Capanna Technique Research Articles

Outcomes of Upper Extremity Reconstruction with a Modified Capanna Technique

Outcomes of Upper Extremity Reconstruction with a Modified Capanna Technique

A NOVEL TECHNIQUE FOR MANAGEMENT OF A CRITICALLY-SIZED BONE DEFECT IN THE OPEN PROXIMAL TIBIAL FRACTURE: EMPLOYING THE CAPANNA TECHNIQUE IN TRAUMA

A NOVEL TECHNIQUE FOR MANAGEMENT OF A CRITICALLY-SIZED BONE DEFECT IN THE OPEN PROXIMAL TIBIAL FRACTURE: EMPLOYING THE CAPANNA TECHNIQUE IN TRAUMA

Reconstructive Allograft Preparation for Long Bone Intercalary Segments After Tumor Resections: Toronto Sarcoma Protocol.

Reconstructive Allograft Preparation for Long Bone Intercalary Segments After Tumor Resections: Toronto Sarcoma Protocol.

Establishment of a rabbit's model for modified Capanna technique

Massive bone allograft with an intramedullary vascularized fibula (Capanna technique) represents one of the most widely used methods for the reconstruction of massive bone defect. However, the mechanisms, healing process, and underlying influential factors were poorly understood due to the lack of suitable experimental animal models. Critical-sized defects (CSD) in bone were constructed in the proximal tibia of 24 rabbits and randomly divided into two groups. Allogeneic bone segments of the same size as CSDs were obtained from another 12 rabbits and then inactivated. In group Ⅰ, an ipsilateral pedicled vascularized fibula was dissociated and transferred into the intramedullary cavity of allograft to assemble a composite for CSD reconstruction (Capanna technique), while group Ⅱ received a reconstruction with allogeneic bone alone. Radiographic evaluation was performed every week after the operation to assess union status. All animals were sacrificed at 16th week, and the specimens were histologically analyzed. All animals survived without severe intraoperative complications. There was one rabbit (8.33%) in group Ⅰ developed a postoperative infection and died, while three rabbits (25%) had postoperative complications in group Ⅱ (two died of infection and one died of internal fixation fracture). Radiographically, the mean time to union at the allograft-host junction in group Ⅰ was 12.8±1.80 weeks, significantly shorter than in group II (>15.18±1.12 weeks; p<0.001). The grade of graft union of group Ⅰ was significantly higher than that of group Ⅱ both at 8th and 16th week (8th week: p=0.035; 16th week: p=0.033). Fully bone union at the junctions was histologically confirmed in all specimens in group Ⅰ and 66.67% (8/12) in group Ⅱ. Combined allograft and intramedullary vascularized fibula transfer in rabbit's tibia represent an ideal model that accurately simulates the Capanna technique for CSD reconstruction.

Preliminary Results of the "Capasquelet" Technique for Managing Femoral Bone Defects-Combining a Masquelet Induced Membrane and Capanna Vascularized Fibula with an Allograft.

We describe the preliminary results of a novel two-stage reconstruction technique for extended femoral bone defects using an allograft in accordance with the Capanna technique with an embedded vascularized fibula graft in an induced membrane according to the Masquelet technique. We performed what we refer to as “Capasquelet” surgery in femoral diaphyseal bone loss of at least 10 cm. Four patients were operated on using this technique: two tumors and two traumatic bone defects in a septic context with a minimum follow up of one year. Consolidation on both sides, when achieved, occurred at 5.5 months (4–7), with full weight-bearing at 11 weeks (8–12). The functional scores were satisfactory with an EQ5D of 63.3 (45–75). The time to bone union and early weight-bearing with this combined technique are promising compared to the literature. The osteoinductive role of the induced membrane could play a positive role in the evolution of the graft. Longer follow up and a larger cohort are needed to better assess the implications. Nonetheless, this two-stage technique appears to have ample promise, especially in a septic context or in adjuvant radiotherapy in an oncological context.

Is the Capanna Technique a Reliable Method for Revision Surgery after Failure of Previous Limb-Salvage Surgery?

