This method, with slight deviations, is substantially that of Richard Mackenzie of Edinburgh, Wood of New York, Jones of Jersey.
Hæmorrhage must then be stopped, and that as thoroughly as possible, by torsion, cold, and pressure, and the flap brought accurately together with sutures.
In some rare cases, it may be found necessary to divide the hamstring tendons to rectify spastic contraction of the muscles; but this can generally be done quite well from the original wound.
Holt makes a dependent opening in the popliteal space for drainage. This is unnecessary if the incisions are made sufficiently far back, and if the wound is properly drained. It is unsafe, as approaching so close to the artery and veins. If much bagging takes place, the use of a drainage-tube will prove quite sufficient.
After-treatment.—Wire splints lined with leather and provided with a foot-piece; special box-splints with moveable sides, as Butcher's;[65] plaster-of-Paris moulds are used by Dr. P.H. Watson[66] of Edinburgh and others; this last form of dressing is the best, and allows the limb to be suspended from a Salter's swing.
H-shaped incision.—The internal incision should commence at a point about two inches below the articular surface of the tibia, and in a line with its inner edge; it should then be carried up along the femur in a direction parallel to the axis of the extended limb, so as to pass in front of the saphena vein, and thus avoid it, for a distance of five inches. The external incision, commencing just below the head of the fibula, must be carried upwards parallel to the preceding for the same distance. Both incisions must be made by a heavy scalpel with a firm hand, so as to divide all the tissues down to the bone. The vertical incisions are then united by a transverse one passing across just below the lower angle of the patella. The flaps thus formed must then be dissected up and down, and the internal and external lateral ligaments divided, thus thoroughly opening the joint and exposing the crucial ligaments. These must be divided carefully, remembering the position of the artery. The bones are then to be cleared and divided, as in the operation already described. This is the method of Moreau and Butcher.[67]
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.