Chapter 10 - Amputations About Foot

E. Greer Richardson

Foot Amputations
Amputations about the foot and ankle often are painful and debilitating. However, these procedures can
be life saving and can dramatically improve a patient's quality of life. Thus ablation by amputation or
disarticulation should be viewed as a reconstructive procedure rather than a failure of treatment.
Because patients who require distal amputations often have multiple medical problems, consideration
should be given to special handling of the soft tissues. Avoidance of excessive pressure on the skin edges
with forceps and use of thick skin flaps may decrease wound complications. Refraining from tourniquet
use, controlling hemostasis meticulously, and avoiding hematoma formation may be of some benefit.
The nutritional status of a patient also is critical in wound healing after ablation procedures about the foot
and ankle. According to Dickhout et al., serum albumin of less than 3.0 g/dl and total lymphocyte count
(TLC) of less than 1500 both correlate with poor healing. A healing rate of 82% can be obtained with a
TLC of more than 1500 and albumin of at least 3.0 g/dl. Patients with poor nutritional status should be
evaluated for dietary supplementation before surgery to maximize healing. Alternatively, a higher level
amputation may be chosen if delaying amputation carries an unacceptable risk to the patient.
Amputation of a single toe, with few exceptions, usually causes little disturbance in stance or gait.
Amputation of the great toe does not materially affect standing or walking at a normal pace. If the patient
walks rapidly or runs, however, a limp appears because of the loss of push-off normally provided by the
great toe. Amputation of the second toe frequently is followed by severe hallux valgus because the great
toe tends to drift toward the third to fill the gap left by amputation. Amputation of any of the other toes
causes little disturbance. Of these the fifth is most commonly amputated, the usual indication being
overriding on the fourth toe. Here amputation can be performed with impunity and usually is preferred to
reconstructive procedures because it is simple and definitive ( Fig. 10-1 ). Amputation of all toes causes
little disturbance in ordinary slow walking but is somewhat disabling during a more rapid gait and when
spring and resilience of the foot are required. Furthermore, it interferes with squatting and tiptoeing.
Usually it requires no prosthesis other than a shoe filler ( Fig. 10-2 ).
Amputation through the metatarsals is disabling in proportion to the level of amputation: the more
proximal the level, the greater the disability. The loss of push-off in the absence of a positive fulcrum in
the ball of the foot is chiefly responsible for impairment of gait. Again, no prosthesis is required other
than a shoe filler.
Amputations more proximal than the transmetatarsal level result in considerable awkwardness in walking
because of the loss of support and push-off. Consequently most amputations of the forefoot and midfoot
have been discarded in favor of more functional ones in the hindfoot or at the ankle. However, such
procedures occasionally are indicated, especially in diabetic patients and less often after severe trauma.
Better preoperative tests for tissue vascularity have made it possible to predict with reasonable accuracy
those diabetic patients in whom toe, ray, and partial foot amputations will heal. In addition to using the
ankle/brachial index, toe pressures of greater than 45 mm Hg and transcutaneous PO2 of more than 30
both correlated with healing of wounds. On the other hand, a
*Dr. Jon F. Robinson contributed to this chapter.

Figure 10-1 Clinical photographs after removal of fifth toes bilaterally.

PO2 of less than 20 indicated that healing would be unlikely at that level. Roach and McFarlane have
reported good healing and good functional results in a small series of diabetic patients after open Lisfranc
or Chopart amputations with secondary closure. Lisfranc amputation at the tarsometatarsal joints often
results in an equinus deformity because of loss of the foot dorsiflexor attachments ( Fig. 10-3 ). Chopart
amputation through the midtarsal joints may result in a severe equinovarus deformity. Amputations at
either level may require revision to a higher level or subtalar arthrodesis because such deformities prevent
ambulation. By performing heel cord tenotomies, Roach and McFarlane were able to prevent early
equinus deformities from becoming fixed. This is our experience also ( Fig. 10-4 ). Consequently, only 1
of 44 midfoot amputations in their series required revision to a higher level. In a series of similar size,
Millstein et al. reported a much higher failure rate for Lisfranc and Chopart amputations done for severe
foot trauma. However, they had no failures from equinovarus deformity; the failures were caused by the
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extensive trauma. Those patients who healed functioned well with simple prosthetic devices. These
reports and others indicate that good results can be achieved with amputation levels that have been
unsatisfactory in the past. As such, they provide reason to reevaluate the uses of amputation in the
forefoot and midfoot.

