The vascular anatomy and harvesting of the medial femoral condyle flap in pigs

The vascular anatomy and harvesting of the medial femoral condyle flap in pigs | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The vascular anatomy and harvesting of the medial femoral condyle flap in pigs Yanhai Zuo, Lei Yi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5322635/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Dec, 2024 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted 4 You are reading this latest preprint version Abstract Introduction Clinically, there has been increasing employment of the medial femoral condyle flap. Pigs have been employed as a model of the medial femoral condyle flap. However, related anatomical studies from the perspective of comparative medicine are rare. The objective of this study was to explore the vascular anatomy of the medial femoral condyle in pigs, explore the surgical procedure of the medial femoral condyle flap in pigs, and compare the medial femoral condyle flap in pigs and humans. Materials and Methods 20 fresh cadaveric hindlimbs of hybrid pigs were used in this study. The origination, course, and branches of the vessels nourishing the medial femoral condyle were observed in 15 specimens. The variability in the anatomy of the vessels and the length and outer diameter of the vessels were evaluated. Surgical procedures for the medial femoral condyle flap were conducted on five specimens. Results The nourishing artery of the medial femoral condyle in pigs was the second descending geniculate artery, which was observed in all 15 pigs and had a diameter and length of 2.013 ± 0.316 mm and 1.527 ± 0.212 cm, respectively. A skin incision of approximately 10 cm was used to harvest the medial femoral condyle flap of the pig in the supine position. After the adductor muscle was cut, the whole course of the second descending geniculate artery artery and its venae comitantes were exposed. Conclusions The vascular anatomy of the medial femoral condyle in pigs and that of humans exhibited great similarities. The medial femoral condyle flap in pigs was as easily harvested as that in humans. Pigs could serve as a suitable animal model for the medial femoral condyle flap. anatomical study descending genicular artery large animal model medial condyle pig Figures Figure 1 Figure 2 Introduction Clinically, the medial femoral condyle (MFC) flap has been widely employed in the treatment of nonunions, bone defects, joint injuries, etc. It is also regarded as a workhorse flap in hand reconstruction. The MFC flap has a dual blood supply from the descending geniculate artery (DGA) and the medial superior genicular artery. 1 Compared to other commonly used flaps, the MFC flap offers minimal donor site morbidity and a relatively straightforward harvesting technique. This makes it particularly suitable for the treatment of limb defects, as demonstrated in several clinical studies. 1-5 Large animal models have been widely used in various clinical fields due to their similarities with humans. 6 These characteristics make large animals particularly useful for flap research. Among them, pigs are the most commonly utilized model because of the high similarity between pig and human skin. ,7-9 Both the vascular anatomy and surgical procedure of flap models have been comprehensively explored and have shown great similarities to their human counterparts. 10 Moreover, pigs have long been employed as a model of knee-related diseases. 11,12 There are several reports of the use of MFC flaps in pig models. 13,14 However, anatomical studies of MFC flaps in pigs from the perspective of comparative medicine are rare. Based on these observations, this study was designed to 1. explore the vascular anatomy of the MFC in pigs, 2. explore the surgical procedure of the MFC flap on pigs and 3. compare the MFC flap in pigs and humans. Materials and Methods This study was approved by the Scientific Investigation Board of **. 20 fresh cadaveric hindlimbs (amputated at the level of the hip joint) of hybrid pigs were used in this study. The preparation and infusion of latex were performed according to method described by Zheng et al. with some modifications. 15 Briefly, an infusion tube was inserted into and tightly sealed with with the superficial femoral artery (SFA). The lateral saphenous vein was punctured using a venous indwelling needle. Normal saline was infused into the SFA under constant manual pressure until clear effluent was noted from the corresponding veins. Black or red dye (Shanghai M&G stationery Inc. China) was added to the latex (Beijing Latex Factory) at a volume ratio of 1:5 to make red- and black-colored latex. The lateral saphenous vein was infused with red-colored latex using a 50-mL syringe. The SFA was slowly infused with black latex in the same way. The infused specimens were stored at a temperatures of 20 ℃ and a humidity of 70% for 24 hours. A 20 cm skin incision along the lateral midline of the knee joint was made on 15 samples to expose the underlying tissue. Thereafter, the skin was pulled forward and back to observe the skin perforators originating from the medial side of the knee joint. After removing the skin, the saphenous artery(SA) was exposed. The retrograde anatomy of the SA was carefully conducted to explore its source artery-the SFA. After dissecting distally along the SFA, all of the branches to the medial side of the knee joint were observed. The variability in the anatomy of the vessels and the length and outer diameter of the vessels were evaluated. Out of 20 cadaver specimens, some were assigned for vascular study(n=15), while the others were allocated for the MFC flap surgical study(n=5). Results The anatomy of the vessels around the MFC The SA originated directly from SFA at the middle of the thigh and could be divided into two segments. The first segment of the SA was completely covered by the sartorius and could not be touched. The second segment of the SA(SA-2) ran along medial side of the MFC distally just in the subcutaneous tissue and gave off several skin perforators, without any obvious branches into the MFC. Under the origination of the SA, several branches originated directly from the SFA, two of which ran distally and nourished the medial side of the joint. In accordance with the DGA in humans and for ease of description, the two branches were named the first DGA(DGA-1) and the second DGA(DGA-2), respectively. DGA-1 originated directly from the SFA approximately 1 cm inferior to the origin of the SA and was observed in all 15 pigs (15/15)(Fig 1a). DGA-1 ran along the intermuscular septum between the gracilis and the adductor muscle and gave off several muscular branch into the adductor muscle. DGA-1 ended on the medial side of the knee joint capsule, without any obvious branches into the MFC(Fig 1b). DGA-2 originated directly from the SFA approximately 1 cm inferior to the origin of the DGA-1 and ran distally along the deep side of the adductor muscle. DGA-2 was observed in all 15 pigs, and it seems that DGA-2 was completely separated from DGA-1 by the adductor muscle(Fig 1c). DGA-2 had a diameter and length of 2.013±0.316 mm and 1.527±0.212 cm, respectively, as measured at their origination. DGA-2 gave off several muscular branches to the adductor