[Illustration]
92. This operation should be performed in the following manner: Begin
the incision behind the external malleolus, an inch and a half above
its lower extremity, and carry it downward and then forward across the
front of the ankle-joint, then under the internal malleolus and upward,
close behind this process, to the extent of an inch and a half; this
incision should merely divide the skin, and should not, on any account,
wound the subjacent parts. Raise the flap thus made, and, placing the
leg on its inside, detach and turn aside the peronei tendons from the
groove behind the external malleolus. Cut through the external lateral
ligaments of the ankle-joint, keeping the knife close to the end of the
fibula; then, with the large bone-scissors or nippers, cut through the
fibula from one-half to three-quarters of an inch above its junction
with the tibia, and, after dividing the ligamentous fibers connecting
the two bones, remove the malleolus externus. Turn the leg on to its
outer side, and cut through the internal lateral ligament close to the
tibia, to avoid wounding the posterior tibial artery; this will allow
the foot to be dislocated outward, and the lower end of the tibia
to be brought well out through the wound. An assistant keeping the
foot and tendons out of the way, the lower end of the tibia is to be
removed by a fine saw to the same extent as the fibula, or as high as
the injury or disease requires. The articulating surface, or injured
part of the astragalus, is then to be removed, after which the foot
is to be returned to its proper position, and the cut surfaces of the
tibia and astragalus brought into close approximation, and so kept by
suture, strapping, and bandage. The limb is to be placed on an outside
leg-splint, having a foot-piece to it; and in order to prevent any
matter oozing, an opening should be maintained on the outside of the
joint, with a corresponding hole in the dressing and splint for this
purpose, until the recovery is completed. The shot-hole will sometimes
answer the purpose, when the injury is inflicted by a musket-ball.
There are no vessels to tie, unless wounded accidentally.