Operation.—The foot being held at a right angle to the leg, the point of a straight bistoury, with a pretty strong blade, should be entered just below the centre of the external malleolus (Plate IV. figs. 12, 13), (1.) and then carried right across the integuments of the sole, in a straight line (or in the case of a prominent heel, slightly backwards), (2.) to a point at the same level on the opposite side. (3.) This incision should reach boldly through all the tissues down to the bone. Holding the heel in the fingers of his left hand, the operator then inserts his left thumb-nail into the incision, and pushes the flap downwards, as with the knife kept close to the bone, and cutting on it, he frees the flap from its attachments. The thumb-nail guards the knife from in any way scoring the flap. (4.) This process is continued till the tuberosity of the os calcis is fairly turned, and the tendo Achillis nearly reached. Shifting his left hand he then extends the foot, and joins the extremities of the first incision by a transverse one right across the instep. (5.) Thus he opens the joint between the astragalus and tibia, (6.) divides the lateral ligaments, disarticulates, and still keeping close to the bone, removes the foot by the division of the tendo Achillis.
The lower ends of the tibia and fibula are then to be isolated from the soft parts, and a thin slice, including both malleoli, to be removed. If the disease of the joint has affected the lower end of the bone, slice after slice may be removed, till a healthy surface of cancellated texture is obtained. The vessels are then secured.
Dressing of the Stump.—From its peculiar shape and position, the escape of any blood into the stump is much to be deprecated, for as it cannot easily get out, on the one hand it gives pain, and may cause sloughing from its pressure, and on the other it is sure eventually to cause suppuration, and delay union. To avoid such results care must be taken to secure every vessel that can be seen; if there is any general oozing it is best merely to pass the sutures through the edges of the flaps, but not bring them together, thus leaving the stump open for some hours; then apply cold, and when the surfaces are fairly glazed over, remove any clots and bring the flaps together.41
Another plan introduced by Mr. Syme was to make a longitudinal slit in the flap, through which all the ligatures are to be drawn; these give a dependent drain to any pus that may be formed, and by their presence greatly expedite the healing of the wound. Again, in cases where from the amount of disease existing before the operation, and the gelatinous thickening of the flap and neighbouring parts, much suppuration may be looked for, probably it will be found best to keep the flaps quite apart for some days, by stuffing the wound with lint, and aiming only at secondary union by granulations.
A drainage tube passed through the breadth of the flap, and brought out at the angles, and retained for a few days, will do admirably.
Notes.—(1.) If commenced further forward, as in Pirogoff's modification, it will be found difficult to turn the corner of the heel; if further back, the nutrition of the flap is endangered.
(2.) This is very important. In several well-known text-books, even in the last edition of Gross's Surgery, the incision is figured passing obliquely forwards. This is a fatal error, for besides making a flap far too long, it forces the operator to cut fairly into the hollow of the sole, quite off the prominence of the os calcis, and he finds that it is utterly impossible to free his flap without using great force, and inevitably scoring it in all directions. Sloughing is almost inevitably the result.
(3.) The incision is to stop at least half-an-inch below the internal malleolus. Most surgical manuals, even when they profess to describe Mr. Syme's own method of operating, say that the incision should extend from malleolus to malleolus. If this is done, the flap becomes unsymmetrical, too long, and also the posterior tibial artery, on which much of the vascular supply of the flap depends, is cut. When the incision is properly made, the vessel is not cut till after its division into the plantar arteries.
(4.) Scoring the flap. Some may ask, Why do you object to a little scoring, the tissues are thick enough, and besides, don't you advise a slit in the flap yourself? Yes. One look at an injected preparation will show that the vessels supplying this thick flap come to it from its inner surface, and are inevitably cut across in any scoring of it, and also, that scoring cuts across the vessels, and must divide dozens of them; the slit we make is parallel with their course, and may not divide one.
(5.) Across the instep. Some authors recommend a semilunar anterior flap; this is quite unnecessary, increases bagging and delays union. It can be required only in cases where the heel flap has been destroyed or lessened by disease, or by operators in whose hands the heel flaps occasionally slough.
(6.) It is not impossible that a careless operator may (by cutting a little too low) miss the joint and get into the hollow of the neck of the astragalus, where he may cut away for a long time without making much progress.
Advantages.—1. It is wonderfully free of danger to life. It is very hard to obtain exact statistical information, but my experience is that the mortality is certainly not more than about 10 per cent., a very remarkable result when compared with that of amputations through the leg, the operation which used to be required for those cases which now require only amputation at the ankle-joint.
