The Syme Amputation
Sai Sajja, MD
O riginally described in 1843 by James Syme, Professor of
Surgery in Edinburgh, Syme amputation continues to
generate controversy and debate regarding its role in trau-
matic injuries to the foot, peripheral vascular disease, and
diabetes. Syme reported the successful outcome in a case of
suppurative disease of the tarsus by disarticulation of the foot
at the ankle and removal of the malleoli flush with the lower
articular surface of the tibia.1 It is interesting to note that he
described this procedure twenty-two years before Joseph
Lister, his son-in-law, first embarked on his experiments with
antiseptic surgery.2 The procedure has remained popular
with Canadian and Scottish surgeons, but has found less
favor elsewhere.
The Syme amputation provides an end-bearing stump
with excellent weight bearing characteristics that is covered
with tough and durable skin of the heel flap. From a technical
standpoint, it is one of the most difficult amputations to
perform, and meticulous attention to detail is essential to
ensure a satisfactory outcome.
The primary disadvantages of Syme amputation are its
high failure rate and cosmetically unappealing bulbous
stump. Over the years, various modifications to the original
technique have been introduced to improve the cosmetic
appearance and outcomes in patients with peripheral vascu-
lar disease and diabetic foot infections. Wagner popularized a
two-stage technique for use in diabetic patients with an in-
fected or gangrenous foot lesion.3 Sarmiento, in 1972, intro-
duced a modification that consisted of osteotomy of the tibial
and fibular malleoli to narrow the medio-lateral diameter of
the distal end of the stump so that a more cosmetically ac-
ceptable prosthesis can be fitted.4
Indications
One of the most important requirements for a positive out-
come when performing Syme amputation is patient selection.
The principal indications are congenital deformity of the foot
and traumatic foot injuries in which a viable heel pad re-
mains. It can also be performed in patients with peripheral
vascular disease and diabetic infections of the forefoot. A
Penn State Hershey Medical Center, College of Medicine of the Pennsylvania
State University, 500 University Drive, Hershey, PA.
Address reprint requests to Dr. Sai Sajja, Fellow in Vascular Surgery, Penn
State Hershey Medical Center, College of Medicine of the Pennsylvania
State University, 500 University Drive, Hershey PA 17033-2390. E-mail:
ssajja@psu.edu
74 1524-153X/05/$-see front matter © 2005 Elsevier Inc. All rights reserved.
doi:10.1053/j.optechgensurg.2005.07.003
two-stage procedure is recommended in these patients. Dur-
ing the first stage, the ankle joint is disarticulated, followed
six to eight weeks later by osteotomies of the malleoli. A
palpable posterior tibial artery pulse is considered essential
for healing following Syme amputation. In the presence of
vascular insufficiency, patient selection can be further refined
by Doppler studies and transcutaneous PO2 measurements.
An ankle-brachial index of 0.35 to 0.4 or an absolute Doppler
value of 40 to 70 mm of Hg is often quoted as critical to
wound healing.5 An absolute reliance cannot be placed on
these tests, as factors determining the ideal level of amputa-
tion in vascular patients are many and complex. Syme ampu-
tation should not be performed in the presence of ulceration
involving the heel pad, or when the viability of heel pad is
questionable. Although an insensate stump is generally con-
sidered a contraindication, Srinivasan reported good results
in twenty Syme amputations in patients with anesthetic
stumps.6 Gaine and McCreath also reported no problems in
three patients with neuropathic stumps in a review of forty-
six cases of Syme amputation.7
Technical Principles
There are several important principles that must be observed
during the procedure to achieve successful outcome. These
were emphasized in the initial report by Syme and later by
Harris.1,2 The posterior tibial artery must be preserved as it
provides the blood supply to the heel flap. It is at risk during
the division of medial ligaments and malleolar transaction.
The heel pad must be dissected subperiosteally from the cal-
caneum. This ensures that the septae that run from the plan-
tar aponeurosis to the periosteum of the calcaneum remain
intact. These tight compartments contain adipose tissue that
provides resilience and hydraulic resistance to the deforming
forces of weight bearing. If the loculi are opened, the fat is
extruded by pressure because they are no longer closed
spaces. Subperiostal dissection also protects the calcaneal
branches of the posterior tibial artery from injury. The heel
flap lined with periosteum adheres to the cut surface of tibia
more firmly and may allow new bone formation to ensure
firm fixation of the heel flap. The heel flap will contain the
origins of short muscles of the foot. Excessive debridement of
the heel flap should be avoided, as this can lead to damage to
the plantar aponeurosis. Overzealous trimming of the cor-
ners of the flap (“dog ears”) must be avoided, as it may com-
promise the viability of heel flap. The heel flap must be firmly
secured to the tibia.
The Syme amputation 75

