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Vascularized Bone Grafting in Scaphoid Nonunion: A Review of Patient-Centered Outcomes
Ram K. Alluri, MD1; Christine Yin, BS1; Lakshmanan Sivasundaram, BS1; Matthew Lorio, MD2; Alidad Ghiassi, MD1; Milan Stevanovic, MD, PhD1; Ketan Patel, MD1
1Keck School of Medicine at USC, Los Angeles, CA; 2Harvard Medical School, Boston, MA

Introduction: Scaphoid fractures are among the most common upper extremity fractures, and 10% can result in nonunion. Vascularized bone grafting (VBG) has become an increasingly popular option to restore hand function, reporting significant improvement in objective clinical and radiographic outcomes. Equally important, however, are patient-centered outcomes such as functionality and overall satisfaction. The purpose of this study was to determine the effect of VBG for scaphoid nonunion on patient-centered outcomes.
Methods: The MEDLINE and PubMed databases were queried for the use of VBG in scaphoid nonunion. We included studies which reported on patient-centered outcomes. We excluded studies with less than 10 patients or six months follow-up. The primary outcomes assessed included functionality, percent and time to return to preinjury activity, postoperative pain, and patient satisfaction. Data analysis was completed with weighted means based on sample size. Statistical significance was defined as P < 0.05.
Results: Twenty-six articles described the outcomes of 520 subjects with an average of 19.3 subjects per study. 91.1% of subjects were male with an average age of 29.3 years. The mean follow-up was 35.1 months. The average duration of nonunion before VBG was 31.4 months. Functionality was most commonly assessed by the MMWS and DASH scores which increased 53.8% and 81.7% postoperatively, respectively (P < 0.05). 90.3% of patients returned to their previous occupation or sporting activity within 16 weeks. Pain was most commonly reported using a 0-10 scale. Preoperative pain was 5.20 while postoperative pain was 0.99, a fourfold improvement (P < 0.05). Complete satisfaction was reported by 92% of patients postoperatively. The most common complications were superficial infections (1.56%), nerve irritation (1.56%), and complex regional pain syndrome (1.25%).
Conclusions: VBG for scaphoid nonunion results in significant improvement of patient-centered outcomes. The available literature suggests that VBG can markedly improve functionality and pain, resulting in excellent rates of return to preinjury activity level and patient satisfaction. Multiple metrics of patient-centered outcomes were utilized by the studies in our review without a clear consensus as to which metric is most responsive and accurate.

Figure 1: Flow Chart of Article Selection

Figure 2: Assessment tools utilized to assess postoperative functionality in this systematic review.

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