A Syme amputation is an amputation done through the ankle joint. The foot is removed but the heel pad is saved so the patient can put weight on the leg without a prosthesis (artificial limb). The goals of a Syme amputation are to remove diseased tissue or a non-usable foot and create a functional, painless limb.
This type of amputation is indicated for foot trauma, infection or tumors as well as certain types of limb deformities when the foot cannot be saved. A Syme amputation is not appropriate in the following situations:
• In those with medical conditions where the risks of surgery outweigh the benefits. If the medical conditions can be improved, surgery can be reconsidered.
• Poor blood flow through the artery that supplies the heel pad. Without good blood flow, the surgical wound will not heal.
• Lack of an intact heel pad. If there is any ulcer, wound or dead tissue at the heel, a Syme amputation should not be performed and a higher-level amputation is recommended.
• Infection, tumor or trauma that involves the ankle. A Syme amputation will not adequately treat the problem so a higher level of amputation is needed.
The surgery is performed with the patient asleep under general anesthesia. For patients with risk factors that make general anesthesia dangerous, the surgery can be done with spinal anesthesia or a leg nerve block with sedating medication. A tourniquet can be used to help minimize blood loss.
The incision is made where the foot and ankle meet. The heel pad is protected. The ligaments and tendons attaching the foot to the ankle are cut and the soft tissues are removed from the foot bones. Arteries are tied off and then cut as well. The bony prominences at the ankle are removed so that the end of the leg has a flat surface after wound closure. A drain sometimes is used to help prevent a pool of blood from developing deep in the tissue that might cause failure of the procedure. Lastly, a bulky soft dressing and a cast are applied.
After the surgery, patients are monitored in the recovery unit for a short time. Patients may start walking once the wound is healed. Length of stay in a hospital can vary. Patients who can get around safely on one leg with crutches or a front-wheeled walker and have help at home can go home after surgery. Patients who need more assistance or daily physical therapy may go to a rehabilitation center, transitional care unit, or skilled nursing facility before going home.
Skin staples or sutures are removed when the wound is healed. Swelling can be managed with a compression stocking, but it is normal to have swelling for up to a year after surgery.
After the wound is healed and the majority of the leg swelling is gone, an experienced prosthetist makes a prosthesis (artificial limb) for the lower leg and stump. The prosthesis may need multiple adjustments so it fits properly. When the prosthesis is ready, additional therapy is done to learn how to walk well with the prosthesis.
RISKS AND COMPLICATIONS
The most significant complication is failure to heal the wound. This can lead to infection, death of tissue, and the need for an amputation at a higher level. Another potential problem after this procedure is too much motion of the heel pad stump, which can cause areas of increased pressure at the bottom of the amputation and lead to ulcers. These ulcers sometimes can be treated with local wound care and prosthesis modification. If there is a bony prominence causing the ulcer, additional surgery should be done to remove the bony prominence and allow healing.
Many patients start out with a sensation the foot is still there (phantom limb sensation). This is normal and not painful. However, some patients may develop nerve pain where major nerves were cut (phantom limb pain).
How do I decide between a Syme amputation and a below the knee amputation (BKA)?
In many cases, either a Syme amputation or a below the knee amputation is a reasonable treatment. Both have advantages and disadvantages. Patients with Syme amputations have the ability to be walk on the limb without a prosthesis. This may be beneficial in situations like getting up in the middle of the night to go to the bathroom. Prosthesis training is easier with a Syme amputation than with a BKA because it feels more functionally normal. The increased energy demands on the body are also less with a Syme amputation than with a BKA.
Because of potential complications of Syme amputations discussed above, sometimes a Syme amputation has to be revised to a below the knee amputation. If the risk of developing complications is high after a Syme amputation, it may be better to choose a BKA from the beginning. Multiple surgeries can be emotionally and physically stressful. A below-knee prosthesis can be more cosmetically appealing. The ankle portion of a Syme amputation prosthesis has to be wider to fit the end of the stump.
There are multiple aspects to consider in the decision-making process for an amputation. Your orthopaedic surgeon will work with you to decide what is best for you.
Will I be able to drive after a Syme amputation?
If there are no other physical or cognitive impairments preventing driving, Syme amputation patients should not have problems with driving after getting used to the prosthesis.
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