Bony union at the lower ends of the tibia and fibula, whether spontaneous or intentionally induced, stabilizes the relation of the remnants throughout their entire length. Not only are they more adaptable to pressure at their lower ends, permitting some end-bearing, but the upper tibiofibular articulation is more stable and the difficulties so commonly encountered in this region are mostly eliminated.
The method is applicable in many old bothersome stumps, or may be instituted at the time of the primary amputation. When instituted at the time of a primary amputation, other surgical principles now generally accepted for amputations below the knee should be followed. In old bothersome stumps, amputation neuromata, adherent scars, ulcerations, sharply pointed bone ends, or other contributing factors should be dealt with in whatever manner they may require. In growing children, the difference of the increment in growth of the tibia and fibula from their proximal epiphyses requires special consideration.
The examples here presented were selected from some thirty odd patients, who have been seen during a period of fifteen and one-half years, to illustrate a simple means of rendering leg amputations less sensitive to the compressive force of prosthetic limbs, when employed for weight-bearing. Other patients on whom equally good results were obtained seemed dispensable to the present purpose. In general, it can be said that no serious consequences have resulted. All but a few have benefited appreciably. In but a single instance was it necessary to remove the fragment of bone which had been placed between the leg bones. In this instance, a large full-thickness skin graft, obtained from the opposite knee to cover a skin defect resulting from the excision of a large ulcer, was applied immediately following the operation on the bones. Only part of the skin graft lived, and, because of a persistent discharge, the bone fragment was removed from between the tibia and fibula a few weeks after the operation. Needless to say this patient was not benefited.
Leg amputations below the knee still present far more problems than all other amputations combined. A great deal has been accomplished in establishing better principles and procedures to ensure more suitable stumps, but opinions expressed and results observed attest the need of a continued search for even better methods.