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Table 1 Summary of all articles included in this systematic review ( N= 12)

From: The use of the free vascularised bone graft for nonunion of the scaphoid: a systematic review

Reference Study type Number of patients = 245 Technique Union rate (%) Average time to union (weeks) Complications Average follow-up (years) Immobilisation (weeks) Comments
Pechlaner et al. [25] Retrospective 25 Resection of the pseudarthrosis or the necrotic bone. Insertion and Kirschner wire fixation of corticocancellous graft from the iliac crest isolated on its vascular pedicle and anastomosed to the radial artery 25 (100%) - - - 8 AVN proximal pole preoperatively
Fernandez et al. [26] Retrospective 11 Resection of the necrotic bone and inserting a corticocancellous bone graft from the iliac crest; the second dorsal intermetacarpal artery is implanted into the proximal fragment of the scaphoid 10 (91%) 10 Nonunion and cystic area increased in 1 patient 5 years 10 Six patients had had previous unsuccessful operative attempts to obtain union
Eight nonunions were in the proximal one third, and three at the waist of the scaphoid
Gabl et al. [23] Retrospective 15 Microvascular pedicled iliac crest bone graft anastomosed to the radial artery after debridement of nonunion 12 (80%) - 20% patients who failed to unite progressed to carpal collapse 6 years 1 month 12 Patients undergoing union had an average grip strength of 107 kg-force versus 73 kg-force in patients failing to unite
Gabl et al. [24] Retrospective 56 Microvascular pedicled iliac crest bone graft anastomosed to the radial artery after debridement of nonunion 47 (85%) - 15% patients failed to unite and progressed to carpal collapse. Arthrosis developed in all these patients 8 years 9 months follow-up 12 In those undergoing union, grip strength was 95% and range of motion 75% compared to the noninvolved wrist. Carpal collapse did not occur. Arthrosis was reduced in 25%
Harpf et al. [22] Retrospective 60 Microvascular pedicled iliac crest bone graft anastomosed to the radial artery after debridement of nonunion. Kirschner wire fixation 55 (92%) - 8.3% who failed to unite progressed to carpal collapse 7 years 5 months 12 61.37% of patients had bone deformations detected radiologically at the donor site, and 31.7% of patients had impairment of the lateral cutaneous nerve of the thigh
Doi et al. [21] Retrospective 10 Free vascularised periosteal bone graft harvested from the supracondylar region of the femur and nourished by the articular branch of the descending genicular artery and vein. Kirschner wire fixation 10 (100%) 12 1 patient suffered transient knee joint stiffness, 1 patient suffered transient saphenous nerve dysaesthesias and 2 patients developed ectopic bone formation requiring resection 3 years 6 months 6 All patients had preoperative AVN proximal pole
Mayo wrist scoring system used to score outcome and showed 8 patients with excellent or good outcomes. Grip strength returned to 33 kg-force on the affected side versus 40 kg-force on the unaffected. All patients resumed activities
Doi et al. [29] Retrospective 11 Free vascularised periosteal bone graft consisting of periosteum, cortex and underlying cancellous bone harvested from the supracondylar region of the femur and nourished by the articular branch of the descending genicular artery and vein. Kirschner wire fixation 11 (100%) - - - Until bony union achieved Recommends use of iliac crest donor site if large bone graft required or injury to donor site
Lanzetta [28] Case report 1 Osteochondral-free vascularised graft from the rib based on the inferior and superior intercostal arteries. Kirschner wire fixation 1 (100%) 4 - 5 years 4 No donor site morbidity. Bone formation occurred at the radioscaphoid joint from the graft requiring radiocarpal arthrolysis. Grip strength improved by 30%
Jones et al. [30] Retrospective 12 Free vascularised bone graft harvested from the medial supracondylar region of the femur and nourished by the articular branch of the descending genicular artery and vein. Scaphoid screw or Kirschner wire fixation 12 (100%) 13 Ectopic bone formation noted 1 year Until bony union achieved Comparative study against pedicled VBGs showing a significantly short time to union in free VBGs (p < 0.001) and a significantly higher rate of union (p < 0.005)
Larson et al. [31] Retrospective 11 Free vascularised bone graft harvested from the medial supracondylar region of the femur and nourished by the articular branch of the descending genicular artery and vein. Scaphoid screw or Kirschner wire fixation 11 (100%) 12 Ectopic bone formation at periosteal flap in 2 patients - Until bony union achieved Final 12th patient only 2 months postsurgery and so excluded from results
Mayo wrist scoring system showed excellent or good results in 8 patients. No donor site morbidity
Arora et al. [27] Retrospective 21 Microvascular pedicled iliac crest bone graft anastomosed to the radial artery after debridement of nonunion. Kirschner wire fixation 16 (76%) 19 - 5 years 7 months 12 Difference in pre- and postoperative grip strength statistically significant in patients undergoing union (p < 0.03). 11 of 16 patients with union showed no signs of osteoarthritis, and 5 patients showed stage 1 signs of osteoarthritis. All patients with persistent nonunion showed signs of osteoarthritis
Jones et al. [32] Retrospective 12 Free vascularised bone graft harvested from the medial supracondylar region of the femur and nourished by the articular branch of the descending genicular artery and vein. Scaphoid screw or Kirschner wire fixation 12 (100%) 13 1 concurrent donor-site stitch abscess debridement - Until bony union achieved Radial styloidectomy required after union in 1 patient