One objection used to be urged against this mode of operating, the fear lest the thickened, brawny, and often ulcerated textures in the neighbourhood of a diseased knee-joint, would not make a good covering. This, however, is no longer a bugbear, as we see in cases of resection, where the diseased joint alone is taken away, how very soon all swelling and disease departs, once its cause is removed.
Mr. Syme's original operation was briefly as follows:—With an ordinary amputating-knife make a lunated incision ([Plate I.] fig. 19) from one condyle to the other, across the front of the joint, on a level with the middle of the patella, divide the tissues down to the bones, and then draw the flap upwards, then cut the quadriceps extensor immediately above the patella. The point of the blade should then be pushed in at one end of the wound, thrust behind the femur, and made to appear at the other end; it should then be carried downwards ([Plate III.] fig. 5), so as to make a flap from the calf of the leg, about six or eight inches in length, in proportion to the thickness of the limb; the flap should then be slightly retracted, and the knife carried round the bone a little above the condyles to clear a way for the saw, which should be applied so as to leave the section as horizontal as possible.
This method is now hardly ever used, as the following seems a much better one:—
Gritti's[44] Amputation.—In this two flaps are formed—an anterior long one rectangular and a posterior short one. The condyles of the femur are divided through their base, and the lower surface of patella is removed by a small saw, and then the surfaces of bone approximated.
Stokes's[45] modification of Gritti's amputation.—In this "supracondyloid" amputation, the femur is sawn just above the condyles, without going into the medullary canal. The anterior flap is oval, twice as long as posterior, and the patella is brought up after denudation against end of femur.
Carden's Amputation at the Condyles of the Femur.[46]—The operation consists in reflecting a rounded or semi-oval flap of skin and fat from the front of the knee-joint, dividing everything else straight down to the bone, and sawing the bone slightly above the plane of the muscles, thus forming a flat-faced stump, with a bonnet of integument to fall over it.
The operator standing on the right side of the limb, seizes it between his left forefinger and thumb at the spot selected for the base of the flap, and enters ([Plate II.] fig. 8) the point of the knife close to his finger, bringing it round through skin and fat below the patella to the spot pressed by his thumb; then turning the edge downwards at a right angle with the line of the limb, he passes it through to the spot where it first entered, cutting outwards through everything behind the bone ([Plate IV.] fig. 16). The flap is then reflected, and the remainder of the soft parts divided straight down to the bone; the muscles are then slightly cleared upwards, and I saw it applied.
I have ventured to make a slight change in the method of performing this most excellent operation, for having found the posterior flap, as cut in the method above described, rather scanty in the earlier cases in which I have had occasion to perform it, after dissecting back the anterior flap and cutting into the knee-joint, I shape a slightly convex posterior flap of skin only, at least one and a half inches in length in adult, and allow it to retract before dividing the muscles by a circular cut to the bone, and have had every reason to be satisfied with the change.
Amputation of the Thigh.—Amputation of the thigh has been the favourite battle-ground where flap and circular, antero-posterior and lateral, long and short flaps, double, triple, and conical incisions, have striven with each other; so were I to attempt to describe one quarter of the various methods employed, I should need to rewrite the history of Amputation.
It will suffice merely to describe the best modes of amputating the thigh through its lower, middle, and upper thirds respectively, and at the hip-joint.