Outcome and Quality of Life after Reconstruction of Complex Defects of the Forearm and Hand with Osteocutaneous Free Flaps

Complex defects of the forearm and hand often require microvascular reconstruction with composite osteocutaneous free flaps for limb salvage.

Fifteen patients with combined osseous and soft tissue defects of the forearm and hand were treated with osteocutaneous flaps between 1992 and 2004 and were evaluated for the postoperative results. The assessment focused on the range of motion, the pain and grip strength, as well as on the patients individual physical functioning and self perception, measured with the DASH questionnaire. Additionally, complications, return to work, and donor site morbidity were documented.

Etiologies of the combined defects were trauma, infections, or malignant tumors. Eight microvascular osteoseptocutaneous fibula transplantations were performed; six patients were treated with osteocutaneous scapular or parascapular flaps. In one patient, an osteocutaneous lateral arm flap was used for thumb reconstruction. The patients' average age was 40.6 years (range, 13 to 67 years). The average osseous defect was 11.7 cm (range, 2 to 21 cm). All patients suffered from additional soft tissue defects of varying dimensions.

All defects could be covered in a one–step reconstructive procedure after sequential debridements or after oncologic resection. Every patient had a markedly reduced hand function, compared with the unaffected extremity; however, in all but one patient, the functional result was still satisfactory, with a mean DASH score of 25.3 (range, 0 to 42). This reflected only a moderate disability in activities of daily living. Two patients developed a pseudarthrosis; one had to undergo an ablation procedure due to persistent infection. Two patients suffered from wound dehiscence at the donor site, and one patient required a fasciotomy due to an imminent compartment syndrome after fibula harvest.

From the patients' point of view, the functional results were more than acceptable, when the potential alternatives (e.g., major amputation or long hospitalization and callus distraction procedures) were taken into consideration. This was also reflected by a high individual satisfaction score.

This retrospective analysis demonstrated that limb salvage with osteocutaneous free flaps is the treatment of choice for three–dimensional defects in the forearm and hand.