Chapter III: Excision of Joints (2)

_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--

245 cases; 25 deaths, and 47 failures.
Spence's--33 cases; 22 recovered, 11 died.

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. Access to 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:--

68 below 16 years: 50 recovered--18 died; or 26 per cent. died.
114 above 16 years: 55 recovered--59 died; or 51.7 per cent. died.

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 of the 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 inevitable _dernier ressort_.

_Methods of Operating_:--

_Mr. Hancock_ has 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, remove this 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 parts _in 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's_ method by _lateral incisions_ is 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 internal lateral 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, I divided 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's _Military Surgery_, p. 227.

EXCISION OF METACARPALS AND PHALANGES.--To _excise_ the metacarpal implies that the corresponding finger 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 his _Observations 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. It should 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.

_Hancock's Method._--A single flap was formed in the sole, with the
convexity looking forwards, by an incision from one malleolus to
the other.

_Greenhow's Method._--Incisions made from the inner and outer
ankles, meeting at the apex of the heel, and then others extending
along the sides of the foot, the flaps being dissected back so as
to expose the bone and its connections.[75]

EXCISION OF ASTRAGALUS.--A curved incision on the dorsum of the foot extending from one malleolus to the other, and as far forwards as the front of the scaphoid. The chief caution required is to divide all ligaments which hold the bone in place, and dissect it clean on all other parts before meddling with its posterior surface where the groove exists for the flexor longus pollicis tendon near which the posterior tibial vessels and nerve lie.[76]

EXCISION OF ASTRAGALUS AND SCAPHOID.--An incision similar to the anterior one in Syme's amputation at the ankle. The flap was then turned back from the dorsum of the foot. The joint was then opened, the lateral ligaments of the ankle-joint divided, the foot dislocated so as to show the astragalo-calcanean ligaments, and allow them to be divided. The bones were then grasped with the lion-forceps and pulled forwards, while the posterior surface of the astragalus was very cautiously cleaned, so as to avoid the posterior tibial artery.[77]

EXCISION OF METATARSO-PHALANGEAL JOINT OF GREAT TOE.--Butcher performs it by splitting up the sinuses leading to the carious joint, exposing it and cutting off with bone-pliers the anterior third of the metatarsal bone, and the proximal end of the first phalanx. He also cuts subcutaneously the extensor tendons to prevent them from cocking up the toe.[78] Pancoast prefers a semilunar incision. A lateral incision is usually to be preferred.

The author has performed this excision frequently for disease; when the whole cartilages are removed and the wound is freely drained, an admirable result is obtained.

In cases of compound dislocation of the head of the metatarsal bone, it will occasionally be found necessary to excise it either by the original, or a slightly enlarged wound.

The author lately excised one-half of shaft of metatarsal and the corresponding half of proximal phalanx of great toe for exostosis, with antiseptic precautions. The result was a useful toe with a _mobile joint_.

EXCISION OF METATARSAL BONE OF GREAT TOE.--For this operation a quadrilateral flap has been recommended, but this is quite unnecessary. A single straight incision along the inner border of the foot, extending the whole length of the bone, renders it very easy to remove the whole bone from joint to joint. This is an operation, however, which is rarely needed, and which would leave a very useless flail of a toe. The operation, which is at once more commonly required, and also gives promise of a more satisfactory result, is the one performed for cario-necrosis of the shaft only, and in the following manner:--

A straight incision through all the tissues, including the periosteum, right down to the bone; then with nail or handle of the knife to separate the periosteum from the bone; then with a pair of bone-pliers or a fine saw to divide the shaft from both its extremities and remove it entire.[79]

FOOTNOTES:

[52] _On Diseases and Injuries of Joints_, p. 121.

[53] For a very large amount of most interesting and valuable information on the whole subject of excisions of joints, I would refer to Dr. Hodge's most excellent work on this subject--_On Excisions of Joints_. By Richard M. Hodge, M.D., Boston, Massachusetts.

[54] See Syme's _Observations on Clinical Surgery_, pp. 55, 57; Hodge _on Excision of Joints_, p. 63.

[55] Maunder's _Operative Surgery_, 2d ed. p. 123.

[56] _Edin. Med. Journal_, May 1873.

[57] Quoted by Mr. Porter. _Dublin Quarterly Journal_ for May 1867, p. 264.

[58] A-A. Deep palmar arch; B. Trapezium; C. Articular surface of ulna; Dotted lines include the amount removed in Lister's earlier operations; Unshaded portions are those removed by Lister in cases where the disease is limited to the carpus. (Reduced from Lister's diagram in _Lancet_, 1865.)

[59] Skey, _Op. Surg._, 2d ed. p. 438.

[60] Abridged from Butcher, _Op. and Con. Surgery_, p. 208.

[61] _Science and Art of Surgery_, 3d ed. p. 745.

[62] _On the Surgical Treatment of Children's Diseases_, pp. 454-6.

[63] _Clinical Society's Transactions_, vol. xiii. p. 71.

[64] Billroth of Vienna and Pelikan of St. Petersburg, quoted from Heyfelder by Hodge _on Excision of Joints_, p. 161.

[65] _Operative and Conservative Surgery_, pp. 28, 138.

[66] _On Excision of Knee-Joint_, pp. 18, 20.

[67] _Operative and Conservative Surgery_, p. 169.

[68] Mr. Jones of Jersey, _Med. Chir. Trans._, vol. xxxvii. p. 68.

[69] _Lancet_, Oct. 1, 1859.

[70] Barwell _On Diseased Joints_, p. 464.

[71] Syme _On Excision of the Scapula_, pp. 13-26, 1864.

[72] Butcher's _Operative and Conservative Surgery_, p. 225.

[73] For an excellent case, see Annandale on _Diseases of the Finger and Toes_, p. 261.

[74] Holmes's _Surgery_, 3d edition, vol. iii. p. 771.

[75] _Brit. and Foreign Med. Chir. Review_ for July 1853.

[76] Mr. Holmes in _Lancet_ for February 18, 1856.

[77] _Ibid._ for May 1865.

[78] Butcher, _Operative and Conservative Surgery_, p. 354.

[79] See Butcher, _Operative and Conservative Surgery_, p. 356.