In the Statistical Report by the Surgeon-General of the United States, 9705 cases of amputation resulted in death, the proportions being as follows:—
2. It is the most perfect stump that can be made, in fact the only one in the lower extremity which can bear pressure enough to support the weight of the body; all the others require the weight to be distributed over the general surface of the limb by means of apparatus. A good ankle-joint stump can bear the whole weight of the body, as when the patient hops on it without any artificial aid, or without even the interposition of a stocking between the stump and a stone floor. More than this, I have seen a patient who had both his feet amputated at the ankle-joint run without shoes or stockings on the stone passages, without even the aid of a stick, and with very great swiftness.
The reason of this may be found in the nature of the flap itself, originally intended to bear the weight of the body, there being no cicatrix at the part on which pressure is borne. I have noticed that perfection in walking on an ankle-joint stump has a certain relation to the freedom of movement which the pad has over the face of the bone. This ought to be pretty considerable. It is explained by the new attachments formed by the tendons, and is under the control of the patient, being elicited when he is told to move his toes.
It has been objected to this operation that the flap is apt to slough. When improperly performed, as when the flap is scored transversely in its separation, and especially when the flap is cut too long (as has been already noticed), this may occur; but that there is nothing whatever in the position or condition of the flap itself that at all necessitates its sloughing, is thoroughly proved by the following remarkable case, given by Mr. Syme in his volume of Observations in Clinical Surgery. I quote it entire:—
"P.C., aged thirty-three, was admitted into the hospital on the 25th July 1860, in the following state:—He had been treated in the Manchester Infirmary for popliteal aneurism by pressure, so decidedly applied that it had caused an ulcer, of which the cicatrix remained; but without producing the effect desired. The femoral artery was then tied with success, in so far as the aneurism was concerned, but with the unpleasant sequel, some months afterwards, of mortification in the foot, which was thrown off, with the exception of the astragalus and os calcis with their integuments, a large raw surface being presented in front where the bone was bare. Although the patient was extremely weak, and the parts concerned might be supposed more than usually disposed to slough, I did not hesitate to perform the operation, with the speedy result of a most excellent stump and complete restoration to health."—Pp. 49, 50.
The modifications of Mr. Syme's original operation have been very various. It will be unnecessary even to name them all. One or two may require notice. Retaining Mr. Syme's incisions in their integrity, some operators prefer not to disarticulate the foot, but remove it by sawing through the tibia and fibula at once, while still in connection with the foot. That most excellent surgeon and first-rate operator, Dr. Johnston of Montrose, used to prefer this method.
In cases where the pad of the heel has been destroyed by disease or accident, so as to be partially or entirely unavailable for the flap, the late Dr. Richard Mackenzie42 practised the following operation by internal flap:—With the foot and ankle projecting from the table with their internal aspect upwards, he entered the point of the knife (Plate I. fig. 14) in the mesial line of the posterior aspect of the ankle, on a level with the articulation, carried it down obliquely across the tendo Achillis towards the external border of the plantar aspect of the heel, along which it is continued in a semilunar direction. The incision is then curved across the sole of the foot, and terminates on the inner side of the tendon of the tibialis anticus, about an inch in front of the inner malleolus. The second incision (Plate III. fig. 4) is carried across the outer aspect of the ankle in a semilunar direction, between the extremities of the first incisions, the convexity of the incision downwards, and passing half an inch below the external malleolus.
Precisely the same principle might supply the flap from the outer side in cases where the internal flap as well as the heel was deficient, but probably the nutrition of the external flap would be more doubtful. Neither the one nor the other is nearly so good as the true heel flap, and they are both only very poor substitutes for it when it cannot be had.
The modification devised by Dr. Handyside does not seem to have any advantages over the original operation, and has not been adopted.
The modification invented by Professor Pirogoff involves a much more important principle than any of the preceding. Instead of dissecting the flap from the posterior projecting portion of the os calcis, and removing the tarsus entire, he sawed off the posterior portion of the os calcis obliquely, leaving it in contact with the pad of skin, which is retained. Immediately after making the cut which defines the posterior flap and divides the tissues down to the bone, he opens the joint in front, disarticulates, and then putting on a narrow saw immediately behind the astragalus and over the sustentaculum tali, he saws the os calcis obliquely downwards and forwards till he reaches the first incision; then removes the ends of the tibia and fibula and brings up the slice of os calcis into contact with them.
