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T. Yano
38.3 Pre-Operative Investigation
PAP ap perforators from the profunda femoris artery usually tend not to have anatomical variations or anomalies, a
hand-held Doppler will be enough for pre-operative investigation. After identifying the adductor longus and gracilis
muscles, two or three perforators will be found with a handheld Doppler below these two muscles. However, if CT angiography is available, a CT image will provide more specic
information to identify the dominant perforators in each
patient.
Nowadays, a duplex ultrasound is another useful tool to
perform pre-operative investigation for free ap planning.
Duplex ultrasound images provide the exact raising point of
perforators from the adductor magnus muscle, and show the
size and quality of the perforators. Kehrer et al. (2018)
reported that they could map almost the exact emergence
point of the PAP ap perforators with no false-negative sign.
This information will help to determine which perforator to
include in the ap.
38.4 Flap Design andMarkings
muscles are marked on the surface of the medial thigh. One
to three perforators will be marked during the pre-operative
investigation with a hand-held Doppler, CT angiography or
duplex ultrasound. A red circle with an asterisk indicates a
dominant perforator in this case. Because the donor site
exists close to the hip joint, and the donor site wound tends
to have relatively strong tension according to the patient’s
body movement post-operatively, it recommends designing
the width of the PAP ap less than 8cm for a safe donor site
closure.
There are two types of ap incision markings, the transverse and vertical designs (Fig.38.2a, b). The design can be
selected according to patient demands, the amount of subcutaneous fat and perforator locations.
If indocyanine green (ICG) angiography is available, it is
recommended to evaluate the lymphatic ow of the medial
thigh in order to avoid damaging the lymphatic system, as
reported by Karakawa etal. (2020). White arrows show the
medial lymphatic ow in this patient.
38.5 Flap Raise/Elevation: AStep-by-Step
Guide
The perforators are marked and the ap design is drawn as
the patient is positioned in the frog-leg position (Fig.38.2a,
b). The adductor longus muscle can be palpated between the
pubic tubercle and medial knee joint, when you ask the
patient to adduct the thigh. Just below the adductor longus
muscle, the gracilis muscle can be palpated, and these two
Step 1. Make a Skin Incision. Find the Great Saphenous
Vein If Necessary
Start by making a skin incision to the anterior incision line of
the ap. In the subdermal tissue, the great saphenous vein
(short white arrows) and its branch, named the posterior
Fig. 38.2 (a) (left): Vertical design of the PAP ap (left), (b) (right): transverse design of the PAP ap. White arrows indicate lymphatic vessel
identied with ICG lymphography. White asterisk shows a dominant perforator. White dotted line represents inguinal crease
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accessory saphenous vein (long white arrows), can be identied (Fig.38.3). Karakawa etal. (2019) reported the usability
of including the accessory saphenous vein in the PAP ap. If
the recipient vein has a rather large calibre size, and the ap
needs a large drainage vein, including the accessory saphenous vein in the ap will be another option for ap venous
drainage.
Step 2. Find the Landmark Muscle, The Adductor
Longus Muscle
After making the skin incision, it is easy to dissect the skin
paddle from the anterior border to the posterior border.
Dissection of the skin paddle continues under the deep fascia, which will help you to identify both the adductor longus
and gracilis muscles. You can identify the adductor longus
muscle rst, just after making an incision into the deep fascia
(Fig.38.4a).
Step 3. Find the Second Landmark Muscle, the Gracilis
Muscle
Next to the adductor longus muscle, the gracilis muscle will
appear 2–3cm posterior to the adductor longus muscle. The
adductor longus and gracilis muscles are key muscles to tell
you that your dissection is in the right layer, and you will nd
the adductor magnus muscle next to these two muscles
(Fig.38.4b).
Step 4. Identify the Adductor Magnus Muscle
The adductor magnus muscle is next to the gracilis muscle
(Fig.38.5a). To start dissecting the adductor muscle means
that you have stepped into the “Hot zone” to nd the perforators from the profunda femoris artery penetrating the adductor magnus muscle. Therefore, dissection should be
meticulous once you have found the adductor magnus
muscle.
