A Manual of the Operations of Surgery, Joseph Bell [suggested reading .txt] 📗

Amputation of Distal Phalanx of Great Toe.—This is comparatively rarely required now. It used to be thought necessary for the cure of those not uncommon cases of exostosis of the distal phalanx, but it is now found that most of these can be cured by simply clipping off the exostosis. When necessary, however, and when the choice of flaps is possible, the best plan is by a long flap from the plantar surface (Fig. v. 4), as in the similar operation on the thumb; laying the edge of the knife over the dorsal aspect of the joint, cutting through it, and turning the edge of the knife round close to the bone, so as to cut out a large flap from the ball of the toe.

Amputation of a Single Lesser Toe—second, third, or fourth.—This operation is on exactly the same principle as that described for the corresponding finger; but it must be remembered that the metatarso-phalangeal joint is more deeply situated in the soft parts than is the metacarpo-phalangeal; and thus the commencement of the elliptical incision which is to surround the base of the toe must be proportionally higher up (Fig. v. 1). On the other hand, as it is very important to avoid as much as possible any cicatrix in the sole of the foot, the plantar end of the incision need not be carried to a point exactly opposite the one from which it set out, but it will be sufficient if it reaches the groove between the toe and sole. A little more care may thus be required in dissecting out the head of the first phalanx, but this is quite repaid by the cicatrix in the sole being avoided. Early division of flexor tendons renders disarticulation easy.

Amputation of the First and Fifth Toes.—The incisions are conducted on the same principle as in the other operations, the operator being careful to preserve as much as possible (Fig. v. 2) of the hard useful pad of the inner and outer sides respectively.

Most surgeons are now agreed that in these toes it is best not to remove the head of the metatarsal bone with the toe. Cutting off the large cartilaginous head obliquely with a pair of bone-pliers may prevent an awkward unseemly projection, but it does diminish the strength of the transverse arch of the foot.

Amputation of one or more Toes with their Metatarsals.—It is not necessary to give very particular details regarding such operations, as the surgeon must be guided in the individual cases by the specialties of accident or disease.

One or two guiding principles are important:—

1. Having made up your mind at what point you are to cut the metatarsal, if the amputation be a partial one, or as to the exact position of the joint, if you intend to disarticulate, commence your dorsal incision (Fig. v. 3) at a point fully half an inch higher up than the selected spot, as free access is of the very last importance.

2. Whenever it is possible, cut the bone through its continuity rather than disarticulate. Specially is this important in the case of the metatarsal bone of the great toe, that the insertion of the tendon of the peroneus longus may be saved. If, however, the terminal branch of the dorsalis pedis artery be wounded, it may be necessary to disarticulate the first metatarsal to secure it rather than trust to compression to stop the bleeding.

3. In cutting through the first and fifth metatarsals, remember to apply the bone-pliers obliquely, not transversely, so as to avoid unseemly projection.

4. As far as possible avoid cutting into the sole at all.

The plantar cicatrix is almost a fatal objection to a plan of removing the first and fifth toes and their metatarsals which has much otherwise in rapidity and elegance to recommend it. In the great toe, for example, it is performed as follows:—Seizing the soft parts of the inner edge of the foot in his left hand, the surgeon draws them inwards, transfixes just at the tarso-metatarsal joint, and, keeping as close as possible to the inner edge of the metatarsal bone, cuts the flap as long as to the middle of the first phalanx; then the soft parts of the foot being drawn as far outwards as possible by an assistant, the surgeon enters his knife between the first and second toes, and succeeds in entering his former incision so as to separate the metatarsal bone without removing any skin. All that remains is to open the tarso-metatarsal joint. It is a very neat-looking operation, leaves a very good covering for the parts, and is performed with extreme rapidity. This last is not so much required in these days of anæsthetics, and the cicatrix in the sole is a very formidable objection to it.

The simplest and shortest rule that can be given for the amputation of a toe, with the part or whole of its metatarsal, is to make one dorsal incision, commencing about a quarter of an inch above the spot at which you intend to divide the bone or to disarticulate, extending downwards in a straight line to the metatarso-phalangeal articulation, and then bifurcating so as to surround the base of the toe at the normal fold of the skin. The soft parts are then to be cleared from the metatarso-phalangeal joint, and the toe still being retained on the metatarsal bone, it should be carefully dissected up, avoiding any pricking of the soft parts below, till the joint is reached, or the spot at which the bone-pliers are to be applied is fully cleared.

Amputation of the anterior portion of the Foot at the Tarso-metatarsal Joint—Hey's Operation.—This operation, which is now comparatively rarely performed, has been invested with a halo of difficulty and complexity which is to a great extent unnecessary.

There is no doubt that the anatomical conformation of the joints involved, especially the manner in which the head of the second metatarsal (Fig. v. C) projects upwards into the tarsus, and is locked between the cuneiform bones, renders disarticulation in the healthy foot rather difficult; but it must be remembered that in cases where for accident we have to deal with previously healthy tissues, it is quite unnecessary to disarticulate, a better result being attained by simply sawing the foot across in the line of the articulation; and again, where we have to operate for disease, the tissues are so matted, and the bones so soft, that complete removal of the metatarsus is much easier than it appears when practising on the dead subject.

Very various plans of incision have been proposed. Mr. Hey's original procedure has not been much improved upon. His short account of it has at once surgical value and historical interest:—

"I made a mark across the upper part of the foot, to point out as exactly as I could the place where the metatarsal bones were joined to those of the tarsus. About half an inch from this mark, nearer the toes, I made a transverse incision through the integuments and muscles covering the metatarsal bones (Plate IV. figs. 10, 11). From each extremity of this wound I made an incision (along the inner and outer side of the foot) to the toes. I removed all the toes at their junction with the metatarsal bones, and then separated the integuments and muscles forming the sole of the foot from the inferior part of the metatarsal bones, keeping the edge of my scalpel as near the bones as I could, that I might both expedite the operation and preserve as much muscular flesh in the flap as possible. I then separated with the scalpel the four smaller metatarsal bones at their junction with the tarsus, which was easily effected, as the joints lie in a straight line across the foot. The projecting part of the first cuneiform bone which supports the great toe I was obliged to divide with a saw. The arteries, which required a ligature, being tied, I applied the flap which had formed the sole of the foot to the integuments which remained on the upper part, and retained them in contact by sutures....

"The patient could walk with firmness and ease; she was in no danger of hurting the cicatrix by striking the place where the toes had been against any hard substance, for this part was covered with the strong integuments which had before constituted the sole of the foot. The cicatrix was situated upon the upper part of the foot, and had very little breadth, as the divided parts had been kept united after being brought into close contact."[36]

Lisfranc's method has, briefly, the following modifications.—Having fixed the position of the articulations of the first and fifth metatarsals with the tarsus, the operator unites them by a curved incision across the dorsum of the foot, with its convexity downwards. He then divides the dorsal ligaments over the articulations, opens the first from the inside, the fifth, fourth, and third from the outside, he then with a strong narrow-bladed knife divides the interosseous ligaments between the sides and end of the head of the second metatarsal and the cuneiforms, thus completing the disarticulation; bending the fore part of the foot downwards, he then keeps the edge of the knife close to the lower surface of the bones, separating the plantar ligaments, and cutting out a long plantar flap of skin and muscles.

In every case it must be