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Rex L. Diveley and Richard H. Kiene
J Bone Joint Surg Am. 1956;38:219-221.

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Publisher Information          The Journal of Bone and Joint Surgery
                               20 Pickering Street, Needham, MA 02492-3157
                           AX               IMPROVED                                         PROSTHESIS                                               FOR                 A
                                                                                                                                                                        SYME                       AMPUTATION

              BY         REX               L.        DIVELEY,            M.D.,                   AND               RICHARD            H.          KIENE,                  M.D.,                KANSAS             CITY,               MISSOURI

                                                                         Front               the        Dickson-Dii’eley                              Clinic, Kansas                        City

           A        Syme                   amput.atioms,                            which                    is     the            most               conservative                below-the-kmiee                           amputation                                and
which               provides                           the         best             functioning                                    stump                     for           w-eight-bearing, has                      been               rarely                  recom-
mended                     for       women,                        because                     the    unsightly                               prosthesis                                 is objectionable.
          Some                    time    ago                     it was                    necessary          to                          amputate                             the         foot     of a female                                     patient,                       twenty-
two           years               old.               After          a         conference                                with          the              young                      woman,                    it      was           decided                      that             the        many
merits    of a Syme                                      amputation                          far                   outweighed                          the                objection     of the    unattractive                                                      prosthesis,
and    an amputation                                         of the                      Syme                      type    was                    carried                   out.    A very    good      stump                                                   was    obtained,
and     it was   fitted     with      the      conventional        prosthesis.         Although         the  artificial       limb
                                                                                                                                most     was
serviceable,       it was      indeed         unsightly       amid our      patient       was unhappy.
                                                                                       very                    The      problem          of
finding      a more     pleasing          prosthesis        was   discussed         with     our   limb     maker       and,       after     several
attempts,                         a        very              mseat,           light,               atsd              fumictiomial                           pm’osthesis                          was          comistructed                           from               laminated
plastic     material                                     reimiforced        with     glass   cloth.                                                               After       the     first                              lamination                         or          moldimig,                       a
window      was cut                                  out     of the   back      of the prosthesis                                                                  sufficiemitly         large                              to allow                     the          stump       to
slip   completely                                     imito the      socket.       Following        the                                                           last     laminatiomi,                                   the     opemi                  area           was    closed
with           a      leather                     lacer.
           Although                             the          stump                  had                the           usual                 bulbous                        emid,            it       was       possible      to make     the                                               bulge
less       apparent                             by       the        proper                    build-up                         of         the         shims                     the
                                                                                                                                                                         portiomi                  prosthesis
                                                                                                                                                                                                   of                  amid by thinning
the        plastic                    material               in   the           region                   of         the           malleoli                        during                   the          lamimiatimig                        process.

