The following modification, suggested and practised by the late Mr. Maunder, seems to be a step in the right direction when it is practicable. "After a longitudinal incision crossing the point of the olecranon I next let the knife sink into the triceps muscle, and divide it longitudinally into two portions, the inner one of which is the more firmly attached to the ulna, while the outer portion is continuous with the anconeus muscle, and sends some tendinous fibres to blend with the fascia of the fore-arm. It is these latter fibres that are to be scrupulously preserved."Two points have to be remembered: first, the ulnar nerve, often unseen, must be lifted from its bed, and carried over the internal condyle to a safe place, and then the outer portion of the triceps muscle with its tendinous prolongation, the fascia of the fore-arm and the anconeus muscle must be dissected up, as it were, in one piece, sufficiently to allow of its being temporarily carried out over the external condyle of the humerus."[55]This method aids in retaining the power ofactiveextension of the elbow-joint.
The following modification, suggested and practised by the late Mr. Maunder, seems to be a step in the right direction when it is practicable. "After a longitudinal incision crossing the point of the olecranon I next let the knife sink into the triceps muscle, and divide it longitudinally into two portions, the inner one of which is the more firmly attached to the ulna, while the outer portion is continuous with the anconeus muscle, and sends some tendinous fibres to blend with the fascia of the fore-arm. It is these latter fibres that are to be scrupulously preserved.
"Two points have to be remembered: first, the ulnar nerve, often unseen, must be lifted from its bed, and carried over the internal condyle to a safe place, and then the outer portion of the triceps muscle with its tendinous prolongation, the fascia of the fore-arm and the anconeus muscle must be dissected up, as it were, in one piece, sufficiently to allow of its being temporarily carried out over the external condyle of the humerus."[55]
This method aids in retaining the power ofactiveextension of the elbow-joint.
Excision for osseous anchylosis in the extended position of the joint may be sometimes rendered very difficult by the density, firmness, and extensive hypertrophy of the bones, which become fused into one solid mass. Any attempt to isolate the bones, and remove the anchylosed joint entire, by incising the bones as if for disease, will both prove very laborious, and also probably end in doing some damage to the vessels and nerves in front. But by sawing through the anchylosis about its centre, as was pointed out many years ago by Mr. Syme, the fore-arm may be flexed, and the bones as easily displayed, cleaned, and removed, as in the operation for disease. In this operation, as there is less thickening of the skin and subjacent textures, and in consequence more risk of deficiency and even sloughing of the flaps made by the H-shaped incision, a single straight incision will serve the purpose admirably.
Partial incisions of the elbow-joint are, as a rule, less successful and more dangerous to life than complete ones, except in cases of excision for anchylosis. Even in gunshot wounds, where the bones were previously healthy, and where uninjured portions might have been left with some hopes of success, this is the case.
Dr. Heron Watson has devised the following operation for cases of anchylosis the result of injury:—(1.) A linear incision over ulnar nerve at inner side of olecranon. (2.) The ulnar nerve to be carefully turned over the inner condyle. (3.) A probe-pointed bistoury to be introduced into the elbow-joint in front of the humerus, and then behind and carried upwards, so as to divide the upper capsular attachments in front and behind. (4.) A pair of bone-forceps to be next employed to cut off the entire inner condyle and trochlea of the humerus, and then introduced in the opposite diagonal direction so as to detach the external condyle and capitulum of the humerus from the shaft. (5.) The truncated and angular end of the humerus to be divided, turned out through the incision, and smoothed across at right angles to the line of the shaft by means of the saw, whereby (6.) room might be afforded, so that partly by twisting and partly by dissection the external condyle and capitulum areremoved without any division of the skin on the outer side of the arm.[56]Six cases have had satisfactory results.
Dr. Heron Watson has devised the following operation for cases of anchylosis the result of injury:—(1.) A linear incision over ulnar nerve at inner side of olecranon. (2.) The ulnar nerve to be carefully turned over the inner condyle. (3.) A probe-pointed bistoury to be introduced into the elbow-joint in front of the humerus, and then behind and carried upwards, so as to divide the upper capsular attachments in front and behind. (4.) A pair of bone-forceps to be next employed to cut off the entire inner condyle and trochlea of the humerus, and then introduced in the opposite diagonal direction so as to detach the external condyle and capitulum of the humerus from the shaft. (5.) The truncated and angular end of the humerus to be divided, turned out through the incision, and smoothed across at right angles to the line of the shaft by means of the saw, whereby (6.) room might be afforded, so that partly by twisting and partly by dissection the external condyle and capitulum areremoved without any division of the skin on the outer side of the arm.[56]Six cases have had satisfactory results.
