Part I., p. 539. (Part 6)

THE SURGICAL ANATOMY TIBIO-TARSAL REGION,' ' Reprinted from American Journal of Hadloal Soiences, April, 1876. Tbia Esaa; •ms nnnrd«d the Annaal Friia of One Hundred Doliars, offarad b; Prof Jameg B. Wood, to the Alumni Assoeiation «f tbe BelteTus Hospital HediDnl College, for "The best Esiay on -in; subjaot oonneotad with Surgioal Pothologj or Oparntive Surgery," Febru- nry, 1876. Tbe Committee were Professore W. H. Vab Bdh»s, Auaris Flint, Sr,, und Alfhsus B. Crobbt. (247) 248 PRIZE ESSAY. In both the amputations at the tibio-tarsal articulation (Syme's and Pirogoff's), surgeons agree that the perfect success of the ope- ration depends upon the vitality, ^. e,^ the non-interference with the blood supply of the inferior or calcanean flap. Descriptive and surgical anatomists and operative surgeons agree, with remarkable unanimity, that the integrity of this flap is depend- ent upon its blood supply, partly from the anterior and posterior peroneal arteries^ on the outer side, but principally from the calcanean branches of the posterior tibial on the inner side of the ankle-joint. In reference to this, Gross says: *Care should be taken not to wound the posterior tibial prior to its separation into its plantar branches, otherwise sloughing of the soft parts might ensue from deficient nourishment;" while Valentine Mott, in his edition of Vel- peau\s Surgery {(\io\\g from Syme), uses almost the same language: "Both incisions should be continuous, and exactly opposite to each other. Care should be taken not to cut the posterior tibial before it divides into Vae i:>lantars^ as in two instances when this happened (to Mr. Syme) there was partial sloughing of the flap." Erichsen says, " unless care be taken to cut the plantar arteries long, the flap will be insufficiently supplied with blood, and slough- ing, especially of its outer angle, will be likely to occur;" and Ham- ilton, in the same connection, writes, " th^e operator must not wound the posterior tibial before it has given off the internal calcanean branches. Division of the posterior tibial at a point lower than this does notj as has been affirmed, endanger the vitality of the flap, as it receives no arterial supply f^om a lower source^^ Holmes is of the opinion that "the integrity of the posterior tibial, though desirable, is by no means essential, provided the rest of the subcutaneous tissue has been left uninjured."^ Apropos to the generally accepted idea of the origin of this prin- cipal blood supply, the following quotations are given: — "The internal calcanean consist of several large branches which arise from the posterior tibial ]n^, before its division." — Gray. Quain, while mentioning these vessels in his text only in a gene- J The italics are the writer's, not Prof. Hamilton's. 2 Laying no claim to personal experience, the author cannot understand how it would be possible to dissect out a bone so full of indentations and rough eminences, so covered with the insertions and origins of ligaments and muscles, and sheaths, through which tendons play, and leave " the subcutaneous tissue uninjured.' There are no less than thirteen muscles in relation to this dissection, to say nothing of ligaments. TIBIO-TARSAL REGION. 249 ral way, gives them specially in his diagrams as branches from the posterior tibial^ anastomosing with branches of the 2>osterior peroneal. "The internal calcanean branches^ three or four in number, pro- ceed from the postei'ior tibial artery immediately before its division." — Wilson, '*The calcanean arteries are two or three branches from the lower part of the posterior tibial^ — Leidy. "Under the arch oi the GfiXetiXiexim the posterior tibial gives origin, 1st, to branches distributed to the periosteum, to the adductor (?) of the great toe, the short flexor of the toes, and to the superficial structures; and, 2d, to other branches of less calibre, which mount the inner border of the foot, to anastomose with descending branches of the internal malleolar branch of the anterior tibial^^ Hyrtl mentions the operation of amputation at the ankle joint, but does not consider the surgical anatomy relating to this pro- cedure. T assert, without equivocation, that the arterial supply to the calca- nean region, as given