Reconstruction of a massive bone defect caused by previous failed limb-salvage surgery in patients with bone sarcoma is challenging. Many procedures have been used, but they all have their inherent disadvantages. The Capanna technique has demonstrated good functional outcomes and a low incidence of complications in primary reconstructive surgery of massive bone defect. However, few studies have focused on its usage in revision surgery after failed primary limb-salvage surgery. Between June 2011 and January 2017, 13 patients underwent revision surgery with the Capanna technique for reconstruction of a secondary segmental bone defect caused by a previous failed surgical procedure. The demographics, operating procedures, graft union, functional outcomes, oncologic outcomes, and postoperative complications of each patient were recorded. The current study investigated 13 patients. The rate of limb salvage was 100 %. Bone union was achieved for all patients during a mean time of 8.54 ± 2.15 months (range 4-11 months) at the fibula-host bone junction and 14.92 ± 2.33 months (range 12-21 months) at the allograft-host bone junction. The postoperative complications included wound healing issues and internal fixation loosening. Allograft fracture, nonunion, and infection were not observed. All the patients achieved good functional outcomes, with a Musculoskeletal Tumor Society (MSTS) score of 0.86 ± 0.03 at the latest follow-up visit. The Capanna technique is a reliable alternative method for revision reconstruction of a segmental bone defect caused by a previous failed surgical procedure. Level IV, therapeutic study.

Combined massive allograft and intramedullary vascularized fibula transfer: the Capanna technique for treatment of congenital pseudarthrosis of the tibia

Background and purpose — Congenital pseudarthrosis of the tibia (CPT) is caused by local periosteal disease that can lead to bowing, fracturing, and pseudarthrosis. Current most successful treatment methods are segmental bone transport and vascularized and non-vascularized bone grafting. These methods are commonly hampered by discomfort, reoperations, and long-term complications. We report a combination of a vascularized fibula graft and large bone segment allograft, to improve patient comfort with similar outcomes.Patients and methods — 7 limbs that were operated on in 6 patients between November 2007 and July 2018 with resection of the CPT and reconstruction with a vascularized fibula graft in combination with a bone allograft were retrospectively studied. The mean follow-up time was 5.4 years (0.9–9.6). Postoperative endpoints: time to discharge, time to unrestricted weight bearing, complications within 30 days, consolidation, number of fractures, and secondary deformities.Results — The average time to unrestricted weight bearing with removable orthosis was 3.5 months (1.2–7.8). All proximal anastomoses consolidated within 10 months (2–10). 4 of the 7 grafts fractured at the distal anastomosis between 6 and 14 months postoperatively. After reoperation, consolidation of the distal anastomosis was seen after 2.8 months (2–4). 1 patient required a below-knee amputation.Interpretation — This case series showed favorable results of the treatment of CPT through a combination of a vascularized fibula graft and large bone segment allograft, avoiding the higher reintervention rate and discomfort with ring frame bone transport, and the prolonged non-weight bearing with vascularized fibula transfer without reinforcement with a massive large bone segment allograft.

Is frozen tumour-bearing autograft with concurrent vascularized fibula an alternative to the Capanna technique for the intercalary reconstruction after resection of osteosarcoma in the lower limb?

The use of frozen tumour-bearing autograft combined with a vascularized fibular graft (VFG) represents a new technique for biological reconstruction of massive bone defect. We have compared the clinical outcomes between this technique and Capanna reconstruction. From June 2011 to January 2016 a retrospective study was carried out of patients with primary osteosarcoma of lower limbs who underwent combined biological intercalary reconstruction. Patients were categorized into two groups based on the reconstructive technique: frozen tumour-bearing autograft combined with concurrent VFG (Group 1) and the Capanna method (Group 2). Demographics, operating procedures, oncological outcomes, graft union, limb function, and postoperative complications were compared. A total of 23 patients were identified for analysis: eight in Group 1 and 15 in Group 2. There was no difference in the demographics (age, sex, and affected site) and operating procedures (resection length, duration of surgery, and blood loss) between the two groups. No significant difference was found in local recurrence in Group 1 versus Group 2 (p = 0.585). Mean union time for the frozen autograft-host junction was 8.4 months (7.0 to 11.0), significantly earlier than for the allograft-host junction in Group 2 (mean 14.1 months (10.0 to 28.0); p < 0.001). Mean Musculoskeletal Tumor Society scores in groups 1 and 2 were 90.3% (SD 7.4%) and 88.0% (SD 9.0%), respectively, with no significant statistical difference (p = 0.535). In terms of complications, infection (n = 1, 6.7%) and delayed union (n = 2, 13.3%) occurred in Group 2, but no such complications were observed in Group 1. Frozen tumour-bearing autograft in combination with VFG can be used as an alternative to the Capanna reconstruction in properly selected patients with osteosarcoma. Cite this article: Bone Joint J 2020;102-B(5):646-652.

