The principles and practice of modern surgery

AMPUTATIONS OF THE LOWER EXTREMITY.

The most important physiological purposes of the foot are those of support and locomotion, not mere tactile sensibility nor prehension. Its purposes being different from those of the upper extremity, the tenets previously held regarding the advantage of conservatism may be changed to some degree, for a tender foot or leg-stump is sometimes extremely annoying, even disabling, and it is in the end far better to so plan an amputation of this extremity as to make the stump most serviceable, without primary reference to its exact length. As in the hand, foot-stumps should be covered with dense plantar (instead of palmar) tissues, and the long flap should, therefore, be made from the sole. When this is impossible it would be wiser to shorten the stump. Moreover, as there will be constant friction upon the resulting cicatrix, this should be placed in the most protected location, on the dorsum of the foot.

The most important indication, then, in all foot amputations is to furnish a complete plantar flap and to place the scar on top of the foot.

The Toes.

—Amputations of the toes are, by virtue of their shortness, nearly always disarticulations. The basal row of phalanges should be preserved when possible, and even here the covering of the stump should be as far as possible fashioned from the sole.

The big toe may be removed by either internal or oval plantar flaps, which should be long enough to cover the metatarsal head, otherwise the latter must be decapitated. These same principles also apply to the little toe. When all or most of the toes have to be severed it may as well be done by a single dorsal incision, as seen in Fig. 692, which will permit either their disarticulation or their removal along with that of the ends of the metatarsals. These methods are shown in Figs. 692 and 693.

Amputation of a toe with its metatarsal is best effected by a racket incision. This may extend up to the posterior tarsal joint. Some have recommended to enucleate the metatarsals subperiosteally, through dorsal incisions, all the soft parts being scrupulously left behind. With the first and fifth toes the scar should be so placed as to be removed from the edge of the foot (Fig. 693).

Partial amputations of the foot have been suggested and devised in great numbers, and the subject has been greatly complicated by the number of methods that were taught. Modern ideas of conservative surgery have caused a complete departure from the anatomist’s standard, and it has been shown that with aseptic technique there is no advantage in disarticulating when it leaves irregular lines. As Matas says: “As Agnew taught long ago in this country, and others elsewhere, the skeleton of the foot must be considered a surgical unity, to be treated by the knife and saw just as the femur and humerus would be, at the exact point which will yield the longest and most useful stump to the patient. What is essential in every case is the application of the principle of plantar flaps—preservation and scar protection.”

Concerning the utility of many of these methods and the usefulness of the resulting stumps we may learn more from the makers of artificial limbs than from almost any other source. Thus, Truax, for instance, who has had large experience as a mechanic, has given this advice, as quoted by Matas: “Avoid amputation within three inches of the ankle-joint; do not amputate between the metatarsal bones and the junction of the lower and middle thirds of the tibia. At other points save all you can, and you will in every case have done the best for your patient.” Should one be rationally governed by this advice a large number of amputation methods which cumber most text-books would be discarded.

For my own part I would advise to save all of a foot that can be saved, providing a sufficiently long plantar or heel flap can be retained; but if these are not available, then I would advise amputation, at least three inches above the ankle.

I would advise, moreover, to discard the complicated rules and technique of stilted methods and to use the saw whenever it can be made useful, rather than to go farther back to a row of joints simply because they are joints (Fig. 694).

Figs. 695 and 696 illustrate conservative modern methods, which are perfectly available for most purposes, and from which departure need be made only when peculiar circumstances obtain, which so complicate the case that none of the ordinary rules would apply. A surgeon of judgment and experience is competent to devise a flap for a given case, whether it complies with standard methods or not. It seems to me, therefore, worth while to describe only the so-called mediotarsal disarticulation of Chopart, in which but the astragalus and calcis remain of the proper bones of the foot. The joint line extends from just behind the tuberosity of the scaphoid to the outer side of the body of the calcis, where a tubercle can be usually felt. Across this line an incision is carried obliquely over the dorsum of the foot. The plantar flap is the long one, and the line of division is just behind the balls of the toes. Two lateral incisions can be made to facilitate disarticulation if desirable.

