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the condyles, nor the upper portion of the patellar articular surface. Saw the bone horizontally to the surfaces of the condyles, and not to the axis of the bone; the same amount of bone in length is removed from each condyle, thus preserving the obliquity of the axis to the plane of the lower end of the femur.
Separate the tissues from the upper end of the tibia to the extent of one half inch. Retract the tissues, and, by means of a Butcher's saw, divide the bone from behind forward. The saw should remove the articular surface and a thin layer of bone at a right angle to the long axis of the tibia. The section of bone is above the level of the head of the fibula.
Turn upward the flap containing the patella, and, by making parallel incisions toward the bone begin. ning from above, enucleate the bone from its capsule. By putting the fingers under the upturned flap, the patella is made prominent and its separation expedited.
Bring the sawn surfaces of the femur and tibia into exact apposition, and wire them together. Suture with catgut the divided ligamentum patellæ. Provide drainage from the pouch above the bones to the lower angles of the wound. Suture the deep tissues (capsule) together by means of buried sutures of catgut. Close the external wound, providing for drainage from the superficial parts of the wound.
Ankle-Joint.—Turn the leg upon its inner surface.
Make an incision three inches long over the lower subcutaneous portion of the fibula, down along the posterior border of the external malleolus. Extend the incision to the tip and up along the anterior bor. der of the malleolus. Divide all the tissues against the bone. Separate the tissues from the bone up to the interosseous space by means of an elevator. Pass a wide director through the interosseous space to protect the tissues while the bone is sawn by means of a chain-saw. Grasp the lower sawn end of the fibula, and separate its lower and internal attachments, keeping the edge of the knife against the bone.
Turn the leg upon its outer surface. Make an incision three inches long over the tibia near its inner border, extending over the internal malleolus near its posterior border. Continue the incision over the lower to the anterior border of the malleolus, Di. vide the tissues and separate them from the bone to a level above the joint. Saw the internal malleolus, and complete its division by means of cutting forceps. Remove the internal malleolus, cutting toward the bone to avoid the tendons and vessels in close proximity. Protrude the tibia and saw off its articular surface.
Push the astragalus into the opening, and remove its articular surface by means of the rongeur. Appose the cut end of the astragalus to that of the tibia.
AMPUTATIONS AND DISARTICULATIONS.
MANIPULATION OF THE AMPUTATING-KNIFE.
1. How to hold the Knife.—In operating gracefully, several methods of holding the amputating-knife are practiced :
(a) The knife is held ordinarily as a table-knife. This method was discussed as practiced with the scalpel.
(6) The knife is held with the handle in the full grasp of the hand. If the edge of the knife be turned from the palm of the hand, the thumb should be placed as a support on the back of the handle.
(c) The handle of the knife near its extremity is held between the pulps of the index and middle fin. gers and the thumb. The extremity of the handle can be made to describe an arc in the space between the index finger and thumb without touching the palm of the hand. The knife, pointing upward, has its edge turned toward the palm of the hand.
This method is used in making a circular incision around a limb.
2. How to cut with the Knife.-In cutting with the amputating-knife the blade should be given a free sawing movement.
When the knife is used to pierce, its point should be steadily advanced; never partially withdrawn and again advanced, because the first thrust may have wounded some important structure.
STEPS IN OPERATING.
1. Tissues belonging to the part distal to the site of the operation must be left in continuity, to serve as a covering for the wound-surface caused by the amputation.
(a) Circular Method.—In this method one or more cellulo-cutaneous flaps are raised to cover the wounded surface. All the tissues are divided at a right angle to the long axis of the limb near the level of the base of this cellulo-cutaneous covering. The soft parts are divided at a lower level, and the bone is sacrificed up to a little higher level than the base of the covering
(6) Flap Method.—In this method other tissues besides skin and subcutaneous fascia enter into the formation of the covering provided for the woundsurface. The covering may be formed by transfixion and cutting toward the surface, or by cutting from the surface toward the bone, and may consist of one or more flaps.
2. Periosteal Flap.—The bone is provided with a covering of periosteum for its sawn surface by raising this tissue from the bone to be sacrificed before
applying the saw.
(This flap is made to prevent the atrophy of the end of the bone; it also lessens the chance of an adherent cicatrix.)
3. Interosseous Flap.—Where two bones are to be sawn through, the tissues between should be divided transversely at a level one half inch lower than the saw-cut, and then separated from the bones up to this level.
The vessels in this flap are easily controlled.
4. The bone is generally removed up to a little higher level than that of the divided soft parts. If the bone is to be divided, it is sawn off ordinarily at a right angle to the long axis of the limb.
The sacrifice of the soft parts is not necessarily in fixed proportion to that of the bone.
AMPUTATIONS AND DISARTICULATIONS OF
Amputation and Disarticulation of Fingers.-During all the operations on the hand, compress the arteries at the wrist. The three rows of knuckles are formed by the heads of the proximal bones entering into the articulations.
Disarticulation at the Distal Phalanx.Pronate the hand. The finger should point toward the operator, and be held between his thumb above and his index-finger beneath.
Make incisions in the long axis of the finger in the middle of the lateral surfaces which begin over the expanded base, and continue downward two thirds of the length of the phalanx. Flex the joint to a right angle, and join the proximal ends of the lateral incisions by a dorsal incision over the line of the joint. Open the joint by an incision slightly convex toward the body, and divide the lateral ligaments.
Pass the finger-knife, with its edge directed to