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

The author has within the last few years operated nine times in this manner, in cases of accident in which the heel flaps had been completely destroyed; and seen a tenth case in which Mr. Syme did so. All ten cases recovered completely and rapidly, and walked on useful limbs, with the free movement of the knee-joint.

Where from injury in a muscular patient a long anterior flap cannot be had, recourse should be had at once to the operation at the seat of election, rather than run the risk of pressure on the cicatrix by using a double flap operation, or trust that broken reed, the long posterior flap from the great muscles of the calf.

In June 1865, Mr. Henry Lee described a method of operating which he hoped would unite the benefits of Mr. Teale's method to the ease of performance of the old flap from the calf. I append a short account of his method. From its position, however, it has the great disadvantage of retaining the discharges, and by its weight straining the stitches and weighing down the cicatrix:—

Lee's Amputation of the Leg by a long rectangular flap from the Calf.—The operation described was performed according to Mr. Teale's method, as far as the external incisions were concerned, but the long flap was made from the back instead of from the front of the limb (Plate IV. figs. 14, 15). Two parallel incisions were made along the sides of the leg, these were met by a third transverse incision behind, which joined the lower extremities of the first two. These incisions, which formed the three sides of the square, extended through the skin and cellular tissue only. A fourth incision was made transversely through the skin in front of the leg so as to form a flap in this situation, one-fourth only of the length of the posterior flap. When the skin had somewhat retracted by its natural elasticity, an incision was made through the parts situated in front of the bones, which were reflected upwards to a level with the upper extremities of the first longitudinal incisions. The deeper structures at the back of the leg were then freely divided in the situation of the lower transverse incision. The conjoined gastrocnemius and soleus muscles were separated from the subjacent parts, and reflected as high as the anterior flap. The deeper layer of muscles, together with the large vessels and nerves, were divided as high as the incision would permit, and the bones sawn through in the usual way. The flaps were then adjusted in the manner recommended by Mr. Teale.[42]

The patients were able to bear the weight of the body on the end of the stump.

In cases of chronic disease, where the muscles are atrophied and condensed, the following posterior flap method may be used with advantage. It is approved of by Mr. Spence. An incision is made across the front of the leg from the posterior edge of the fibula to the posterior edge of the tibia, or vice versâ, according to the limb. The limb is then transfixed behind the bones from the same points, and a long and gently rounded posterior flap cut. The bones are then cleaned, and cut through at a little higher level.

Amputation immediately below the Knee at the "true seat of election."—The principles on which this operation is founded are—1. That a muscular flap is not necessary, skin being perfectly sufficient; 2. That as the muscles retract they must be cut at a lower level than the bones, and as they retract unequally from their varying length, the cuts must be made with due reference to that inequality; 3. That no more of the tibia need be retained than what is just sufficient to retain the attachment of the ligamentum patellæ, and to insure its vitality; 4. That the head of the fibula must be retained in every case, as in a certain proportion the tibio-fibular articulation communicates with the knee-joint.

Operation.—Two equal semilunar flaps of skin must be cut—from the outside, not by transfixion,—one anterior and external, the other posterior and internal, their extremities meeting at points about two inches below the tuberosity of the tibia on either side (Plate I. figs. 17, 18). These must be reflected up, and with them a further extent of skin, embracing the whole circumference of the limb, must be dissected up (as if pulling off the fingers of a glove), so as to expose the bone one inch below the tuberosity. The anterior muscles being very close to their origin, and consequently being able to retract very slightly, must be cut as high as exposed, and the posterior ones about the middle of their exposed surface.

The bones must then be sawn as high as exposed, with the following precautions:—1. In order to prevent splintering of the fibula, endeavour to saw it along with the tibia, so as to finish it first; 2. To prevent projection of a sharp prominence of the edge of the tibia, enter the saw obliquely a little higher up than where you intend to divide the bone, then withdraw it, and enter the saw again at right angles to the bone, and a line or two lower down. Some surgeons prefer to make this section afterwards with a finer saw or the bone-pliers.

This operation is very frequently required to remedy painful and unhealed stumps, the result of amputations lower down, specially those in which the long posterior flap from the muscles of the calf has been used. In the above amputation the patient will not be able to rest the weight of his body on the face of the stump, but by putting the limb into a well-padded case with soft rounded edges, the weight might be borne partly on the sides of the stump, and partly on the lower edge of the patella; and the patient will be able to walk with great comfort, preserving the use of his knee-joint.

Amputation at the Knee-joint.—This "relic of ancient surgery," as Mr. Skey calls it, has been revived only of late years, and seems in certain cases to be a justifiable and successful operation.

Practised by Fabricius Hildanus and Guillemeau in the sixteenth and seventeenth centuries, it had fallen into disuse till revived by Hoin, Velpeau, and Baudens, on the Continent, Professor Nathan Smith in America, and Mr. Lane in London.

It is not possible that this operation can be at all frequent, since the cases in which it is applicable are comparatively rare; for, to be successful, the following conditions are essential:—1. That there be abundant skin in front of the knee-joint to make a long anterior flap; 2. That the patella and articular surface of the femur are healthy. These conditions at once exclude nearly every case of disease or accident. If the joint is diseased some amputation through the thigh must be attempted; if injured, and the front of the knee is safe, it may very likely be possible to amputate below the knee. Hence this operation may be useful in cases where, for malignant disease, the whole tibia requires removal, and yet the knee-joint is sound, or for gunshot injuries, in which the tibia is splintered but the soft tissues comparatively uninjured.

Operation.—A long anterior flap should be cut with a semilunar end (Plate II. figs. 6, 7), extending as far as the insertion of the ligamentum patellæ. This flap, including the patella, should be thrown up, the joint cut into, and a short posterior flap made by transfixion.

It is important to retain the patella, if possible, as it fills up the hollow between the condyles; it sometimes becomes anchylosed, but in other cases it remains freely mobile, and adds to the value of the stump.

Professor Pancoast has practised an amputation at the knee-joint by three flaps, performed entirely by the scalpel, which, he says, results in a good stump. One flap, the anterior one, is longest and semilunar in shape, its convexity passing three inches below the tuberosity of the tibia; the other two are much smaller, and postero-lateral.[43]

Advantages.—The bone is not cut into at all, there is a free drain for matter, no tendency to retraction of the flaps, and the weight of the body is borne on skin previously habituated to pressure.