Figure 1 The incision begins at the

distal tip of the lateral malleolus and
passes along the anterior aspect of the
ankle joint at a point one-finger
breadth inferior to the tip of the me-
dial malleolus. It is further extended
across the sole of the foot to the lat-
eral aspect, ending at the lateral start-
ing point.

The tibia must be divided just above the dome of the
articular surface to provide a wide area for optimal weight
bearing. The plane of the tibial osteotomy must be parallel to
the ground to prevent migration of the heel pad over the cut
surface of tibia.
Operative Technique
Single-Stage Syme Amputation
After appropriate preparation and isolation of any forefoot
infective process, the incision is placed as follows. It begins at
the distal tip of the lateral malleolus and passes along the
anterior aspect of the ankle joint at a point one-finger breadth
inferior to the tip of the medial malleolus. The incision is then
extended across the sole of the foot to the lateral aspect,
ending at the lateral starting point (Fig. 1). All the soft tissues
are transected down to the bone.
The foot is then plantar flexed. The tendons crossing the
ankle joint are sharply divided. Anterior tibial artery is ligated
and anterior capsule of the ankle joint is divided (Fig. 2). The
knife is then inserted into the joint space between the medial
malleolus and talus and the deltoid ligament is divided taking
care to avoid injury to posterior tibial artery. The clacaneo-
fibular ligament on the lateral aspect of the joint is sectioned
in a similar maneuver. A bone hook is placed on the posterior
surface of the talus and foot is further plantar flexed. The
posterior capsule of the ankle joint is then divided. This
brings the superior surface of calcaneus into view. Now be-
gins the painstaking subperiostal dissection of calcaneus. The
dissection is continued posteriorly along the superior surface
of the calcaneus (Fig. 3). Tendo-Achilles is identified at this
stage and divided. The skin in this area is densely adherent to
calcaneum and care must be taken to avoid buttonholing.
Using a periosteal elevator or several sharp knives, the soft
tissues are separated from the medial and lateral surfaces of
the calcaneum. The foot is plantar flexed even more and the
dissection is continued along the inferior surface of the cal-
caneus to the end of the plantar flap. The entire foot with the
exception of heel pad is then removed from the field. The
posterior tibial artery is identified at the distal end of the heel
pad and ligated.
The flap is retracted superiorly and the soft tissues are
separated from the distal ends of tibia and fibula. The peri-
osteum is divided one-half centimeter proximal to the joint
line so that the line of bone division is through the superior
most part of the articular surface of tibia (Fig. 4). This osteot-
omy should be performed so that the surface will be parallel
to the ground when the patient is standing. (The correct
plane may not necessarily be perpendicular to the long axis of
the tibia.) The sharp edges of the bone are rounded off. Only
minimal debridement of the soft tissues in the heel pad flap is
performed (see preceding section). The wound is irrigated
with antibiotic solution.
A variety of techniques are available to prevent heel pad
migration over the cut surface of the tibia. These include
taping the heel pad with adhesive tape, using a Kirshner wire
to transfix the heel pad to the bone, or drilling holes in the
anterior edge of tibia and fibula and suturing the plantar
fascia to the bone (Fig. 5). A suction drain is recommended
and can be brought out through a separate stab incision in the
distal third of the leg. The skin of the heel pad is then sutured
to the skin of the anterior flap using nonabsorbable sutures.
Redundant corners (“dog-ears”) are inevitable and should not
be sculpted or debrided. Finally, a padded rigid dressing is
applied to minimize swelling and to prevent heel pad slip-
page.
Two-Stage Syme Amputation
In the presence of gross infection of the forefoot in patients
who are not candidates for a more distal amputation and have
insufficient vascularity, a two-stage Syme amputation is pref-
erable. Wagner has demonstrated that, in a carefully selected
group of patients, successful healing can be achieved in
ninety-five percent of patients using this approach.3
The first stage consists of disarticulation at the ankle
joint. The incision is placed one cm distal to the incision
described for the one-stage procedure. No attempt is made
to resect the malleoli or the articular surface of the tibia.
76 S. Sajja

