Introduction
Originally described in 1843 by James Syme, Professor of Surgery in Edinburgh, Syme amputation continues to generate controversy and debate regarding its role in traumatic 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 vascular disease and diabetic foot infections. Wagner popularized a two-stage technique for use in diabetic patients with an infected or gangrenous foot lesion.3 Sarmiento, in 1972, introduced 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 acceptable prosthesis can be fitted