Syme Amputation

Syme amputation is used for the surgical treatment of congenital femoral dysplasia. Congenital femoral hypoplasia, currently referred to as proximal femoral focal deficiency (PFFD). The incidence rate is 1 in 50,000 for live babies. Focal proximal defects of the femur include a wide range of defects, mild manifestations of mild femoral dysplasia, and severe cases of complete femoral dysplasia. The most common PFFD manifested as a partial skeletal defect in the proximal femur, instability of the hip joint, short-term deformity of the limb, and abnormalities in other parts. Most PFFD patients, especially those with bilateral lesions, are associated with malformations, such as humeral extremity deformity and knee cruciate ligament hypoplasia, congenital clubfoot, congenital heart abnormalities, congenital spinal dysplasia, and facial development. bad. The classification of focal defects in the proximal femur is as follows: The Aitken four-class classification (A, B, C, D) is one of the earliest classification methods: Type A: normal femoral head and acetabulum, short femoral deformity, early X-ray film showing lack of femoral neck. With the increase of age, the cartilage femoral neck may be ossified and self-healing, and pseudo-joints may also be formed. X-ray films showed severe hip varus and significant limb shortening. Type B: Similar to type A, the acetabulum and femoral head are present, there is no bone connection between the proximal femur and the femoral head, and the pseudo joint is formed. Type C: acetabular dysplasia, lack of femoral head, and femoral shortening deformity. There is a plexiform cap on the proximal femur. Type D: Absence of the acetabulum, femoral head, and proximal femur. There is no plexiform cap on the proximal femur. Pappas (1983) nine-level classification, according to its severity, from complete proximal femoral loss (grade I) to mild femoral dysplasia (level IX), in order of classification, Pappas II is equivalent to Aitken D Type; Pappas III is equivalent to Aitken B; Pappas IV and V are equivalent to Aitken A. Kalamchi's simplified five-category classification: Type I: femoral shortening deformity, hip joint integrity; type II: femoral shortening malformation, hip varus deformity; type III: femoral shortening malformation, acetabular and femoral head well developed; type IV: hip absent, femur Segmental dysplasia; V: the entire femur is completely absent. Treatment should be highly individualized, and alternative treatment options range from amputation and prosthetic to limb salvage surgery, limb extension and hip reconstruction. The stability of the hip is critical to the choice of treatment. For patients with both the acetabulum and the femoral head (Aitken Type A and Type B), the purpose of the procedure is to restore continuity between the femoral head and the femur. If the proximal end of the femur is small, it is advisable to postpone the operation to the femoral head and the proximal metaphysis. In some patients, the femur is too short, and it is necessary to do the knee joint fusion in one stage, and the lower limbs of the single bone are produced. The bones that can be fixed at the proximal end of the femur during surgery should be implanted at the pseudo joint. For severe deformities without femoral head or acetabulum (Aitken C and D or Pappas II and III), most scholars recommend not attempting hip reconstruction. King recommends patellofemoral fusion and Chiari Osteotomy to create a bone bed that can accommodate the femoral stump, allowing the knee joint to function as a hip joint. Steel et al believe that untreated Aitken type C or D malformation will have progressive instability and proximal femoral displacement. Femoral closed osteotomy and tibiofemoral fusion should be performed to eliminate the forward arch. deformity. An extension of the affected limb or a contralateral limb shortening is a prerequisite for the completion of the affected femur, the stability of the hip, and the stability of the ankle. Gillespie and Torode considered limb lengthening when the length of the affected femur was at least 60% of the normal side. Ilizarov extension uses an annular external fixator that extends proximally or distally to prevent knee or hip subluxation. For patients with unequal length >12cm, prolongation can be performed in stages: the first-stage operation is 4 years old or 5 years old, the second stage operation is 8 years old or 9 years old, and the third stage operation is in adolescence. According to the predicted length of the lower limbs of the normal side of the sick child, it is decided whether to perform the contralateral epiphyseal block operation. If it is not appropriate to choose limb lengthening, foot amputation is feasible. Severe PFFD, if limb lengthening is not appropriate, knee joint fusion and foot amputation combined surgery can be used. Postoperative prosthesis can help maintain the length of the lower limbs and rehabilitation function. Foot amputation should be performed between 1 and 2 years of age, otherwise parents and sick children may be psychologically difficult to accept this treatment. Foot amputations include ankle dissection, Sam's amputation, and Boyd amputation. Syme and Boyd surgery keeps the heel stable, so it is superior to simple ankle dissection and is the two common amputations commonly used in reconstructive surgery. Sam's amputation is an improved ankle joint dissection. The Boyd procedure removes all foot bones except the calcaneus and fuses with the distal radius. Treatment of diseases: femoral skull and tibial rickets Indication Syme amputation applies to: 1. Congenital femoral dysplasia, age 1 to 2 years old. 2. The affected femur is intact and the hip joint is stable. 3. Limb shortening deformity is serious, it is not appropriate to choose limb lengthening. Contraindications 1. The affected femur is incomplete and the hip joint is unstable. 2. Limb shortening deformity, should choose limb lengthening surgery. Preoperative preparation Regular preoperative preparation. Equipped with blood 200 ~ 400ml. Surgical procedure 1. Incision and exposure Make a fish-mouth incision, starting from the external iliac crest, over the back of the foot, stop at 1 cm from the inner iliac crest, and cut the subcutaneous tissue of the skin. The flap of the plantar portion should be of sufficient length to allow the skin incision to be sutured to the instep. The foot is fully deformed and has a horseshoe shape, which is convenient for revealing and cutting the front ankle joint capsule. Then, cut the ligament between the talus and the medial malleolus, but do not damage the blood vessels in the posterior part of the tibia. Cut off the lateral Achilles tendon. 2. Resection of the calcaneus and ankle joint The talus is clamped with a towel clamp and forcefully made into a horseshoe-foot shape to facilitate cutting the posterior portion of the ankle joint capsule, and the posterior side of the calcaneus is exposed through the subperiosteum of the ankle joint. The Achilles tendon was cut at the attachment of the calcaneus, and the heel was further pulled and flexed into a horseshoe foot. The soft tissue was removed and the entire calcaneus was removed and the ankle joint was broken. 3. Fixed heel pad Drill a hole in front of the distal end of the humerus and suture it to the aponeurosis at the distal end of the humerus with a thick wire from the distal side of the calcaneus pad. However, if there is a wider bearing surface for the extremity of the amputated limb, the distal cartilage should not be removed. The flexor tendon is pulled distally and then transversely cut and allowed to retract. Ligation of the anterior and posterior tibial arteries. 4. Close the incision A drainage tube is placed in the wound, and a full-thickness suture is used to close the skin incision. complication 1. Vascular injury in the posterior tibia. 2. Avascular necrosis of the flap. 3. The calcaneus pad is damaged.

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