Step 5. Identify the Dominant Perforator of the PAP
Flap
Usually, the perforators from the profunda femoris artery
give off several skin perforators. You can choose one or two
perforators that will be suitable for a ap setting. The white
arrows show the dominant perforator (Fig.38.5b). Sometimes
two skin perforators are found to be joined during muscular
dissection. Therefore, if you can nd two close skin perforators, it is recommended to dissect both perforators expecting
both perforators to be joined together, and the ap can have
a stable vascular supply.
Step 6. Dissection of the Flap Pedicle to Obtain Enough
Length for Flap Setting
Once the perforator is identied, skeletonizing the perforator
is relatively straightforward. Unlike the DIEP ap or ALT
ap pedicle, the PAP ap pedicle usually runs straight into
the profunda femoris artery. This route makes skeletonizing
the PAP ap pedicle rather simple. But the perforator gives
off several small muscle branches (Fig.38.6a), so careful
ligation and separation are necessary. The muscle branch of
the PAP ap becomes relatively larger in the proximal side,
and the calibre size of the side branch vessels become large
enough for micro-anastomosis (Fig.38.6a). This side branch
will be a recipient vessel if the stacked PAP ap is considered for use.
In the end, the PAP ap with adequate bulk can be harvested (Fig.38.6b). The PAP ap can include the posterior
saphenous vein as a lifeboat vessel for an extra drainage.
38.6 Core Surgical Techniques inFlap
Dissection
First, after making the skin incision to the anterior incision
line, you have to perform careful dissection of subcutaneous
Fig. 38.3 Short white arrows indicate the great saphenous vein, and
long white arrows show the posterior accessory saphenous vein
branched off from the great saphenous vein
tissue so as not to damage the saphenous vein (Step 1). When
you try to identify the landmark muscles, the adductor lon-
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T. Yano
Fig. 38.4 (a) (left): The adductor longus muscle can be identied after
opening the deep fascia, (b) (right): the gracilis muscle can be found
posterior to the adductor longus muscle. Short arrows indicate the per-
forator from the gracilis muscle to the skin paddle. White dotted lines
show the anterior and posterior border of the gracilis muscle
Fig. 38.5 (a) (left): The adductor magnus muscle can be identied after dissecting the deep fascia next to the gracilis muscle, (b) (right): white
arrows indicate the perforator from the adductor magnus muscle to the skin paddle
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Fig. 38.6 (a) (left): Both white arrows indicate side branches of the PAP ap pedicle, which can use as a recipient vessel for the stacked PAP ap,
(b) (right): white short and long arrows indicate the posterior saphenous vein and the PAP ap pedicle, respectively
369
gus and gracilis muscles, subfascial dissection makes it easy
for you to nd these muscles. Therefore, you have to open
the fascia of the adductor longus, gracilis and adductor magnus one by one as shown in steps 2–4 (Figs.38.4a and 38.6a).
If you are confused about which muscle you are dissecting,
the gracilis muscle will be a guide for you. The gracilis muscle has a distinctive shape (step 3). It looks like a muscle belt,
and it is easily separated from the surrounding tissues. Once
you can recognize the gracilis muscle, you can identify the
adductor magnus muscle posterior to the gracilis muscle.
Usually, you can nd two or three perforators penetrating
you can obtain enough length of the ap pedicle for the ap
setting. Even though the ap pedicle seems to have enough
length for your plan, it is recommended to dissect further to
provide an extra 1 or 2cm length. Because the PAP ap pedicle tends to become shorter after a ap harvesting, this extra
dissection will prevent you having trouble with ap setting.
When you have skeletonized approximately 8 to 10cm of the
ap pedicle, the calibre size of the perforator becomes large
enough up to about 2mm to anastomose to any kind of recipient vessels, such as the internal mammary artery or superior
thyroid artery (step 6).
the adductor magnus muscle. You can choose which one to
dissect according to the size or location of the perforator.