muscle and an articular branch. The articular branch was permanently divided into three terminal branches in 15 pigs: a transverse branch, a middle longitudinal branch, and a posterior-lateral branch. The transverse branch coursed anteriorly along the deep side of the medial vastus muscle and terminated at the patella and the anterior wall of the articular capsule. The middle longitudinal branch ran along the lateral side of the MFC and gave off many small branches (Fig. 1d). The posterior-lateral branch ran closely along the origination of the medial head of gastrocnemius muscle. There was a large network of capillaries between the middle longitudinal branch and the posterior-lateral branch(Fig 1e,f). In five specimens (5/15), the articular branch also gave off a short longitudinal branch located between the middle longitudinal branch and the posterior-lateral branch(Fig 1d). The two venae comitantes ran consistently on either side of DGA-2 (Fig. 1e). For ease of understanding, all of the vessels around the MFC were isolated freely and are shown in Fig. 1g. Surgical procedure of the MFC flap Due to the ease of dissection and better visual clarity, five specimens in this part were not infused with red latex. The operation was performed in the supine position. The following two methods were suggested for locating the skin incision: First, SA-2 on the medial side of the knee joint could be easily touched in infused specimens, and a 10-cm skin incision was made along the SA. Second, after determining the joint space by probing the joint with a needle or moving the joint, the MFC was touched, and a 10 cm- skin incision was made along the posterior-medial side of the MFC (Fig. 2a). After pulling the skin sideways, the SA-2, the sartorius, the medial vastus muscle, and the gracilis were exposed (Fig. 2b). The SA-2 was pulled forward, and the gracilis was cut along its end. The gracilis was pulled backward, and SA-2, together with the medial vastus muscle and DGA-1, were pulled forward (Fig. 2c). Thereafter, the origins of DGA-2 and its venae comitantes were revealed (Fig. 2d). Next, SA-2 was pulled backward, and the medial vastus muscle was further pulled forward. The transverse branch, middle longitudinal branch of the articular branch of DGA-2, and MFC were subsequently exposed (Fig. 2e, f). After the size and anatomical site of the MFC and the length of the pedicles were determined, the whole MFC flap was harvested. Importantly, if the femoral trochlea was not in the flap plane, maintaining the integrity of the joint capsule was essential. Comparison of the MFC flap in pigs and humans Gross observation revealed that most of the MFCs in pigs are covered by muscles and cannot be located as easily as they are in humans. The knee joint can be clearly located in pigs but is less mobile than it is in humans. More importantly, in the infused specimens, the SA can be clearly palpated and is more obvious than that in humans. The anatomy of the vessels around the MFC shows that the pedicle of the MFC flap in pigs is relatively shorter and has less anatomical variation compared with that in the corresponding human pedicle. More importantly, the skin perforator was absent in all specimens. The surgical procedure of the MFC flap is similarly easily performed in pigs and humans, even though there are still some differences between the two procedures (e.g., the cutting of muscles, type of tissues included in the chimeric flap, and the method of pedicle exposure). A detailed comparison of the MFC flap in pigs and humans is summarized in Table 1. Discussion Clinically, the MFC has long served as an ideal donor site for bone flaps. 1-5 As one of the most commonly employed large animals, pigs have been widely used in flap research. 7,10 However, it seems that the MFC of pigs has been neglected. In this cadaveric study using pig knees, we explored the feasibility of using pigs as an animal model of the MFC flap. The MFC flaps in pigs and humans exhibited great similarities in anatomy. The MFC flap in pigs was as easily harvested as that in humans. Both the pedicle of the MFC flap in pigs and that of humans originate directly from the SFA and can be regarded as a type of direct periosteal branch. Although the length of the pedicle of the MFC flap in pigs was shorter than that in humans, it might have been overcome to some extent by the following two methods: first, other muscular branches were cut and harvested as closely as possible to the origination of the pedicle. Second, some branches into the MFC were cut, and the free pedicle was lengthened. Clinically, the MFC flap has long been regarded as an ideal method for treating small bone defects or nonunion at various anatomical sites, especially for nonweight-bearing areas. 3 Primarily due to the local anatomical features, harvesting of the MFC flap results in very low morbidity at the donor site. 1 Moreover, a recently published study revealed that the donor site in 36 patients exhibited complete restoration of the blood supply and bone tissue. 3 Despite being increasingly employed clinically, the MFC flap has several limitations, the greatest of which is the anatomic variability of the pedicle. For example, when the DGA is dominant (80% of cases), an 8- to 12-cm long pedicle can be harvested, and when the medial superior genicular artery is dominant, a pedicle of only 3 to 4 cm in length can be harvested. 16 For another example, the DGA can be categorized into different types based on the origin of its three branches: the osteoarticular branch, the muscular branch, and the cutaneous branch (also known as the saphenous branch). For a more in-depth discussion, we refer the readers to the studies by Dubois et al. 17 and Hirtler et al. 18 Pigs have long been employed as an animal model for flap studies. An increasing number of flap models have been used in surgical training, 7 and these models exhibit highly similar pedicle calibers and lengths to those of their human counterparts. For example, the deep cranial epigastric artery perforator flap in pigs simulates the human deep inferior epigastric artery perforator flap; the cranial gluteal artery perforator flap in pigs simulates the human superior gluteal artery perforator flap; and the myocutaneous gracilis flap in pigs corresponds to the human gracilis flap. 10,19 Unfortunately, MFC flap models of pigs are rare. A brief literature search for this type of pig model revealed two reports in which pigs were used as an animal model of the MFC flap. In the first report, the MFC flap in five pigs was employed in the reconstruction of the temporomandibular joint, and the results revealed that the reconstructed condyle had almost the same appearance and histological characteristics as the natural condyle. 13 In the second study, the MFC flap in 18 pigs was used as an arterialized venous flap, and the results demonstrated that the MFC flap could be supported and survive through the arterialization of the venous network. This study suggests that revascularization of free flaps is feasible even in cases where the artery is inadequate but the veins are well-developed. 