Figure 10-2 A, Transmetatarsal amputation in 20-year-old man. B, Patient is able to wear high-top tennis shoes with custom
shoe insert.
TOE AMPUTATION

TECHNIQUE 10-1
Fashion a long plantar and a short dorsal skin flap. Begin the incision at the level of intended bone section
at the midpoint on the medial side of the toe and curve it over the dorsal aspect to end at a similar point
on the lateral side. Now fashion a similar plantar flap but make it slightly longer than the dorsoplantar
diameter of the toe at the level of bone section. Dissect the skin flaps proximally to the level of bone
section. Divide the flexor and extensor tendons and let them retract just proximal to the end of the bone.
Isolate and divide the digital nerves and ligate and divide the digital vessels. Then section the bone at the
selected level and smooth its end with a rasp. Close the flaps with interrupted nonabsorbable sutures
( Fig. 10-5 ).

AFTERTREATMENT.

Protect the amputation site with a sterile dressing for 12 to 16 days. Remove the sutures in dysvascular
patients at 21 to 23 days unless the wound has obviously healed sooner. Protected weight-bearing usually
is not needed. A shoe with the toe box cut out or a wood-soled postoperative shoe is worn until the sutures
are removed.

Figure 10-3 Severe equinus deformity after amputation through Lisfranc joints.

Figure 10-4 A, Amputation through Chopart midtarsal joints with insertion of tibialis anterior into bone. In this patient,
equinovarus deformity did not develop. Lengthening of tendo calcaneus is indicated for salvage of procedure before
proceeding to more proximal amputation. B and C, Shoe filler with ankle corset and shoe allowed reasonably good function.

Figure 10-5 Amputation of two of central toes showing dorsal and plantar flaps. Removal of adjacent metatarsal heads may be
necessary, especially in elderly patients with atrophic forefoot pads. Even though this patient had diabetes mellitus, primary
reason for amputation was deformity that interfered with shoe wear.
AMPUTATION AT BASE OF PROXIMAL PHALANX

Box 10-nomum. TECHNIQUE 10-2

The skin incision varies with the toe involved. For instance, make a long posteromedial flap if the
procedure involves the great toe. Begin the incision at the base of the toe in the midline anteriorly and
curve it distally over the medial and posteromedial aspects for a distance slightly greater than the
anteroposterior diameter of the digit; then extend it proximally across the plantar surface of the toe to
the web. During closure reflect this flap laterally and suture it to the medial edge of the skin in the web.
In the second, third, and fourth toes amputation is performed through a short dorsal racquet-shaped
incision. Begin the incision 1 cm proximal to the metatarsophalangeal joint and pass it distally to the
base of the proximal phalanx, dividing it to pass around the toe and across the plantar surface at the
level of the flexor crease. After amputation close the wound by side-to-side approximation of the skin
edges. In the fifth toe fashion a lateral flap long enough to cover the defect left by the amputation. Then
close the wound by approximating the flap to the skin in the web. In each instance, after making the
incision, reflect the flaps proximally to the level of bone section. Draw the tendons distally, divide
them, and allow them to retract. Then identify the digital nerves and divide them proximal to the end of
the bone and divide and ligate the digital vessels. Close the skin edges with interrupted nonabsorbable
sutures.

AFTERTREATMENT.

The aftertreatment is the same as that for Technique 10-1 .

Figure 10-6 A and B, Metatarsophalangeal joint disarticulation. Single-layer closure using 3-0 or 4-0 monofilament nylon.
METATARSOPHALANGEAL JOINT DISARTICULATION

In the diabetic foot, ischemia or osteomyelitis or both are the most compelling indications for amputation
of the great toe at the metatarsophalangeal joint ( Fig. 10-6 ).
Box 10-nomum. TECHNIQUE 10-3
Disarticulation of the metatarsophalangeal joint is carried out in the same manner as amputation through
the base of the proximal phalanx, differing only in the level and manner of amputation of bone. The skin
flaps may vary. A longer plantar flap is probably indicated ( Fig. 10-7, A to D ). Raise the flaps to the level
of the metatarsophalangeal joint or joints. Identify the capsule of the metatarsophalangeal joint and, with
the toe in acute flexion, incise its dorsal side first ( Fig. 10-7, E ); then straighten the toe and expose and
incise the remainder of the capsule after dividing the flexor tendons and neurovascular bundles,
cauterizing the latter. Removing the sesamoids in the insensitive foot is recommended. Stay close to the
periosteum over the sesamoids ( Fig. 10-7, F ).
AFTERTREATMENT.

