When the nature of the injury renders amputation necessary at or immediately below the tuberosity of the tibia, the operation may be done with safety. Baron Larrey recommended the removal of the head of the fibula in such cases; I have done it with impunity, and thereby made a better stump than if it had not been done; but as the articulating surface of the head of the fibula does sometimes enter into the composition of the knee-joint, and as this cannot be known beforehand, the removal of this portion of the fibula is not advisable, neither must the tibia be sawn through above the tuberosity lest the capsular ligament be implicated. As an operation by which the knee-joint is saved, it is important; for although the stump is very short, it forms a solid support for the body, enables the patient to walk without the aid of a stick, and admits of the adaptation of an artificial leg. The skin, in these cases, must be saved in every direction by flaps, to form a covering. When in sufficient quantity, the operation may be done by the circular incision, as much muscle as possible being saved to aid in forming a covering on the under and outer sides. The posterior tibial artery will be found to have retracted behind the head of the bone, whence it, or others which may bleed, must be drawn out. The nerves should be cut as short as possible.
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.