The mortality from this operation is considerably less than that from amputation of the arm. Of a series of excisions for disease, injury, and anchylosis, 22.15 per cent. died, while out of a similar series of amputations of the arm the mortality was 33.4 per cent.[57]Our mortality of excision of the elbow here is certainly much less than the above. All of the cases, between thirty and forty, in which I have done it have recovered with but one exception, and Mr. Syme lost only one during the time I was his assistant.
Professor Spence lost only 16 in 189 cases, or 8.3 per cent.
Gurlt's statistics for gunshot injury give a mortality of over 24 per cent.
Out of 82 cases where the joint was excised for injury in the Schleswig-Holstein and Crimean campaigns, only 16 died; and out of 115 cases in which the joint was excised for disease, only 15 died.
The period after the injury at which the excision is performed seems to be important.
Excision of the Wrist.—Very various methods have been proposed and executed for the purpose of excising this joint. These vary much in difficulty and complexity, in proportion to the endeavours made to save the tendons from being cut.
The principles which must guide all attempts at operative interference with this joint are—
1. To remove all the diseased bone, including the cartilage-covered portions of the radius, ulna, and of the metacarpal bones, as little of these bones being removed as possible, beyond the cartilage-covered portions.
2. To disturb the tendons as little as possible, especially to avoid isolating them from the cellular sheath.
3. To commence passive motion of the fingers very soon after the operation.
It is rarely possible to remove the carpal bones as a whole, from the diseased condition which renders the operation necessary, and the digging out of the various bones piecemeal renders the operation very tedious, especially if the proximal ends of the metacarpal bones are involved and require to be removed, hence this operation was practically impossible till after the discovery of anæsthesia.
In describing the operation elaborated and described by Professor Lister, the type of the various plans in which the tendons are saved is given, while a very few words descriptive of the incisions used by others who cut the tendons will suffice.
Lister's Operation of Excision of the Wrist-Joint.—Even an abridgment of Mr. Lister's account of his operation must necessarily be long, because the operation itself is so complicated and prolonged, and guided by such precise principles, as to render much abridgment almost impossible.
A tourniquet is put on, to prevent oozing, which would conceal the state of the bones; any adhesions of the tendons must be then broken down by free movement of all the joints.
The radial incision(Plate IV.fig.a.) is then made. It commences at the middle of the dorsal aspect of the radius, on a level with the styloid process, passes as if going towards the inner side of the metacarpo-phalangeal joint of the thumb, in a line parallel to the extensorsecundi internodii, but turns off at an angle as it passes the radial border of the second metacarpal, and then longitudinally downwards for half the length of that bone. The extensor carpi radialis brevior tendon is divided in the incision. The soft parts at the radial side are to be carefully dissected up, and the tendon of the extensor carpi radialis longior divided at its insertion. The cut tendons, and the extensor secundi internodii tendon and the radial artery can thus be pushed outwards, enabling the trapezium to be separated from the carpus by cutting-pliers. The extensor tendons being relaxed by bending back the hand, the soft parts must be cleared from the carpus as far as possible towards the ulnar side.
Fig. VI.Fig. vi.[58]
The ulnar incision(Plate IV.fig.b.) extends from two inches above the end of the ulna, in a line between the bone and the flexor carpi ulnaris, straight down as far as the middle of the palmar aspect of the fifth metacarpal. The dorsal lip of this incision is then raised, and the tendon of the extensor carpi ulnaris cut at its insertion, and reflected up out of its groove in the ulna along with the skin. The extensor tendons are then raised from the carpus, and the dorsal and lateral ligaments of the wrist divided, the tendons still being left as far as possible undisturbed in their relation to the radius. In front the flexor tendons are cleared from the carpus, the pisiform bone separated from the others though not removed, and the hook ofthe unciform divided by pliers. The knife must not go further down than the base of the metacarpal bones, in case of dividing the deep palmar arch. The anterior ligament of the wrist being now divided, the carpus and metacarpus are to be separated by cutting-pliers, and the carpus extracted by strong sequestrum forceps. By forcible eversion of the hand, the ends of radius and ulna can be protruded at the ulnar incision; as little as possible should be removed, consistent with removing all the disease. The ulna should be cut obliquely, leaving the base of the styloid process, and removing all the cartilage-covered portion. A thin slice of the radius is then to be cut also with the saw, so thin as to remove only the bevelled ungrooved portion, and leaving the tendons as far as possible undisturbed in their grooves. The ulnar articular facet is to be snipped off with bone-pliers. If the bones are more deeply carious, the diseased parts must at all hazards be removed with pliers or gouge. The metacarpal bones must then be treated in precisely the same way, their ends sawn off and their articular facets snipped off with the bone-pliers longitudinally. The trapezium is then to be seized by forceps and carefully dissected out, the metacarpal bone of the thumb pared like the others, the articular surface of the pisiform removed, the rest of the bone being left if it is sound. The radial incision is stitched closely throughout, and also the ends of the ulnar incision, any ligature being brought out through the centre of the ulnar incision, which is kept open with a piece of lint, which also gives support to the extensor tendons.