Protected weight-bearing with crutches or a walker for 5 to 10 days is indicated for comfort. Some
patients will not need this, and the wound conditions may or may not suggest protection. Once the sutures
have been removed, the patient may need a shoe with an open toe box because of edema. When the
edema has subsided, ambulation in a supportive, soft-soled, accommodating shoe is allowed.
FIRST OR FIFTH RAY AMPUTATION (BORDER RAY AMPUTATION)

Box 10-nomum. TECHNIQUE 10-4

For amputations at the first (or fifth) metatarsophalangeal joint (border digit), the following incision is
used ( see Fig. 10-7, D ). Base the incision laterally, extending from the midline of the medial eminence
(or lateral eminence of the fifth metatarsal) dorsally and then plantarward to about the level of the middle
of the proximal phalanx. If the toe is being amputated because of acute or chronic deep infection, such as
in a diabetic foot with osteomyelitis, press the incision to bone because the tissue planes are obscured and
this flap may not survive if left thin. Once the dorsal full-thickness flap has been raised to the
metatarsophalangeal joint, complete the plantar flap in the same manner and raise it to the joint. Open the
capsule dorsal to the plantar flap ( see Fig. 10-7, E ) and, retracting both flaps proximally, complete the
disarticulation. Cauterize the neurovascular bundles. Removing the sesamoids may be wise in diabetic
patients or patients with callosities beneath the first metatarsal head ( see Fig. 10-7, F ).
By extending the racquet-shaped incision proximally along the metatarsal shaft as shown in Fig. 10-7, G ,
part or all of the first (or fifth) metatarsal may be removed. Again, take the incision to bone, raise the flaps
at bone level, and section the bone from proximal medial to distal lateral ( Fig. 10-7, H ). Lifting the bone
medially, section the lateral soft tissues to remove the intended segment. This is made easier by first
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disarticulating the hallux at the metatarsophalangeal joint. If a disarticulation of the first metatarsal at the
medial cuneiform is done, try to preserve the penetrating branch of the dorsalis pedis artery, coursing
plantarward about 1 cm distal to the joint. Cautery or suture ligature often is necessary if it is sectioned.
Close in a single layer of nonabsorbable suture ( Fig. 10-7, I ).

AFTERTREATMENT.

Aftertreatment is the same as for metatarsophalangeal joint disarticulation.

MULTIPLE RAY AMPUTATION

If necessary, the second ray also can be removed through the same incision ( Fig. 10-8, A ). If skin for
coverage is limited, a fillet flap can be based laterally ( Fig. 10-8, B ). If the form of the amputation is
dictated by trauma rather than infection or arteriosclerosis, preservation of as much bony architecture as
possible is reasonable. This may require a free vascularized flap, particularly in a younger patient ( Fig.
10-9 ).

Figure 10-7 A, Disarticulation at metatarsophalangeal joint of great toe. B and C, Osteomyelitis of hallux with deep
ulceration. D, Skin incision for disarticulation at first metatarsophalangeal joint or, with extension proximally, first ray
amputation. E, Dorsal capsulotomy at metatarsophalangeal joint. F, Sesamoids were removed because of extent of adjacent
bone and soft tissue infection. G, Metatarsal shaft exposed. H, Section of bone proximal medial to distal lateral. I, Closure.

Figure 10-8 A, Complete amputation; first ray and base only of second metatarsal, both through medial incision. B, Use of
fillet flap for coverage.

Figure 10-9 A, Traumatic amputation through first ray in adolescent; coverage was obtained with latissimus dorsi
myocutaneous free flap. B and C, Medial and plantar views. This is indicated when preservation of bony architecture is
paramount and neither deep infection nor arteriosclerosis is present. Vascularized free flap can be used in treatment of infection
but only in selected patients and with selected types of wounds.

Partial foot amputations are especially desirable in a diabetic patient whose opposite foot is at significant
risk. Amputation of the lateral two or even three rays often provides a functional weight-bearing foot
( Fig. 10-10 ). Amputation of the medial two and even three rays in special circumstances may provide a
weight-bearing, sensitive, reasonably functional foot ( Fig. 10-11 ).

Figure 10-10 A, Lateral two rays amputated in elderly diabetic patient with ischemia and infection of lateral border of foot,
including osteomyelitis. B, Diabetic patient with preservation of bases of fourth and fifth metatarsals and part of shaft of third.
Note proximal transmetatarsal amputation on left foot.