This operation sometimes leaves the foot in a bad equinus position; accordingly it is wise to make tenotomy of the tendo Achillis, as well as to attach the dorsal or extensor tendons to the stump end. (See Figs. 699 and 700.)

Amputations of the Foot (Tibiotarsal).

—The former favorite method of amputating the foot proper was that of Syme, illustrated in Fig. 701. This preserved the plantar surface and tip of the heel, thus forming a cutaneous hood, which was made to cover the lower ends of the tibia and fibula, whose malleoli were usually removed close to their terminations. The incision is made directly down to the bone, from the apex of one malleolus across the sole and up to the other. Then the foot is forced into extreme flexion and another incision carried directly across the dorsum, by which the upper ends of the first are joined. This permits opening the ankle-joint in front, after which the lateral ligaments are divided and the astragalus dislocated forward. The heel hood is next carefully separated from the calcis with the knife, and it and all the parts retracted from the ends of the leg bones, which are divided just above the articular surfaces, or the latter may be left and the malleoli alone removed. Now the heel hood is raised, made to cover the end of the leg, and united to the anterior incision, drainage being made by a small opening on the outer side of the tendo Achillis, as the plantar surface of the flap should not be opened (Fig. 703).

Fig. 702, the complement of Fig. 701, illustrates the appearance of the stump after the completion of the disarticulation and before the removal of the malleoli.

Pirogoff introduced a serviceable modification by obliquely dividing the os calcis in front of the heel, turning up its sawed surfaces without any dissection of the hood from the heel, and uniting its fresh bone aspect with that made by removal of the articular ends of the leg bones. This would seem to be preferable to Syme’s disarticulation, affording a better walking stump. (See Figs. 704 and 705.)

A reverse of this operation was suggested by Mikulicz and Wladimiroff, independently, and at about the same time, the heel being excised by an incision across the sole and then behind the ankle, the calcis being divided and its posterior end removed, while the articular surfaces of the leg bones are also removed. The foot is then brought down so that these surfaces can be brought in contact, it being expected that after their reunion the individual will walk in the exaggerated equinus position and upon the ends of the metatarsal bones. The operation is, in effect, an exsection rather than an amputation, and is applicable to but a very small number of cases, in which, however, it sometimes gives excellent results. (See Fig. 707).

Amputations Of the Leg.

—Modern prosthetic methods have materially changed the indications in amputating the leg. The pressure in artificial limbs is not borne upon the end of the stump, but is rather circumferential and borne by a conical socket. It is now, therefore, an object to preserve as much of the limb as practicable, in order to have better leverage or control of the artificial member. Consequently the point of election is now the middle of the leg, unless the amputation may be made even below this point. The objection to a short leg stump is the inevitable flexion which the hamstring flexors will produce; in such cases the pressure will be borne upon the knee, while the appearance of the stump is by no means ideal. If, therefore, one is forced to make a high amputation of the leg it would be far preferable to make a good knee disarticulation, or, better still, a supracondyloid amputation, with preservation of the patella, thus furnishing a stump which affords perhaps the only exception to the general rule, i. e., that weight cannot be borne upon the stump end.

Let us, then, consider but one or two amputations of the leg—that low down or near the middle and that at the knee. Whatever the method it is most desirable that the scar be kept off to the side, and especially away from the front of the shin. This can be best accomplished by a modified circular (Fig. 708) or a bilateral flap method (Fig. 711), or by the oblique method with lateral incisions, which practically convert it into an anteroposterior operation, while for certain instances the method of Teale may be preferred, i. e., that with a long anterior and short posterior flap, or its modification by which the flaps are made more lateral, or the even long flap method of Bell.

