-Reported Outcomes Measurement Information Systems (PROMIS) instruments (Pain Interference (PI), Physical Function (PF), and Depression), and the SF-36. Unpaired student t-tests and Fisher’s exact test were utilized to compare patient cohorts. Statistical analysis was performed using Stata®.Results:The majority (17/18) of Chopart and half (2/4) of Syme patients developed complications including wound dehiscence and recurrent/persistent infection. Readmission and unexpected return to the OR for irrigation and debridement or revision occurred in 11/18 (61%) of Chopart and 2/4 (50%) of Syme patients. Revision amputations occurred in 10/18 (56%) Chopart patients (2 Syme, 8 BKA), and 1/4 (25%) Syme patients (BKA). Half of Chopart patients never received a prosthesis due to delayed wound healing and revision amputation. All Syme amputation patients received a prosthesis and resumed ambulation. The average time to prosthesis was 4.5 and 6.5 months for Syme and Chopart patients, respectively.There was no significant difference between Syme and Chopart patients in all PROMIS domains, or the SF-36 (p-values > 0.05) (Table 1).Conclusion:We found a high rate of complications and revision procedures in Chopart amputation patients. In our patient cohort, there was a high likelihood that a patient who underwent a Chopart amputation ultimately received a below knee amputation. Even after wound healing, patients with Chopart amputations may struggle with obtaining a prosthesis suitable for ambulation. Syme amputation patients were less likely to require revision amputation, and received a prosthesis more rapidly relative to Chopart amputation patients. The complication and revision rates of Chopart amputations indicate that surgeons should exercise judicious patient selection prior to performing these procedures.

Comparison of Prosthetic Feet for People With Syme's Amputation (XF Symes Study)

Comparison of Prosthetic Feet for People With Syme's Amputation (XF Symes Study)

Syme Amputation: Function, Satisfaction, and Prostheses.

Syme amputation (SA) is a term used to describe an amputation at the level of the ankle joint in which the heel pad is preserved. It is performed for a number of indications in a pediatric population. SA is purported to hold the advantage of allowing weight bearing without a prosthesis. A limb length discrepancy (LLD) is useful for ambulation without a prosthesis but can be restrictive with regards to the fitting of modern prostheses. A voluntary survey was distributed to persons living with SA. Recruitment occurred through hospital electronic database and electronic advertising. Data collected included baseline demographic information, data pertaining to weight bearing in different environments, as well as 2 validated outcome measures: the Trinity Amputation and Prosthesis Experience Scales-Revised (TAPES-R activity restriction scale) and the Locomotor Capabilities Index-5 (LCI-5). An illustration was designed to allow participants to classify their LLD by zone in relation to their nonamputated limb. At total of 47 persons living with SA participated. The average age at amputation was 3.7 years (range, 0.5 to 14.1 y), and at survey completion 15.8 years (1.7 to 60.3). Five of the described "zones" of LLD were represented. Average LCI-5 score was 52.6. Mean TAPES-R activity restriction scale was 0.59, the lowest mean being achieved by zone E participants, indicating the least restriction. Ability to walk without a prosthesis was lower in those participants over 11 years, when compared with those under, as well as being dependent on the walking environment. Our study found no trend indicating that a very low LLD was functionally optimal, and indeed found participants with a moderate LLD (zone E) to have the least mean restriction with regard to their prosthesis. Our study demonstrates that ambulation without a prosthesis depends on the environment (ie, flooring), and rates decrease significantly into adulthood. Optimal care should not focus simply "preserving length," but rather functional optimization and length modulation in parallel with a nuanced understanding of actual daily activities and prosthetic options. Level III-retrospective comparative study.

Results of the modified Pirogoff amputation with cannulated screws for diabetic foot infection.

