Amputations at Ankle 



499 



and at the back of the joint, on either side of the tendo Achillis. 

 Such universal bulging is indicative of ankle-joint disease ; when 

 fulness in the neighbourhood is due to extra-articular causes it is 

 limited to one aspect, or, at the most, to two aspects of the ankle. 



Excision of the ankle-joint may be performed by lateral incisions 

 which descend along the posterior borders of the malleoli, and by 

 prolonging them a little forwards so as to obtain more room. The 

 tendons are carefully turned back the peroneus longus and brevis,. 

 and the tibialis posticus and flexor longus digitorum. The lateral 

 ligaments are divided ; the lower end of the fibula is sawn off, and 

 the lower end of the tibia is scraped or sawn, as may be expedient, 

 and the astragalus is thoroughly scraped over. 



In Syme's amputation all the bones of the foot are removed, and 

 a flap is shelled from the back of 

 the os calcis which is flexed over 

 the ends of the tibia and fibula, 

 the malleoli having been re- 

 moved. 



The land-marks for the ope- 

 ration are the tip of the external 

 malleolus, and a spot on the inner 

 side on exactly the same level, 

 which is below and behind the 

 tip of the inner malleolus. A large 

 scalpel is used. The heel-flap is 



first cut by an incision connecting P I RO GO F F 1 ' 



these points, and passing under 



the os calcis. It is sloped a little backwards, so that the flap is not 

 made needlessly long and cup-shaped. This incision divides every- 

 thing down to the bones : skin, superficial fascia, external saphenotis 

 vein and nerve ; deep fascia (external and internal annular ligaments) ; 

 the tendons of peroneus longus and brevis ; the posterior tibial vessels 

 and nerve ; the flexor longus hallucis ; the plantar fascia ; the points 

 of origin of the abductor hallucis, flexor brevis digitorum, and abductor 

 minimi digiti. Then the end of the os calcis is uncovered by carefully 

 peeling back the flap down to the bone, and round the point of the 

 heel, care being taken to make no ' button-hole.' 



The second incision is carried straight over the front of the ankle- 

 joint, beginning and ending in the horns of the plantar incision. No 

 attempt is made at shaping a dorsal flap ; the knife is carried straight 

 across, down to the bones and into the ankle-joint. This incision 

 divides : skin, superficial fascia, internal saphenous vein and nerve, 

 and the musculo-cutaneous nerve ; the deep fascia (anterior, and part 

 of internal annular ligament) ; the peroneus tertius and the extensor 

 longus digitorum ; the anterior tibial nerve and vessels ; the extensor 

 proprius hallucis, and the tibialis anticus ; and, last or first, according- 

 ly K 2 



/ 'SYME 