Pediatric extremity bone sarcoma reconstruction with the vascularized fibula flap: Observational study assessing long-term functional outcomes, complications, and survival

BackgroundLimb salvage is important in pediatric patients with bone sarcomas. The vascularized fibula flap is a versatile option, combined or not with a bone allograft. The authors evaluated the functional long-term outcomes, complications, and survival of using this technique in pediatric patients. MethodsA retrospective review of 27 pediatric patients reconstructed between 2011 and 2018 with the fibula flap after bone sarcoma resection was conducted. Long-term functional outcomes, complications, and survival were assessed. Variables analyzed were age, sex, Capanna technique, follow-up, complications, additional surgeries, time to weight bearing, length discrepancy, and sport practice. ResultsTwenty-seven patients with a mean age of 9.3 years were included. The mean follow-up was 44.33 months. The Capanna technique was performed in 15 patients. All extremities but one were salvaged. The overall complication rate was 74.07%. Fibula fracture and nonunion rates were 34.04% and 11.11%, respectively. Partial weight bearing was resumed at a mean of 9.07 months. About 79.17% of patients with a 12-month follow-up achieved full weight bearing.An age below 8 years was significantly associated with a lower major complication rate and a shorter time to weight bearing and full weight bearing. Major complications and additional surgeries were significantly associated with longer periods until weight bearing and full weight bearing. ConclusionsThe fibula flap allows the majority of extremities to be reconstructed. However, a high rate of complications and additional surgeries should be anticipated. Full weight bearing is usually achieved within the first year, with modest functional increase afterward. Less complications and a faster functional recovery are expected in patients below the age of 8 years.

A Modification of an Established Method of Intercalary Extremity Bone Defect Reconstruction: The "Hemi-Capanna" Technique.

Skeletal reconstruction of segmental defects of the appendicular skeleton is among the most challenging tasks in reconstructive surgery. A popular method of reconstruction of large osseous defects is the combination of massive allografts and vascularized bone transfer. We present and discuss our experience with a modification of the traditional Capanna technique in which the allograft is split in half longitudinally to provide for more space for postoperative fibula hypertrophy. Patients who underwent reconstruction of segmental intercalary defects of the tibia using our modified technique were retrospectively identified. The following parameters were retrieved: patient age, race, sex, length of skeletal defect, recipient vessels, type of microsurgical anastomosis, union rate, complication rate, ambulation (yes/no), and follow-up (in months). Two male patients underwent reconstruction of the tibia via the modified "hemi-Capanna" technique. The tibia defect measured 12 and 13 cm, respectively. No intraoperative or postoperative complications were encountered. Osseous union was obtained in both patients who are both ambulatory. The hemi-Capanna technique not only leaves more room for hypertrophy of the vascularized fibula, but also simplifies the technique of combining an allograft with vascularized bone transfer in reconstructions of segmental skeletal defects of the appendicular skeleton.

The combinative biological reconstruction of bony defect following limb bone tumor resections

Objective To analyze the image and histological results of the combined use of allograft/extracorporeally frozen tumor-bearing bone and vascularized fibular flap for the reconstruction of bony defects following tumor resection, guiding clinical practice. Methods From March 2007 to June 2013, we enrolled 63 patients who had combinative biological reconstruction after bone tumor resection(11 in humerus, 22 in femur, 21 in tibia, 4 in calcaneus). There were 36 male and 27 female in this series. The average age at time of operation was 20 years, ranging from 9 to 48 years. The follow-up ranged from 16 to 102 months with average of 48 months. We investigated the X-ray and CT images for all patients and histological findings of two patients. Patients were assessed functionally with the Musculoskeletal Tumor Society 93 score. Results Three patients with local soft tissue recurrence and one patient with infection underwent amputation. The survival of construct was 93.6%. Bone union achieved in all cases with the average MSTS score of 92.8%. Bone union ranged from 11 to 28 months in allograft group and 9 to 14 months in devitalized tumor bearing bone group. Significant difference of bone union time was found between two groups(Z=-3.638, P=0.000).Viability of the fibular grafts was verified in 58 of 63 patients(92%).Three types of images were observed in complex. Osteopenia and spongy change in fibula were found in 51 patients(81%)with stable fixation of the complex. Five complexes with failed blood supply of fibula and stable fixation revealed no density change of fibula, small amount of callous formation and relative delayed union. In seven complexes(11%)with unstable complex due to patients' incompliance, fibula reacted with dense hypertrophy and micro-fracture. Fusion of grafts with amount of callus was obviously observed. Union at allograft-host bone junctions occurred by residual host bone-derived external callus and fibular-derived internal callus that bridged the junction and filled the gap between abutting cortices. Callus from fibular graft was mature than that from periosteum of residual host bone. Internal repair was observed at the internal surface of the allografts. Fibula showed significant spongy changes. Conclusion Recycled tumor-bearing bone in combined with fibular flap is a reliable reconstruction as an alternative to traditional Capanna technique. The survival of the fibula is a cornerstone in success of complex reconstruction. Sponginess of fibula and internal repair of allograft compromise the intensity of complex, necessitating the strong instrumentation during reconstruction. Key words: Extremities; Bone neoplasms; Bone transplantation; Histology