Syme amputation has been shown to have value in patients with diabetic foot infections, but it has inherent drawbacks. A potential alternative is the modified Pirogoff amputation. Our objective was to evaluate the outcome of modified Pirogoff amputation using internal fixation with 6.5-mm cannulated screws in the management of diabetic foot. This is a prospective study of 13 patients admitted from January 2012 to June 2015. Inclusion criteria were infection limited to the forefoot, presence of a palpable posterior tibial pulse and an ankle-brachial index of more than 0.7. Internal fixation of the calcaneum to the tibial was performed using two 6.5-mm cannulated screws under image intensifier control. In ten cases, the wounds were healed at three weeks. Osseous union was observed in ten cases; the time taken for its occurrence was 2-5 months. Removal of screws was performed in five cases. Five cases developed technical complications of screw tract infection, with two cases having distal screw migration. Good results, defined as cases not requiring a below-knee amputation for two years postoperatively, were obtained in 10 (77%) cases. At the three-year follow-up, three additional cases required proximal amputation, leaving 7 (54%) cases with good outcomes. Our prospective study showed that with careful selection of patients, good postoperative results can be obtained. There is a definite role for modified Pirogoff amputation in the management of diabetic foot problems.

A Meta-analysis of the Types and Outcomes of Conservative Excisional Surgery for Recalcitrant or Infected Diabetic Toe Ulcers.

Although they occur frequently, diabetic toe ulcers (DTUs) are poorly investigated. Long-term antibiotics or toe amputation are the usual indications for complicated DTU treatment. Some authors reported good to excellent results following conservative surgery (CS) for recalcitrant or infected wounds; yet no systematic review has been published. Seven studies, comprising 290 patients with 317 ulcers, met the inclusion criteria of this meta-analysis. Three types of CS were found: resection arthroplasty of the interphalangeal joint, toe-sparing bone excision (internal pedal amputation), and distal Symes amputation. The meta-analytical results were as follows: healing rate of 98.3%, healing time of 6.8 ± 3.9 weeks, recurrence rate of 2.3%, wound dehiscence/recurrent infection rate of 6.4%, skin necrosis rate of 2.8%, and revision surgery rate of 7.4%. Subgroup analyses showed no significant differences in outcomes between recalcitrant ulcers and infected ulcers nor between surgery types. Significance was found in relation to ulcer location; when compared with the hallux, DTU on the lesser toes demonstrated better outcomes. Compared with the reported overall results of standard of care associated with antibiotics or toe amputation of complicated DTUs in the literature, CS seems to be a better option for the treatment of recalcitrant or infected DTUs. Levels of Evidence: Level III.

Accuracy of Daily Foot Temperature Monitoring for Patients with Recently Healed Diabetic Foot Ulcers or History of Amputation

Diabetic foot ulcers (DFU) result in significant morbidity, mortality, and healthcare costs. Fortunately, recent data suggest as many as 75% of DFU and 60% of lower extremity amputations (LEA) may be preventable. Clinical practice guidelines recommend evidence-based foot temperature monitoring (thermometry) for preventing DFU and its complications in high-risk patients. Despite this, several authors have noted that thermometry is not commonly practiced. This is potentially due to lack of evidence on the accuracy of thermometry in some of the highest-risk cohorts, including those with a recently-healed DFU or with history of LEA. The former may present with ipsilateral inflammation as part of normal healing, while the latter may lack the anatomy required for direct contralateral comparison of temperatures. Whether these concerns affect the accuracy of thermometry needs to be assessed. A recent study suggests that a novel thermometric mat may address some barriers to adoption. The mat was found to predict as many as 97% of non-traumatic plantar DFU with an average lead time of five weeks in a cohort with history of DFU. In the current investigation, we hypothesized no difference in the predictive accuracy of thermometry in two subgroups: those who healed from a DFU fewer than three months before enrolling, and those with a history of partial LEA (Syme amputation or more distal). Of the 129 subjects studied, 31% had recently-healed DFU and 56% had history of LEA. Although no difference in DFU incidence was found in the LEA subgroup, we found significantly higher incidence in those with recently-healed DFU (0.88 vs. 0.63 DFU/subject/year). Importantly, we found no differences in accuracy or lead time in either cohort. These data suggest thermometry is appropriate for monitoring both recently-healed DFU or partial LEA patients. Utilization of thermometry in these high-risk patients may significantly reduce morbidity, mortality, and resource utilization. Disclosure I.L. Gordon: None. A. Nouvong: None. B. Najafi: None. G.M. Rothenberg: Consultant; Self; Podimetrics. B. Petersen: Employee; Self; Podimetrics, Inc.. Stock/Shareholder; Self; Podimetrics, Inc. J.D. Bloom: Employee; Self; Podimetrics, Inc. Board Member; Self; Podimetrics, Inc. Stock/Shareholder; Self; Podimetrics, Inc. R. Frykberg: None.

