LISFRAXC 



500 SymJs Amputation 



as the operation is on the right or left side, the tibialis posticus and 

 flexor longus digitorum, for these two tendons just escaped division 

 by the first incision. 



The front of the foot bsing depressed, the articular ligaments are 



easily divided, and the joint 

 traversed ; and the knife, pass- 

 ing along the upper part of the 

 os calcis, behind the tibia, 

 reaches and divides the tendon 

 of Achilles and the plantaris. 

 The ends of the tibia and 

 fibula are then sawn off. 



The posterior tibial artery 

 lies just where the two in- 

 cisions meet, at the spot a little 

 below and behind the tip of 

 the inner malleolus. 



When the operation is being 

 clone for disease of a child's 

 ankle, the epiphysis, which re- 

 presents the posterior part of 

 the os calcis, may be detached. 

 If so, it had better be dissected 

 out, as it is likely to be un- 

 sound (v. p. 508). 



The vitality of the flap 

 depends on the calcanean 

 branches of the posterior tibial, 

 the malleolar of the anterior 

 tibial, and the posterior 

 branches of the peroneal. 



Lines of incisionsjor am^tations (After S> , n plroffoff >. modification 



of Syme's amputation, most of 



that part of the os calcis which is behind the astragalus is cut off and 

 turned up, so that its sawn surface may become ossified on to the sawn 

 surface of the tibia. The incision in the sole, therefore, may be sloped 

 a trifle forwards, the plantar muscles, vessels, nerves, and tendons 

 being cut right through to the bones. The heel-flap, of course, is not 

 dissected up, but the back of the os calcis is sawn off after the ankle- 

 joint has been opened from the front. To ensure rest and perfect ap- 

 position of the sawn surfaces, the tendon of Achilles should be divided. 



THE FOOT 



The plantar fascia is very thick and strong where it is attached 

 to the tuberosities of the os calcis. Coming forwards, it spreads into 