above, is not correct, in the main; and that the operative surgery at the ankle-joint, based upon the idea that the arterial supply to the calcanean flap is derived from the poste- rior tibial, is unsafe. Having failed to find this distribution, as given in the text-books some years ago, I determined to investigate this matter thoroughly, and to that end, made 80 consecutive dissections of this region, with all requisite care, the result of which is given in the table and r^- sume appended to this essay. In 72 of 80 cases the posterior tibial bifurcated into its plantar branches on a line between the lower border of the inner malleolus and the middle or centre of the heePs convexity. In four of the remaining cases, the separation occurred one-fourth of an inch, and in the other four cases one-half an inch behio th^ line M N {see dia- gram). Any variations in the point of division tend, in all cases, toward the line of incision in amputations in this region. In 38 out of 80 dissections {almost one-half \ there was not a single calcanean artery derived from the posterior tibial (K O, see diagram). 1 Sous le vdute da oalcaneum la tibiale post^rieure donne naissance ; 1% a des ra- meauz qui se distribueut au p^rioste, an musole addacteur da gros orteil, aa court fl6chissear commun des orteil, et aux t6gamouts ; 2<>, a d'autres rameaux d'un moiudre calibre qui remontent sur le bord interne da pied pour s'auastomoser avec des ra- meaux descendants de la malleolaire interne, branohe de la tibiale ant^rieure. — Sappey, 250 PRIZE ESSAY. So it must follow that any line of incision that approximates the terminal bifurcation of this vessel will, in a great many cases, en- danger the blood supply, and consequently the success of the ope- ration. I cannot think that the exceptional cases in which good recov- eries have resulted, after division of this vessel, above or at its bifurcation, are arguments of any weight in favor of the incision "well back toward the heel," when compared with the fact that, in such a great proportion of cases, there is no blood supply above this point to the inner side of the flap, and that in some recorded cases where this accident has happened, dangerous sloughing has occurred. From the standpoint of surgical anatomy, the incision recom- mended and practised by Prof. Gross, and represented in the annexed diagram by the line M C, is the most rational, since it is farthest removed from the most constant blood supply to this inferior flap, viz., the calcanean branches of the external plantar artery. In 80 cases, 51 calcanean branches were derived above the bifur- cation. In 80 cases, 18 were derived opposite this point. While out of 80 cases the number of calcanean branches derived from the external plantar artery, and distributed to the posterior or calcanean flap, safely within the line of incision of Gross (M C) given above, was 221, or more than three times in number, and carrying, without the least exaggeration, twice the volume of blood of those derived opposite to and above the bifurcation. Erichsen in his text says: "It is of importance that the incision across the heel should be carried well back over its point. Unless this be done, a large cup-shaped cavity will be left, in which blood and pus will accumulate, and retard the cicatrization of the stump. The principal point to be attended to, however, is that the plantar arteries be cut long." These two propositions I hold as anatomically incompatible. The arteries will be cut short, dangerously shorty if the incision is carried " well back over the point of the heel," while the great danger of re- tardation of healing, on account of retained septic matter, might be obviated, by leaving the wound open for drainage at its most depend- ent part, or cutting a drainage hole in the under surface of this cup-shaped flap, as is recommended by surgeons of experience. In fact, strict attention to cleanliness should render the collection and absorption of septic matter impossible. TIBIO-TARSAL REGION. 