The after-treatment is important, the principal specialities being—(1.) early and free movement of the fingers; (2.) secure fixing of the wrist to procure consolidation. (1.) By passive motion of the joints of the knuckles and fingers, commenced on the second day, and continued daily after the operation; (2.) By a splint supporting the fore-arm and hand, the fingers being held in a semiflexedposition by a large pad of cork fastened firmly on to the splint and made to fit the palm; this prevents the splint from slipping up the arm, and by a turn of a bandage insures fixation of the wrist-joint. The anterior part of this splint below the fingers may be gradually shortened, allowing more and more passive motion of the fingers, but the patient must wear it for months, indeed, till he finds his wrist as strong without it as with it.
Among the various operations that have been devised, the following require notice:—Mr. Spence, Dr. Gillespie, Dr. Watson, and the author, use a single dorsal incision with excellent results, and find it quite easy to remove all the bones from it. Mr. Spence had sixteen cases without a death.
Posterior Semilunar Flap, from carpal attachment of metacarpal of index finger round to styloid process of ulna; dividing integuments only, then separating the tendons of the common extensor longitudinally, and drawing them aside by blunt hooks, the diseased bones are removed piecemeal by curved parrot-bill forceps.[59]Posterior Curved Flap.—An incision down to the carpal bones, extended from a point two lines to the ulnar side of the extensor secundi internodii pollicis, and from a quarter to half an inch below the radio-carpal articulation, swept in a curvilinear direction downwards, close to the carpal extremities of the metacarpal bones, to a point just below the end of the ulna. The flap thus marked out was dissected up, and consisted of the integuments, areolar tissue, and extensor tendons of the four fingers, together with large deposits of fibrine, the products of repeated and prolonged inflammatory action. The tendon of the second extensor and its soft parts around were separated from the bones. The remains of the ligaments were cut, flexion of the hand protruded the carious ends of radius and ulna. The bones were then dissected out, leaving the trapezium, which was not diseased, and hand placed on a splint.[60]
Posterior Semilunar Flap, from carpal attachment of metacarpal of index finger round to styloid process of ulna; dividing integuments only, then separating the tendons of the common extensor longitudinally, and drawing them aside by blunt hooks, the diseased bones are removed piecemeal by curved parrot-bill forceps.[59]
Posterior Curved Flap.—An incision down to the carpal bones, extended from a point two lines to the ulnar side of the extensor secundi internodii pollicis, and from a quarter to half an inch below the radio-carpal articulation, swept in a curvilinear direction downwards, close to the carpal extremities of the metacarpal bones, to a point just below the end of the ulna. The flap thus marked out was dissected up, and consisted of the integuments, areolar tissue, and extensor tendons of the four fingers, together with large deposits of fibrine, the products of repeated and prolonged inflammatory action. The tendon of the second extensor and its soft parts around were separated from the bones. The remains of the ligaments were cut, flexion of the hand protruded the carious ends of radius and ulna. The bones were then dissected out, leaving the trapezium, which was not diseased, and hand placed on a splint.[60]
Excision of the Hip-Joint.—The question as tothe propriety of performing this operation in any case is still debated by some surgeons, and the selection of suitable cases for the operation is greatly modified by the varying opinions of the different schools of surgery. Enough here to describe the method of operating, and the amount of the bone which is to be removed.
As in the shoulder-joint, the head of the femur is much more liable to disease, and, as a rule, much earlier attacked than is the acetabulum, but unfortunately the acetabulum does eventually become affected also in probably a much larger proportionate number of cases than the glenoid. Caries of the head, neck, and trochanters of the femur is a very common disease in this variable climate, and frequently connected with the strumous taint. After much suffering, abscesses form and discharge, giving considerable pain, and often end by carrying off the patient. As a result of the abscess and destruction of the ligaments, the head of the bone is apt to be displaced, and under some sudden muscular exertion or involuntary spasm, consecutive dislocation of the femur (generally on to the dorsum ilii) very often occurs.