What Is the Outcome of Allograft and Intramedullary Free Fibula (Capanna Technique) in Pediatric and Adolescent Patients With Bone Tumors?

After bone tumor resection, reconstruction for limb salvage surgery can be challenging because of the resultant large segmental bony defects. Structural allografts have been used to fill these voids; however, this technique is associated with high complication rates. To circumvent the complications associated with this procedure, massive bony allografts have been supplemented with an intramedullary vascularized free fibula. However, few studies have examined the outcomes using this technique in the pediatric and adolescent populations. The purpose of this study was to examine the revision-free survival using he Capanna technique for limb salvage for pediatric lower limb salvage. We attempted to answer the following questions: (1) What was the overall limb salvage rate along with incidence of reoperation and complications? (2) How did pediatric and adolescent patients functionally perform after this technique? (3) What was the incidence of late complications including infection and fracture? (4) What was the incidence of limb length discrepancy? Eighteen pediatric patients who underwent lower extremity limb salvage with the use of cadaveric allograft and intramedullary free fibular transfer (Capanna technique) were identified. There were nine boys males and nine girls with a mean age of 11years (range, 5-18years) and mean followup of 8years (range, 2-15years), respectively. All patients had at least 2years followup. Three patients have not been seen in followup during the past 5-years; however, all had made it to their 5-year clinical followup. The patients' medical records were reviewed for clinical and functional outcomes as well as postoperative complications. Time to union was recorded through an evaluation of radiographs. Mankin functional outcome and Musculoskeletal Tumor Society (MSTS) rating scale were recorded for each patient. The overall limb salvage rate was 94%. Fourteen patients underwent an additional surgical procedure. Six patients underwent additional procedure(s) to treat a symptomatic nonunion. Seventeen of the patients had a good or excellent Mankin score with a mean MSTS rating of 93% at last followup. Six of the patients underwent a limb length modification procedure. Use of large allografts in conjunction with intramedullary vascularized free fibulas appears to be a reliable method for the reconstruction of large bony tumors of the lower extremity in this population, although we did not directly compare this with allografts alone in our study. The use of locked plates may improve union times. The proportion of patients achieving limb preservation was high and complication rates are acceptable. Level IV, therapeutic study.

New options for vascularized bone reconstruction in the upper extremity.

Originally described in the 1970s, vascularized bone grafting has become a critical component in the treatment of bony defects and non-unions. Although well established in the lower extremity, recent years have seen many novel techniques described to treat a variety of challenging upper extremity pathologies. Here the authors review the use of different techniques of vascularized bone grafts for the upper extremity bone pathologies. The vascularized fibula remains the gold standard for the treatment of large bone defects of the humerus and forearm, while also playing a role in carpal reconstruction; however, two other important options for larger defects include the vascularized scapula graft and the Capanna technique. Smaller upper extremity bone defects and non-unions can be treated with the medial femoral condyle (MFC) free flap or a vascularized rib transfer. In carpal non-unions, both pedicled distal radius flaps and free MFC flaps are viable options. Finally, in skeletally immature patients, vascularized fibular head epiphyseal transfer can provide growth potential in addition to skeletal reconstruction.