Figure 10-11 Three views of 6-year-old child who at 2 years of age had extensive injury from riding lawn mower accident.
After arthrodesis of subtalar joint and transfer of peroneal tendons to dorsum of foot, she functions remarkably well with use of
soft shoe filler. Roentgenogram was taken 10 years after arthrodesis.
CENTRAL RAY AMPUTATION

Occasionally because of infection with or without ischemia, particularly in a diabetic foot, and
occasionally after trauma, removal of one or more of the central rays, either partially or completely, is
indicated. If the third and fourth rays require removal, it is particularly difficult to secure closure because
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of immobility of the recessed second ray. An osteotomy of the base of the fifth metatarsal may facilitate
the closure.
TECHNIQUE 10-5
Begin a dorsal longitudinal incision over the metatarsal shaft of the ray to be resected; place the
incision between the metatarsals if two are to be removed. Leaving a small remnant of the base of the
metatarsal, if not contraindicated because of infection, expedites the excision. Disarticulation at the
cuneiform level is tedious because of the limited exposure, the strength of the supporting
capsuloligamentous structures, and the angles of planes at the tarsometatarsal joints. Disarticulating the
toe or toes at the metatarsophalangeal joint before excising the metatarsal also facilitates excision. The
extensor tendons can be retracted or removed to enhance exposure. By sharp and blunt dissection,
remove the intrinsic muscles on either side, transect the bone transversely and, lifting proximal to
distal, clear the undersurface (plantar surface) of the metatarsal. Again, disarticulation at the cuneiform
or cuboid is an alternative technique. Unless the wound has not been rendered surgically clean, leave it
open. Inspect the wound in 48 to 96 hours. Close primarily or with skin graft when the wound allows.
AFTERTREATMENT.

Protected weight-bearing for 3 to 4 weeks is recommended. Once the edema has subsided, which may
take several weeks, a noncustom soft shoe is worn.
A deep central space abscess with necrosis of the intrinsic muscles of the foot may be managed by
external debridement and excision of one or more central rays with lateral border metatarsal osteotomy to
close the gap. A few large retention sutures (once vascularity of the remaining part of the foot is not in
question) approximating the medial and lateral borders of the foot provide a loose closure and allow
drainage; the remainder of the wound heals by secondary intention. In this extenuating circumstance,
where salvage of any functional part of the foot is the goal, angulation of the metatarsal osteotomy is not
of prime importance or consequence ( Fig. 10-12 ).
TRANSMETATARSAL AMPUTATION

TECHNIQUE 10-6
Fashion a long plantar and a short dorsal flap ( Fig. 10-13, A ). Begin the dorsal incision at the level of
intended bone section on the anteromedial aspect of the foot and curve it slightly distal to the level of
bone section to reach the midpoint of the lateral side of the foot. Begin the plantar incision at the same
point as the dorsal, carry it distally beyond the metatarsal heads, and curve it proximally to end at the
midpoint of the lateral side of the foot. Because of the greater cross-sectional diameter to be covered
with skin medially, the incision is slightly longer on the medial than on the lateral side. Fashion the
plantar flap to include the subcutaneous fat and a thin beveled layer of plantar muscles. Remove the toes
at the metatarsophalangeal joints and section the metatarsals transversely at the junction of their middle
and distal thirds ( Fig. 10-13, B ). If infection is present distally, try not to violate any abscess, leaving
the metatarsophalangeal joint intact. Identify the nerves and divide them well proximally so that their cut
ends fall proximal to the end of the bones. Then divide the tendons under tension so that they retract into
the foot. Finally, bring the long plantar flap over the ends of the bones and stitch it to the dorsal flap with
interrupted nonabsorbable sutures ( Fig. 10-13, C ).

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Figure 10-12 A and B, Progressive collapse of midfoot and hindfoot with loss of bony architecture in elderly patient with
diabetes mellitus and Charcot arthropathy. C, Deep plantar space abscess and osteomyelitis or neuropathic periostitis followed
collapse deformity with ulceration. D and E, By osteotomizing border metatarsal or incising capsule at articulation with
tarsus, gap created by multiple central ray amputations can be closed and occasionally managed without skin graft or flap
coverage.

AFTERTREATMENT.

Except for the need for a shoe filler, the aftertreatment is the same as for multiple metatarsal amputations
( see Fig. 10-2 ).
MIDFOOT AMPUTATIONS