Advantages.—It is easy of performance, saving the dissection from the heel, which some find so hard. It leaves a longer limb. It is said to bear pressure better, and there is certainly not so much chance of bagging of pus, and the mortality is exceedingly small, Hancock's collected cases giving only 8.6 per cent.; in cases of injury it is quite a warrantable operation.
Disadvantages.—It is contrary to sound principle in cases of disease, for it wilfully leaves a portion of the tarsus, in which disease is almost certain to return. It leaves too long a limb, for it is found that the shortening in Mr Syme's method is just sufficient to admit of a properly constructed spring being placed in the boot to make up for the loss of the elastic arch of the foot. It brings the firm pad of the heel too much forward, thus tending to lean the weight of the body on the softer tissues behind the heel. It takes much longer to unite and consolidate.
The author has now, in a large number of cases of Syme's amputation for disease, found advantage in leaving the periosteum in the heel flap, i.e. he cuts fairly into the os calcis when dividing the skin of heel, and then using a periosteum scraper instead of the knife, it is quite easy to remove the whole of the periosteum from the bone; this results in a large and more rounded pad of great strength and thickness.
In cases where from disease or injury it is impossible to obtain either a heel flap or a substitute lateral one, the question is, Where should amputation be performed?
It was for a long time the opinion of nearly all the best surgeons, and still is the opinion of many, that amputation of the leg should be performed at what was known as the "seat of election," just below the knee, even in cases where abundance of soft parts could be obtained for an amputation much lower down. The rule in surgery, to save as much of the body as possible in every amputation, was in the leg believed to be set aside by objections which militated strongly against all the other operations in the leg except the one performed just below the knee. Very briefly, these were somewhat as follows:—1. Just above the ankle you have large bones with nothing to cover them except skin and tendons. 2. Higher up in the calf you have plenty of muscle, but it is all on one side, and that the wrong one; it is very heavy, very difficult to dress and keep in position, and then when you have succeeded with it, the muscle wastes away and the stump is flabby. 3. And chiefly, as in all the amputations of the leg, the cicatrices are so much in the way, and the bones are so ill covered, that the patient can never rest his leg on the stump itself, but has either to rest his weight on his patella impinging on the top of a bottle-shaped leg, or just to stick out his stump behind him and kneel on the top of his wooden leg; therefore it is no use to have a stump longer than a few inches; in fact, the longer the stump is the more it is in the way. And more than this, many of the stumps made near the ankle, or through the calf, are not only useless, but positively painful. The skin becomes attached to the bones, the cicatrix never properly firms at all, the patient can hardly bear the pressure of a stocking, far less can he make use of the limb. For these reasons, secondary amputations below the knee are of very common occurrence.
Now, this idea has been much modified, and a few isolated cases in the past, and series of cases considerably more numerous in the present day, show that under certain conditions, and as a result of certain precautions in their performance, such operations are both warrantable and successful.
In the past, as we find in an erudite note in South's Chelius, Dionis, White, and Bromfield had each of them many successful cases of amputation just above the ankle, successful in so far that artificial limbs could be used which preserved the motion of the knee, and gave the patient much more command of the limb than is possible with the short stump below the knee.
A still more important point to be remembered is, that amputation just above the ankle is a much less fatal amputation than that just below the knee (Lister in Holmes's Surgery, 3d ed. vol. iii. p. 716; Gross, 6th ed. vol. ii. p. 1113; Ben. Bell, 6th edit. vol. vii. p. 312).
There is little doubt, however, that the principle so much in vogue in the present day, of one long anterior or posterior flap, instead of two equal flaps, or of circular amputations, has done very much to make amputations at the ankle or through the calf justifiable and useful in bearing the weight of the body.
Amputation just above the Ankle.—Cases admitting of this operation must always be rare, for disease of the tarsus or ankle-joint hardly ever goes so far as to contra-indicate the performance of Mr. Syme's greatly preferable operation; and an accident which would require this operation from injury to the ankle would in most cases require an amputation a good deal higher up from the splintering of the tibia so apt to occur.