14 Unfortunately, after carefully reviewing the surgical procedures described in the two reports, we were unable to find a detailed anatomical description of the MFC flap. This may be due to the ethical limitations of live animal studies, highlighting the significant need for anatomical studies using cadaveric specimens. As a cadaveric study, this study focused on the anatomical distinctions of the MFC flap between pigs and humans. First, DGA-2 in pigs originated solely from the SFA, whereas DGA in humans exhibited a common trunk with one or two other branches; the origination of DGA-2 in pigs was obviously lower than that in humans. 18 It seems that the course of the DGA in humans is from superior to inferior, whereas that of DGA-2 is from posterior to anterior in pigs. Second, the length of the pedicle of the MFC flap in pigs (1.5 cm) was shorter than that in humans (7.5–12 cm). 16,17,20,21 Third, the absence of DGA in humans was greater than that in pigs. 16,20,22-24 Fourth, the MFC flap is nourished by two vessels (the DGA and the medial superior genicular artery) in humans 1 , but by only one vessel (the DGA-2) in pigs. However, based on the area and anatomical site nourished, it seems that the posterior-lateral branch of the DGA-2 in pigs corresponds to the medial superior genicular artery in humans. Finally, the DGA in humans has a strong skin perforator (the saphenous branch). 18 In contrast, DGA-2 in pigs lacks a skin perforator. The reasons might be as follows: first, the muscle on the medial side of the knee joint was rich and thick, which nourished the skin directly; second, SA-2 was thick and gave off several skin perforators; and third, the location of DGA-2 was very deep and fully covered by the adductor muscle. In this cadaveric study, we also focused on the surgical procedure of the MFC flap. Although the surgical procedure for harvesting the MFC flap in pigs was similarly easy compared to that in humans, there are still some differences between the two procedures. First, the most significant difference is that in pigs, the gracilis and adductor muscles need to be cut, whereas in humans, the dissection is mostly conducted along the intermuscular septum, allowing the muscles to be preserved intact. The reasons for this difference may be as follows: in pigs, the muscles around the MFC consist of tightly packed muscle bellies, and most of the DGA-2 is located deep within the adductor muscle. In contrast, in humans, the tendons were more loosely arranged. Second, in humans, the sartorius is very obvious and lies in the center of the skin incision; therefore, it must be pulled back and forward to expose the pedicle. 20 In contrast, in pigs, the sartorius was very small and short, whereas the SA was very thick and had to be pulled back and forward to expose the pedicle. Third, as the origination of DGA in humans is very high, it seems that most skin incisions are made along the distal femur. 1 In contrast, as the origination of DGA-2 in pigs was very low, it seems that most of the skin incisions were made just near the MFC. Fourth, although both pig and human MFC flaps can be harvested as chimeric flaps, MFC flaps in humans can be harvested as flaps consisting of skin, muscles, and bones. 2 In pigs, only muscles and bones are included. Finally, most of the MFCs in pigs are covered by muscles but directly covered by skin in humans; therefore, the location of the skin incision is more feasible in humans than in pigs. A detailed comparison of the MFC flaps in pigs and humans is summarized in Table 1. The disadvantages of this study are as follows: the small sample size and possible bias from anatomical variance, as well as sex and breed. Moreover, we failed to compare the MFC flap in pigs with that in other animals. In summary, we have demonstrated a simple, reliable, and reproducible MFC flap model in pigs, characterized by a consistent pedicle and ease of harvesting. Therefore, we believe that pigs can serve as a suitable animal model for in vivo studies of the MFC flap. It is important that the anatomical differences between the MFC flap in pigs and humans, and the limitations of this study, are considered during study design and data analysis Abbreviations DGA: descending geniculate artery DGA-1: the first DGA DGA-2: the second DGA MFC: medial femoral condyle SA: saphenous artery SA-2: the second segment of the SA SFA: superficial femoral artery Declarations Author Contribution Yanhai Zuo: conception and design, acquisition of data, drafting and revising the manuscript, and final approval of the version to be published.Lei Yi: conception and design, analysis and interpretation of data, final approval of the version to be published, prepared Figures 1, Figures 2 and table1.All authors reviewed the manuscript Acknowledgements: No funding was received for this study. The authors declare that they have no conflict of interest. Ethical approval This study was approved by the Scientific Investigation Board of **. Principles of laboratory animal care (NIH publication No. 86 − 23, revised 1985) were followed, as well as specific national laws. Data Availability Data availability The data that support the fndings of this study are available from the corresponding author, Yanhai Zuo( [email protected] ), upon reasonable request. References Friedrich JB, Pederson WC, Bishop AT, Galaviz P, Chang J (2012) New workhorse flaps in hand reconstruction. Hand (N Y) 7(1):45-54. Hamada Y, Hibino N, Kobayashi A (2014) Expanding the utility of modified vascularized femoral periosteal bone-flaps: An analysis of its form and a comparison with a conventional-bone-graft. J Clin Orthop Trauma 5(1):6-17. Guzzini M, Lupariello D, Argento G, Arioli L, Ferretti A (2022) Vascular and Bone Regeneration of the Donor Site After Corticoperiosteal Flap From the Medial Femoral Condyle. Hand (N Y) 17(2):366-372. Bürger HK, Windhofer C, Gaggl AJ, Higgins JP (2013) Vascularized medial femoral trochlea osteocartilaginous flap reconstruction of proximal pole scaphoid nonunions. J Hand Surg Am 38(4):690-700. Higgins JP, Bürger HK (2017) Medial Femoral Trochlea Osteochondral Flap: Applications for Scaphoid and Lunate Reconstruction. Clin Plast Surg 44(2):257-265. Lunney JK, Van Goor A, Walker KE, Hailstock T, Franklin J, Dai C (2021) Importance of the pig as a human biomedical model. Sci Transl Med 13(621):eabd5758. Zuo Y, Xiao S, Lu M (2024) Porcine thigh as an ideal cadaveric animal model for flap training: a home do-it-yourself model. Eur J Plast Surg 47, 78. https://doi.org/10.1007/s00238-024-02228-8. Meyer W, Schwarz R, Neurand K (1978) The skin of domestic mammals as a model for the human skin, with special reference to the domestic pig. Curr Probl Dermatol 7:39-52. Wollina U, Berger U, Mahrle G. Immunohistochemistry of porcine skin (1991) Acta Histochem 90:87-91. Nistor A, Jiga LP, Miclaus GD, Hoinoiu B, Matusz P, Ionac ME (2022) Experimental swine models for perforator flap dissection in reconstructive microsurgery. PLoS One 17(4):e0266873. doi: 10.1371/journal.pone.0266873. Solla F, Pan H, Watrelot D, Leveneur O, Dubernard JM, Gazarian A (2013) Composite tissue allotransplantation in newborns: a swine model. J Surg Res 179(1):e235-43. doi: 10.1016/j.jss.2012.01.030. Biercevicz AM, Miranda DL, Machan JT, Murray MM, Fleming BC (2013) In Situ, noninvasive, T2*-weighted MRI-derived parameters predict ex vivo structural properties of an anterior cruciate ligament reconstruction or bioenhanced primary repair in