The impact of Syme amputation in surgical treatment of patients with diabetic foot syndrome and Charcot-neuro-osteoarthropathy

Abstract

The crucial diagnostic tool for decision-making in diabetic foot syndrome was MRI, which normally shows osteomyelitis with high sensitivity and specificity. In patients with Charcot-neuro-osteoarthropathy, the bone marrow oedema of the involved parts of the skeleton might misleadingly suggest the diagnosis of osteomyelitis. If amputation is inevitable in severe abscess formation combined with instability and perforation of the dislocated and destroyed bones in Charcot-neuro-osteoarthropathy, these patients might benefit from a foot amputation according to the technique Syme described. For this procedure the blood supply of the posterior tibial artery is essential. All these patients were able to walk without support. The material presented helps to generate hypotheses for further prospective studies.

Charcot Foot in Diabetes: Farewell to the Neurotrophic Theory

“…However, the clinical characteristics of the patients were barely considered, as "complete clinical history and physical examina− tion were not available in many cases" and "11 % had neither pathological proof nor known neurological disease". Neither the clinical course of their patients nor the grading scheme by Eichenholtz [9] were accounted for in the interpretation of the findings [28]. Nevertheless, Brower's and Allman's claim that "all joint changes could be explained by a vascular mechanism" [28] was echoed many times.…”

“…At the toe pulp, skin blood flow response to local heating is re− duced [18]. Clinically, the foot shows the typical signs of acute in− flammation with oedema, hyperthermia, and hyperaemia [9]. The posttraumatic inflammatory reaction sustained and en− hanced by ongoing trauma of weight bearing is accompanied by swelling in the foot that may reach enormous size.…”

“…Transcutaneous oxygen tension is reduced [17]. At the toe pulp, skin blood flow response to local heating is re− duced [18].Clinically, the foot shows less inflammation, oedema, hyperthermia, and hyperaemia than in the previous Eichenholtz stage [9].…”

“…The stage of a healed osteoneuroarthropathy in a foot is de− scribed by Eichenholtz stage III, the stage of bone reconstruction and remodelling, with rounding and smoothing of major bone fragments, reduction of sclerosis, incomplete joint architecture reformation, osseous and fibrous ankylosis. Clinically, the foot shows permanent enlargement and stiffness of affected joints, fixed deformity, but without erythema, hyperthermia, or hyper− aemia [9]. Bone mineral density is no longer decreased, and BSAP, DPD cross−links, and 1CTP [10 ± 12] are no longer in− creased.…”

Boyd Amputation in Adults

“…Although lower extremity arterial disease can be identified noninvasively with the use of doppler technology before clinical manifestation, it has been the consensus that these measurements are unreliable in diabetics due to stiffening of the arteries resulting in falsely high ankle-brachial index values. 7 Doppler flow studies and ankle-brachial index measurements were used in our patients as a diagnostic tool to help to detect the presence of vascular insufficiency that might lead to foot ulceration and gangrene. The level of success could only be reproduced when patients had a sufficient level of tissue nutrition, as evidenced by a threshold serum albumin level of 2.5 g/dl and immunocompetence as measured by a threshold total lymphocyte count of 1,500.…”