Osteocutaneous free flaps for reconstruction of composite hand defects: A systematic review of clinical and functional outcomes.

Abstract

Composite hand defects involving bone and soft tissue are among the most challenging reconstructive scenarios. Numerous osteocutaneous flaps have been described; however, the available evidence is limited to small, heterogeneous clinical series. A systematic review was conducted according to the PRISMA 2020 guidelines (PROSPERO CRD420251207549). The PubMed/MEDLINE, Embase, Scopus, and the Cochrane Library databases were searched. Studies reporting clinical outcomes of free osteocutaneous flaps for reconstruction of composite defects of the hand were included. Data extraction and risk-of-bias assessment (JBI and Newcastle-Ottawa Scale) were performed independently by two reviewers. Given the heterogeneity of indications, techniques, and outcome measures, a narrative synthesis was performed. Twenty-nine studies comprising 92 patients met the inclusion criteria. Most defects were trauma-related (88%) and involved the metacarpals (56.5%) or phalanges (35.9%). The most frequently used flaps were fibula free flap (37%), humerus-based flaps including radial collateral artery perforator and lateral arm variants (23.9%) and iliac crest flaps (19.6%). Radiographic union occurred at a median of 4 months, and flap survival was 98.9%, with few major complications and no reported donor-site morbidity. Recipient vessels were predominantly branches of the radial artery and superficial dorsal or cephalic veins. Flap selection demonstrated consistent anatomical patterns: fibula and iliac crest flaps were most suited for metacarpal reconstruction, whereas humerus-based flaps were ideal for phalangeal defects requiring thin, pliable soft tissue. Multilevel defects occasionally required chimeric or sequential constructs. Although current evidence is limited by small sample sizes and methodological heterogeneity, anatomy-driven trends in flap choice can guide clinical decision-making. This review offers the first structured synthesis of osteocutaneous free flaps for hand reconstruction and includes a graphical overview summarising reconstructive options by defect location.