a porcine model. Am J Sports Med 41(3):560-6. Lin T, Chen S, Xia L, Jie B, Zhang Y, He Y (2023) Reconstruction of the temporomandibular joint using a vascularized medial femoral condyle osteocartilaginous flap: an experimental investigation in miniature pigs. BMC Oral Health 23(1):621. doi: 10.1186/s12903-023-03341-z. Borumandi F, Higgins JP, Buerger H, Vasilyeva A, Benlidayi ME, Sencar L, et al (2016) Arterialized Venous Bone Flaps: An Experimental Investigation. Sci Rep 6:31970. doi: 10.1038/srep31970. Zheng JP, Song M, Zhan XX, Li CZ, Zong XY, Zhang YZ (2015) Anatomical partition of the clival region and adjacent structures via extended endoscopic endonasal approach. Clin Neurol Neurosurg 139:129-37. Iorio ML, Masden DL, Higgins JP (2011) The limits of medial femoral condyle corticoperiosteal flaps. J Hand Surg Am 36(10):1592-1596. Dubois G, Lopez R, Puwanarajah P, Noyelles L, Lauwers F (2010) The corticoperiosteal medial femoral supracondylar flap: anatomical study for clinical evaluation in mandibular osteoradionecrosis. Surg Radiol Anat 32(10):971-7. Hirtler L, Lübbers A, Rath C (2019) Vascular coverage of the anterior knee region - an anatomical study. J Anat 235(2):289-298. Bodin F, Diana M, Koutsomanis A, Robert E, Marescaux J, Bruant-Rodier C (2015) Porcine model for free-flap breast reconstruction training. J Plast Reconstr Aesthet Surg 68(10):1402-9. Xu Q, Zheng X, Li Y, Zhu L, Ding Z (2020) Anatomical Study of the Descending Genicular Artery Chimeric Flaps. J Invest Surg 33(5):422-427. Silva GB, Vellosa MT, Cho AB, Costa RBID, Camargo OP, Mattar R JÚNIOR (2018) Medial femoral condyle corticoperiosteal flap: anatomical study. Acta Ortop Bras 26(3):179-182. Sananpanich K, Atthakomol P, Luevitoonvechkij S, Kraisarin J (2013) Anatomical variations of the saphenous and descending genicular artery perforators: cadaveric study and clinical implications for vascular flaps. Plast Reconstr Surg 131(3):363e-372e. Yamamoto H, Jones DB, Moran SL, Bishop AT, Shin AY (2010) The arterial anatomy of the medial femoral condyle and its clinical implications. J Hand Surg Eur Vol 35(7):569-74. Garcı´a-Pumarino R, Franco JM (2014) Anatomical varibility of descending genicular artery. Ann Plast Surg 73:607-11. Table Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 16 Dec, 2024 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted Editorial decision: Revision requested 26 Oct, 2024 Editor assigned by journal 25 Oct, 2024 Submission checks completed at journal 25 Oct, 2024 First submitted to journal 24 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5322635","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":370640031,"identity":"abbda737-9d33-4c63-a8bd-07aa68768fab","order_by":0,"name":"Yanhai Zuo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyUlEQVRIiWNgGAWjYPCCAwxs7A1AkjQtPAdI1cIgkUCkWvkZycckfu64I88n+fzh4YIaBnlzQloYZ6SlSfaeeWbYJp1jcHjGMQbDnQ0EtDBL5JhJ8LYdZgRqYTjMw8aQYHCAgBY2oBbJv22H7dskjz84zPOPCC08QC3SQFsS2yQYDA7zthGhRYLnWbK1bNvh5DYeoF94+yQMNxDSIt+efPDm27bDtvPbjz/+zPPNRp6gLUDAIoFsK2H1QMD8gShlo2AUjIJRMHIBACP9PxQ3UrxkAAAAAElFTkSuQmCC","orcid":"","institution":"SiJing hospital of SongJiang District","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Yanhai","middleName":"","lastName":"Zuo","suffix":""},{"id":370640032,"identity":"b25df0cb-f902-4f72-ab2f-bb387aa8c5d6","order_by":1,"name":"Lei Yi","email":"","orcid":"","institution":"Ruijin Hospital Affliated to Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Yi","suffix":""}],"badges":[],"createdAt":"2024-10-24 04:38:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5322635/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5322635/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00402-024-05608-8","type":"published","date":"2024-12-16T15:58:09+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":67656006,"identity":"1a5b5e0c-a1de-4f3e-a2c2-2ad1f56e63e4","added_by":"auto","created_at":"2024-10-28 12:14:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2930996,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe vascular anatomy of the MFC flap in pigs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDGA-1 originates directly from the SFA approximately 1 cm inferior to the origin of the SA (a). DGA-1 runs along the intermuscular septum between the gracilis and the adductor muscle and gives off several muscular branches into the adductor muscle. DGA-1 terminates on the medial side of the knee joint capsule, without any obvious branches into the MFC (b). DGA-2 originates directly from the SFA approximately 1 cm inferior to the origin of DGA-1 and runs distally along the deep side of the adductor muscle (c). DGA-2 gives off several muscular branches to the adductor muscle and an articular branch. The articular branch is permanently divided into three terminal branches: a transverse branch, a middle longitudinal branch, and a posterior-lateral branch. In 5 specimens (5/15), the articular branch also includes a short longitudinal branch located between the middle longitudinal branch and the posterior-lateral branch (d). The posterior-lateral branch runs closely along the origination of the medial head of the gastrocnemius muscle. There is a large network of capillaries between the middle longitudinal branch and the posterior-lateral branch. The two venae comitantes run consistently on either side of DGA-2 (e, f). For ease of understanding, all the vessels around the MFC are isolated freely (g)(a-d, the right hindlimb; e,f, the left hindlimb; V1: SFA; V2: SA; V3: DGA-1; V4: DGA-2; ,M1: the medial vastus muscle; M2: the adductor muscle; M3:the gracilis; M4: the medial head of gastrocnemius muscle).\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-5322635/v1/a3f60f1a834c8105015852eb.png"},{"id":67656008,"identity":"dcd67706-bb99-4726-87d3-f7fec06fa93d","added_by":"auto","created_at":"2024-10-28 12:14:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2923764,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe surgical procedure of the MFC flap in pigs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe operation was performed in the supine position. A 10-cm skin incision was made along the posterior-medial side of the MFC (a). After the skin was pulled sideways, the SA-2, the sartorius, the medial vastus muscle, and the gracilis is exposed (b). The SA-2 was pulled forward, and the gracilis was cut along its end. The gracilis was pulled backward, and SA-2, together with the medial vastus muscle and DGA-1, was pulled forward (c). The origins of DGA-2 and its venae comitantes are shown (d). The SA-2 was pulled backward, and the medial vastus muscle was further pulled forward. The transverse branch, the middle longitudinal branch of the articular branch of DGA-2, and the MFC are subsequently exposed (e, f). The operation was performed in the supine position. A 10-cm skin incision was made along the posterior-medial side of the MFC (a). After the skin was pulled sideways, the SA-2, the sartorius, the medial vastus muscle, and the gracilis are exposed (b). The SA-2 was pulled forward, and the gracilis was cut along its end. The gracilis was pulled backward, and SA-2, together with the medial vastus muscle and DGA-1, was pulled forward (c). The origins of DGA-2 and its venae comitantes are shown (d). The SA-2 was pulled backward, and the medial vastus muscle was further pulled forward. The transverse branch, the middle longitudinal branch of the articular branch of DGA-2, and the MFC are subsequently exposed(e, f)(the left hindlimb; -: the patella; +: the joint space; ＃:the ankle; V1: SFA; V2: SA; V3: DGA-1; V4: DGA-2; ,M1: the medial vastus muscle; M2: the adductor muscle; M3:the gracilis; M5: the sartorius).