Linton's Operation
Linton's 1938 describes the anatomy of the
lower extremity veins, emphasizing interruption of
incompetent communicating or perforating veins in
order to mitigate transmission of venous hypertension to the skin. Linton described the more important of these as posterior tibial perforating veins
saying, "they arise from either of the posterior tibial
veins, the uppermost ones being found about the
middle of the proximal third of the lower leg. They
pass outward along the intermuscular septum
between the flexor digitorum longus and the soleus
muscle, passing through some of the fibers of the
latter near its attachment to the posteromedial edge
of the tibia. They frequently arise as double veins,
and as they approach the deep fascia, may unite to
form one trunk and then break up into a variable
number of branches.
The saphenous vein from knee to ankle was removed by developing the anterior skin flap, and the posterior skin flap allowed removal of the short saphenous vein. Linton believed that the fasciectomy reduced the amount of postoperative edema by giving better lymphatic drainage from the skin and subcutaneous tissues directly into the muscle.
Several aspects of Linton's operation proved to be unacceptable. The first was the prolonged period of bedrest, leg elevation, and hospitalization which was needed to heal the ulceration prior to surgery. Another disadvantage of his procedure was the poor healing of the longitudinal incision as it inevitably passed through markedly diseased skin. There was also disappointment that such an extensive incision was necessary to interrupt a very few perforating veins.
Frank Cockett, operating independent of Linton in London, recommended an extrafascial approach to perforating veins. This was possible if the subcutaneous tissues were not severely effaced. He used "an accurate incision of the line of perforating veins." He also cautioned that the longitudinal incision should not be carried below the medial malleolus. His operation was based on the observation that extrafascial removal of the
" Linton described the distal medial perforating veins saying, "the lowest one lies at the level of the lower border of the malleolus and posterior to it.
The saphenous vein from knee to ankle was removed by developing the anterior skin flap, and the posterior skin flap allowed removal of the short saphenous vein. Linton believed that the fasciectomy reduced the amount of postoperative edema by giving better lymphatic drainage from the skin and subcutaneous tissues directly into the muscle.
Several aspects of Linton's operation proved to be unacceptable. The first was the prolonged period of bedrest, leg elevation, and hospitalization which was needed to heal the ulceration prior to surgery. Another disadvantage of his procedure was the poor healing of the longitudinal incision as it inevitably passed through markedly diseased skin. There was also disappointment that such an extensive incision was necessary to interrupt a very few perforating veins.
Frank Cockett, operating independent of Linton in London, recommended an extrafascial approach to perforating veins. This was possible if the subcutaneous tissues were not severely effaced. He used "an accurate incision of the line of perforating veins." He also cautioned that the longitudinal incision should not be carried below the medial malleolus. His operation was based on the observation that extrafascial removal of the
"enlarged ... tortuous veins in the area ... is really as important as tying the perforating veins from which they arise
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