Whichever of these be selected, after division of the muscles and exposure of the bone, it is usually helpful to retract the flaps, whatever their shape, by a cloth retractor made of a piece of sterile bandage torn into three strips, the middle of which should be inserted between the bones of the leg, the interosseous membrane being divided for this purpose; by this they are held more perfectly out of the way during the act of dividing the bones. The anterior border of the tibia, which is practically a sharp ridge, should be divided obliquely (bevelled), either by a small oblique section before the transverse division is made, or by effecting this later, in order that there shall not remain a sharp point to project through the skin or be subject to constant irritation. The tibia is usually divided transversely, with the above exception. The fibula may be divided slightly obliquely. It is customary, however, to make the division simultaneously, and to so conduct the sawing process as to divide the fibula completely before the last strokes of the saw cut through the tibia.

There is greater difficulty in the recognition and securing of vessels in leg amputations than in any other, especially if they have been divided obliquely. The principal vessels may be found from their known anatomical location. They nevertheless sometimes tend to retract and they must be followed up in order to properly secure them. The accompanying nerve trunks should also be seized firmly, drawn down, and divided two or three inches above the line of division of the other tissues, in order that they may retract out of harm’s way. Every nerve which can be recognized, even in the skin, should be thus treated. Before closing the wound it is well, unless one is absolutely sure of his work, to release the tourniquet and ascertain if any vessel which would otherwise bleed be not yet secured. Oozing may be checked with hot water, while muscle surfaces which leak too much blood may be lightly enclosed within catgut sutures inserted with a curved needle.

Providing that these stumps have well-nourished flaps, and that no sharp or angular bone ends interfere with subsequent comfort, and that the scars be kept away from their lower surfaces, they serve their purpose admirably.

Supposing, then, that amputation is to be about the middle, the first incision, made with a stout scalpel, is begun at the anterior border of the tibia and carried downward along it until it is turned abruptly backward to the posterior aspect, and then upward until a point is reached opposite that of commencement. The skin is dissected up for perhaps an inch. Then the flap on the other side is cut after the same fashion, after which, with a short or long knife, the muscles are divided transversely or circularly down to the bone. Much will depend now upon whether the desire is to resort to the more modern osteoplastic methods or adhere to the old. In the latter case it is well to separate the flaps for the necessary distance from the bone, with or without the periosteum, dividing the bones after suitable retraction, as above suggested. If preference be for an osteoplastic flap it is planned and made at this time, the bone being divided at the same level as the muscles, and the amputation being thus practically completed, after which the osteoplastic flap is arranged, it being now necessary to carefully preserve the periosteal bridge and to again divide the bone at the base of this periosteal flap, this being the true end of the bone stump. In this case the fibula is divided at a higher level.

It is perhaps less desirable to preserve periosteum in young children than in adults, for if bone be permitted to grow too rapidly conical stumps result, sometimes even with protrusion of bone ends. Ollier and his pupil Mondan have shown that this so-called atrophic elongation of bone is a consequence of abnormally rapid growth from the upper epiphyseal direction, permitted by lack of pressure from below, and that conical stumps will often happen in children in spite of every precaution. Nevertheless it should not be encouraged, and for this reason periosteum should not be preserved.

The method of Teale was to cut a long anterior flap, raising the coverings from the bone with the least possible disturbance, to divide the bone at the high level, then to double the flap upon itself in such a way as to bring the scar at a level one inch or more above the stump end. Heine modified this slightly by raising the periosteum with the rest of the anterior flap. In cases which permit such a long flap to be formed from one aspect of the leg the method gives excellent results (Fig. 709).

Bruns devised a method which is begun almost as an exsection, by an oblique circular incision, with liberating lateral incisions, and division of all the tissues over the inner border of the tibia and the outer side of the fibula; after which, without disturbing skin attachments in front, the periosteum is separated from the bones as high as the liberating lateral incisions permit, and then the fibula first and later the tibia divided. It is practically a subperiosteal excision of the leg bones and affords a well-protected stump. In effect it is an anteroposterior flap method.

The Knee.