251 Hamilton, agreeing with Erichsen, perhaps a little more emphatic in his method of expressing it, says: **The lines of this second inci- sion ought not to fall vertically from the malleoli; that is, not at right angles with the sole of the foot, as this would give a redun- dancy of flap; it would also increase the danger of sloughing, etc. It is better to carry the lines of incision from the two mal- leoli a little backwards, so that the knife will cross the bottom of the foot about an inch and a half further back; and, in the case of an unusually long heel, it will be proper to carry the incision back- wards two inches." And in the same connection as quoted before, he adds: "The operator must not wound the posterior tibial artery before it has given off the internal cahanean branches, which supply the cellulo-adipose tissue and integument composing the posterior flap. Division of the posterior tibial at a point lower than this does not, as has been affirmed, endanger the vitality of the flap, as ik receives no arterial supply from a lower source." The language of this eminent surgeon is decisive and emphatic. In 38 of 80 dissections^ there ivas not an artery that I could find^ by careful dissection^ derived from the posterior tibial and distributed to the calcanean region^ while in every case of 80 dissections the^*e ivas one or more branches derived from the external plantar, and distributed directly to this part. Lister, author of the chapter on amputations in Holmes^ s Surgery, advises that ** the calcanean incision be made either vertical to, or sloping towards the heel, commencing at the tip of the external mal- leolus, and going under the foot to a point considerably below and behind the tip of the inner malleolus Even the integrity of the posterior tibial artery, though desirable, is by no means essen- tial, provided the rest of the subcutaneous tissue has been left uninjured."^ The great unevenness of the os calcis, its peculiar shape, covered with the attachments of muscles, sheaths, and ligaments, renders it anatomically difficult to be dissected out in this operation, without wounding, more or less, the subcutaneous tissue, upon which, Mr. Lister says, the integrity of the flap depends. Moreover, if the "integrity oi ihe posterior tibial is not essential," why does this gen- tleman recommend so positively an incision that must always save this vessel to the operation? Why not cut an "inch and a half, or, in the case of a long heel," two inches back of the vertical line (as ' Holmes's Surgery, vol. v. pp. 643, 644. 252 PRIZE ESSAY. Hamilton does), where he would have plenty of flap and an easier dissection ? The language of these two phases of his operation is irrecon- cilable, and the assertion that *the integrity of the posterior tibial artery, though desirable, is not essential," is not strictly in accord- ance with the clinical history of this amputation, and is utterly at variance with the anatomy of the blood supply to the calcanean region. Stephen Smith, in his comprehensive report, says the necessity for re-amputation in this operation is three per cent, greater than in any other. Perhaps the cause of this may arise from the reckless sacrifice of the arterial supply to this region, sanctioned by such eminent sur- geons as I have quoted. The writer of this essay, deeming it unnecessary to introduce any further quotations and comments, since he wishes to be concise, simply begs leave to state that he has entrusted his work to no one; that he measured every dissection with accuracy, and noted it on the spot; and that, in differing so widely in his results and conclu- sions with gentlemen of such eminence (whom it seems almost sac- rilege to contradict), he reiterates his assertion that the surgical anatomy of this region has, heretofore^ not been correctly described. TIBIO-TARSAL REGION. 253 TABLE SHOWING ORIGIN OF THE CALCANBAN BRANCHES OP THE POSTERIOR TIBIAL AND EXTERNAL PLANTAR ARTERIES, AS DEDUCED FROM NOTES ON EIGHTY CONSECUTIVE DISSECTIONS. K amber. Number of Calcaneaa Branches derived from the Posterior Tibial Artery. Number of Calcanean Branches derived oppo»«ite the Termi- nal Bifurcation of the Posterior Tibial. Number of Calcaneal! Branches derived from the External Plantar Artery -within l]4 inches of its origin. 1 3 2 1 3 3 3 4 7 5 4 6 2 ' 5 1 1 4 8 1 2 9 1 10^ 1 3 11 1 12^ 1 3 13 1 4 14 4 15 1 3 U 1 3 n 4 18 1 2 19 3 20 1 1 3 21 1 1 2 22 1 2 23 2 24 3 25 2 26 1 2 21 1 1 4 28 1 1 1 29 3 2 30 1 2 31 3 32 1 1 2 33 1 3 34 2 2 35 1 1 2 36 3 37 6 38 1 2 39 1 3 40 1 1 1 This case bifarcated ODe-half iuch lower than usual. < This case bifurcated one-half inch lower than usual. 