Harris MI, Cowie CC, Stern MP, et al (eds): Diabetes in America, 2nd Ed, National Institutes of Health (DHHS Publication 95-1468), Washington, DC, 1995..
Harris MI, Hadden WC, Knowler WC, et al: Prevalence of diabetes and impaired glucose tolerance and plasma glucose levels in US population aged 20-74 yrs. .Diabetes 36::523. ,1987. .
McNeely MJ, Boyko EJ, Ahroni JH, et al: The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration: how great are the risks. ?Diabetes Care 18::216. ,1995. .
Tan JS, Friedman NM, Hazelton-Miller C, et al: Can aggressive treatment of diabetic foot infections reduce the need for above-ankle amputation. ?Clin Infect Dis 23::286. ,1996. .
Grayson ML: Diabetic foot infections: antimicrobial therapy. .Infect Dis Clin North Am 9::143. ,1995. .
Hirschmann JV: “Localized Infections and Abscesses,” in Harrison’s Principles of Internal Medicine, 13th Ed, ed by K Isselbacher, E Braunwald, J Wilson, et al, p 563, McGraw-Hill, New York, 1994..
Lavery LA, Ashry HR, van Houtum W, et al: Variation in the incidence and proportion of diabetes-related amputations in minorities. .Diabetes Care 19::48. ,1996. .
Samos LF, Roos BA: Diabetes mellitus in older persons. .Med Clin North Am 82::791. ,1998. .
Chang BB, Jacobs RL, Darling RC III, et al: Foot amputations. .Surg Clin North Am 75::773. ,1995. .
Pinzur MS, Graham G, Osterman H: Psychological testing in amputation rehabilitation. .Clin Orthop 229::236. ,1986. .
Pinzur MS: Amputation level selection in the diabetic foot. .Clin Orthop 296::68. ,1993. .
Peters A, Kerner W: Perioperative management of the diabetic patient. .Exp Clin Endocrinol Diabetes 103::213. ,1995. .
Wagner FW: “The Diabetic Foot and Amputation of the Foot,” in Surgery of the Foot, 5th Ed, ed by RA Mann, CV Mosby, St Louis, 1986..
Pinzur MS, Sage R, Stuck R, et al: Transcutaneous oxygen as a predictor of wound healing in amputations of the foot and ankle. .Foot Ankle 13::271. ,1992. .
Pinzur MS, Kaminsky M, Sage R, et al: Amputations at the middle level of the foot. .J Bone Joint Surg Am 68::1061. ,1986. .
McCollough NC: “Principles of Amputation Surgery in Vascular Disease,” in Surgery of the Musculoskeletal System, Vol 4, ed by CM Evarts, p 25, Churchill Livingstone, New York, 1983..
Heard GS, Oloff LM, Wolfe DA, et al: PMMA bead versus parenteral treatment of Staphylococcus aureus osteomyelitis. .JAPMA 87::153. ,1997. .
Isakov E, Budoragin N, Shenhav S, et al: Anatomic sites of foot lesions resulting in amputation among diabetics and non-diabetics. .Am J Phys Med Rehabil 74::130. ,1995. .
Yeager RA, Moneta GL, Edwards JM, et al: Predictors of outcome of forefoot surgery for ulceration and gangrene. .Am J Surg 175::388. ,1998. .
Lavery LA, Lavery DC, Quebedeaux-Farnham TL: Increased foot pressures after great toe amputation in diabetes. .Diabetes Care 18::1460. ,1995. .
Quebedeaux TL, Lavery LA, Lavery DC: The development of foot deformities and ulcers after great toe amputation in diabetes. .Diabetes Care 19::165. ,1996. .
Seligman RS, Trepal MJ, Giorgini RJ: Hallux valgus secondary to amputation of the second toe: a case report. .JAPMA 76::89. ,1986. .
Gianfortune P, Pulla RJ, Sage R: Ray resections in the insensitive or dysvascular foot: a critical review. .J Foot Surg 24::103. ,1985. .
Volpicelli LJ, Chambers RB, Wagner FW Jr: Ambulation levels of bilateral lower-extremity amputees: analysis of one hundred and three cases. .J Bone Joint Surg Am 65::599. ,1983. .
Mueller MJ, Allen BT, Sinacore DR: Incidence of skin breakdown and higher amputation after transmetatarsal amputation: implications for rehabilitation. .Arch Phys Med Rehabil 76::50. ,1995. .
Sanders LJ: Transmetatarsal and midfoot amputations. .Clin Podiatr Med Surg 14::741. ,1997. .
Mueller MJ, Strube MJ: Therapeutic footwear: enhanced function in people with diabetes and transmetatarsal amputation. .Arch Phys Med Rehabil 78::952. ,1997. .
Hosch J, Quiroga C, Bosma J, et al: Outcomes of transmetatarsal amputations in patients with diabetes mellitus. .J Foot Ankle Surg 36::430. ,1997. .
Pinzur M, Kaminsky M, Sage R, et al: Amputations at the middle level of the foot. .J Bone Joint Surg Am 68::1061. ,1986. .
Wagner FW Jr: Amputations of the foot and ankle. .Clin Orthop 122::62. ,1977. .
Sage R, Pinzur MS, Cronin R, et al: Complications following midfoot amputation in neuropathic and dysvascular feet. .JAPMA 79::277. ,1989. .
Syme J: Amputation at the ankle joint. .Monthly J Med Sci 2::93. ,1843. .
Stuck RM: Syme’s ankle disarticulation: the transmalleolar amputation. .Clin Podiatr Med Surg 14::763. ,1997. .
Wagner FW Jr, Brodie I, Mooney V, et al: Syme’s amputation done in two stages. .J Bone Joint Surg Am 55::1770. ,1973. .
Francis H, Robert JR, Clagett P, et al: The Syme amputation: success in elderly diabetic patients with palpable ankle pulses. .J Vasc Surg 12::237. ,1990. .
Laughlin RT, Chambers RB: Syme amputation in patients with severe diabetes mellitus. .Foot Ankle 14::65. ,1993. .
Spittler AW, Brenner JJ, Payne JW: Syme amputation performed in two stages. .J Bone Joint Surg Am 36::37. ,1954. .
Stuyck J, Vandenberk P, Reynders P: Syme’s amputation. .Acta Orthop Belg 56::535. ,1990. .
Harris RI: Syme amputation: the technical details essential for success. .J Bone Joint Surg Br 38::614. ,1956. .
McElwain JP, Hunter GA, English E: Syme’s amputation in adults: a long-term review. .Can J Surg 28::203. ,1985. .
Pinzur MS, Smith D, Osterman H: Syme ankle disarticulation in peripheral vascular disease and diabetic foot infection: the one-stage versus two-stage procedure. .Foot Ankle Int 16::124. ,1995. .
Pinzur MS, Morrison C, Sage R, et al: Syme’s two-stage amputation in insulin requiring diabetics with gangrene of the forefoot. .Foot Ankle 11::394. ,1991. .
Smith DG: Principles of partial foot amputations in the diabetic. .Foot Ankle Clin 2::171. ,1997. .
Proper treatment for the compromised diabetic foot often requires surgical correction and subtotal pedal amputation. This article discusses various levels of amputation of the human foot, including digital, ray, transmetatarsal, midfoot, and Syme amputations. Surgical techniques and biomechanical considerations are presented in order to assist the surgeon in planning for the most functional outcome of the patient. A review of the literature and the experiences of the authors are presented. (J Am Podiatr Med Assoc 91(1): 6-12, 2001)