—It was Brinton who, in 1872, suggested the preservation of the semilunar cartilages in all knee disarticulations, as in this way all the normal relations are preserved and retraction is prevented. But the makers of prosthetic apparatus have urged to abandon all true disarticulations, and to substitute for them the supracondyloid method, which affords ideal stumps. Disarticulations are supposed to produce less shock, less loss of blood, and less danger of sepsis from opening up the bone-marrow, while muscle insertions are less disturbed and the stump covering usually is mobile and not very sensitive. No disarticulation should be thought of unless the joint involved be free from disease and unless about it there be met sufficient healthy integument to furnish a satisfactory flap.

For a true disarticulation Stephen Smith’s bilateral method is now almost universally adopted. Here the incision is begun one inch below the tubercle of the tibia and is carried directly down to the bone, downward and forward around the side of the leg, and then inward and upward toward the middle of the popliteal space, the lateral flaps thus made being nearly duplicates. The flaps thus cut out are completely separated from the bone up to the joint level, where the ligaments are divided, the joint being manipulated as may be necessary to best expose them and facilitate division. In this operation the patella is usually removed, the joint being opened by separating its ligament at its insertion into this bone. One should remember that the internal condyle is lower and longer than the external, and that the internal flap should be perhaps made on this account a little the longer of the two. Fig. 710 illustrates the stump resulting from this operation and shows the cicatrix drawn up out of harm’s way and resting in the fossa between the condyles. Fig. 711 illustrates the simple method by lateral flaps.

Amputation of the Thigh.

—Under this head, rather than that of amputation at the knee, should be described the supracondyloid amputations which give decidedly the best results of all, and which are preferable to any others for the middle of the lower extremity. Of these the best is that suggested by Gritti, which consists in not only removing the condyles but sawing off the articular surface of the patella, which is then drawn upward and applied to the end of the femur, the division of the latter being made at a point above the condyles, where the diameter of both bones will nearly correspond, this latter perhaps being a suggestion of Stokes rather than of Gritti, who did not divide the bone quite so high. (See Fig. 712.)

Fig. 712 will best illustrate the intent of the method as well as its performance. The incisions are planned much as in the Stephen Smith disarticulation method, only they are placed higher, and the patellar tendon is divided as low down as possible, or even separated from the tibia, in order that it may be made of use in attaching the divided patellar surface to the femoral end. The rest of the operation is performed as by other methods, the attachment of the patella being effected by tendon sutures, or, if necessary, by an ivory peg, or even a metal tack or nail which may be left in place.

The beauty of this method is that the anterior surface of the patella is preserved with its natural weight-bearing facilities and the bursa between it and the skin, while the latter is undisturbed. On the end of this stump as much weight can be steadily borne as when one ordinarily kneels, and to it a most serviceable kind of artificial limb can be attached, with which one may walk as though nothing had ever happened.

Another osteoplastic method, namely, that of Sabanejeff, is illustrated in Figs. 713 and 714. In this instance the bone covering over the end of the femur is taken from the upper end of the tibia, the patella not being disturbed. It permits a lower division of the femur and the formation of a stump which is of practically the same length as the original thigh.

Amputation of the Thigh above the Knee.

—For removal of the thigh it is well to preserve as much of its length as possible, and yet not at the expense of all other considerations. A thigh stump too short is likely to be pulled awkwardly upward by the psoas muscle, and upon such a stump it is difficult to secure an artificial limb tolerable of control against such action of this muscle. On this account, then, thigh stumps should be long. So far as the method is concerned the circular, or some modification thereof, gives the best results in the majority of instances. It may easily be modified into one of the oblique methods, or liberating incisions may be used whenever they will be of service. If it be absolutely necessary to make the amputation high hemostasis can be secured by the same methods that are used in hip-joint amputations. The dense and strong fascia lata, which lies beneath the superficial fascia, should be divided at the same level with the skin, since it serves admirably, when secured by a separate set of sutures, to make a good covering for the ends of the muscles, after these have been themselves carefully united by buried sutures. The sciatic nerve should be especially sought, thoroughly stretched, and divided high up. The vessels often evince a tendency to retract within Hunter’s canal; it is not, however, difficult to separate the vastus internus from the adductor longus, between which they lie, and in this way gain access to them. Even for high work on the thigh one may, if necessary, do as some have done at the hip, make a preliminary ligation of the femoral artery. This may be especially serviceable as an emergency measure, or in special cases of tumors which have attained large size, are placed high up and call for somewhat atypical methods.