254 PRIZE ESSAY. Number. Namber of Calcanean Branches derived from the Posterior Tibial Artery. Nnmber of Calcanean Branches derived opposite the Termi- nal Bifarcation of the Posterior Tibial. Number of Calcanean Branches derived from the External Plantar Artery within 1^ inches of its origin. iV 2 2 42 1 3 43 1 2 44 3 45 1 2 46 1 4 47 2 48 1 3 49 2 2 50 3 51 3 52^ 1 2 53 2 6 54 1 1 4 55' 3 56 2 57 1 1 58 1 3 59 2 60 2 1 61 1 2 62^ 2 2 63 1 3 64« 3 65 1 1 3 66 3 67 2 1 68 3 69 1 4 70 3 71 1 3 72 1 2 73 2 2 74 1 4 75 4 76 3 77 1 3 78 5 79 2 80 1 1 Total . . 51 18 221 1 This case bifurcated ' Tins case bifurcated ' This case bifurcated * This case bifurcated ^ This case bifurcated ^ This case bifurcated one-fourth inch lower than usual, one-fourth inch lower than usual, one-fourth inch lower than usual, one-half inch lower than usual, one-half inch lower than usual, one-fourth inch lower than usual. tibio-tarsal region. 255 Summary on the Surgical Anatomy of the Arterial Supply TO the Tibio-Tarsal Eegion, as Deduced from 80 Dissec- tions. In 72 of 80 cases the posterior tibial artery bifurcated into the external and internal plantar, on a level with a line drawn from the most dependent portion of the internal malleolus, to the middle of the heel's convexity. {See M N, fig. 1.) In 4 of 80 cases, this bifurcation occurred J inch below this point. In 4 of 80 cases, it was J inch below this point; any variation from the usual point of division tending, in my experience, inva- riably downivard. Although anatomists give the arterial supply to the calcanean region {internal calcanean arteries) as coming from the posterior tibial artery (as shown in extracts given heretofore), the resume of tabu- lated dissections shows that, out of a total of 80 cases, in 88 there ivas not a single calcanean branch derived above the terminal bifurcation of the posterior tibial artery^ while in all of these 80 dissections, one or more good-sized calcanean arteries were derived from the external plantar^ within one and a quarter inches of its origin. In 80 cases, the number of calcanean arteries derived from the posterior tibial was 51. In 80 cases, 18 branches were derived opposite the point of bifur- cation, and distributed to this region. In 80 cases, the number of calcanean arteries derived from the ^ external plantar was 221, and every one of these was safely inside the line of incision in amputations at the ankle-joint, when that in- cision is not more than one-half inch posterior to the axis of the leg {see M C, fig. 1), with the foot at right angles to the leg. In all cases, articular branches are derived either from the posterior tibial or internal plantar^ or from both. In some exceptional cases, the internal 'plantar gave off small branches to the heel. The anterior flap is plentifully supplied in all instances by branches from the anterior tibial^ especially the malleolar arteries. The anterior 2inA posterior peroneal dii^irihutQ branches to the outer portion of the calcanean flap, those from ,\iq posterior anastomosing with the calcanean branches of the external plantar^ and with those of the posterior tibial^ when they are present. I do not think the branches from the peroneal arteries sufficiently large to supply blood enough to maintain the integrity of the calcanean flap, especially when their anastomoses are cut off by section of ,\iQ posterior tibial^ or of its plantar branches, too near their origin. 256 PRIZE ESSAY. Tlie relation of the posterior tihial artery is quite constant with the two muscles between which it runs; the flexor longus digitorum in front, and the flexor longus pollicis behind. The most reliable guide to this vessel is its pulsation; but in the event the tourniquet is applied, the thumb should be placed over the middle of a line drawn from the inner malleolus to the centre of the heel's convexity, while the four lesser toes are held still by an assistant, the surgeon moves the great toe, and marks the point at which he feels thie ten- don gliding under his thumb. The tendon of the longus digitorum is found in the same manner, and half-way between the two