Sometimes, there is one dominant perforator, which is the
38.7 Clinical Scenario
largest of the vessels. Because the PAP ap has a limited
number of perforators in the medial posterior thigh area, it is
38.7.1 Scenario 1
not difcult to decide which perforator to include compared
to the DIEP ap, which has multiple choices of perforators
(step 5). During the pedicle skeletonization, two Weitlaner
retractors or similar retractors will help you to provide a stable dissection window. Start with deroong the perforator,
and the surrounding muscles are divided with a ne mosquito or dissecting scissors. Several muscular branches from
the PAP ap pedicle can be observed during intra-muscular
dissection. Careful separation of these branch vessels with a
The PAP ap could be an alternative option of breast reconstruction for a patient with small- to medium-sized breast.
Moreover, the PAP ap is another option for breast reconstruction if a patient has multiple scars in the abdomen, does
not have enough fat for breast reconstruction in the abdomen
and lumbar region, or plans a future pregnancy. The PAP ap
can be placed in the defect with a cone shape or transverse
settings according to the shape of the patient breast.
surgical ligation clip and a Bipolar should be continued until
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38.7.2 Scenario 2
The PAP ap is available for a simple small to the medium
size of head and neck defect such as hemi-glossectomy or
parotidectomy defect. Using the PAP ap, pliable skin with
adequate volume of adipose tissue can be transferred to the
defect. In this scenario, the skin paddle is better to design in
the vertical fashion by including the distal perforator of the
PAP ap. Sometimes, the PAP ap pedicle becomes shorter
than expected, and which makes the ap setting difcult for
head and neck defect. Vertical design with the distal perforator enables the ap to extend its pedicle length with
de- epithelializing part of the skin paddle as a part of the ap
pedicle.
38.8 Pearls andPitfalls
Pearls
• Find and identify the adductor longus and gracilis
muscles rst. These key muscles tell you that you
are in the right plane to dissect.
• Continue to dissect under the deep fascia until you
can identify the adductor magnus muscle.
Sometimes during a skin paddle elevation, a relatively
robust perforator from the gracilis originating from
the medial femoral circumex system can be found.
In this scenario, you can switch to harvesting the
ap as a transverse upper gracilis (TUG) ap.
• In the case of head and neck reconstruction, often
the defect needs a rather long ap pedicle. In this
scenario, you can de-epithelialize part of the ap,
and use this part as an extension of the pedicle.
• There is a possibility of harvesting the innervated
PAP ap including the cutaneous branch of the
obturator nerve.
T. Yano
Pitfalls
• Do not take too large a skin paddle. The width of
the PAP ap is recommended to harvest within
8cm for a safe donor site primary closure. Donor
site wound problems can be more serious after
harvesting the PAP ap if you harvest too much
material for the skin paddle.
• It is recommended to create a ap pedicle that is
as long as possible. The PAP ap pedicle tends
to be shorter than you expect after detaching the
ap from the donor site. Usually, one single perforator will be enough for nourishing small- to
medium-sized PAP ap. On the other hand, ICG
angiographies such as SPY system or PDE neo
will always help you to reduce the risk of fat
necrosis or wound healing post-operatively.
• In some cases, the donor site scar is little bit
lower than a patient has expected due to the location of the perforator.
• When you perform ap dissection of the posterior part of the ap, you should take care not to
damage the posterior femoral cutaneous nerve.
• In some cases, a hemi-lateral PAP ap might
provide only limited volume for breast reconstruction. For instance, sometimes the PAP ap
cannot provide enough volume in the breast
upper pole area. In that case, you can consider
using both sides of the PAP ap as a stacked PAP
ap. It is a very rare scenario for the PAP ap,
but if you cannot nd any single adequate perforator to raise the PAP ap, you can switch to use
the medial circumex artery perforator as TUG
ap or to harvest the PAP ap from the contralateral side of the thigh.
