Purpose Clavicular nonunion is an uncommon complication with a significant impact on quality of life and can be difficult to manage. In recalcitrant cases, or situations unfavorable for take of nonvascularized grafts, vascularized osseous reconstruction may be utilized. Several donor sites for such flaps have been described, with each associated with unique benefits and drawbacks.

Methods A systematic review utilizing MEDLINE and Embase databases was performed for cases of vascularized bone reconstruction for clavicle nonunion.

Results Twenty-six papers met inclusion, comprising 67 patients. Mean age was 43.1 years, across 32 male and 35 female patients. Mean period of nonunion was 43.2 months in the fibular group, 42.0 months in the medial femoral condyle (MFC), and 12 months in the rib flap group.

Patients had undergone a mean of 2.67 prior operations at the time of vascularized osseous flap; a proportion of patients had undergone prior locoregional radiotherapy (9/26) or been complicated by infection (12/22). Radiological union was achieved in 95.2% (20/21) of fibular flaps, 95.6% (25/27) of MFC flaps, and 66.7% (2/3) of rib flaps. Mean time to union was 10.6 months for the fibular group, 7.8 months for the MFCs, and 4.0 months for the rib flaps. Complications occurred in 55.6% (20/36) of patients having fibular flaps, 26.1% (6/23) of MFC flaps, and 50% (2/4) of rib flaps.

Conclusions All osseous flaps yielded similar and consistent rates of union when used to reconstruct defects of the clavicle. Higher complication rates, particularly donor site morbidity, were noted with fibula and rib flaps when compared to the MFC.