Amputations through the middle of the foot include (1) Lisfranc amputation at the tarsometatarsal joints,
which seldom has been performed because of the equinus deformity that usually develops ( see Fig. 103 ); (2) Chopart amputation at the midtarsal joints, which is frequently followed by severe equinovarus
deformity ( see Fig. 10-4 ); and (3) Pirogoff amputation, in which the calcaneus is rotated forward to be
fused to the tibia after vertical section through its middle.
To salvage tarsometatarsal and midtarsal amputations in which fixed equinus deformity has developed,
Burgess and Lieberman et al. recommend division of the tendo calcaneus. Permanent correction has been
obtained in some patients, eliminating the need for reconstruction or more proximal amputation. The
tendo calcaneus is divided subcutaneously a short distance proximal to its insertion. The ankle and
hindfoot are then stretched into enough dorsiflexion to allow the heel to rest squarely on the floor. The
stump is immobilized in a non-weight-bearing cast extending proximally to just distal to the knee for 10
to 14 days. A walking cast can then be applied, and the patient may bear weight during the next 4 weeks if
there is no contraindication. After removal of the cast at 6 weeks, an appropriate partial foot prosthesis is
used. By this means the equinus is corrected and weight is borne, as it should be, on the plantar skin of
the heel and remaining part of the foot.
Recurrence of the equinus deformity has not been a problem. Slight calcaneus deformity may develop but
will cause no difficulty either in fitting the shoe or as a source of pain. Although push-off is compromised,
the stump before lengthening of the tendo calcaneus is not capable of much push-off in the presence of a
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fixed equinus deformity. By this simple method, skin problems, pressure irritation, and pain associated
with excessive weight on the end of the stump are largely eliminated.

Figure 10-13 A, Dorsal and plantar incisions for transmetatarsal amputation (left) and disarticulation at the
metatarsophalangeal joints (right). B, Level of bone transection in transmetatarsal amputation. Osteotomy locations are gently
curved. C, One-layer closure using monofilament nonabsorbable suture.

Hindfoot and Ankle Amputations

Amputations about the ankle joint not only must fulfill the requirements of an end-bearing stump but also
must leave enough space between the end of the stump and the ground for the construction of some type
of ankle joint mechanism for the artificial foot. The Syme amputation meets these requirements better
than any other in this region. The level of bone section is at the distal tibia and fibula 0.6 cm proximal to
the periphery of the ankle joint and passing through the dome of the ankle centrally. The tough, durable
skin of the heel flap provides normal weight-bearing skin. There is apparently no middle ground for this
amputation: when good, it is the most satisfactory functional level in the lower extremity, but when bad, it
is absolutely valueless and the extremity must be amputated at a more proximal level. The two most
common causes of an unsatisfactory Syme stump are posterior migration of the heel pad and skin slough
resulting from overly vigorous trimming of dog-ears. Both can be prevented by attention to surgical
technique. The chief objection to this amputation is cosmetic. The prosthesis used must accommodate the
flair of the distal tibial metaphysis that is covered with heavy plantar skin and thus is rather large and
bulky. For this reason the amputation usually is not recommended for women. The prosthesis used for a
classic Syme amputation consists of a molded plastic socket, with a removable medial window to allow
passage of the bulbous end of the stump through its narrow shank, and a solid-ankle, cushioned-heel
(SACH) foot ( Fig. 10-14 ).
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Figure 10-14 A, Frontal view of Syme amputation with prosthesis (B). Double upright brace was for opposite foot. C and D,
Anteroposterior and lateral roentgenograms of Syme amputation. Note absenceof malleoli.

Sarmiento has described a modification of the Syme technique that produces a less bulbous stump and
allows the use of a more cosmetic prosthesis. He advises transection of the tibia and fibula approximately
1.3 cm proximal to the ankle joint and excision of the medial and lateral malleoli. This produces a stump
that is only slightly larger in circumference than the diaphyseal portion of the leg and allows fitting with a
prosthesis that incorporates an expandable socket rather than a removable window.
In the past most surgeons did not use the Syme amputation for ischemic limbs because the failure rate of
wound healing was unacceptably high. More recently, preoperative determination of local tissue perfusion
and oxygenation by such techniques as Doppler ultrasound measurement of segmental blood pressures,
radioactive xenon clearance tests, and transcutaneous oxygen measurements have significantly increased
the success rate of the Syme amputation in these limbs. Wyss et al., Malone et al., and Wagner
popularized a two-stage technique of the Syme amputation for use in diabetic patients with an infected or
gangrenous foot lesion and have achieved marked success with this technique in properly selected
patients.
The Boyd amputation also produces an excellent end-bearing stump about the ankle and eliminates the
problem of posterior migration of the heel pad that sometimes occurs after a Syme amputation. It involves
talectomy, forward shift of the calcaneus, and calcaneotibial arthrodesis. The arthrodesis makes the
procedure technically more difficult than the Syme amputation and also produces a somewhat more
bulbous stump. However, a very satisfactory prosthesis that is cosmetically acceptable has been designed
for use after this amputation.
The Pirogoff amputation involves arthrodesis between the tibia and part of the calcaneus; the calcaneus is
sectioned vertically, its anterior part is removed, and its remaining posterior part and the heel flap are
rotated forward and upward 90 degrees until the raw surface of the calcaneus meets the denuded distal
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end of the tibia. This amputation has no advantage over that of Boyd and technically is somewhat more
difficult.
SYME AMPUTATION

