Modified Capanna’s Technique (Vascularized Free Fibula Combined with Allograft) as a Single-Stage Procedure in Post-traumatic Long-Segment Defects of the Lower End of the Femur: Outcome Analysis of a Series of 19 Patients with an Average Gap of 14 cm

Abstract

Objectives Salvage and reconstruction of posttraumatic defects of the long bone are complex due to the multiple procedures involved and increased chances of poor outcomes. We present the outcomes of the modified Capanna’s technique—a reliable single-stage procedure of combining allograft and free vascularized fibular graft—in treating large posttraumatic bone defects in the distal third of the femur.

Study Design This is a retrospective analysis.

Materials and Methods Between April 2012 and September 2016, 19 patients with an average age of 33.8 years (range: 18–49 years) and an average defect of 14.5 cm (range: 9.5–20 cm) in the distal femur were managed by the modified Capanna’s technique. Bone union time and functional outcome using lower extremity functional score (LEFS) after union were noted.

Outcomes and Results Eighteen grafts went onto achieve bony union at an average of 6.6 months (range: 5–9), with an average knee flexion of 80 degrees (range: 45–110 degrees) and an average LEFS of 63 (range: 46–72). One patient had a nonunion with graft resorption at 8 months following persistent infection and was revised with debridement and augmenting the vascularized fibula from the other leg which went on to achieve union. Three patients had superficial infection, and three patients had delayed union.

Conclusion The modified Capanna’s technique provided increased biology and enhanced structural stability and therefore is a good single-stage procedure in the reconstruction of posttraumatic long-segment defects of the distal femur.

Level of Evidence Level 4.

Level of Clinical Care Level I tertiary trauma center.

Keywords

Capanna technique - allograft - vascularized fibula - distal femur bone defect

• References

• 1 Martinet O, Cordey J, Harder Y, Maier A, Bühler M, Barraud GE. The epidemiology of fractures of the distal femur. Injury 2000; 31 (Suppl. 03) C62-C63
• 2 Hoffmann MF, Jones CB, Sietsema DL, Tornetta III P. Koenig SJ. Clinical outcomes of locked plating of distal femoral fractures in a retrospective cohort. J Orthop Surg Res 2013; 8: 43
• 3 Saridis A, Panagiotopoulos E, Tyllianakis M, Matzaroglou C, Vandoros N, Lambiris E. The use of the Ilizarov method as a salvage procedure in infected nonunion of the distal femur with bone loss. J Bone Joint Surg Br 2006; 88 (02) 232-237
• 4 Wang X, Luo F, Huang K, Xie Z. Induced membrane technique for the treatment of bone defects due to post-traumatic osteomyelitis. Bone Joint Res 2016; 5 (03) 101-105
• 5 Bumbasirevic M, Stevanovic M, Bumbasirevic V, Lesic A, Atkinson HDE. Free vascularised fibular grafts in orthopaedics. Int Orthop 2014; 38 (06) 1277-1282
• 6 Capanna R, Bufalini C, Campanacci C. A new technique for reconstructions of large metadiaphyseal bone defects: a combined graft (allograft shell plus vascularized fibula). Orthop Traumatol 1993; 2: 159-177
• 7 Venkatramani H, Sabapathy SR, Dheenadayalan J, Devendra A, Rajasekaran S. Reconstruction of post-traumatic long segment bone defects of the lower end of the femur by free vascularized fibula combined with allograft (modified Capanna’s technique). Eur J Trauma Emerg Surg 2015; 41 (01) 17-24
• 8 Binkley JM, Stratford PW, Lott SA, Riddle DL. North American Orthopaedic Rehabilitation Research Network. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. Phys Ther 1999; 79 (04) 371-383
• 9 Venkatramani H, Sabapathy SR, Nayak S. Free-flap cover of complex defects around the knee using the descending genicular artery as the recipient pedicle. J Plast Reconstr Aesthet Surg 2014; 67 (01) 93-98
• 10 Lasanianos NG, Kanakaris NK, Giannoudis PV. Current management of long bone large segmental defects. Orthop Trauma 2009; 24 (02) 149-163
• 11 Vargas Barreto B, Caton J, Merabet Z, Panisset JC, Pracros JP. Complications of Ilizarov leg lengthening: a comparative study between patients with leg length discrepancy and short stature. Int Orthop 2007; 31 (05) 587-591
• 12 Krappinger D, Lindtner RA, Zegg M, Dal Pont A, Huber B. Masquelet technique for the treatment of large dia- and metaphyseal bone defects [in German]. Oper Orthop Traumatol 2015; 27 (04) 357-368
• 13 Kanakeshwar RB, Jayaramaraju D, Agraharam D, Rajasekaran S. Management of resistant distal femur non-unions with allograft strut and autografts combined with osteosynthesis in a series of 22 patients. Injury 2017; 48 (Suppl. 02) S14-S17
• 14 Donati D, Di Bella C, Colangeli M, Bianchi G, Mercuri M. The use of massive bone allografts in bone tumour surgery of the limb. Curr Orthop 2005; 19: 393-399
• 15 Chang DW, Weber KL. Use of a vascularized fibula bone flap and intercalary allograft for diaphyseal reconstruction after resection of primary extremity bone sarcomas. Plast Reconstr Surg 2005; 116 (07) 1918-1925
• 16 Ridha H, Bernard J, Gateley D, Vesely MJ. Reconstruction of large traumatic segmental defects of the femur using segmental allograft with vascularized fibula inlay. J Reconstr Microsurg 2011; 27 (06) 383-390
• 17 Errani C, Ceruso M, Donati DM, Manfrini M. Microsurgical reconstruction with vascularized fibula and massive bone allograft for bone tumors. Eur J Orthop Surg Traumatol 2019; 29 (02) 307-311
• 18 Momeni A, Weber KL, Kovach SJ. A modification of an established method of intercalary extremity bone defect reconstruction: the “hemi-Capanna” technique. Ann Plast Surg 2018; 81 (02) 240-243
• 19 Bakri K, Stans AA, Mardini S, Moran SL. Combined massive allograft and intramedullary vascularized fibula transfer: the Capanna technique for lower-limb reconstruction. Semin Plast Surg 2008; 22 (03) 234-241
• 20 Jordan DJ, Malahias M, Khan W, Hindocha S. The ortho-plastic approach to soft tissue management in trauma. Open Orthop J 2014; 8: 399-408
• 21 Boriani F, Ul Haq A, Baldini T. et al. Orthoplastic surgical collaboration is required to optimise the treatment of severe limb injuries: A multi-centre, prospective cohort study. J Plast Reconstr Aesthet Surg 2017; 70 (06) 715-722