Figure 2 The soft tissues are transected down to the bone. Foot is then plantar flexed and the tendons crossing the ankle
joint are sharply divided.
The Syme amputation 77

Figure 3 Subperiosteal dissection of the calcaneus is the most pain staking part of the procedure. This is best performed
with a sharp knife.
78 S. Sajja

Figure 4 The periosteum is divided one-half centimeter proximal to the joint line so that the line of bone division is
through the superior most part of the articular surface of tibia. This osteotomy should be performed so that the cut
surface will be parallel to the ground when the patient is standing.
The Syme amputation 79

Figure 5 To prevent heel pad migration over the cut surface of the tibia, holes are drilled in the anterior edge of tibia and
fibula and plantar fascia is sutured to the bone. A suction drain is recommended and is brought out through a separate
stab incision in the distal third of the leg. The skin of the heel pad is then sutured to the skin of the anterior flap using
nonabsorbable sutures.
80 S. Sajja

Figure 6 Elliptical incisions are

made over each malleolus so as to
excise any redundant skin and the
underlying bone.

Figure 7 The malleoli are dissected

subperiosteally and resected flush
with the articular surface of tibia.
The Syme amputation
Small incisions may need to be made on the sides of the
heel pad to accommodate the malleoli. Suction irrigation
drains may be placed to irrigate the wound with antibiotic
solution in the postoperative period. The skin is loosely
reapproximated, and a soft compressive dressing applied.
A plaster cast can be utilized at the discretion of the sur-
geon once the signs of infection subside and the drains are
removed.
The second stage or definitive amputation is performed
after six to eight weeks. Elliptical incisions are made
over each malleolus so as to excise any redundancy (Fig.
6). The malleoli are dissected subperiosteally and resected
flush with the articular surface of tibia (Fig. 7). The me-
dial and lateral flares of the tibial metaphysis are re-
sected to decrease the bulk of the stump. Holes are
drilled in the malleoli, and the plantar aponeurosis is su-
tured to the bones. The skin is closed with nonabsorbable
sutures.
Post-Operative Care and
Prosthetic Considerations
A well-padded rigid dressing is applied in the operating room
to control excessive edema and to enhance the adherence of
the heel flap to the under surface of the tibia. Weight bearing
is delayed until wound healing is assured. As the postopera-
tive swelling decreases, the rigid dressing will need to refash-
ioned to ensure proper stump molding. When weight-bear-
81
ing ambulation is to be instituted, an ambulatory cast should
be constructed by an expert prosthetist.
Conclusion
This chapter has discussed the historical aspects of and indica-
tions for Syme amputation. Particular emphasis is placed on the
technical aspects of the one-stage and two-stage Syme amputa-
tion. The surgical principles essential for a successful outcome
are outlined. While the role of Syme amputation is well estab-
lished in congenital foot deformities and traumatic injuries of
the foot, with appropriate patient selection utilizing segmental
limb perfusion pressures and transcutaneous PO2 measure-
ments, satisfactory results can also be obtained in patients with
vascular insufficiency and diabetic foot infections.
References
1. Syme J: Amputation at the ankle joint. Lond Edinb Month J Med Sci
3:93-96, 1873
2. Harris RI: Syme’s amputation; technical details essential for success.
J Bone Joint Surg [Br] 38:614-632, 1956
3. Wagner FW Jr: Amputations of the foot and ankle: current status. Clin
Orthop 122:62-69, 1977
4. Saramiento A: A modified surgical-prosthetic approach to the Syme’s
amputation: a follow-up report. Clin Orthop 85:11-15, 1972
5. Burgess EM: Amputations. Surg Clin North Am 63:749-770, 1983
6. Srinivasan H: Syme’s amputation in insensitive feet: a review of twenty
cases. J Bone Jont Surg [Am] 55-A:558-562, 1973
7. Gaine WJ, McCreath SW: Syme’s amputation revisited: a review of 46
cases. J Bone Joint Surg [Br] 78-B:461-467, 1996