Box 10-nomum. TECHNIQUE 10-7

A single long posterior heel flap is used. Begin the incision at the distal tip of the lateral malleolus and
pass it across the anterior aspect of the ankle joint at the level of the distal end of the tibia to a point one
fingerbreadth inferior to the tip of the medial malleolus; then extend it directly plantarward and across
the sole of the foot to the lateral aspect and end it at the starting point ( Fig. 10-15, A ). Divide all
structures to the bone.
Next, excise the tarsus as follows. Place the foot in marked equinus and divide the anterior capsule of the
ankle joint. Then insert a knife into the joint space between the medial malleolus and the talus and draw
it inferiorly to section the deltoid ligament, taking care to protect the posterior tibial artery; repeat this
maneuver on the lateral side to section the calcaneofibular ligament ( Fig. 10-15, B ). Place a bone hook
in the posterior aspect of the talus to provide further equinus and proceed with dissection posteriorly,
dividing the posterior capsule of the ankle joint ( Fig. 10-15, C ). Continue the dissection posteriorly,
close to the superior surface of the calcaneus, and identify and expose the tendo calcaneus. Divide the
tendo calcaneus at its insertion on the calcaneus, taking care not to damage the overlying skin. With a
periosteal elevator, dissect the soft tissues from the lateral and medial surfaces of the calcaneus and pull
the bone into even more equinus ( Fig. 10-15, D ). Continue subperiosteal dissection on the inferior
surface of the calcaneus until the distal end of the plantar skin flap is reached ( Fig. 10-15, E and F ).
Then remove the entire foot with the exception of the heel flap. Retract the flap posteriorly and dissect
the soft tissue from the tibia and malleoli. Incise the periosteum circumferentially 0.6 cm proximal to the
joint line and divide the tibia and fibula at this level so that the line of transection passes just through the
dome of the ankle joint centrally ( Fig. 10-15,G ). The plane of the transection should be such that the cut
surfaces of the tibia and fibula will be parallel to the ground when the patient is standing. Round and
smooth all sharp corners of bone. Then dissect the medial and lateral plantar nerves and divide them
proximal to the end of the bone. Pull inferiorly and section all visible tendons to retract proximally into
the leg. Isolate the posterior tibial artery and vein and ligate them just proximal to the cut distal edge of
the heel flap. Ligate the anterior tibial artery as it lies in the anterior flap. Perform minimal debridement
of any soft tissue tags of plantar muscle and fascia lining the inner surface of the heel flap and take care
to preserve intact the subcutaneous fat and its septae because this is specialized pressure-tolerant tissue.
Several techniques have been used to prevent migration of the heel pad on the end of the stump, such as
taping the heel flap to the leg with adhesive strips, skewering the heel flap to the bone with a Kirschner
wire, or leaving a small sliver of calcaneus attached to the heel flap, which will fuse to the end of the
tibia. The technique of Wagner is simple and has been effective in his hands. Drill several holes through
the anterior edge of the tibia and fibula and suture the deep fascia lining the heel flap to the bones
through these holes ( Fig. 10-15, H and I ). Then approximate the skin edge of the heel flap to the skin
edge of the anterior flap with interrupted nonabsorbable sutures ( Fig. 10-15, J ). Large protruding tags of
skin, or dog-ears, will be found at each end of the suture line; these should never be removed because
they carry a large share of the blood supply to the heel flap and disappear later under bandaging. Apply a
cast extending above the knee over a drain and remove the drain 24 to 48 hours after surgery ( Fig. 1015, K ).

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Figure 10-15 Syme amputation. A, Incision and bone level. B, Exposure of ankle and division of ligaments. C, Bone hook
pulling talus distally, exposing distal articular surface of tibia and fibula. D, Dissection of soft tissues from calcaneus. E and F,
Subperiosteal removal of calcaneus, leaving heel pad intact. G, Division of tibia and fibula just through dome of ankle joint
centrally. H, Holes drilled in anterior edge of tibia and fibula to anchor heel pad. I, Edge of deep fascia lining heel pad is
anchored to tibia and fibula. J and K, Skin closure over drain and application of above-the-knee cast. (A, B, D, G to I redrawn
from Wagner WF Jr: The Syme amputation. In American Academy of Orthopaedic Surgeons: Atlas of limb prosthetics, St
Louis, 1981, Mosby.)

AFTERTREATMENT.

