Re: Revision of Symes (fibular hemimelia) to a TT

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Posted By DeAnna Chapman on 3/8/2016 2:03:23 PM
Thank you to all who responded. Below are the responses received to my question regarding revision of a Symes amputation to a TT amputation.

DeAnna Chapman, MSPO, CPO, FAAOP

Revision of Symes (fibular hemimelia) to TT amputee Responses

Many considerations. The length being kept long is great for control but not for cosmetics and minimizes prosthetic foot selection due to the long RL length. If this child is predicted to be a tall adult the RL should be kept long for more control and perpetual weight bearing comfort of what will be a long lower adult limb. If a short adult go shorter a mid to short length will be ok I feel. I hope this helps. Call if you have any questions. I'm a Syme amputation at 17.

We have an 11 yo patient with a fibular hemimelia. He had a transtibial amputation done a few years ago, after failed leg lengthening procedures. He has a long residual limb and has enough clearance for a locking liner and a Rush foot. Although we are changing his suspension system, he has been successful with his long tt amputation.

Two patients I know of have had this done. Mid-length TT amputation that preserves the proximal epiphysis is standard. 8-10 cm seems to work nicely. Prosthetic concerns are rotation because you don't have the fibula and the fossa where the anterior tibial is nests. A good Myo-desis and rounded distal end help with cushioning and to stabilize the muscle groups.

I'm thinking this guy has probably tried many different prosthetists without success? Even with the distal pad pulled back and the bowing, I wouldn't be in a hurry to revise. Do the xrays show any reason for the distal pain?

We don't have any patients who have gone through all of that but we have some with bowed tibias. Consider a 4 inch bk with a fish mouth closure. I'm assuming the pt doesn't have enough calf to do a posterior flap with padding. You can make a silicone distal end pad for the bk for cushion. Make sure to outset the foot to compensate for the bowing.

I have had several patients go from a Symes to a Transtibial amputation. Although, none were fibular hemimelia patients. I always suggest that the surgeon does a standard length 20cm transtibial. That gives you the most options in feet and best length for lever arm and distribution of the weight. One thing to note that because he is a congenital his knee anatomy might not be normal as well. Make sure you evaluate the knee for any laxity as that might affect the varus/valgus moment at the knee in gait. I have a few patients like this, and we have to add higher trim lines and knee sleeves to maintain the knee in appropriate alignment for gait.

What about the possibility of reconstructive surgery to reposition the heel pad? They should also look into the techniques used to minimize the possibility of phantom pain post amputation. Individuals with chronic pain prior to amputation are at greater risk for chronic phantom pain post-amputation.

Yes. Consideration: The tibial kyphosis can be straightened by wedge resection osteotomy: length - as long as possible if function is primary goal; higher if suspension (pin?), and foot/ankle function is primary goal. I suggest referring to a surgeon with considerable experience in amputation/reconstruction: Dr. Jan Ertl in Indianapolis @ U-I, or Dr. William Ertl at U-O in Oklahoma. Both have vast experience in this area.

It could be a nice limb if they cut off enough tibia that they could subsequently pull the heel pad back under the distal end. And they need to do wedge osteotomy to straighten tibia. Just curious, how tall is he? That will impact how much to amputate, if there is a longer shank because he is tall then consider ~9" from the floor to have room for vertical shock feet (L5987), but I wouldn't do that at sacrifice of residual limb length being less than 50% of his sound side (at least).

I saw a female bilateral congenital Symes for 26 years and I am still her prosthetist. On the advice of a surgeon she elected to have a revision surgery on her left residual limb. The distal end of the fibular shaft was migrating back in a posterior direction a short distance but was causing no pain or fitting issues. The surgery and healing did not go was planned and she now has a painful stump. This has reduced her level of activity and her weight gain is compounding her problems along with opiate dependence.

A second case is a very active young man in high school, star athlete and scholar. He had a revision of his PFFP limb in an attempt to "look" more normal to the female gender.

(Femoral length of 3" with normal length tibia with a Symes amputation of his foot when he was an infant) The surgery left a stump with no padding whatsoever on the cut end of the tibial shaft and although it looked more normal he activity level fell off dramatically. No more star football jock.

Last story. Very pretty female 35 yo with a focal issue of the tibia/fibula.

She had worn a 5" lift under her shoe all of her life and was fed up with living that way. I advised her to have an elective surgery to revise her leg to a BK level suitable to have modern feet of that day (1988) used. Huge success story! Very happy lady.

Even with the best intentions and competent surgeon you can never totally assure your patient of a successful outcome. If your patient has a problematic residual limb I would opt for a revision surgery. Not too much to lose. Good luck.

Would not recommend revision to TTA.
1. tibia bowing can be straightened out
2. this happened due to heel pad not being secured in original surgery
3. heel pad can be corrected by securing to distal tibia and return distal weight bearing to the limb
4. if revised to traditional BKA they will have many more problems, especially if it is a "standard BKA"

From: DeAnna Chapman
Sent: Wednesday, March 02, 2016 8:31 AM
To: [Email Address Removed]
Subject: Revision of Symes (fibular hemimelia) to a TT

I have a 22 y/o male patient who has fibular hemimelia and has had a symes amputation since he was 6 months old. He is a new patient who presented for a consultation after speaking with his surgeon about having a revision surgery to amputate the distal end of his tibia to result in a transtibial amputation. He has had chronic distal end pain, wounds and the heel fat pad has migrated posteriorly resulting in a very bony distal end. His tibia has anterior bowing that often happens with fibular hemimelia, so the physician and patient are questioning at what level to amputate.

Has anyone had a patient go through a revision surgery from a symes to a transtibial level? Specifically one with fibular hemimelia? If so, at what level did they amputate the tibia? What concerns does this patient and surgeon need to be aware of?

Thank you in advance,
DeAnna Chapman, CPO, LPO, FAAOP
Gainesville Prosthetics