A rare cause of lower limb deformity.

During an orthopaedic mission in a district hospital in Rwanda, a 10 year old girl was referred for treatment of a bilateral clubfoot. The girl was able to walk. Clinical evaluation (A) showed bilateral marked endotorsion of the lower limb with 90° internal rotation of the foot. There was no equinovarus deformity of the foot with a bilateral plantigrade foot. X-ray evaluation was performed. AP view (B) showed marked bowing and torsion of both tibia and fibula. Lateral lower leg views (C) showed crossing of tibia and fibula with significant diastasis between both bones distally. The diagnosis of congenital diastasis of the inferior tibiofibular joint was made. This is an extremely rare variant of dysplastic tibial anomaly of which the exact etiology is unknown. It is usually associated with equinovarus deformity of the foot and limb shortening. Possible treatments include serial casting if the patient is seen at a very young age, various soft tissue and bony procedures for foot repositioning, Syme amputation and progressive correction with the use of an Ilizarov-external fixator. The girl in the described case had plantigrade feet; given the bilateral presentation, there was no significant leg length discrepancy. Since she was able to walk and local treatment facilities were limited, it was decided to abstain from treatment and accept the deformity.

RETRACTED: Amniotic Band Syndrome With Pseudoarthrosis of Tibia and Fibula: A Case Report

Constriction of the lower limb by a congenital amniotic band has been proposed to explain the development of pseudoarthrosis of the tibia and fibula. We report a case of amniotic band syndrome in a preterm female infant with pseudoarthrosis of the tibia and fibula. She was born at 29weeks of gestation with congenital amniotic bands and was noted to have a severely edematous left foot distal to the constricting band with rudimentary digits. The skin was pink and well perfused with palpable pulses. Radiography demonstrated pseudoarthrosis of the tibia and fibula. The limb deformities were managed with splints, positioning, and physiotherapy. She underwent Z-plasty with soft tissue release on the left lower leg on day 7 of life. At 36weeks of postmenstrual age, a repeat radiograph showed markedly improved growth of the tibia and fibula with mature new bone formation, which avoided the need for further surgical intervention. During the follow-up period, she underwent left Syme's amputation at 18months. At 29months of age, the child was able to walk and run without support. The findings from our case confirm the potential for bone growth in patients with amniotic band syndrome, once the constricting band has been released. Simple release of the constriction band with Z-plasty resulted in growth of mature bone, replacing the pseudoarthrosis and, hence, the patient did not require surgical amputation. Thus, one should be cautious when deciding on surgical amputation, even in the presence of pseudoarthrosis, especially in preterm infants. Early limb-preserving surgery with release of the constricting band with an intention to salvage the limb appears appropriate.

Necessity of secondary Syme amputation of the foot after severely destroyed hindfoot injury due to suicidal jump from height in a psychiatric patient: Case presentation and brief review of literature

Necessity of secondary Syme amputation of the foot after severely destroyed hindfoot injury due to suicidal jump from height in a psychiatric patient: Case presentation and brief review of literature

A Pilot Investigation of the Effect of Postural Control Strategies and Balance in Children with Unilateral Lower-Limb Amputation

ABSTRACT Introduction Previous research has addressed the effects of backpack loads on balance in adults and children, but there is a gap in the literature concerning children with lower-limb amputation. The purpose of this study was to assess the effect of backpack loads on postural sway in children with lower-limb amputation. Materials and Methods Four children with unilateral Syme amputation and five controls were assessed in quiet standing with backpacks loaded with 0%, 10%, 20%, and 25% of body weight. Kinetic data were collected using force platforms, and the path of the center of pressure was calculated. Results Considering the sway parameters, the control group showed the expected increase with each successive weight level, whereas the group of children with amputation showed an unexpected nonlinear response as weight increased. Conclusions Postural control mechanisms used by the children with amputation may be different from their able-bodied counterparts.

A case of bilateral Syme amputation for forefeet necrosis due to the frostbite

A case of bilateral Syme amputation for forefeet necrosis due to the frostbite