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Free transfer of vascularized bone grafts (VBG) can be used to promote union in bone defects of the hand and wrist. We review reported patient-centered outcomes after microvascular VBG to the upper extremity following nonunion after previous operative repair.
Methods
A systematic review of free VBG in hand and wrist reconstruction was performed querying MEDLINE and PubMed databases. Patient characteristics, perioperative details, and patient-reported and functional outcomes were critically evaluated. Subgroup analysis was performed using the t-test, α=0.05.
Experience
Sixteen studies were included in the analysis, constituting 189 patients (average age 29.5±10.9 years old, 89.4%±24.8% male, and average follow-up of 57.5±28.0 months).
Results
The rate of union after free VBG to the distal upper extremity was 89.9%±13.4% with union occurring at 13.9±2.1 weeks postoperatively. The union rate after free VBG as a primary procedure was 89.9%±15.0%, while free VBG for operative revision reported 90.3%±28.7% rate of union (p=0.9). Four studies reported smoking status with 29.5%±21.4% prevalence. After free VBG, smokers demonstrated 72.7%±26% rate of union compared to 100% of non-smokers (p<0.01). There was no difference in bony union in fractures of the waist (95%±19.2%) compared to proximal pole fractures (93%±7.8%) of the scaphoid when treated with free VBG. There was no difference in union rates based on time from injury to free VBG (p=0.1), or use of K-wire or screw fixation (p=0.9). Compared with the contralateral wrist, patients postoperatively demonstrated 69.4%±12.1% of flexion, 73.8%±6.5% of extension, 72.2%±11.9% of radial deviation, 73.0%±11.2% of ulnar deviation, and 82.1%±15.1% of grip strength. Patients reported 91.3%±12.9% satisfaction rate, average DASH score 18.4±10.5, and an average Mayo wrist score of 79.3±6.4. By 4.7±2.4 months, 91.6%±5.5% of patients returned to work. Major complications, including flap loss and reoperation occurred in 7.4% of cases, and 61.4% of patients reported minor complications at the donor or recipient site, including pain, paresthesia, or deformity.
Conclusions
The use of free VBG to the hand and wrist facilitated bone union in patients with nonunion following previous repair. Smokers demonstrated significantly worse outcomes compared to nonsmokers. High functional recovery scores, levels of satisfaction and rates of return to work were reported. The rate of major complications was low, justifying the use of free VBG in patients at risk or with history of nonunion after surgery.