In such a case the operation of excision of the head of the femur is by no means difficult, and not excessively dangerous, especially in young children.
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 becarried 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 thatmaybe 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 theinfluence 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.
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, threedecidedly 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.
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 theSemilunar Incision.
Operation.—The limb being held in an extended position, a single semilunar incision (Plate I.fig.b.) ismade, 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. Itmustinvolve 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 distance of five inches. The external incision, commencing just below the head of the fibula, must be carried upwards parallel to the preceding for the same distance. Both incisions must be made by a heavy scalpel with a firm hand, so as to divide all the tissues down to the bone. The vertical incisions are then united by a transverse one passing across just below the lower angle of the patella. The flaps thus formed must then be dissected up and down, and the internal and external lateral ligaments divided, thus thoroughly openingthe joint and exposing the crucial ligaments. These must be divided carefully, remembering the position of the artery. The bones are then to be cleared and divided, as in the operation already described. This is the method of Moreau and Butcher.[67]
Patella and Ligamentum Patellæ retained.—"A longitudinal incision, full four inches in extent, was made on each side of the knee-joint, midway between the vasti and flexors of the leg; these two cuts were down to the bones, they were connected by a transverse one just over the prominence of the tubercle of the tibia,care being taken to avoid cutting by this incision the ligamentum patellæ; the flap thus defined was reflected upwards, the patella and the ligament were then freed and drawn over the internal condyle, and kept there by means of a broad, flat, and turned-up spatula; the joint was thus exposed, and after the synovial capsule had been cut through as far as could be seen, the leg was forcibly flexed, the crucial ligaments, almost breaking in the act, only required a slight touch of the knife to divide them completely. The articular surfaces of the bones were now completely brought to view, and the diseased portions removed by means of suitable saws, the soft parts being hold aside by assistants."[68]
Results of Excision of Knee-joint:—Holmes's Table of recent cases from 1873-1878—
Buck's Operation for Anchylosed Knee-Joint.—The principle of this operation is to remove a triangular portion of bone, which is to include the surfaces of the femur and tibia, which have anchylosed in an awkward position, and by this means to set the bones free, and enable the limb to be straightened. Accessto the joint may be obtained by either of the two methods already described. Sections of the bones are then to be made with the saw, so as to meet posteriorly a little in front of the posterior surface of the anchylosed joint, and thus remove a triangular portion of bone; the portion still remaining, and which still keeps up the deformity, is then to be broken through as best you can, either by a chisel, or a saw, or forced flexion. The ends are to be pared off by bone-pliers, and the surfaces brought into as close apposition as possible. The operation is a difficult one, a gap being generally left between the anterior edges of the bones, from the unyielding nature of the integuments behind, and the difficulty of removing the posterior projecting edges from their close proximity to the artery. Of twenty cases on record, eight died, and two required amputation.
Relation of Age to result in Excision of Knee-Joint from Hodge's Tables.
Of 182 complete cases:—
Excision of the Ankle-Joint.—In what cases is it to be done, and how much bone is to be removed?
In cases of compound dislocation of the ankle-joint, the tibia and fibula are apt to be protruded either in front or behind. When this happens it is a dislocation generally very difficult to reduce, and when reduced to retain in position. In such cases, if there seems to be any chance of retaining the foot, excision of the articular ends of tibia and fibula greatly add to the probabilities in its favour. It may be done without any new wound, and, in general, by an ordinary surgeon's saw.
When the astragalus does not protrude, it seems to matter little for the future result whether its articular surface be removed or not. When, on the other hand, it protrudes, as a result either of the displacement ofthe entire foot, or of a dislocation complete or partial of the astragalus itself, there is no doubt that excision either of its articular surface or of the entire bone will give very excellent results. Jäger reports twenty-seven such cases, with only one fatal, and one doubtful result.
In cases of disease of the Ankle-joint.—Excision has been performed a good many times, and should in most cases be complete. A work like this is not the place to discuss the propriety of operations so much as the method of performing them, but one remark may be permitted. Few points of surgical diagnosis are more difficult than it is to tell whether in any given case disease is confined to the ankle-joint, and whether or not the bones of the tarsus participate. If they do even to a slight extent, no operation which attacks the ankle-joint only has any reasonable chance of success. It may look well for a time, but sinuses remain, the irritation of the operation only hastens the progress of the disease of the bone, and the result will almost certainly be disappointing, amputation being almost the inevitabledernier ressort.
