A NEW MODE OF AMPUTATION AT THE I was called by Dr. Craig, May 18, 1866, to see Michael Donohoe, æt. 10 years, who had been run over by a city horse-car, the wheels passing over his foot high up in the instep, nearly severing the foot from the leg, with the exception of the astragalus and os calcis, the former being partially dislocated. The soft parts were terribly lacerated and contused, and a portion of them carried away. After a careful examination of the case, we determined to perform an operation that I had performed before with satisfactory results, viz., make a curvilinear incision across the dorsum of the foot, commencing anterior to and a little below the internal malleolus, and terminating at a corresponding point a little below the external malleolus, and then uniting the two extremities of the dorsal section by an incision across the sole of the foot, forming an anterior and posterior flap, similar to the operation performed by M. Pirogoff, of Russia. After forming the anterior flap and turning it back, I then dissected out the astragalus from its attachments, being careful to keep close to the bone. Then forming the posterior flap from the sole of the foot, I made a careful dissection, exposing the anterior half of the calcaneum; this being done, and the soft parts being well retracted by an assistant, the saw was applied so as to remove the anterior half of the bone by an oblique incision from above downward and from behind forward. The sharp edges of the remaining portion of the bone were then rounded off, and the sawed surface was applied directly to the articular surface of the tibia, without removing any part of the cartilaginous surface. After stitching up the flap in the usual way, a strip of adhesive plaster was applied, three inches in width, extending from the upper portion of the gastrocnemius muscle to a corresponding point on the anterior surface of the leg, passing directly over the os calcis, so as to keep it closely and pretty firmly in apposition to the articular surface of the tibia, which was kept there until union between the bones had taken place. The adhesive plaster, and the manner of using it as recommended by Dr. H. G. Davis, I regard as a very important auxiliary in the treatment, as it effectually prevents the retraction of the gastrocnemius muscle and the gaping of the wound. In the present case the patient was able in six weeks' to bear some weight upon the stump, and in two months could walk quite well; and in three months was going to school, running and playing with the rest of the boys, with but very little apparent inconvenience, and without any artificial assistance from crutch or cane. As there are some new and important facts developed in this case (such as the placing the sawed surface of bone directly in contact with a cartilaginous surface, and obtaining union by the first intention), and as this is the third operation I have performed, with like results in all, I thought it proper to call the attention of this learned Association and of the medical profession generally to the advantages of this amputation over any other at the ankle-joint. The advantages of this operation are: First, that the relations of the tibia and fibula, and of their cartilaginous surfaces, are not in the Cast of sound limb four years after the operation. Cast of amputated limb four years after the operation. least disturbed, and there is on that account a better chance for the growth and development of the limb in young subjects. That the limb continues to grow and attain its full development in exact proportion and equally with the sound limb, is proven beyond The case was seen at this stage by Prof. A. C. Post, who was very much pleased with the result, and recommends this method of amputation in young subjects. contradiction by the two casts that I here present. The operation in this case, as above stated, was performed May 18, 1866. The two casts which I here present were taken under my direction on the 28th of April, 1870. One is a model of the sound limb, the other was taken from the limb on which the operation was performed, and it is obvious that the one is as well developed as the other. The second advantage of this operation is that the vascular relations of the principal flaps are much less disturbed by dissection, and there is therefore much less danger of sloughing or tardy or imperfect healing of the wound. The third advantage is that it gives a more perfect stump, better adapted to bear all the weight of the body than those resulting from Syme's or Pirogoff's operation. Fourth, the shortening of the limb 'does not exceed half an inch to an inch, consequently he can wear an ordinary boot by lacing it to the limb above the stump, and stuffing the distal extremity of the boot with hair or wool; or if he prefer to wear an artificial foot, such an appliance can be well adapted to it. The fifth advantage is that this operation will not be followed by osteo-myelitis Photo taken from life two months after the operation. Photos taken from life four years after or periostitis, which may be the case with those operations where the malleoli together with a thin slice of the bone is sawn off. It is a well-known fact that inflammatory action, such as osteomyelitis or periostitis, does sometimes follow Syme's or Pirogoff's operation, especially in young subjects. Sixth, that the operation can be done in one-half of the time of either of the operations to which I have referred, and with less dissection around the anklejoint; consequently there is less danger of injuring the plantar arteries, and union by the first intention is more likely to occur. Seventh, I believe that the plan, generally adopted by surgeons, of removing healthy cartilaginous incrustations before adjusting the soft parts to the bone, is not founded on correct principles, and that there is no reason for apprehending any injurious consequences from placing a sawed section of bone in contact with cartilage. |