A soft dressing can be applied and treatment continued as discussed in Chapter 9 . A preferable approach
is to apply a properly padded rigid dressing in the operating room at the conclusion of surgery. If
ambulation is to be delayed until wound healing is assured, a simple well-padded cast is adequate. If early
ambulation is preferred or when subsequent prosthetic ambulation is to be instituted in the postoperative
period, a true prosthetic cast should be applied as follows. Apply a light sterile dressing to the wound and
then apply a sterile stump sock. Sterile felt pads are appropriately fashioned and skived by the prosthetist
to relieve pressure over the tibial crest and the edges of the transected bones; the prosthetist glues these
pads to the stump sock with medical adhesive and then applies the plaster cast. Use elastic plaster of Paris
in the initial wrap to provide good control of tension; reinforce this with conventional plaster. Gentle
compression should be maximal over the end of the stump and gradually decrease proximally. The cast
need not extend above the knee because the shape of the stump and the intimate fit between the stump and
the rigid dressing provide sufficient suspension. The end of the rigid dressing is flattened for weightbearing by pressing a board against the wet plaster. The proximal part of

Figure 10-16 Immediate postsurgical prosthesis for Syme amputation. (From Burgess EM, Romano RL, Zettl JH: The
management of lower extremity amputations, TR 10-6, Washington, DC, 1969, Veterans Administration.)
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the dressing is molded to create a patellar bar and a popliteal bulge, as in a patellar tendon-bearing
prosthesis, to allow partial weight-bearing by the patellar tendon and tibial condyles. A filler block is
added if needed to correct leg length discrepancy, and a Syme prosthetic foot or a rubber walking heel is
attached to the cast. A waistbelt and suspension straps are used for additional suspension ( Fig. 10-16 ).
Gait training and further aftertreatment then proceed as discussed in the section on below-the-knee
amputations ( Chapter 11 ).
TWO-STAGE SYME AMPUTATION

The two-stage Syme amputation procedure was developed to increase the success rate of amputations
performed at the Syme level in patients with gross infection of the forefoot. It has proved to be extremely
beneficial in the diabetic population, especially when coupled with the use of sophisticated techniques for
preoperatively determining segmental limb viability. Initially described by Hulnick, Highsmith, and
Boutin, the procedure was successfully used and reported by Spittler, Brennan, and Payne at the Walter
Reed Hospital in 1954. However, Wagner popularized the technique and was most successful in using it at
Rancho Los Amigos Hospital. He used the procedure for patients with gangrene or infection of the
forefoot who did not respond to conservative treatment, who were not candidates for a more distal
amputation, and who exhibited sufficient local vascularity, as determined by Doppler ultrasound
segmental blood pressure testing, to successfully heal their wounds. Ninety-five percent of the patients
meeting these criteria had successfully healed amputations at the Syme level, using the two-stage
procedure.
The procedure consists of performing an ankle disarticulation as the first stage, preserving the tibial
articular cartilage and the malleoli, and performing a Syme-type closure over a suction-irrigation system
that allows installation of an antibiotic solution into the wound. Irrigation is continued until local and
systemic signs of infection have resolved. After 6 weeks, if the stump is nicely healed, a second procedure
is performed to remove the malleoli and narrow the stump for good prosthetic fitting.
Box 10-nomum. TECHNIQUE 10-8 (Wyss et al., Malone, et al., Wagner)
First Stage. To allow slightly longer skin flaps to cover the malleoli, start the incision 1 cm distal and 1
cm anterior to the tip of each malleolus. Carry the inferior incision directly across the sole of the foot to
connect these two points, cutting all layers down to the bone. Carry the superior incision obliquely across
the ankle joint, connecting the two points and cutting all layers down to the bone. Pull the tendons on the
dorsum of the foot distally into the wound and transect them so that they will retract well proximal to the
skin edge. Identify and ligate the dorsalis pedis artery. Incise the anterior capsule of the ankle joint, plantar
flex the foot, and transect the medial and lateral collateral ankle ligaments, taking care to preserve the
posterior tibial artery. Use a bone hook in the body of the talus to pull the foot into even greater plantar
flexion and begin subperiosteal dissection on the superolateral surface of the calcaneus. Continue this
dissection posteriorly and medially, transect the tendo calcaneus near its insertion on the calcaneus, and
protect the posterior tibial artery medially. Separate the foot from the leg by transection of the plantar
aponeurosis. Now ligate the posterior tibial artery near the margin of the heel flap and transect the tibial
nerve so that its cut end retracts well proximal to the skin edge. Insert suction-irrigation tubes into the
wound. Trim the distal edge of the heel flap to allow accurate closure with no tension but do not attempt to
trim the dog-ears from the sides of the wound. Occasionally it will be necessary to divide fascial bands in
the heel pad to prevent medial or lateral shifting of the pad. Similarly, it may be necessary to make small
incisions into the fat pad to make a nest for each malleolus. These maneuvers usually will allow secure
seating of the heel pad on the end of the bones. Suture the deep fascia of the anterior flap to the deep
fascia of the posterior flap with interrupted absorbable sutures and approximate the skin edges with
interrupted nonabsorbable sutures. Cover the wound with a soft compression dressing.