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38.9 Selected Readings
• Angrigiani C, Grilli D, Thorne CH.The adductor ap: a
new method for transferring posterior and medial thigh
skin. Plast Reconstr Surg 2001;107:1725–1731.
• The rst article about the application of the PAP ap as a
free ap for soft tissue defects.
• Allen RJ, Haddock NT, Ahn C, Sadeghi A.Breast reconstruction with the profunda artery perforator ap. Plast
Reconstr Surg 2012;129:16–23.
• The rst report to describe the usability of the PAP ap
for breast reconstruction.
• Haddock NT, Gassman A, Cho MJ, Teotia SS. 101 consecutive profunda artery perforator aps in breast reconstruction: lessons learned with our early experience. Plast
Reconstr Surg 2017; 140: 229–239.
• A report on the experiences of using a large number of
PAP aps for breast reconstruction
• Qian B, Xiong L, Li J, Sun Y, Sun J, Guo N, Wang Z.A
systematic review and meta-analysis on microsurgical
safety and efcacy of profunda artery perforator ap in
breast reconstruction. J Oncol 2019;29:1–12.
• A systematic review and meta-analysis on the PAP ap in
breast reconstruction.
• Ito R, Huang JJ, Wu JCW, Lin MCY, Cheng MH. The
versatility of profunda femoral artery perforator ap for
oncological reconstruction after cancer resection-clinical
cases and review of literature. J Surg Oncol 2016;
114:193–201.
• A report on the usability of the PAP ap for various kinds
of defects.
• Heredero S, Sanjuan A, Falguera M, Dean A, Ogledzki
M. The thin profunda femoral artery perforator ap for
tongue reconstruction. Microsurgery 2020; 40:117–124.
• Report on experiences of the usage of the PAP ap for
head and neck reconstruction.
• Largo RD, Chu CK, Chang EI, Liu J, Abu-Ghname A,
Wang H, Schaverien MV, Mericli AF, Hanasono MM, Yu
P. Perforator Mapping of the Profunda Artery Perforator
Flap: Anatomy and Clinical Experience. Plast Reconstr
Surg 2020; 146: 1135–1145.
• PAP ap perforator mapping in the medial thigh area for
ap design and planning.
• Algan S, Tan O.Profunda femoris artery perforator aps:
a detailed anatomical study. J Plast Surg Hand Surg 2020;
54: 377–381.
• Anatomical study on the detailed information of perfora-
tors of the PAP ap using fresh cadavers.
• Kehrer A, Hsu MY, Chen YT, Sachanandani N, Tsao
CK. Simplied profunda artery perforator (PAP) ap
design using power Doppler ultrasonography (PDU): a
prospective study. Microsurgery 2018;38: 512–523.
• Clinical evaluation and description of the perforator of
the PAP ap using power Doppler ultrasonography.
• Karakawa R, Yoshimatsu H, Tanakura K, Miyashita H,
Shibata T, Kuramoto Y, Yano T. An anatomical study of
the lymph-collecting vessels of the medial thigh and clinical applications of lymphatic vessels preserving profunda
femoris artery perforator (LpPAP) ap using pre- and
intraoperative indocyanine green (ICG) lymphography. J
Plast Reconstr Aesthet Surg 2020;73:1768–1774.
• Clinical and anatomical study of the relation between
lymphatic vessels and the profunda femoris artery
perforator.
• Karakawa R, Yoshimatsu H, Fuse Y, Hayashi A, Tanakura
K, Heber UM, Weninger WJ, Tzou CHJ, Meng SM, Yano
T. The correlation of the perforators and the accessory
saphenous vein in a profunda femoris artery perforator
ap for additional venous anastomosis: a cadaveric study
and clinical application. Microsurgery 2019;40:200–206.
• Cadaveric and clinical evaluation of usage of the poste-
rior saphenous vein for the PAP ap.
• Ciudad P, Maruccia M, Orfaniotis G, Weng HC,
Constantinescu T, Nicoli F, Cigna E, Socas J,
Sirimahachaiyakul P, Sapountzis S, Kiranantawat K, Lin
SP, Wang GJ, Chen HC.The combined transverse upper
gracilis and profunda artery perforator (TUGPAP) ap for
breast reconstruction. Microsurgery 2016; 36: 359–366.