The Hip-joint.

—Amputation here is essentially a disarticulation and constitutes one of the usually formidable and serious operations of major surgery. Although the joint itself is generally easily reached there are many things to be considered in the performance of this operation, of which the mere arthrotomy is by no means the most important.

Preparations being all made, the first consideration is the control of hemorrhage, for which several methods have been suggested, but of which but two or three are in general use. Such procedures as compression of the abdominal aorta, either with the hand or by tourniquet, or of the common aorta through the rectum, with a lever, as suggested by Davey, or with the hand, as suggested by Woodbury, or the exposure of the common iliac, either within the peritoneum as practised by McBurney, or externally, or exposing the common femoral above Poupart’s ligament, are now adopted by very few surgeons. Langenbeck used to be fond of preliminary ligation of the femoral where it is most accessible in the groin, and this is probably the best of all of these methods. But they have been all practically discarded since Wyeth introduced the simple method of transfixing the limb with his pins (i. e., long mattress needles or skewers made for the purpose), these serving to hold in place an elastic cord or tourniquet (Fig. 715). This has been found to be a great improvement on the suggestion of Senn, who excised the femoral head and then compressed each half of the limb with a separate elastic band.

The directions for the use of Wyeth’s pins are simple. Here, as in other cases, it may not be practicable to use the elastic bandage from the lower end of the limb, but one may at least elevate the limb and thus coax the blood out of it by gravity or by gentle manipulation. While it is still in this position one of the long pins is introduced just below the anterosuperior spine and a trifle to its inner side, and made to emerge on a level with and about three inches from the point of its entrance. The other needle is inserted just to the inner side of the saphenous opening, and below the level of the crotch, and brought out about one inch below the tuberosity of the ischium. Corks should then be placed upon them so as to protect the needle points. Next a piece of elastic tubing or band is placed around the limb above these pins and tightened, each turn being made a little tighter, so as to absolutely control the circulation. The effect of this is felt upon practically every vessel in that part of the body, and if the method be properly practised it affords absolute security.

The surgeon now has his choice of various methods of disarticulation, either that by anteroposterior flaps or lateral flaps, or by the circular, with the free liberating lateral incision; or he may devise any method of his own which will best meet the indication in a given case. Fig. 715 illustrates the employment of Wyeth’s pins and the first circular incision made as for the circular method. Of these all the latter seems preferable when circumstances permit. It should be combined with a sufficient lateral incision, which should be made to pass well over the great trochanter. The cuff raised through this incision should extend down to the deep fascia and up to the level of the lesser trochanter, at which level the deeper tissues are divided transversely or by a circular cut.

It is well next to lay down the knife and secure the large vessels, after which the deep muscles are separated from the upper end of the shaft and the proximity of the joint, while the entire limb may be still used as a lever in so stretching the joint capsule as to better expose and divide it. So soon as the capsule has been opened, and the entrance of air thus permitted, it will be easy to expose and divide the teres ligament, after which the balance of the disarticulation is easily effected. The large nerve trunks are now sought, retracted, and divided high up, all visible vessels are secured firmly, after which the elastic constriction may be gradually released and any vessels that spurt may still be secured. There will nearly always be troublesome oozing from the cut ends of the large muscles, and here, if hot water prove insufficient to check it, with large curved needles and catgut sutures the muscle ends may be secured by ligature en masse, before they are brought together for the purpose of closing the stump.

