_Patella and Ligamentum Patellæ retained._--"A longitudinal incision, full four inches in extent, was made on each side of the knee-joint, midway between the vasti and flexors of the leg; these two cuts were down to the bones, they were connected by a transverse one just over the prominence of the tubercle of the tibia, _care being taken to avoid cutting by this incision the ligamentum patellæ_; the flap thus defined was reflected upwards, the patella and the ligament were then freed and drawn over the internal condyle, and kept there by means of a broad, flat, and turned-up spatula; the joint was thus exposed, and after the synovial capsule had been cut through as far as could be seen, the leg was forcibly flexed, the crucial ligaments, almost breaking in the act, only required a slight touch of the knife to divide them completely. The articular surfaces of the bones were now completely brought to view, and the diseased portions removed by means of suitable saws, the soft parts being hold aside by assistants."[68] Results of Excision of Knee-joint:--Holmes's Table of recent cases from 1873-1878-- 245 cases; 25 deaths, and 47 failures. Spence's--33 cases; 22 recovered, 11 died. BUCK'S OPERATION FOR ANCHYLOSED KNEE-JOINT.--The principle of this operation is to remove a triangular portion of bone, which is to include the surfaces of the femur and tibia, which have anchylosed in an awkward position, and by this means to set the bones free, and enable the limb to be straightened. Access to the joint may be obtained by either of the two methods already described. Sections of the bones are then to be made with the saw, so as to meet posteriorly a little in front of the posterior surface of the anchylosed joint, and thus remove a triangular portion of bone; the portion still remaining, and which still keeps up the deformity, is then to be broken through as best you can, either by a chisel, or a saw, or forced flexion. The ends are to be pared off by bone-pliers, and the surfaces brought into as close apposition as possible. The operation is a difficult one, a gap being generally left between the anterior edges of the bones, from the unyielding nature of the integuments behind, and the difficulty of removing the posterior projecting edges from their close proximity to the artery. Of twenty cases on record, eight died, and two required amputation. _Relation of Age to result in Excision of Knee-Joint from Hodge's Tables._ Of 182 complete cases:-- 68 below 16 years: 50 recovered--18 died; or 26 per cent. died. 114 above 16 years: 55 recovered--59 died; or 51.7 per cent. died. EXCISION OF THE ANKLE-JOINT.--_In what cases is it to be done, and how much bone is to be removed?_