• Explaining the idea of conjoined TUG ap and PAP ap
for breast reconstruction.
Medial Femoral Condyle Flap
AnthonyL.Logli andAlexanderY.Shin
39
39.1 Introduction
The medial aspect of the knee, and specically the descending genicular artery (DGA), was rst recognized as a potential donor site for a vascularized ap in 1981 [1]. In 1985, the
osteoarticular branch (OAB) of the DGA was realized as a
ap supply source in harvesting the adductor magnus tendon
and tubercle [2].
The contemporary medial femoral condyle (MFC) ap
was rst described in 1988 as a free corticoperiosteal ap to
address pseudoarthrosis of the upper limb [3]. The innovative feature of this ap was inclusion of cortical bone, thereby
preventing disruption of the highly osteogenic cambrium
layer of periosteum violated with vascularized periosteal
aps [4].
The MFC ap can be raised as a pedicled or free corticoperiosteal, corticocancellous, or osteochondral graft with or
without a neurotized skin island. The ap is extremely versatile and can be shaped according to donor site needs without
compromising blood supply. Use of the MFC graft has been
described in the clavicle [5–7], manubrium [8], humerus [4,
5, 9, 10], metacarpal [4, 11], scaphoid [12–15], capitate [16,
17], lunate [16, 18], forearm [4, 5], tibia [19, 20], femur [21],
talus [5], calcaneus [22], as well as head and neck reconstruction [23–27] with indications encompassing radiationinduced pathologic fractures, primary or recalcitrant
nonunions, or sites with known or anticipated poor vascularity or healing potential [6, 28]. When inclusive of cartilage
from the trochlea, the graft is instead given the moniker of
medial femoral trochlea (MFT) graft [29, 30].
A. L. Logli
Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
A. Y. Shin (*)
Division of Hand Surgery, Department of Orthopaedic Surgery,
Mayo Clinic, Rochester, MN, USA
e-mail: shin.alexander@mayo.edu
39.2 Anatomy
The vascular anatomy of the medial knee in the context of
vascularized grafts was rst explored by Hertel and
Masquelet in 1989, simultaneously marking the appearance
of the MFC ap in the American literature [19]. The MFC
ap is supplied by the descending (or supreme) genicular
artery (DGA) (present intraoperatively in 93% of knees) and
venae comitantes [13, 19, 31]. The DGA originates off the
medial aspect of the supercial femoral artery (SFA) approximately 14cm above the joint line (11–18cm) just before the
SFA passes through the adductor magnus hiatus [4, 13, 19].
Mean diameter and length is sufcient for microvascular
anastomosis at 1.5–2.1mm and 1.2cm, respectively [19, 31].
It consistently branches into an osteoarticular branch (OAB)
(90% from the DGA; 6% directly from the SFA), the predominant supply for the MFC graft, a saphenous artery
branch (SAB) (79% present), which can simultaneously supply a skin ap for transfer, and a muscular branch (MB) [13,
19]. The mean distance of the OAB origination is 11.3cm
above the joint line [13]. The vessel runs on the posterior
surface of the medial intermuscular septum with a mean
diameter of 1.2 mm at its origin [19]. Proximal branching
near the origin (40%) and distal branching near the adductor
tubercle (60%) then occurs, where the OAB splits into medial
and lateral branches, some of which supply the posterior border of the vastus medialis. Just proximal to the knee joint
capsule and MCL origin, the OAB joins with the sMGA to
create a rich, almost circular, anastomosis supplying the
overlying periosteum. Recent mappings and in-depth reexamination of the microvascular anatomy of this region suggest there to be an average of 30 osteoarticular perforators
extending to a depth of 13mm with highest concentration of
these located in the posterior-distal quadrant of the condylar
surface [31].
