A manual of operative surgery . e sur-geon paying specialattention to the jointcapsule behind theextensor tendons, theprolongation upwardsof the cavity between the tibia and fibula, and to diseased poucheswhich are often present on either side of the joint. If these lattercannot be dissected out, they must be thoroughly scraped withVolkmanns scoops. The tourniquet should then be removed, and the haemorrhage,chiefly from terminal branches of the peroneal artery in front andbehind the joint, should be stopped. Malleolar twigs from both anteriorand posterior tibial will also require attention. Fi
A manual of operative surgery . e sur-geon paying specialattention to the jointcapsule behind theextensor tendons, theprolongation upwardsof the cavity between the tibia and fibula, and to diseased poucheswhich are often present on either side of the joint. If these lattercannot be dissected out, they must be thoroughly scraped withVolkmanns scoops. The tourniquet should then be removed, and the haemorrhage,chiefly from terminal branches of the peroneal artery in front andbehind the joint, should be stopped. Malleolar twigs from both anteriorand posterior tibial will also require attention. Finally the cavityis irrigated with warm sterilised water, and any divided tendonssutured with fine silk. Both lateral wounds are sewn up with silk-worm gut, the insertion of a small drainage-tube on either side beinggenerally advisable. It can easily be arranged to remove the tubesafter forty-eight hours without disturbing the dressings or the positionof the foot. Comment.—The operation just described follows the subperiosteal. FIG. 480.—A, Excision of astragalus (inner incision)B, Excision of ankle (inner incision). 764 OPERATIONS ON BONES AND JOINTS [part vii method, and in all suitable cases that form of excision should beobserved so far as is possible. The lateral incisions may vary considerably from those describedin the text. The outer incision may follow the posterior border of the fibula,and be made to bend suddenly forwards beneath the malleolus whenthe tip of that process is reached. This was the outer incision ofMoreau. Or a vertical cut so placed may be met by a transverse linewhich extends as far forwards as the tendon of the peroneustertius. The inner incision has been made to form a U-shaped flap corre-sponding in width to the shaft of the tibia, or has assumed somethingof the outline of an anchor, a vertical cut being joined by a transverseincision at its upper end and a curved one at its lower. The removal of the entire astragalus is insisted upon by manywho
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