Syme ankle disarticulation in peripheral vascular disease and diabetic foot infection: the one-stage versus two-stage procedure.

A prospective randomized trial compared performing a Syme ankle disarticulation using a one-stage versus Wagner's two-stage technique. Surgery was performed at two University Medical Centers where patients underwent amputation surgery for gangrene or nonsalvageable diabetic foot infection. Those undergoing surgery subsequent to trauma or congenital anomaly were eliminated. Initially, 21 patients were randomized into one-stage and two-stage surgery. The randomization was stopped for ethical reasons when the results of both procedures appeared to be similar. The next 22 consecutive patients underwent 23 Syme ankle disarticulations in one-stage surgery. Selection of amputation level was based on clinical examination, transcutaneous oximetry as a measure of vascular inflow, serum albumin as a measure of tissue nutrition, and total lymphocyte count as a measure of immunocompetence. As a total group, 31 of 44 amputations progressed to amputation wound healing and prosthetic limb fitting. In the randomized group, 9 of 13 one-stage and 5 of 8 two-stage surgeries healed. In the subsequent consecutive group, 17 of 23 healed. In all, 26 of 36 one-stage and 5 of 8 two-stage surgeries healed successfully. We concluded from this study that Syme ankle disarticulation may be performed as safely in one stage as in two stages in properly selected patients and, therefore, recommend the one-stage Syme ankle disarticulation in those patients suitable for this level amputation.