                                                                                             DETAIL                          OF       PREPARATION

           A plaster-of-Paris                                     mold              of       the             stump                  is made                       extetidimig                      to     the            knee          aisd          closed                 distally.
From                this              mold              ami exact                      model                       of        the           stump                        made
                                                                                                                                                                    is in the                       usual                way           with              the            usual
vented                   tube              incorporated                                to         serve                 as     a hamsdle                           at         the          upper                 etsd.          The           latidmarks                            amid         the
plumb-line                            are            redrawis                    oti         the              model                  with                  ati          indelible                      pemscil.             Additiomsal                          plaster                  cream
is     used         to       accentuate                            horsy               prominemices                                 amid sensitive                                  areas.               The             model               is thems             thoroughly
dried            at 140                    degrees   Fahremsheit                                             amid            coated                   with               a plastic                      parting                 agemit              to      keep              the         mold
from            adherimig                     to the  model.
           Two                   layers                 of        stockinet                            are              drawmi                  tightly                       over               the          model                   and           carefully                         stitched
about               the            distal               emid;           next,                glass                 cloth             is         added                    as       reinforcememit                                in      the             upper                and          lower
thirds.                  Three                   more             layers                    of         stockitset                         are          t.hemi              drawn                    tightly                over               the         model                  and             tied
about               the           handle.
           A        polyvinyl                           alcohol                  sheet                 is         formed                   imito            a      bag              over               a template                       its       the           usual               maImer.
The           bag            is then                   stretched                       over                 the          model                  amsd the                      proximal                      end           is tied                 tightly               aroummd                  the
handle.                 Plastic                        resimm is poured                                       immto the                         opemm end                           of         the        polyvimsyl                         alcohol                    bag        amid is
forced                imito the                       layers    of stockimiet                                     as the                         cotie-sha.ped                                 bag         is pulled                        proximally                          over   the
model.                   The               forcing                 of         the            resims                imito            the           stockimiet                          is         facilitated                      by          massaging                             the          bag
toward                     its         proximal                         emsd.            All            wrimmkles                         are          pressed                           out           amsd         all         air          is     forced                    out          of      the
stockinet.                        Mixed                     styretie                polyester                            resins                 are          used              its the                 proportioms                      of        omw-half                    rigid             amid
one-half                     flexible.
           The               polyvimmyl                        alcohol                   bag             is         themi           tied        tightly                             over           the    distal        emid of the                                      mold,               and
curing                is      effected                       at 130                 to            140              degrees                  Fahrenheit                                 for          about        thirty      minutes.                                      After                the
resin              has           jelled,                 the           final             cure                 is        effected                      at          250             degrees                  Fahrenheit                              for          approximately
thirty         minutes.
           The    top                       of        the         mold              is trimmed                                 and              the              plaster                  model               is removed                            while               the           mold              is

von.      38-A,            NO.        1,    JANUARY                    1956                                                                                                                                                                                           219

                                                                                                                                                                                         Fig.               1 Photograph
                                                                                                                                                                                                            .                                        of          the
                                                                                                                                                                                 front                V1(”V      of the                plastic                 Synse
                                                                                                                                                                                 ljrosthi(’sis                    vithsout                 a shoe.
                                                                                                                                                                                        Fig.  2.      This VI(’W         illustrates
                                                                                                                                                                                 tls(’ leather          lacer      amid the          (‘avit.v
                                                                                                                                                                                 requir(’d          to      a(s’onsnl(I(lat(’               t hi’
                                                                                                                                                                                 llulbous        stUnk1).
                                                                                                                                                                                     Fig.             3. The sizs                     of    the      leather
                                                                                                                                                                                 lacs’r              msi:t’ lIe 55(15                       ims    this        side
                                                                                                                                                                                         1”ig.  4.     \\‘hiems        the     prosthesis
                                                                                                                                                                                 is        \‘oIIs1)\’ the         pati(’nt,        it ma’
                                                                                                                                                                                 be seen           Isow      su(’c(’ssful        has      been
                                                                                                                                                                                 the     attempt              to make            the      pros-
                                                                                                                                                                                 thsesis     follov        the       (‘otstour       of the
                                                                                                                                                                                 msormal         leg.

                                                                                                                                                                                         Fig.   5. The           al)llearanc(’               of
                                                                                                                                                                                 this     prosthi(’sis          whets        the      l)atiemit
                                                                                                                                                                                 is fitlly       dressed.           This        prosthesis
                                                                                                                                                                                 has      beers        fulls’     accepted              by      the
                                                                                                                                                                                 patient,           ami(l     its her           opitsions           it
                                                                                                                                                                                 Is much           simperior           to any           of the
                                                                                                                                                                                 conventiomsal                          t\’p(’s            of     prosthesis
                                                                                                                                                                                 US((l              pr(viously.

