Floor plan - 2013 Annual Meeting - American Association for Hand ...

Long-Term Functional Outcome of the Upper Extremity following Osteocutaneous Radial
Forearm Free Flap Harvest
Institution where the work was prepared: University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Justin M. Sacks, MD1; Kia M. McLean, MD1; Ernest K. Manders, MD2; James M. Russavage, MD, DMD1; Frederic W.-
B. Deleyiannis, MD, MPhil, MPH2; (1)University of Pittsburgh Medical Center, (2)University of Pittsburgh
BACKGROUND/INTRODUCTION:
The osteocutaneous radial forearm free flap (ORFFF) represents a versatile modality in the reconstruction of composite tissue defects of
the head and neck. Poor cosmetic outcomes and the possibility of pathologic fractures have been cited as the primary disadvantages.
The purpose of this study was to determine any long-term functional morbidity of the donor upper extremity following flap harvest.
METHODS:
A prospective cross-sectional analysis was performed on twelve patients who were at least one-year post-operative. Patient, injury and
tumor variables were obtained. Clinical outcomes included donor site appearance, size and any history of wound complications.
Functional capacity was quantified by comparing range of motion (ROM) of the thumbs, digits and wrists along with pronation and
supination of bilateral forearms. Pinch and grip strengths were obtained. Neurovascular assessment using two-point discrimination in
the median, ulnar and radial nerve distribution along with digital plethysmography of the thumb and index fingers was assessed.
Disability of the Arm, Shoulder and Hand (DASH) questionnaires were elicited at long-term post-operative evaluation. Radiographs of
bilateral forearms were utilized to evaluate for deformity and occult fracture.
RESULTS:
All radial forearm donor sites were healed with no evidence of tendon exposure. The mean ROM of full active wrist flexion, wrist extension,
and thumb flexion measured respectively 83% (p =0.01), 82% (p=0.01), and 89% (p=0.03) of the non-flap arm. Forearm supination
was reduced 83% (p=.03). Three of the patients (25%) were unable to fully oppose their thumb to their little finger (p=0.08). No significant
differences were found between forearm pronation, full composite grip, pinch or grip strength, digital plethysmography, or twopoint
discrimination. Five of the 12 patients (41.6%) reported a DASH score greater than 10, and 3 (25%) patients indicated that harvest
of the ORFFF created a disability. Radiographs revealed one malunion secondary to post-operative pathological fracture.
CONCLUSION:
Harvest of the ORFFF is associated with a significant reduction in ROM of the wrist, forearm, and thumb. Patients frequently reported
upper extremity limitations. The ORFFF, although versatile and reliable, is associated with long-term functional morbidity of the upper
extremity. Surgeons should pre-operatively counsel their patients about these possible risks.
Vascularized Scapular Grafts: An Excellent Option for Humeral Nonunions
Institution where the work was prepared: Denver Clinic for Extremities at Risk, Denver, CO, USA
Jerrod Keith, MD1; David P. Schnur, MD2; William Brown2; Ross Wilkins2; Ronald Hugate, MD2; Cynthia Kelly2;
(1)University of Colorado Health Science Center, (2)Denver Clinic for Extremities at Risk
Posttraumatic humeral nonunions are uncommon, ranging from 0% to 13% in published series, yet this is a problematic complication,
challenging to surgeons and debilitating to patients. A variety of conventional techniques have been described to treat nonunions,
including intramedullary nailing, plating with and without bone grafting, and external fixation. These methods can be successful, as
reports of bony union range from 22 % to 95%. An attractive alternative to these traditional methods for humeral reconstruction is the
addition of vascularized bone grafts, which are especially advantageous in patients with local devascularization and infection. Most
microvascular surgeons utilize the free fibula graft to treat humeral nonunions. Only a few case reports and small case series, the largest
being 3 patients, describe the use of lateral boarder of scapula bone grafts to treat this problem. We retrospectively reviewed 23
patients from a single institution treated with vascularized bone graft for humeral nonunion using the lateral border of the scapula. Our
mean population age was 59, and patients underwent an average of 3 prior operations. The length of time from injury to grafting averaged
33.4 months. Healing occurred in 21/23 patients (91.3%), with an average time of 18 weeks to bony union. 19/23 grafts were pedicled,
and the remaining 4 were free grafts. Three of the four free grafts included skin paddles. Fracture locations involved the entire
length of the humerus, although the majority was in the middle third (61%). There were three distal nonunions that were successfully
treated with osteocutaneous free grafts. Three complications occurred in only 2 patients. One patient developed an infection and ulnar
nerve entrapment, while the other formed thrombosis in the graft vein. Both complications resolved after operative revisions and these
patients achieved union of their fractures. Throughout follow-up, patients completed a modified MSTS upper extremity functional evaluation
score. The average length of follow up was 30 months and the average MSTS functional score was 80%. Based on these results,
we believe that the lateral border of the scapula as a vascularized bone graft is an excellent option for humeral nonunions. The majority
of grafts can be performed on a pedicle, obviating the need for lengthy operations and complications associated with vascular anastamoses.
Additionally, the operative field is limited to one region of the body, which may aid in patient comfort and hasten recovery.
160