Bridging the Gap: Biological Reconstruction with Vascularised Fibula, Massive Allograft, or Capanna Technique After Intercalary Resection in Children and Young Adults with Lower Limb Bone Sarcoma.
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Background. When free margins can be achieved and adjacent joints can be preserved, limb salvage surgery is the preferred treatment for intercalary paediatric bone tumours in the lower extremity. Biological reconstruction techniques include allograft, free vascularised fibular graft (FVFG), and allograft combined with FVGF (Capanna technique). This review summarises current evidence on outcomes and complications, and proposes directions for future research to refine patient selection. Methods. A systematic review was conducted using PubMed, Scopus, Embase, and Cochrane Library. Eligible studies reported outcomes of allograft, FVFG, or combined techniques for intercalary lower limb reconstruction in children or adolescents. Results. Twenty-five articles met the inclusion criteria (8 allograft, 7 FVFG, 14 Capanna); four studies reported two techniques. In total, 391 patients were included (allograft 147, FVFG 51, Capanna 193). Mean defect lengths were 14.9 cm (allograft), 14.5 cm (FVFG), and 14.7 cm (Capanna). Time to union was 8.5 months for allografts, 11.4 for Capanna, and 12.5 for FVFG. Non-union occurred in 14.7%, 13.2%, and 10.3%, and delayed union in 13.6%, 4.8%, and 7.9% for FVFG, allograft, and Capanna, respectively. Fractures were 40.5% for FVFG, 18.4% for allograft, and 23.5% for Capanna. Infections were least common with FVFG (2.7%). Conclusions. The reconstruction strategy should be tailored to anatomical location, defect size, and patient-specific factors. Although infections rates were lowest with FVFG, time to union was longer and the postoperative fracture rate was higher compared to the allograft or Capanna technique. Allografts demonstrated the shortest time to union and lowest fracture risk. The Capanna technique may be beneficial when factors including chemotherapy, poor host bone quality, or high mechanical load are present, but comes at a cost of morbidity and complexity.