The Syme's amputation provides an end-bearing stump that in many circumstances allows ambulation without a prosthesis over short distances. It is an excellent amputation for children, in whom it preserves the physes at the distal end of the tibia and fibula (26). The Syme's amputation works well for tumors and trauma, assuming that the heel flap has been spared from the trauma. In the past, it has had a high failure rate in ischemic limbs because of failure of wound healing. Today, the success of amputation at this level has increased because local tissue perfusion is preoperatively determined with Doppler ultrasound measurement of blood pressures, with radioactive 133 Xe clearance tests, and with transcutaneous measurement of oxygenation.
The Boyd procedure provides a broad weight-bearing surface of the heel by creating an arthrodesis between the distal tibia and the tuber of the calcaneus
Compared to a Syme's amputation, it provides more length and better preserves the weight-bearing function of the heel pad. Its increased complexity and morbidity have made it less used now than the Syme's amputation.
The Pirogoff amputation removes the anterior two thirds of the calcaneus but has no advantage over the Boyd amputation,
Amputation through the knee offers numerous advantages. The main advantage is the creation of an endbearing stump and preservation of the distal femoral physes, which is particularly desirable in children. Another advantage is the maintenance of a long active lever arm for control of the prosthesis, with excellent muscle attachments. The bulbous distal stump enhances suspension of the prosthesis.
In elderly dysvascular patients, the longer stump helps prevent hip flexion contractures and it provides better balance for wheelchair activities. Knee disarticulation is most useful in young athletic amputees in whom a below-knee amputation is not feasible.
Involvement of the multidisciplinary team is essential: physio for mobility, provision of stump board for wheelchair OT for home assessment and safety issues, social work, benefits, motability car, district nurse for wound checks and/or control of diabetes.
Two weeks after surgery, muscle-contraction exercises and progressive desensitization of the residual extremity are initiated.
Desensitization is started with a towel for distal residual extremity pressure, and distal-end bearing is started on a soft structure (usually a bed).
Prosthetic management is begun 6 weeks after surgery, depending on the condition of the extremity and wound. Some patients are not candidates for prosthetic limb replacement because of poor balance, weakness, or cognitive impairment. To avoid disappointment and expense, a permanent prosthesis should not be ordered for these patients.
. If a digit is hanging on by a small “bridge” of skin or muscle, attempt to bandage it without completing the separation. If the body part can be easily recovered and the victim can be brought to a hospital within 6 hours of the injury, do the following: 1. Gently rinse the body part if the cut end is contaminated with dirt. 2. Wrap the body part in clean cloth or gauze and keep the covering moist. The ideal solution is saline (not ocean water, because of infection risk), if that is available; if not, fresh water will do. Do not immerse the part in a bag of water; merely keep the covering moist. Keep the body part cool by placing it on ice after wrapping it securely in a bandage, cloth, or towel. To avoid a frostbite injury, do not apply ice directly to the body part or immerse it in ice water. 3. Bring the body part with the victim to the hospital.