A Manual of the Operations of Surgery, page 139 by Joseph Bell
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ent, 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 pu