In a suitable case the plan of the operation should be as follows:—A long anterior flap slightly rounded at the end should be cut (Plate I. figs. 15, 16)—from the outside, not by transfixion,—and the anterior muscles dissected up along with it. It should be long enough to fall down over the face of the bones at the point of section, and easily cover the point of the posterior flap, which is to be made by cutting through all the tissues with one bold transverse stroke of the knife. This operation, which is the plan of Mr. Teale of Leeds very slightly modified, is equally applicable at any point of the leg, with this difference only, that the length of the anterior flap must always be carefully proportioned to the mass of the muscular flap behind it has to cover in.
This operation provides a skin covering, without any danger of the cicatrix being pressed on or becoming adherent.
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.43
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.44
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.
The statistics seem to be favourable: out of 55 cases, Continental, American, and English, 21 died, a mortality of 38 per cent., while in a table of 1055 cases of amputation of the thigh, 464 died, being a mortality of 44 per cent. In some of the American cases the articulating extremity of the femur seems to have been removed, as in the following operation:—
Amputation through the Condyles of the Femur.—In the London and Edinburgh Journal of Medical Science for 1845, Mr. Syme advocated a method of amputation through the condyles of the femur as specially suitable in case of diseased knee-joint. Amputation at this spot has certain advantages:—1. The shaft of the bone being untouched, there is no injury of the medullary cavity, and hence no fear of inflammation of its lining membrane. 2. There is less risk of exfoliation, the cancellated texture of the epiphysis not being liable to it. 3. Being close to the joint, the muscles are cut through where they are tendinous, thus very much diminishing the risk of retraction and consequent protrusion of the bone. 4. A large broad surface of bone is left to bear the weight of the body, and one which, like the ankle-joint stump, will round off and afford a comfortable pad over which the skin of the flap will freely play.
One objection used to be urged against this mode of operating, the fear lest the thickened, brawny, and often ulcerated textures in the neighbourhood of a diseased knee-joint, would not make a good covering. This, however, is no longer a bugbear, as we see in cases of resection, where the diseased joint alone is taken away, how very soon all swelling and disease departs, once its cause is removed.
Mr. Syme's original operation was briefly as follows:—With an ordinary amputating-knife make a lunated incision (Plate I. fig. 19) from one condyle to the other, across the front of the joint, on a level with the middle of the patella, divide the tissues down to the bones, and then draw the flap upwards, then cut the quadriceps extensor immediately above the patella. The point of the blade should then be pushed in at one end of the wound, thrust behind the femur, and made to appear at the other end; it should then be carried downwards (Plate III. fig. 5), so as to make a flap from the calf of the leg, about six or eight inches in length, in proportion to the thickness of the limb; the flap should then be slightly retracted, and the knife carried round the bone a little above the condyles to clear a way for the saw, which should be applied so as to leave the section as horizontal as possible.
This method is now hardly ever used, as the following seems a much better one:—
Gritti's45 Amputation.—In this two flaps are formed—an anterior long one rectangular and a posterior short one. The condyles of the femur are divided through their base, and the lower surface of patella is removed by a small saw, and then the surfaces of bone approximated.
Stokes's46 modification of Gritti's amputation.—In this "supracondyloid" amputation, the femur is sawn just above the condyles, without going into the medullary canal. The anterior flap is oval, twice as long as posterior, and the patella is brought up after denudation against end of femur.
Carden's Amputation at the Condyles of the Femur.47—The operation consists in reflecting a rounded or semi-oval flap of skin and fat from the front of the knee-joint, dividing everything else straight down to the bone, and sawing the bone slightly above the plane of the muscles, thus forming a flat-faced stump, with a bonnet of integument to fall over it.
The operator standing on the right side of the limb, seizes it between his left forefinger and thumb at the spot selected for the base of the flap, and enters (Plate II. fig. 8) the point of the knife close to his finger, bringing it round through skin and fat below the patella to the spot pressed by his thumb; then turning the edge downwards at a right angle with the line of the limb, he passes it through to the spot where it first entered, cutting outwards through everything behind the bone (Plate IV. fig. 16). The flap is then reflected, and the remainder of the soft parts divided straight down to the bone; the muscles are then slightly cleared upwards, and I saw it applied.
I have ventured to make a slight change in the method of performing this most excellent operation, for having found the posterior flap, as cut in the method above described, rather scanty in the earlier cases in which I have had occasion to perform it, after dissecting back the anterior flap and cutting into the knee-joint, I shape a slightly convex posterior flap of skin only, at least one and a half inches in length in adult, and allow it to retract before dividing the muscles by a circular cut to the bone, and have had every reason to be satisfied with the change.