Whatever the method selected as perfect a closure of the wound as possible should be made, with ample provision for drainage. By careful deep suturing, with tiers of buried sutures, it is possible to avoid leaving dead spaces at any point except perhaps the acetabulum. Through retaining sutures may also be used to advantage. It is most desirable to so plan the incisions and the closure of the wound as to keep them, so far as possible, away from the region of the perineum. Therefore the longer the inner flap or inside of the stump the better. As conditions which necessitate removal of the limb at the hip-joint are always serious, and have each their own peculiarities, any method which will best serve the purpose should be used.

Plates LIX and LX, designed by Prof. Matas, afford the best and briefest epitome of the choicest amputation methods which can be furnished.

THE STUMP.

An amputation having been effected, and the stump closed, there is still occasion to consider how it may best be treated to fit it for its future purposes. When entire chapters, or even small monographs, can be written on the subject of “diseases of stumps” it would appear that the consideration is not one of merely trifling import.

A good stump has a regular outline, with a protected scar, and should be firm, yet mobile, and without tender or sensitive surfaces. It should constitute the lower end of a truncated cone, and needs to be of sufficient length to permit leverage within the socket of the artificial limb which will be fitted about it.

A stump failing in these characteristics is a bad stump, the features which especially tend to make it bad being undue conicity (Fig. 716) or sensitiveness of surfaces, ulceration from friction, or, worse yet, occurring without it, and neuralgia from inclusion of nerve ends, or from bone ends which present osteophytic outgrowths and thus distort and displace tissues (Fig. 717). Acute osteomyelitis occurs in stumps, as do slower carious processes which may call for re-amputation, perhaps even at a distance. The stump is for a long time more or less tender and troublesome, and its owner may be a sufferer from hyperesthesia or perverted sensations.

The possibility of the production of a conical stump in children as the result of atrophic elongation was mentioned early in this chapter. While this cannot always be prevented it may sometimes be foreseen, and one should be prepared at any time in such cases to circumcise the bone, forcibly retract the tissues, and then divide the bone ends on a higher level.

An exquisitely neuralgic stump is usually made so by the entanglement of nerve ends and their subsequent enlargement into so-called amputation stump neuromas (which are histologically fibromas), from pressure upon nerve terminals. Under these circumstances their excision through incisions planned for the purpose, or the exsection of a portion of the nerve trunk at a higher level, may be necessitated (Fig. 717).

While patients may prefer disuse of a stump for as long a time as possible the judicious surgeon will prepare it as rapidly as he may for early application of the expected artificial limb. Inasmuch as leg stumps allowed to hang downward become cyanotic and edematous it is well to keep them bandaged, and the makers of artificial limbs prefer to have the bandages kept wet. When the stump is healed, passive motion of the remainder of the limb should be begun, in order that there may be a minimum of stiffening of joints. If, then, such a stump be bathed, massaged, moved, and then bandaged with comfortable snugness with cold, wet bandages, over which oiled silk may be fastened, and if this be done at least once each day, the stump will be prepared for the artificial limb, on the average, in two to three months. One should not wait for this expiration of time if it be thoroughly healed; or, on the other hand, he may have to wait much longer under unfortunate circumstances; but the above general principles of treatment and general statements will be found to prevail. Figs. 718 and 719 illustrate the difference between good and bad stumps, while Plates LIX and LX (reproduced from Matas) furnish the surface outlines for selection of the various amputations of the lower limb.

CINEPLASTIC OR CINEMATIC AMPUTATIONS OF THE UPPER EXTREMITY.

The most pronounced and illustrative of recent methods is perhaps the “cinematic” or “cineplastic” procedure of Vanghetti. This Italian surgeon proposed a prosthetic method, in 1898, which is illustrated in Figs. 720, 721 and 722. He has shown that tendon terminations may be left exposed in stumps, under favorable conditions, and so utilized as to serve remarkably useful purposes—though under exceptional conditions. For a description of these methods the reader is referred to his monograph. (G. Vanghetti, Plastica e Protesi Cinematiche, Empoli, 1906.)