Syme amputation. A, Incision and bone level. B, Exposure of ankle and division of ligaments. C, Bone hook pulling talus distally, exposing distal articular surface of tibia and fibula. D, Dissection of soft tissues from calcaneus. E and F, Subperiosteal removal of calcaneus, leaving heel pad intact. G, Division of tibia and fibula just through dome of ankle joint centrally. H, Plane of transection to keep cut surfaces of tibia and fibula parallel to ground with patient standing. I, Holes drilled in anterior edge of tibia and fibula to anchor heel pad. J, Edge of deep fascia lining heel pad is anchored to tibia and fibula. K and L, Skin closure over drain, and application of above-knee cast. SEE TECHNIQUE 15.9.