stillwarm.                        This                mold             is     the          trial              socket.                    It       vill          be        attached                               to         a     foot              port.ioms                 and            after
adjustmemsts                           vilI       serve                as     a mold                       for         the           fitsal         complete                            prosthesis.
           A      foot           of      time         propel’               size          is        selected,                      givitsg               comssideratiomi                                    to        the         heel              height.                   A      set-up
for       lemsgth              atsd           aligmmmemst                   is made i)y                    settitig                the          tm’ial         socket.                 oti          the           foot            amid             temporarily
secimrimsg               it      with            steel           bamids                from                 the          foot              to       time         suits                by         small                  screws.                     The               i)ack          side            of
tise       socket                 is      cut           out            sufficietitly           to         allow              the         stump                  to      inserted.
                                                                                                                                                                          i)e                                         The      t.m’ial socket     is
mso\\-         fitted             to           time      stump                     arid              a(ijustnlemsts                              ate            made that
                                                                                                                                                                so             it                       is            comfortable           durimmg
standitsg,                     valkimmg,               amid        sitting.         \Vhems                 the        socket              vitlm          its         attacised                        foot              is emitim’ely                     comfort-
ai)le,          time          screws             are          replaced                     vitli             m’ivets                amid          the          imtsit           is       ready                   final the Iamimmatiomm.
           The            foot.           is      trimmed                       umstil               it       is       umidersize,                        amid           the                outer                     surfaces                      of         time       foot              amid
socket              am’e roughened                              with               a fitie                rasp          or         sandpaper.                            To            ol)taims                  the            most               pleasitig                   cosmetic
effect           possible,                      the          spaces                from               foot.             to         shims          are          filled                 with              a        compatible                               resimm              amid         filler.
It       is cured                amid          samided.         rfhe         socket                   is      tmov            coated                inside               with                   a plastic                         parting                       agent                and

                                                                                                                                                    THE              JOURNAL                     OF         BONE                AND         JOINT              SURGERY
                                                         IMPROVED                  PROSTHESIS                       FOR             A         SYME           AMPUTATION                                                              221

a        secotid             model          of     plaster-of-Paris                    is poured                       into             it,        a vented                    tube          having                 i)eets            installed
aisd          all      opemmimigs                 havimig       beets              sealed.
             For        the          second               lamination,                      two          layers              of stockinet                           of appropriate                            size          are         pulled           o’ct’
time toe       portion,                            up      over      the               bands      on the     shimm, and     stretched          tightly                                                        but     not   tied.  Glass
cloth     reinforcement                                    is wrapped                      about     the    wood      of the      foot     and      over                                                      the    top    of the   cots-
miectimig     bands.                          Three            additional                    layers      of stockinet         are      pulled        into                                                      place      so that     the
first          layer           extemids                   from   the     toes                    to imsches
                                                                                                        two                   above          the            glass            cloth            which                imieludes       the
top           of the            hands.                   It is stretched                          tightly;                  the         seconsd              atsd           third            layers               are    stretched                       from
the          toes        to      the             top       of     the          socket            amid      tied             around                   the         vetmted              tube            with             limmen thread.
             The        same               techtiique                   amid      the       same           resins                 are         used          in      this         lamination                       as       in        the    first        one,
except                that           the         resin          mixture                 should            be      70         per         cent              rigid           and          30      per          cent               flexible             styremme
polyester                     resins.             The           mold            is oven-cured,                              amid        the   top                  and         back      openimigs    are    trimmed                                         to
the     original                   size           while          warm.             All cut edges                             are        smoothed                         and      sealed      so that     moisture                                       can-
not   penetrate                             the   cotton                  fiber.     Excess                      plasticized                          stockinet                is cut                from              the           foot       which           is
sammdpapered,                             the   edges                 being      feathered                        so that                     no       ridges              remain.
     A leather                              lacer      is attached         over    the  back       opening.                                                           The             foot       is     covered                       in    the        usual
mammner   and                        the        prosthesis         is ready     for final    fitting       and                                                       use.


              With            this          prosthesis                  it is possible                    to      overcome                           the      major              objection                   to        a Syme               amputa-
tiomm imm womemm                             patients                   and        to      offer          them                the             mammy              advammtages                    of      the             weight-bearing,
below--the-kmiee                                 amputation                       of      the      Syme             type.


    1.    STAFF         OF      ARTIFICIAL                   LIMBS             PROJECT,            Department          of     Engineering,                   University                 of    California.                    Manual             of
          Upper          Extremity                     Prosthetics.               Edited           by      R.      Deane                Aylesworth.                     Los
                                                                                                                                                                   Angeles,             University           of        California,

VOL.          38-A,      NO.         1,    JANUARY               1956

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