A Manual of the Operations of Surgery, Joseph Bell [suggested reading .txt] 📗
- Author: Joseph Bell
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Operation.—It is hardly necessary, or indeed possible, to lay down exact rules for the performance of this operation, in so far as the external incisions are concerned, for the sinuses which exist ought in general to be made use of.
When the surgeon has his choice, a straight incision (Plate II. fig. a.), parallel with the bone, extending from the top of the great trochanter downwards for about two inches, and also from the same point in a curved direction with the concavity forwards, upwards towards the position of the head of the bone (see diagram), will be found most convenient. The incisions should be carried boldly down to the bone, which will often be felt exposed and bathed in pus, any remains of the ligamentous structures must be cautiously divided with a probe-pointed bistoury, and then by bringing the knee of the affected side forcibly across the opposite thigh, with the toes everted, the head of the bone is forced out of the wound. The head, neck, and great trochanter should be fully exposed, and the saw applied transversely below the level of the trochanter, so as to remove it entire. If this is not done, it prevents discharge, protrudes at the wound, and besides this it is almost invariably diseased along with the head. Chain saws are quite unnecessary, it being in most cases easy to apply an ordinary one to the bone, if it is properly everted.
Great care in the after-treatment is required to prevent undue shortening of the limb, or in the event of a cure to secure the most favourable position for the anchylosis. The femur occasionally tends to protrude at the wound, and hence may require to be counter-extended by splints. If required at all, the splint should be made with an iron elbow opposite the wound to admit of its being easily dressed. In most cases counter-extension may be best managed by a weight and pulley.
Various forms of hammock swings to support the whole body, and slings of leather or canvas to support the limb only, have been found to aid recovery, and render the patient much more comfortable.
When the acetabulum is also diseased the prognosis is much more unfavourable than when it is sound.
The experiments of Heine and Jäger on the dead body, and operations by Hancock, Erichsen, and Holmes, on patients, have shown that in cases of extensive disease of the acetabulum it is quite possible by a prolonged and careful dissection to remove it all without injury of the pelvic viscera.
The details of incisions for such an operation need scarcely be given, as they must vary in each case with the amount of bone diseased, and the position of the already existing sinuses. The amount of bone that may be removed varies much. Erichsen in one case excised "the upper end of the femur, the acetabulum, the rami of the pubis, and of the ischium, a portion of the tuber ischii, and part of the dorsum ilii."[61]
A less formidable proceeding may be useful in cases where the acetabulum is diseased, but not deeply. The moderate use of an ordinary gouge may succeed in removing the diseased bone.
Experience and the cold evidence of statistics prove, however, that the prognosis in any case is modified very much for the worse by the presence of any disease of the acetabulum, more than one-half of the cases proving fatal in which it is diseased, whether attempts to remove the disease of the acetabulum be made or not, and that those cases do best in which the head of the femur has been displaced, and lies outside the joint almost like a loose sequestrum among the soft parts.
The results of excision of the hip have as yet been very discouraging, the mortality of the whole series of published cases being, according to Dr. Hodge's careful table, very little under 1 in every 2 cases, viz., 1 in 2-5/53. Later statistics are however more favourable.
Like all other excisions, the mortality increases very much with the patient's age.
Thus of 103 completed cases in which the age is given, 53 recovered and 50 died, but dividing the cases at the end of the sixteenth year, we find that of the children below this age 43 recovered and 29 died, a mortality of 40.2 per cent.; of the adults, 10 recovered, and 21 died, or a mortality of 67.6 per cent.
If we remember the marvellous power of recovery from joint diseases we find in childhood, under the influence of good diet, cod-liver oil, and fresh air, we cannot shut our eyes to the fact that such results and such a mortality are by no means encouraging.
From an extensive experience in a special hospital for hip-disease, where fresh air, abundant nourishment, and very excellent nursing are provided, the author is learning more and more to trust to the power of nature in the cure of even very advanced cases of hip-disease in children, and he believes that operation is rarely necessary, or even warrantable, except for the removal of sequestra.
Mr. Holmes's[62] statistics are interesting. He has operated on no fewer than nineteen cases. Of these seven died, one after secondary amputation at the hip. Another required amputation and recovered. Two others died of other diseases without having used their limb. Of the remaining nine, three were perfectly successful, four were promising cases, and two unpromising.
Professor Spence in 19 cases had 6 deaths, or a mortality of 31.6 per cent.
Culbertson's collection gives out of 426 cases, 192 deaths, or 45 per cent.