\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-5322635/v1/9efe6ef0b7f4ccad89de0d76.png"},{"id":72202616,"identity":"3dfd40e3-2967-45b2-930b-58e877bf42d1","added_by":"auto","created_at":"2024-12-23 16:15:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":9718985,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5322635/v1/025a68d5-ccaa-485e-9891-95e153284dc0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The vascular anatomy and harvesting of the medial femoral condyle flap in pigs","fulltext":[{"header":"Introduction","content":"\u003cp\u003eClinically, the medial femoral condyle (MFC) flap has been widely employed in the treatment of nonunions, bone defects, joint injuries, etc. It is also regarded as a workhorse flap in hand reconstruction. The MFC flap has a dual blood supply from the descending geniculate artery (DGA) and the medial superior genicular artery.\u003csup\u003e1\u003c/sup\u003e Compared to other commonly used flaps, the MFC flap offers minimal donor site morbidity and a relatively straightforward harvesting technique. This makes it particularly suitable for the treatment of limb defects, as demonstrated in several clinical studies.\u003csup\u003e1-5\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eLarge animal models have been widely used in various clinical fields due to their similarities with humans.\u003csup\u003e6\u003c/sup\u003e These characteristics make large animals particularly useful for flap research. Among them, pigs are the most commonly utilized model because of the high similarity between pig and human skin.\u003csup\u003e,7-9\u003c/sup\u003e Both the vascular anatomy and surgical procedure of flap models have been comprehensively explored and have shown great similarities to their human counterparts.\u003csup\u003e10\u003c/sup\u003e Moreover, pigs have long been employed as a model of knee-related diseases.\u003csup\u003e11,12\u003c/sup\u003e There are several reports of the use of MFC flaps in pig models.\u003csup\u003e13,14\u003c/sup\u003e However, anatomical studies of MFC flaps in pigs from the perspective of comparative medicine are rare.\u003c/p\u003e\n\u003cp\u003eBased on these observations, this study was designed to 1. explore the vascular anatomy of the MFC in pigs, 2. explore the surgical procedure of the MFC flap on pigs and 3. compare the MFC flap in pigs and humans.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis study was approved by the Scientific Investigation Board of **. 20 fresh cadaveric hindlimbs (amputated at the level of the hip joint) of hybrid pigs were used in this study. The preparation and infusion of latex were performed according to method described by Zheng et al. with some modifications.\u003csup\u003e15\u003c/sup\u003e Briefly, an infusion tube was inserted into and tightly sealed with with the superficial femoral artery (SFA). The lateral saphenous vein was punctured using a venous indwelling needle. Normal saline was infused into the SFA under constant manual pressure until clear effluent was noted from the corresponding veins. Black or red dye (Shanghai M\u0026amp;G stationery Inc. China) was added to the latex (Beijing Latex Factory) at a volume ratio of 1:5 to make red- and black-colored latex. The lateral saphenous vein was infused with red-colored latex using a 50-mL syringe. The SFA was slowly infused with black latex in the same way. The infused specimens were stored at a temperatures of 20 ℃ and a humidity of 70% for 24 hours.\u003c/p\u003e\n\u003cp\u003eA 20 cm skin incision along the lateral midline of the knee joint was made on 15 samples to expose the underlying tissue. Thereafter, the skin was pulled forward and back to observe the skin perforators originating from the medial side of the knee joint. After removing the skin, the saphenous artery(SA) was exposed. The retrograde anatomy of the SA was carefully conducted to explore its source artery-the SFA. After dissecting distally along the SFA, all of the branches to the medial side of the knee joint were observed. The variability in the anatomy of the vessels and the length and outer diameter of the vessels were evaluated. Out of 20 cadaver specimens, some were assigned for vascular study(n=15), while the others were allocated for the MFC flap surgical study(n=5).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eThe anatomy of the vessels around the MFC\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe SA originated directly from SFA at the middle of the thigh and could be divided into two segments. The first segment of the SA was completely covered by the sartorius and could not be touched. The second segment of the SA(SA-2) ran along medial side of the MFC distally just in the subcutaneous tissue and gave off several skin perforators, without any obvious branches into the MFC. Under the origination of the SA, several branches originated directly from the SFA, two of which ran distally and nourished the medial side of the joint. In accordance with the DGA in humans and for ease of description, the two branches were named the first DGA(DGA-1) and the second DGA(DGA-2), respectively. DGA-1 originated directly from the SFA approximately 1 cm inferior to the origin of the SA and was observed in all 15 pigs (15/15)(Fig 1a). DGA-1 ran along the intermuscular septum between the gracilis and the adductor muscle and gave off several muscular branch into the adductor muscle. DGA-1 ended on the medial side of the knee joint capsule, without any obvious branches into the MFC(Fig 1b).\u003c/p\u003e\n\u003cp\u003eDGA-2 originated directly from the SFA approximately 1 cm inferior to the origin of the DGA-1 and ran distally along the deep side of the adductor muscle. DGA-2 was observed in all 15 pigs, and it seems that DGA-2 was completely separated from DGA-1 by the adductor muscle(Fig 1c). DGA-2 had a diameter and length of 2.013±0.316 mm and 1.527±0.212 cm, respectively, as measured at their origination. DGA-2 gave off several muscular branches to the adductor muscle and an articular branch. The articular branch was permanently divided into three terminal branches in 15 pigs: a transverse branch, a middle longitudinal branch, and a posterior-lateral branch. The transverse branch coursed anteriorly along the deep side of the medial vastus muscle and terminated at the patella and the anterior wall of the articular capsule. The middle longitudinal branch ran along the lateral side of the MFC and gave off many small branches (Fig. 1d). The posterior-lateral branch ran closely along the origination of the medial head of gastrocnemius muscle. There was a large network of capillaries between the middle longitudinal branch and the posterior-lateral branch(Fig 1e,f). In five specimens (5/15), the articular branch also gave off a short longitudinal branch located between the middle longitudinal branch and the posterior-lateral branch(Fig 1d). The two venae comitantes ran consistently on either side of DGA-2 (Fig. 1e). For ease of understanding, all of the vessels around the MFC were isolated freely and are shown in Fig. 1g.