Independently perfused or dual-supply MFC grafts based
off the superomedial genicular artery (sMGA) were described
early-on to further enhance ap vascularity [4]. While dual
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_39
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A. L. Logli and A. Y. Shin
vascularity remains an option, incorporation is not essential.
The sMGA is present 98% of the time and originates from
the medial aspect of the popliteal artery at a mean distance of
5.2cm above the joint line [13, 32]. These vessels are typically shorter, smaller, harder to dissect, and have no cutaneous vascular supply to support skin if needed for transfer,
however, they are the dominant supply to the MFC region in
23% of intraoperative exposures and the only vessel in 7% of
cases [32]. In the native knee, both the DGA and sMGA
serve as the principal nourishment to the periosteum of the
MFC, while playing a relatively minor role in corticomedullary perfusion [5]. Thus, destruction of residual perfusion to
the donor site bed is not a concern.
39.3 Preoperative Investigation
The anatomy of the medial knee is highly consistent, thereby
obviating the need for preoperative vascular mapping in
most instances. If desired, Doppler ultrasonography can be
used. This may be most useful to identify and mark the SAB
if a skin island is planned. This vessel is located distally in
the medial thigh just posterior to the midlateral line [21]. It
perfuses an area of skin approximately 361cm2 [33]. Smaller
skin islands, measuring up to 70 cm2, may also be raised
solely on cutaneous perforators of the DGA [33]. Prior incisions should be recognized and incorporated if possible. Use
of the ipsilateral knee is preferred for recipient sites of the
upper extremity. This allows two surgical teams in the room
to operate simultaneously. In upper extremity recipients, use
of the ipsilateral knee also allows the patient to use a cane in
the contralateral hand if necessary. Otherwise, either knee
may be used.
The patient is placed supine with the hip and knee exed
and externally rotated. The recipient site should be exposed
rst if not done simultaneously by a second operating team.
A sterile tourniquet is applied to the proximal thigh and
raised (usually to 300mmHg) just prior to medial thigh incision and exposure.
39.4 Flap Design andMarkings
A bulk section of distal medial femoral metaphyseal bone
6–8cm in length may be harvested in most instances, as well
as 5–7 cm corticoperiosteal aps. The proximal extent of
periosteal perfusion of the DGA is much greater (up to
13.7 cm or 29% of total femur length in cadaveric specimens) [34]. Despite this, it is important not to extend the
harvest past the metaphyseal-diaphyseal junction as it creates a stress riser that may result in a delayed supracondylar
femur fracture. This is a well-known complication in the
total knee replacement literature when femoral condyle bone
cuts extend past the metaphyseal diaphyseal junction [35].
Thin corticoperiosteal grafts with large dimensions
(8×13cm2) have been successfully raised for humeral nonunions in the past with no known incident of perioperative
fracture [36].
The portion of the MFC used for ap harvest is that which
has the greatest density of perforating vessels. This has been
previously dened as the posterior-distal quadrant of the
femoral condyle and has the following borders: (1) the hamstring insertion and medial collateral ligament (MCL) origin
posteriorly, (2) the anterior horn of the medial meniscus
anteriorly, (3) the hamstring insertion proximally, and (4) the
proximal pole of the patella distally.
39.5 Flap Raise/Elevation: AStep-by-Step
Guide
1. Incision
Incision is dependent on indication. A straight
18–20cm medial thigh incision starting at the joint line
and extending proximally along the posterior border of
the vastus medialis is used for non-articular grafts
(Fig.39.1), while a 15 cm curvilinear incision with the
apex at the proximal pole of the patella is used when
inclusion of articular cartilage into the graft is desired.
2. Exposure
(a) Vastus medialis muscle fascia is divided at its poste-
rior border along the entire length of the incision and
the muscle belly is retracted anteriorly to fully appreciate the MFC and overlying vascularity in the bed of
the wound (Fig.39.2).