Long Term Functional Outcomes of the Capanna Technique for Pediatric Limb Salvage

INTRODUCTION: Large intercalary bone defects have historically been reconstructed with massive cadaveric allograft, however this practice is associated with multiple complications including infection, fracture and nonunion (1–3). In contrast, the Capanna technique combines the use of large cadaveric allograft with an intermedullary vascularized fibular flap to allow for immediate rigid fixation of the allograft, but allow for the potential of accelerated bony union through the fibula flap (Fig. 1 and 2) (4). METHODS: Between 1997- 2009, we operated the lower limb of 17 children with Capanna technique. Average age was 11.05 ± 4.02 years at the time of operation. All the patients were skeletally immature. We collected data retrospectively and our follow up ranged between 20 and 135 months (Mean 71.46 ± 37.14 months). All the patients' tumours were biopsied before the surgery and appropriate chemotherapy was started before limb salvage and continued 3 weeks after the surgery. METHODS: 8 were femur (47%) and 9 were tibia (53%). According to the pathology reports, 45% of the tumors (8 patients) were osteosarcoma; 35% (6 patients) were Ewing's sarcoma and there was one adamantinoma, one chondrosarcoma and one osteofibrous dysplasia. Mean excised tumor volume was 120.62 ± 205.05 cm3. The mean bone defect was 14.34 ± 4.71 cm. Mean length of harvested free fibula was 18.56 ± 3.69. All the patients healed well except one patient whose graft was replaced by bone allograft 31 months after the limb salvage surgery. We excluded this patient and last two patients from union time analysis because their follow-up hasn't reached to one year. Mean union time for the allograft placed in femur was 12.41 ± 5.47 months and in tibia was 14.43 ± 6.5 months. Mean union time for the fibula flap placed in femur was 8.16 ± 2.48 months and in tibia was 6.56 ± 2.61 months. 2 of the patients had distant metastasis to lung, sphenoid bone and hand. 7 patients re-operated because of the allograft non-union. We did not encounter any wound or bone infection. All limbs were salvaged. At final follow-up, only two patients had more than 2cm of leg length discrepancy. Mankin score was excellent for 87% of patients and good for the rest. CONCLUSION: Compared to other long bone reconstruction methods, the Capanna technique is a single step, effective and durable limb salvage surgery that has earlier bone union time.Figure 1: Vascularized fibula flap was inserted into the cadaveric allograft and a window was created for the vascular pedicle.Figure 2: Bone defect was filled with the combined cadaveric allograft and free fibula flap and fixed with Less Invasive Stabilization System (LISS). The pedicle was ready for the anastomosis.

Reconstruction of Large Traumatic Segmental Defects of the Femur Using Segmental Allograft with Vascularized Fibula Inlay

Segmental defects of the distal femur following trauma pose a reconstructive challenge. A stable reconstruction capable of withstanding high forces while allowing early mobility is paramount. The Capanna technique of reconstruction combining allograft with vascularized bone graft provides such a construct and has been described for oncological resection. We describe a modified Capanna technique, the "inlay" construct. Three reconstructions were performed for distal femoral segmental loss following trauma. One patient had bilateral reconstructions. Bone defects measuring 11, 9, and 8 cm were reconstructed using a large segmental allograft and free fibular flap inlay assembly. Both patients made uneventful recoveries and achieved full weight-bearing without walking aids 6 months postreconstruction. Range of movement of each knee joint achieved at least 90 degrees of active flexion. We have shown that large segmental traumatic defects of the femur can be successfully reconstructed using segmental allograft with vascularized fibula inlay. This reconstruction provides early mechanical stability, protecting the fibula from fracturing and allowing axial loading of healing bone. The inlay assembly allows a large area of bony contact between allograft and vascularized bone, optimizing bony healing. It is a good alternative to other established techniques of managing significant segmental defects of the distal femur.

Management of large traumatic segmental defects of the femur with the Capanna technique

Management of large traumatic segmental defects of the femur with the Capanna technique

Combined Massive Allograft and Intramedullary Vascularized Fibula Transfer: The Capanna Technique for Lower-Limb Reconstruction

Limb salvage has now replaced amputation as the standard treatment for primary bone tumors and can usually be offered to more than 85% of patients. Recently, a novel approach to limb salvage has been described by Capanna and colleagues whereby a massive bone allograft and intramedullary vascularized fibula are combined to reconstruct large, segmental bone defects. This produces a structurally competent reconstruction with enhanced vascular and osteogenic capabilities and the potential to achieve lower rates of infection, fracture, and nonunion. The Capanna technique has become a well-established means of long bone reconstruction and limb salvage in cases of large bony resection. The operative technique and reported outcomes of the Capanna technique are reviewed, and cases are presented.