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical procedure of the MFC flap\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to the ease of dissection and better visual clarity, five specimens in this part were not infused with red latex. The operation was performed in the supine position. The following two methods were suggested for locating the skin incision: First, SA-2 on the medial side of the knee joint could be easily touched in infused specimens, and a 10-cm skin incision was made along the SA. Second, after determining the joint space by probing the joint with a needle or moving the joint, the MFC was touched, and a 10 cm- skin incision was made along the posterior-medial side of the MFC (Fig. 2a). After pulling the skin sideways, the SA-2, the sartorius, the medial vastus muscle, and the gracilis were exposed (Fig. 2b). The SA-2 was pulled forward, and the gracilis was cut along its end. The gracilis was pulled backward, and SA-2, together with the medial vastus muscle and DGA-1, were pulled forward (Fig. 2c). Thereafter, the origins of DGA-2 and its venae comitantes were revealed (Fig. 2d). Next, SA-2 was pulled backward, and the medial vastus muscle was further pulled forward. The transverse branch, middle longitudinal branch of the articular branch of DGA-2, and MFC were subsequently exposed (Fig. 2e, f). After the size and anatomical site of the MFC and the length of the pedicles were determined, the whole MFC flap was harvested. Importantly, if the femoral trochlea was not in the flap plane, maintaining the integrity of the joint capsule was essential.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of the MFC flap in pigs and humans\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGross observation revealed that most of the MFCs in pigs are covered by muscles and cannot be located as easily as they are in humans. The knee joint can be clearly located in pigs but is less mobile than it is in humans. More importantly, in the infused specimens, the SA can be clearly palpated and is more obvious than that in humans. The anatomy of the vessels around the MFC shows that the pedicle of the MFC flap in pigs is relatively shorter and has less anatomical variation compared with that in the corresponding human pedicle. More importantly, the skin perforator was absent in all specimens. The surgical procedure of the MFC flap is similarly easily performed in pigs and humans, even though there are still some differences between the two procedures (e.g., the cutting of muscles, type of tissues included in the chimeric flap, and the method of pedicle exposure). A detailed comparison of the MFC flap in pigs and humans is summarized in Table 1.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eClinically, the MFC has long served as an ideal donor site for bone flaps.\u003csup\u003e1-5\u003c/sup\u003e As one of the most commonly employed large animals, pigs have been widely used in flap research.\u003csup\u003e7,10\u003c/sup\u003e However, it seems that the MFC of pigs has been neglected. In this cadaveric study using pig knees, we explored the feasibility of using pigs as an animal model of the MFC flap. The MFC flaps in pigs and humans exhibited great similarities in anatomy. The MFC flap in pigs was as easily harvested as that in humans. Both the pedicle of the MFC flap in pigs and that of humans originate directly from the SFA and can be regarded as a type of direct periosteal branch. Although the length of the pedicle of the MFC flap in pigs was shorter than that in humans, it might have been overcome to some extent by the following two methods: first, other muscular branches were cut and harvested as closely as possible to the origination of the pedicle. Second, some branches into the MFC were cut, and the free pedicle was lengthened.\u003c/p\u003e\n\u003cp\u003eClinically, the MFC flap has long been regarded as an ideal method for treating small bone defects or nonunion at various anatomical sites, especially for nonweight-bearing areas.\u003csup\u003e3\u003c/sup\u003e Primarily due to the local anatomical features, harvesting of the MFC flap results in very low morbidity at the donor site.\u003csup\u003e1\u003c/sup\u003e Moreover, a recently published study revealed that the donor site in 36 patients exhibited complete restoration of the blood supply and bone tissue.\u003csup\u003e3\u003c/sup\u003e Despite being increasingly employed clinically, the MFC flap has several limitations, the greatest of which is the anatomic variability of the pedicle. For example, when the DGA is dominant (80% of cases), an 8- to 12-cm long pedicle can be harvested, and when the medial superior genicular artery is dominant, a pedicle of only 3 to 4 cm in length can be harvested.\u003csup\u003e16\u003c/sup\u003e For another example, the DGA can be categorized into different types based on the origin of its three branches: the osteoarticular branch, the muscular branch, and the cutaneous branch (also known as the saphenous branch). For a more in-depth discussion, we refer the readers to the studies by Dubois et al.\u003csup\u003e17\u0026nbsp;\u003c/sup\u003eand Hirtler et al.\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003ePigs have long been employed as an animal model for flap studies. An increasing number of flap models have been used in surgical training,\u003csup\u003e7\u003c/sup\u003e and these models exhibit highly similar pedicle calibers and lengths to those of their human counterparts. For example, the deep cranial epigastric artery perforator flap in pigs simulates the human deep inferior epigastric artery perforator flap; the cranial gluteal artery perforator flap in pigs simulates the human superior gluteal artery perforator flap; and the myocutaneous gracilis flap in pigs corresponds to the human gracilis flap.\u003csup\u003e10,19\u003c/sup\u003e Unfortunately, MFC flap models of pigs are rare. A brief literature search for this type of pig model revealed two reports in which pigs were used as an animal model of the MFC flap. In the first report, the MFC flap in five pigs was employed in the reconstruction of the temporomandibular joint, and the results revealed that the reconstructed condyle had almost the same appearance and histological characteristics as the natural condyle.\u003csup\u003e13\u003c/sup\u003e In the second study, the MFC flap in 18 pigs was used as an arterialized venous flap, and the results demonstrated that the MFC flap could be supported and survive through the arterialization of the venous network. This study suggests that revascularization of free flaps is feasible even in cases where the artery is inadequate but the veins are well-developed.\u003csup\u003e14\u003c/sup\u003e Unfortunately, after carefully reviewing the surgical procedures described in the two reports, we were unable to find a detailed anatomical description of the MFC flap. This may be due to the ethical limitations of live animal studies, highlighting the significant need for anatomical studies using cadaveric specimens.