3. Graft Planning
(a) Once the supply vessel has been chosen (DGA or
sMGA), the pedicle should be isolated by suture ligation of the unused vessel. The planned graft is then
outlined on the MFC periosteum using bipolar electrocautery at posterior-distal aspect of the MFC for
non-articular grafts, anterior-proximal MFC for articular grafts, and broadly across the condylar surface
for corticoperiosteal grafts in order to maximize perfusion potential (Fig. 39.3—structural (a), corticoperiosteal (b), and MFT (c) graft plans are shown).
4. Graft Separation
(a) A small very sharp curved osteotome or microsagittal
saw is used to vertically divide the borders of the
graft to the desired depth. The proximal border is the
last cut made for non-articular grafts while division
39 Medial Femoral Condyle Flap
Fig. 39.1 Illustration of the medial knee incision for obtaining a nonarticular graft starting at the joint line and extending proximally
18–20cm. For an articular graft, the incision would curve distally starting at the proximal pole of the patella. (Reproduced with permission of
the Mayo Foundation)
375
through the cartilage is the nal cut made in articular
grafts (Fig.39.4—structural (a) and corticoperiosteal
(b) graft separation is shown).
5. Graft Elevation
(a) One critical step unique to raising a structural graft to
prevent graft fragmentation or fracture is to raise an
adjacent small wedge of bone 1–2 cm large. This
permits undercutting the graft with a curved osteotome at the desired depth and elevation of the graft
en-bloc. Otherwise, nonstructural grafts may be
elevated after the nal cut is carefully made
(Fig. 39.5—structural (a) and corticoperiosteal (b)
graft elevation is shown with the additional technical feature recommended when raising a structural
graft highlighted (c)).
6. Graft Preparation and Division
(a) The graft pedicle is clipped and divided. Once, har-
vested, it is customized according to recipient site
geometry (Fig.39.6—structural (a) and corticoperiosteal (b) grafts shown after graft division).
ab
Fig. 39.2 Illustration showing release of the fascia overlying the vastus medialis in-line with the skin incision (a). Once the vastus medialis
is retracted anteriorly, the medial femoral condyle and overlying vascu-
lature will be visualized in the bed of the wound (b). (Reproduced with
permission of the Mayo Foundation)
abc
Fig. 39.3 The chosen pedicle (DGA or sMGA) is isolated and clearly
visualized using a green background (a, b). Bipolar cautery or a surgical marker can be used to outline the planned dimensions of the graft.
Shown is a planned structural (a), corticoperisoteal (b), and articular (c)
graft. (Reproduced with permission of the Mayo Foundation)
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Fig. 39.4 A microsagittal saw (a) or sharp, curved osteotome (b) may be used to permit graft separation. Shown is a structural (a) and cortico-
periosteal graft (b) being carefully separated from the medial femoral condyle donor site
A. L. Logli and A. Y. Shin
abc
Fig. 39.5 A small block or wedge of bone is removed adjacent to a
planned structural graft so that it can be elevated en-bloc using a curved
osteotome. An example of this critical step is shown clinically (a) and
in an illustrated form (b). This is not necessary for raising a corticoperiosteal graft (c). (Reproduced with permission of the Mayo Foundation)
7. Donor Site Closure
(a) The donor site defect is lled with synthetic hydroxy-
apatite bone ller (for non-articular grafts) and the
wound is irrigated and closed in a layered fashion
with absorbable sutures over suction drains.
8. Graft Inset and Anastomosis
(a) Non-articular grafts should be inset and xed into the
a
donor bed while corticoperiosteal grafts are wrapped
around bone and xed with sutures. Both press-t
and supplemented xation options may be used for
articular grafts. Microvascular anastomosis is then
performed using an operative microscope and adequacy of perfusion conrmed (Fig.39.7—structural
graft for scaphoid osteonecrosis (a), MFT graft for
proximal pole scaphoid nonunion with fragmentation
(b) and corticoperiosteal graft for clavicle nonunion
(c) are shown).
b
Fig. 39.6 A divided and custom-trimmed corticoperiosteal (a) and
structural (b) medial femoral condyle vascularized bone graft and associated pedicle is shown
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