Note 11 — Chapter V

In England, of course, this is always called Syme's amputation. It constitutes the type par excellence of the end-bearing stump. Upon a good Syme stump a patient may be able to walk ten miles without an artificial foot, wearing simply an "elephant boot." Amputations above the Syme level are not end bearing, however long the stump may be. The other amputations in this region seen in English war surgery are the various types of osteoplastic amputations in which a part of the os calcis is retained (Pirogoff's amputation, etc.). These have the following defects:—

(1) There is often sepsis between the tibia and the os calcis, necessitating re-amputation. Osteoplastic amputations are unsuitable for septic surgery.

(2) Ankylosis between the os calcis and the tibia is often imperfect so that the bulbous end of the stump is unstable.

(3) The stump is too long to allow of the fixation of a good artificial ankle joint beneath it. A Syme's amputation leaves two to two and a half inches clearance between it and the ground.

I have not yet seen a sub-astragaloid amputation in war surgery, and only once a disarticulation through the ankle joint, the latter could not bear pressure and it was necessary to convert it into a Syme's amputation. In fact, in this region there is Syme's amputation and a number of other far inferior amputations which should never be considered when a Syme's amputation is possible. (Ed.)