\u003c/p\u003e\n\u003cp\u003eAs a cadaveric study, this study focused on the anatomical distinctions of the MFC flap between pigs and humans. First, DGA-2 in pigs originated solely from the SFA, whereas DGA in humans exhibited a common trunk with one or two other branches; the origination of DGA-2 in pigs was obviously lower than that in humans.\u003csup\u003e18\u003c/sup\u003e It seems that the course of the DGA in humans is from superior to inferior, whereas that of DGA-2 is from posterior to anterior in pigs. Second, the length of the pedicle of the MFC flap in pigs (1.5 cm) was shorter than that in humans (7.5–12 cm).\u003csup\u003e16,17,20,21\u003c/sup\u003e Third, the absence of DGA in humans was greater than that in pigs.\u003csup\u003e16,20,22-24\u003c/sup\u003e Fourth, the MFC flap is nourished by two vessels (the DGA and the medial superior genicular artery) in humans\u003csup\u003e1\u003c/sup\u003e, but by only one vessel (the DGA-2) in pigs. However, based on the area and anatomical site nourished, it seems that the posterior-lateral branch of the DGA-2 in pigs corresponds to the medial superior genicular artery in humans. Finally, the DGA in humans has a strong skin perforator (the saphenous branch).\u003csup\u003e18\u003c/sup\u003e In contrast, DGA-2 in pigs lacks a skin perforator. The reasons might be as follows: first, the muscle on the medial side of the knee joint was rich and thick, which nourished the skin directly; second, SA-2 was thick and gave off several skin perforators; and third, the location of DGA-2 was very deep and fully covered by the adductor muscle.\u003c/p\u003e\n\u003cp\u003eIn this cadaveric study, we also focused on the surgical procedure of the MFC flap. Although the surgical procedure for harvesting the MFC flap in pigs was similarly easy compared to that in humans, there are still some differences between the two procedures. First, the most significant difference is that in pigs, the gracilis and adductor muscles need to be cut, whereas in humans, the dissection is mostly conducted along the intermuscular septum, allowing the muscles to be preserved intact. The reasons for this difference may be as follows: in pigs, the muscles around the MFC consist of tightly packed muscle bellies, and most of the DGA-2 is located deep within the adductor muscle. In contrast, in humans, the tendons were more loosely arranged. Second, in humans, the sartorius is very obvious and lies in the center of the skin incision; therefore, it must be pulled back and forward to expose the pedicle.\u003csup\u003e20\u003c/sup\u003e In contrast, in pigs, the sartorius was very small and short, whereas the SA was very thick and had to be pulled back and forward to expose the pedicle. Third, as the origination of DGA in humans is very high, it seems that most skin incisions are made along the distal femur.\u003csup\u003e1\u003c/sup\u003e In contrast, as the origination of DGA-2 in pigs was very low, it seems that most of the skin incisions were made just near the MFC. Fourth, although both pig and human MFC flaps can be harvested as chimeric flaps, MFC flaps in humans can be harvested as flaps consisting of skin, muscles, and bones.\u003csup\u003e2\u003c/sup\u003e In pigs, only muscles and bones are included. Finally, most of the MFCs in pigs are covered by muscles but directly covered by skin in humans; therefore, the location of the skin incision is more feasible in humans than in pigs. A detailed comparison of the MFC flaps in pigs and humans is summarized in Table 1.\u003c/p\u003e\n\u003cp\u003eThe disadvantages of this study are as follows: the small sample size and possible bias from anatomical variance, as well as sex and breed. Moreover, we failed to compare the MFC flap in pigs with that in other animals.\u003c/p\u003e\n\u003cp\u003eIn summary, we have demonstrated a simple, reliable, and reproducible MFC flap model in pigs, characterized by a consistent pedicle and ease of harvesting. Therefore, we believe that pigs can serve as a suitable animal model for in vivo studies of the MFC flap. It is important that the anatomical differences between the MFC flap in pigs and humans, and the limitations of this study, are considered during study design and data analysis\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eDGA: descending geniculate artery\u003c/p\u003e\n\u003cp\u003eDGA-1: the first DGA\u003c/p\u003e\n\u003cp\u003eDGA-2: the second DGA\u003c/p\u003e\n\u003cp\u003eMFC: medial femoral condyle\u003c/p\u003e\n\u003cp\u003eSA: saphenous artery\u003c/p\u003e\n\u003cp\u003eSA-2: the second segment of the SA\u003c/p\u003e\n\u003cp\u003eSFA: superficial femoral artery\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eYanhai Zuo: conception and design, acquisition of data, drafting and revising the manuscript, and final approval of the version to be published.Lei Yi: conception and design, analysis and interpretation of data, final approval of the version to be published, prepared Figures 1, Figures 2 and table1.All authors reviewed the manuscript\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e \u003cp\u003eNo funding was received for this study. The authors declare that they have no conflict of interest.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003eThis study was approved by the Scientific Investigation Board of **. Principles of laboratory animal care (NIH publication No. 86\u0026thinsp;\u0026minus;\u0026thinsp;23, revised 1985) were followed, as well as specific national laws.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData availability The data that support the fndings of this study are available from the corresponding author, Yanhai Zuo([email protected]), upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFriedrich JB, Pederson WC, Bishop AT, Galaviz P, Chang J (2012) New workhorse flaps in hand reconstruction. Hand (N Y) 7(1):45-54.\u003c/li\u003e\n\u003cli\u003eHamada Y, Hibino N, Kobayashi A (2014) Expanding the utility of modified vascularized femoral periosteal bone-flaps: An analysis of its form and a comparison with a conventional-bone-graft. J Clin Orthop Trauma 5(1):6-17.\u003c/li\u003e\n\u003cli\u003eGuzzini M, Lupariello D, Argento G, Arioli L, Ferretti A (2022) Vascular and Bone Regeneration of the Donor Site After Corticoperiosteal Flap From the Medial Femoral Condyle. Hand (N Y) 17(2):366-372.\u003c/li\u003e\n\u003cli\u003eB\u0026uuml;rger HK, Windhofer C, Gaggl AJ, Higgins JP (2013) Vascularized medial femoral trochlea osteocartilaginous flap reconstruction of proximal pole scaphoid nonunions. J Hand Surg Am 38(4):690-700.\u003c/li\u003e\n\u003cli\u003eHiggins JP, B\u0026uuml;rger HK (2017) Medial Femoral Trochlea Osteochondral Flap: Applications for Scaphoid and Lunate Reconstruction. Clin Plast Surg 44(2):257-265.\u003c/li\u003e\n\u003cli\u003eLunney JK, Van Goor A, Walker KE, Hailstock T, Franklin J, Dai C (2021) Importance of the pig as a human biomedical model. Sci Transl Med 13(621):eabd5758.\u003c/li\u003e\n\u003cli\u003eZuo Y, Xiao S, Lu M (2024) Porcine thigh as an ideal cadaveric animal model for flap training: a home do-it-yourself model. Eur J Plast Surg 47, 78. https://doi.org/10.1007/s00238-024-02228-8.\u003c/li\u003e\n\u003cli\u003eMeyer W, Schwarz R, Neurand K (1978) The skin of domestic mammals as a model for the human skin, with special reference to the domestic pig. Curr Probl Dermatol 7:39-52.