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Figure 10-17 Second stage of Wagner-Syme amputation. A and B, Removal of dog-ears over each malleolus. C and D,
Resection of metaphyseal flare parallel with shaft of fibula; same procedure is carried out at distal tibia. (Redrawn from Wagner
WF Jr: The Syme amputation. In American Academy of Orthopaedic Surgeons: Atlas of limb prosthetics, St Louis, 1981,
Mosby.)

After surgery the wound is irrigated with an antibiotic solution for 48 to 72 hours or until local and
systemic signs of infection have subsided. After the drains are removed, apply a well-padded plaster cast
to the stump, using contoured felt pads to protect the dog-ears. Ambulation with or without weight-bearing
can be started at this point under strict supervision. Healing usually is secure enough at 6 weeks to
perform the second stage or definitive amputation.
Second Stage. Make an elliptical incision over each malleolus to remove the dog-ears. The volume of
tissue removed should be equal to that of the malleolus ( Fig. 10-17, A and B ). Expose the malleoli by
subperiosteal dissection, taking care to protect the posterior tibial artery medially. Now resect each
malleolus flush with the joint surface and remove the adjacent metaphyseal flares parallel with the shafts
of the tibia and fibula ( Fig. 10-17, C and D ). This narrows and flattens the stump both medially and
laterally but still leaves anterior and posterior flares for prosthetic suspension. Tailor the soft tissues to
allow secure positioning of the heel pad over the ends of the bones. Suture the deep fascia of the sole
through holes drilled in the bone and close the wound with interrupted sutures.

AFTERTREATMENT.

Apply a soft compression dressing until wound healing is apparent. Then apply a walking cast and begin
weight-bearing 10 to 12 days after surgery. The cast should be changed at 2-week intervals or more often
if it becomes loose or uncomfortable. Definitive prosthetic fitting usually is possible about 8 weeks after
surgery.
BOYD AMPUTATION

Box 10-nomum. TECHNIQUE 10-9

Fashion a long plantar flap and a short dorsal flap. Begin the incision at the tip of the lateral malleolus
and pass it over the dorsum of the foot at the level of the talonavicular joint to a point one fingerbreadth
inferior to the medial malleolus; then curve it inferiorly and distally across the sole of the foot at the
level of the metatarsal bases; and finally carry it superiorly and proximally to the tip of the lateral
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malleolus ( Fig. 10-18 ). Elevate the skin flaps and amputate the forefoot through the midtarsal joints.
Divide the ligaments between the calcaneus and tibia by sharp dissection close to the bone. Then
remove the talus. Next, excise the anterior part of the calcaneus by transverse osteotomy just distal to
the peroneal tubercle. Remove the cartilage from the appropriate surfaces of the tibia, fibula, and
calcaneus to prepare them for arthrodesis. Draw distally any tendons present in the wound and section
them high. Then section the medial and lateral plantar nerves to prevent their being subject to pressure.
Now shift the calcaneus forward in its relationship to the ankle joint and mortise it into position for
arthrodesis, its undersurface being parallel with the ground. If desired, pass a Steinmann pin superiorly
through the heel to fix the calcaneus to the tibia in proper position. Then approximate the skin flaps with
interrupted sutures and insert a drain, which is to be removed at 48 to 72 hours.

Figure 10-18 Boyd amputation with calcaneotibial fusion. A, Full-thickness flaps with longer plantar extension in midtarsal
amputation. Note that these flaps extend distal to the metatarsophalangeal joints so that wound can be closed without skin
tension. B, Midtarsal joint(s) disarticulation, talectomy, and partial fibulectomy. C, Talus has been excised. Calcaneus and
tibial platform prepared for arthrodesis. D, Single-layer closure with 2-0 monofilament nonabsorbable suture (over a drain).
(A, B, and D modified from Slocum DB: An atlas of amputations, St Louis 1949, Mosby.)

AFTERTREATMENT.

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Remove the sutures after 2 weeks and any Steinmann pin after 4 weeks. Prohibit weight-bearing on the
stump until the eighth week. Then apply a walking cast and leave it in place until arthrodesis is complete.
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