Mr. Croft, whose skill and success as an operator are well known, has recorded 45 cases of excision of hip in his own practice; of these 16 died, 11 were under treatment, 18 had recovered, of which 16 had moveable joints and useful limb; the other two are "potentially cured."[63]
Various other incisions have been devised for gaining access to the joint. The most noticeable are those in which a flap is made instead of a linear incision. Sedillot makes a semilunar or ovoid flap, the base of which is just below the great trochanter, and which includes it, the convexity being upwards and the flap being turned down. Gross's modification of this is preferable, being turned the opposite way, the convexity being downwards (Plate III. fig. e.), and the flap thus being turned up.
Results in successful cases.—Of fifty-two in Hodge's table, thirty-one had useful limbs, six indifferent, three decidedly useless, four died within three years, and of the remaining eight no details are given.
The shortening is always considerable, a high-heeled shoe being required in most cases; a stick is indispensable; in many, crutches are necessary.
Various operations have been devised for the treatment of osseous anchylosis of the hip-joint when in a bad position. All are more or less dangerous. Perhaps one of the least dangerous is the plan of subcutaneous division of the neck of the femur by a narrow saw, proposed by Mr. Adams of London. It is sometimes a very laborious operation.
Excision of Knee-Joint.—Removal of Bone.—In every case the excision of the joint ought to be complete. Some attempts have been made to save one or other of the articular surfaces, but they have proved failures. The patella has frequently been left when it was not diseased, as is often the case, but the results have not been such as to recommend such a practice.
Direction of Section of the Bones.—The bones should be cut transversely, and, as far as possible, be in accurate and complete apposition. A slight bevelling at the expense of the posterior margin will produce an anchylosis of the limb in a very slightly flexed position, which is found to aid the patient in walking.
It has been proposed by some[64] to cut both bones obliquely, so as to obviate the difficulty of making the transverse surfaces parallel. This involves a still greater practical difficulty in keeping these oblique surfaces in position during the after-treatment.
This plan might possibly be valuable in cases where the disease was limited to one or other edge of the bone.
Among the various incisions recommended, the best seems to be the Semilunar Incision.
Operation.—The limb being held in an extended position, a single semilunar incision (Plate I. fig. b.) is made, entering the joint at once, and dividing the ligamentum patellæ. It should extend from the inner side of the inner condyle of the femur to a corresponding point over the outer one, passing in front of the joint midway between the lower edge of the patella and tuberosity of the tibia. The flap is then dissected back, the ligaments divided, when by extreme flexion of the limb the articular surface of the tibia and femur are thoroughly exposed. The crucial ligaments must then be divided cautiously, and the articular portion of the femur cleaned anteriorly by the knife, posteriorly by the operator's finger, so far as possible to avoid injury of the artery. The whole articular surface of the femur must then be removed by a transverse cut with the saw as exactly as possible at a right angle with the axis of the bone. The amount of the femur which will require removal will in the adult vary from an inch to an inch and a half or even more. It must involve all the bone normally covered by cartilage; and this being removed, if the section shows evidence of disease, slice after slice may require removal till a healthy surface is obtained. Occasionally, if the diseased portion appears limited, though deep, the application of a gouge may succeed in removing disease without involving too great shortening of the limb. Specially in children, it is of great importance to avoid removing the whole epiphysis. The tibia must then be exposed in a similar manner, and a thin slice removed; if the bone be tolerably healthy, even less than half an inch will prove quite sufficient.
This method has an immense advantage in that it provides an excellent anterior flap for the amputation, which may be required in cases where the disease of bone is found too extensive to admit of the excision being practised.
This method, with slight deviations, is substantially that of Richard Mackenzie of Edinburgh, Wood of New York, Jones of Jersey.
Hæmorrhage must then be stopped, and that as thoroughly as possible, by torsion, cold, and pressure, and the flap brought accurately together with sutures.
In some rare cases, it may be found necessary to divide the hamstring tendons to rectify spastic contraction of the muscles; but this can generally be done quite well from the original wound.
Holt makes a dependent opening in the popliteal space for drainage. This is unnecessary if the incisions are made sufficiently far back, and if the wound is properly drained. It is unsafe, as approaching so close to the artery and veins. If much bagging takes place, the use of a drainage-tube will prove quite sufficient.
After-treatment.—Wire splints lined with leather and provided with a foot-piece; special box-splints with moveable sides, as Butcher's;[65] plaster-of-Paris moulds are used by Dr. P.H. Watson[66] of Edinburgh and others; this last form of dressing is the best, and allows the limb to be suspended from a Salter's swing.
H-shaped incision.—The internal incision should commence at a point about two inches below the articular surface of the tibia, and in a line with its inner edge; it should then be carried up along the femur in a direction parallel to the axis of the extended limb, so as to pass in front of the saphena vein, and thus avoid it, for a
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