File:Text-book of operative surgery (1903) (14784302123).jpg

Identifier: textbookofoperat1903koch (find matches)
Title: Text-book of operative surgery
Year: 1903 (1900s)
Authors: Kocher, Theodor, 1841-1917 Stiles, Harold J
Subjects: Surgery, Operative Surgery
Publisher: London : Adam and Charles Black
Contributing Library: Yale University, Cushing/Whitney Medical Library
Digitizing Sponsor: Open Knowledge Commons and Yale University, Cushing/Whitney Medical Library

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f the metatarsalbones are applied to the sawn surfaces of the bones of the leg, the foot being broughtinto a vertical position continuous with the axis of the leg. The patient walks uponthe anterior surfaces of the heads of the metatarsal bones, the toes being markedlydorsiflexed. If the scaphoid and cuboid, or the latter and the three cuneiforms, aresawn through, a broader and firmer surface is obtained. The same principle is applied here as in Pirogoffs amputation, in which theposterior part of the foot is rotated 90° so as to elongate the leg. 35o OPERATIVE SURGERY As, however, Mikuliczs method presupposes a defect of the skin of the heel, whichis an exceptional condition, and in the presence of which the management of theincisions is self-evident, we prefer to describe the method of operation in a typicalcase, namely, when the disease affects the entire tarsus and leaves an available skincovering. The incision is just the same as that for excision of the posterior tarsus, namely,
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Fig. 171.—Besection of the lower thirdof the leg. Fig. 170 shows the result after complete resectionof the tarsus (from a photograph of a caseoperated on by the author). a postero-lateral curved incision (Fig. 169), beginning a hand-breadth above theankle-joint, and extending downwards behind the external malleolus and peroneitendons, and then forwards to the fifth metatarsal bone. As in the method alreadydescribed, the bones and joints between the leg and the metatarsus are laid bare byseparating the tendo Achillis and periosteum from the os calcis, and by freeing theperonei tendons from their sheaths and drawing them forwards. The insertions ofall the long tendons of the foot (peroneus tertius, brevis, and longus) are detachedfrom the upper, outer, and under surfaces of the tarsus respectively, as also are theinsertions of the tibialis anticus and posticus from their upper, inner, and undersurfaces. In doing this the blood-vessels and nerves are to be preserved. LOWER EXTREMITY 35

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