Methods of Operating:—
Mr. Hancockhas been very successful by the following method:—
Commence the incision (Plate II.figs.B.B.) about two inches above and behind the external malleolus, and carry it across the instep to about two inches above and behind the internal malleolus. Take care that this incision merely divides the skin, and does not penetrate beyond the fascia. Reflect the flap so made, and next cut down upon the external malleolus, carrying your knife close to the edge of the bone, both behind and below the process, dislodge the peronei tendons, and divide the external lateral ligaments of the joint. Having done this, with the bone-nippers cut through the fibula, about an inch above the malleolus, removethis piece of bone, dividing the inferior tibio-fibular ligament, and then turn the leg and foot on the outside. Now carefully dissect the tendons of the tibialis posticus and flexor communis digitorum from behind the internal malleolus. Carry your knife close round the edge of this process, and detach the internal lateral ligament, then grasping the heel with one hand, and the front of the foot with the other, forcibly turn the sole of the foot downwards, by which the lower end of the tibia is dislocated and protruded through the wound. This done, remove the diseased end of the tibia with the common amputating saw, and afterwards with a small metacarpal saw placed upon the back of the upper articulating process of the astragalus, between that process and the tendo Achillis, remove the former by cutting from behind forwards. Replace the partsin situ; close the wound carefully on the inner side and front of the ankle; but leave the outside open, that there may be a free exit for discharge, apply water-dressing, place the limb on its outer side on a splint, and the operation is completed.
Skin, external, and internal ligaments, and the bones are the only parts divided, no tendons and no arteries of any size.[69]
Barwell'smethod bylateral incisionsis briefly as follows:—
On the outer side, an incision over the lower three inches of the fibula turns forward at the malleolus at an angle, and ends about half an inch above the base of the outer metatarsal. The flap is to be reflected, fibula divided about two inches from its lower end by the forceps, and dissected out, leaving peronei tendons uncut. A similar incision on the inner side terminates over the projection of the internal cuneiform bone; the sheaths of the tendons under inner angle are then to be divided, and the artery and nerve avoided; the internallateral ligament is then to be divided, the foot twisted outwards, so as to protrude the astragalus and tibia at the inner wound. The lower end of the tibia and top of the astragalus are to be sawn off by a narrow-bladed saw passing from one wound to the other.[70]
Dr. M. Buchanan of Glasgow has described an operation by which the joint can be excised through a single incision over the external malleolus.
Results.—So far as can be gathered from cases already published, the results are very often (at least in one out of every two cases) unsatisfactory. Sinuses remain, which do not heal, the limbs are useless, and amputation is in the end necessary.
Langenbeck has performed it sixteen times during the last Schleswig-Holstein war (in 1864), and the Bohemian war in 1866, with only three deaths. In these cases the operation was subperiosteal.
Excision of the Scapula.—More or less of the scapula has in many cases been removed along with the arm, and even with the addition of portion of the clavicle.
Excision of the entire bone, leaving the arm, has been performed in two instances by Mr. Syme. The procedure must vary according to the nature and shape of the tumour on account of which the operation is performed. Mr. Syme operated as follows:—
In the first case, one of cerebriform tumour of the bone, he "made an incision from the acromion process transversely to the posterior edge of the scapula, and another from the centre of this one directly downwards to the lower margin of the tumour. The flaps thus formed being reflected without much hæmorrhage, I separated the scapular attachment of the deltoid, and divided the connections of the acromial extremity of the clavicle. Then, wishing to command the subscapular artery, Idivided it, with the effect of giving issue to a fearful gush of blood, but fortunately caught the vessel and tied it without any delay. I next cut into the joint and round the glenoid cavity, hooked my finger under the coracoid process, so as to facilitate the division of its muscular and ligamentous attachments, and then pulling back the bone with all the force of my left hand, separated its remaining attachments with rapid sweeps of the knife." (Plate III.fig.g.)
Mr. Syme's second case was also one of tumour of the scapula; the head of the humerus had been excised two years before.
He removed it by two incisions, one from the clavicle a little to the sternal side of the coracoid, directed downwards to the lower boundary of the tumour, another transversely from the shoulder to the posterior edge of the scapula. The clavicle was divided at the spot where it was exposed, and the outer portion removed along with the scapula.[71]
The author has in a case of osseous tumour removed the whole body of the scapula, leaving glenoid, spine, acromion and anterior margin with excellent result and a useful arm.