\u003c/li\u003e\n\u003cli\u003eWollina U, Berger U, Mahrle G. Immunohistochemistry of porcine skin (1991) Acta Histochem 90:87-91.\u003c/li\u003e\n\u003cli\u003eNistor A, Jiga LP, Miclaus GD, Hoinoiu B, Matusz P, Ionac ME (2022) Experimental swine models for perforator flap dissection in reconstructive microsurgery. PLoS One 17(4):e0266873. doi: 10.1371/journal.pone.0266873.\u003c/li\u003e\n\u003cli\u003eSolla F, Pan H, Watrelot D, Leveneur O, Dubernard JM, Gazarian A (2013) Composite tissue allotransplantation in newborns: a swine model. J Surg Res 179(1):e235-43. doi: 10.1016/j.jss.2012.01.030.\u003c/li\u003e\n\u003cli\u003eBiercevicz AM, Miranda DL, Machan JT, Murray MM, Fleming BC (2013) In Situ, noninvasive, T2*-weighted MRI-derived parameters predict ex vivo structural properties of an anterior cruciate ligament reconstruction or bioenhanced primary repair in a porcine model. Am J Sports Med 41(3):560-6.\u003c/li\u003e\n\u003cli\u003eLin T, Chen S, Xia L, Jie B, Zhang Y, He Y (2023) Reconstruction of the temporomandibular joint using a vascularized medial femoral condyle osteocartilaginous flap: an experimental investigation in miniature pigs. BMC Oral Health 23(1):621. doi: 10.1186/s12903-023-03341-z.\u003c/li\u003e\n\u003cli\u003eBorumandi F, Higgins JP, Buerger H, Vasilyeva A, Benlidayi ME, Sencar L, et al (2016) Arterialized Venous Bone Flaps: An Experimental Investigation. Sci Rep 6:31970. doi: 10.1038/srep31970.\u003c/li\u003e\n\u003cli\u003eZheng JP, Song M, Zhan XX, Li CZ, Zong XY, Zhang YZ (2015) Anatomical partition of the clival region and adjacent structures via extended endoscopic endonasal approach. Clin Neurol Neurosurg 139:129-37.\u003c/li\u003e\n\u003cli\u003eIorio ML, Masden DL, Higgins JP (2011) The limits of medial femoral condyle corticoperiosteal flaps. J Hand Surg Am 36(10):1592-1596.\u003c/li\u003e\n\u003cli\u003eDubois G, Lopez R, Puwanarajah P, Noyelles L, Lauwers F (2010) The corticoperiosteal medial femoral supracondylar flap: anatomical study for clinical evaluation in mandibular osteoradionecrosis. Surg Radiol Anat 32(10):971-7.\u003c/li\u003e\n\u003cli\u003eHirtler L, L\u0026uuml;bbers A, Rath C (2019) Vascular coverage of the anterior knee region - an anatomical study. J Anat 235(2):289-298.\u003c/li\u003e\n\u003cli\u003eBodin F, Diana M, Koutsomanis A, Robert E, Marescaux J, Bruant-Rodier C (2015) Porcine model for free-flap breast reconstruction training. J Plast Reconstr Aesthet Surg 68(10):1402-9.\u003c/li\u003e\n\u003cli\u003eXu Q, Zheng X, Li Y, Zhu L, Ding Z (2020) Anatomical Study of the Descending Genicular Artery Chimeric Flaps. J Invest Surg 33(5):422-427.\u003c/li\u003e\n\u003cli\u003eSilva GB, Vellosa MT, Cho AB, Costa RBID, Camargo OP, Mattar R J\u0026Uacute;NIOR (2018) Medial femoral condyle corticoperiosteal flap: anatomical study. Acta Ortop Bras 26(3):179-182.\u003c/li\u003e\n\u003cli\u003eSananpanich K, Atthakomol P, Luevitoonvechkij S, Kraisarin J (2013) Anatomical variations of the saphenous and descending genicular artery perforators: cadaveric study and clinical implications for vascular flaps. Plast Reconstr Surg 131(3):363e-372e.\u003c/li\u003e\n\u003cli\u003eYamamoto H, Jones DB, Moran SL, Bishop AT, Shin AY (2010) The arterial anatomy of the medial femoral condyle and its clinical implications. J Hand Surg Eur Vol 35(7):569-74.\u003c/li\u003e\n\u003cli\u003eGarcı\u0026acute;a-Pumarino R, Franco JM (2014) Anatomical varibility of descending genicular artery. Ann Plast Surg 73:607-11.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003e\u003cimg src=\"data:image/png;base64,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\" width=\"695\" height=\"701\"\u003e\u003cbr\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"anatomical study, descending genicular artery, large animal model, medial condyle, pig","lastPublishedDoi":"10.21203/rs.3.rs-5322635/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5322635/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eIntroduction\u003c/b\u003e\u003c/p\u003e \u003cp\u003eClinically, there has been increasing employment of the medial femoral condyle flap. Pigs have been employed as a model of the medial femoral condyle flap. However, related anatomical studies from the perspective of comparative medicine are rare. The objective of this study was to explore the vascular anatomy of the medial femoral condyle in pigs, explore the surgical procedure of the medial femoral condyle flap in pigs, and compare the medial femoral condyle flap in pigs and humans.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMaterials and Methods\u003c/b\u003e\u003c/p\u003e \u003cp\u003e20 fresh cadaveric hindlimbs of hybrid pigs were used in this study. The origination, course, and branches of the vessels nourishing the medial femoral condyle were observed in 15 specimens. The variability in the anatomy of the vessels and the length and outer diameter of the vessels were evaluated. Surgical procedures for the medial femoral condyle flap were conducted on five specimens.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe nourishing artery of the medial femoral condyle in pigs was the second descending geniculate artery, which was observed in all 15 pigs and had a diameter and length of 2.013\u0026thinsp;\u0026plusmn;\u0026thinsp;0.316 mm and 1.527\u0026thinsp;\u0026plusmn;\u0026thinsp;0.212 cm, respectively. A skin incision of approximately 10 cm was used to harvest the medial femoral condyle flap of the pig in the supine position. After the adductor muscle was cut, the whole course of the second descending geniculate artery artery and its venae comitantes were exposed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe vascular anatomy of the medial femoral condyle in pigs and that of humans exhibited great similarities. The medial femoral condyle flap in pigs was as easily harvested as that in humans. Pigs could serve as a suitable animal model for the medial femoral condyle flap.\u003c/p\u003e","manuscriptTitle":"The vascular anatomy and harvesting of the medial femoral condyle flap in pigs","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-28 12:14:00","doi":"10.21203/rs.3.rs-5322635/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-26T07:59:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-25T14:34:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-25T14:32:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Orthopaedic and Trauma Surgery","date":"2024-10-24T04:30:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4e5214c7-de57-4354-91b5-2ee0ad73e09a","owner":[],"postedDate":"October 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-23T16:08:20+00:00","versionOfRecord":{"articleIdentity":"rs-5322635","link":"https://doi.org/10.1007/s00402-024-05608-8","journal":{"identity":"archives-of-orthopaedic-and-trauma-surgery","isVorOnly":false,"title":"Archives of Orthopaedic and Trauma Surgery"},"publishedOn":"2024-12-16 15:58:09","publishedOnDateReadable":"December 16th, 2024"},"versionCreatedAt":"2024-10-28 12:14:00","video":"","vorDoi":"10.1007/s00402-024-05608-8","vorDoiUrl":"https://doi.org/10.1007/s00402-024-05608-8","workflowStages":[]},"version":"v1","identity":"rs-5322635","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5322635","identity":"rs-5322635","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}