Neudörfer’s method of amputation by primary division of the bone, before shaping the flaps. Neudörfer used the chisel, but one may use the Gigli saw with special advantage in performing this operation. The method is applicable to any portion of the upper or lower extremity, especially in the continuity of the long bones. (Matas.)
Flaps may be formed by transfixion, for which purpose a long, sharp, amputating knife is required. Inasmuch as it makes an oblique and irregular division of the principal vessels, which are in consequence more difficult to secure, and by which nutrition of flaps is endangered, it is not to be commended, save perhaps in certain amputations about the wrist. A better method of making the flap is to divide the skin and fascia with an ordinary stout scalpel, and then, permitting them to retract, to divide the muscles obliquely toward the bone in such a way as to leave a flap wedge-shaped at its base. The anteroposterior amputations of the foot, thigh, and arm are better performed in this way, each flap being in length preferably three-fourths the diameter of the limb. (Matas.) An extension of this method furnishes the possibility for various subperiosteal amputations to be described below.
The osteoplastic methods of today furnish desirable operative procedures. One of the earliest of the good ones was Teale’s method, as applied to the leg, of double quadrangular flaps, the anterior being much the longer. A minor degree of this work includes simply the preservation of a cuff of periosteum, which is supposed to afford protection to the marrow cavity and a smoothly rounded bone end, without adhesions to the overlying soft parts; but much more complete operations are afforded by Pirogoff’s amputation at the heel, and by Wladimiroff and Mikulicz’s amputation of the foot (practically an exsection of the heel), or by Gritti’s and the other methods of supracondyloid knee amputation, with preservation of the patella. Bier and other foreign and domestic surgeons have also devised methods of reflecting or raising bone flaps from the continuity of bone shafts, which, being still connected by periosteal bridges, are so turned and fastened in place as to furnish a complete bone end over the stump ([Figs. 678] and [679]).
The choice of method must depend, to a large extent, on the character of the case. Some injuries will leave parts so exposed that a portion of a limb can still be utilized if only flaps be cut in an atypical way. One need never hesitate to resort to these, especially about the hand and upper extremity, where it is so desirable to save every inch of tissue. It is not necessary to preserve every possible inch of tissue in the foot and leg, as the makers of artificial limbs can adapt an artificial leg to any kind of a stump. The intent in making these statements is that while it is best to follow conventional methods under ordinary circumstances, there need be no hesitation in departing from them when occasion demands it.
Fig. 678
Bier’s osteoplastic amputation of the leg (procedure advocated by Bier in 1897 and 1899): F, long anterior flap reflected on the tibia; A, cross-section of tibia; B, periosteal flap after excision of intervening section of bone; C, osteoperiosteal flap; D, projecting border of periosteum to be sutured to tibial periosteum.
Fig. 679
Bier’s osteoplastic amputation of the leg, with osteoperiosteal flap in position.