Large portions of the shafts of the humerus, radius, and ulna have been removed for disease or accident, and useful arms have resulted; but as the operative procedures must vary in every case, according to the amount of bone to be removed, and the number and position of the sinuses, no exact directions can be given.
For very interesting cases of such resections reference may be made to Wagner's treatise on the subject, translated and enlarged by Mr. Holmes, and to Williamson'sMilitary Surgery, p. 227.
Excision of Metacarpals and Phalanges.—Toexcisethe metacarpal implies that the correspondingfinger is left. Except in cases of necrosis, where abundance of new bone has formed in the detached periosteum, the results of such excisions do not encourage repetition, the digits which remain being generally very useless. It is quite different, however, if it is the thumb that is involved; and every effort should, in every case, be made to retain the thumb, even in the complete absence of its metacarpal bone. For the good results of a case in which Mr. Syme excised the whole metacarpal bone for a tumour, see hisObservations in Clinical Surgery, p. 38.
The operation is not difficult, and requires merely a straight incision over the dorsum, extending the whole length of the bone.
In the same way the proximal phalanx of the thumb may be excised, and yet, if proper care be taken, a very useful limb be left. I quote entire the following case by Mr. Butcher of Dublin:—
Excision of Proximal Phalanx of the Thumb.—The thumb of the right hand was crushed by the crank of a steam-engine. The proximal phalanx was completely shivered; its fragments were removed, the cartilage of the proximal end of the distal phalanx, and also of the head of the metacarpal bone, were pared off with a strong knife. The digit was put up on a splint fully extended. In about a month cure was nearly complete, a firm dense tissue took the place of the removed phalanx, and the power of flexing the unguinal was nearly complete.[72]
Excision of the Joints of the Fingers.—These operations may be performed for compound dislocation, specially when the thumb is injured; no directions can be given for the incisions.[73]
In cases of disease it is rarely necessary or advisable to attempt to save a finger, but if the metacarpo-phalangeal joint of the thumb be affected, excision should be performed with the hope of saving the thumb. A single free incision on the radial side of the joint will give sufficient access.
Excision of the Os Calcis.—In those comparatively rare cases in which the os calcis is alone affected, the rest of the tarsus and the ankle-joint being healthy, a considerable difference of opinion exists as to the proper course to be followed. By some surgeons it is considered best merely to gain free access to the diseased bone, and then remove by a gouge all the softened and altered portions, leaving a shell of bone all round, of course saving the periosteum and avoiding interference with the joint. This operation requires no special detailed instruction. We find many surgeons, among them Fergusson and Hodge, supporters of this comparatively modest operation. The author has many times performed this operation with excellent results. Even when nothing but periosteum is left, the new bone becomes strong and of full size.
Excision of the whole of the diseased bone at its joints, with or without an attempt to leave some of the periosteum, has been deemed necessary by others. Holmes, who has had considerable experience, removes the bone at once by the following incisions, without paying any reference to the periosteum:—
Operation.—An incision (Plate III.fig.f.) is commenced at the inner edge of the tendo Achillis, and drawn horizontally forwards along the outer side of the foot, somewhat in front of the calcaneo-cuboid joint, which lies midway between the outer malleolus and the end of the fifth metatarsal bone. This incision should go down at once upon the bone, so that the tendon should be felt to snap as the incision is commenced. Itshould be as nearly as possible on a level with the upper border of the os calcis, a point which the surgeon can determine, if the dorsum of the foot is in a natural state, by feeling the pit in which the extensor brevis digitorum arises. Another incision is then to be drawn vertically across the sole, commencing near the anterior end of the former incision, and terminating at the outer border of the grooved or internal surface of the os calcis, beyond which point it should not extend, for fear of wounding the posterior tibial vessels. If more room be required, this vertical incision may be prolonged a little upwards, so as to form a crucial incision. The bone being now denuded by throwing back the flaps, the first point is to find and lay open the calcaneo-cuboid joint, and then the joints with the astragalus. The close connections between these two bones constitute the principal difficulty in the operation on the dead subject; but these joints will frequently be found to have been destroyed in cases of disease. The calcaneum having been separated thus from its bony connections by the free use of the knife, aided, if necessary, by the lever, lion-forceps, etc., the soft parts are next to be cleaned off its inner side with care, in order to avoid the vessels, and the bone will then come away.[74]
Attempts may occasionally be made in such an operation to save a portion of periosteum in attachment to the soft parts, but success or failure in this seems to have very little effect on the future result.