Comparative outcomes of allograft with vascularized fibula graft vs vascularized fibula graft alone for post-oncologic lower extremity salvage – Systematic review and meta-analysis

Background: Vascularized fibular grafts (VFGs) can be combined with an allograft (Capanna technique) or used alone. Our study aims to compare the outcomes of these two widely used techniques in lower limb salvage. Methods: PUBMED, EMBASE, Scopus and Web of Science databases were queried, and relevant articles were selected following PRISMA guidelines. Only cohort studies and case series in English and with complete data were included. Results: Thirty-three studies comprising 560 patients were included. In pediatrics, Capanna and VFG had similar rates: fibula fracture (32.1% vs. 41.0%, p = 0.33), non-union (26.0% vs. 22.7%, p = 0.83), infection (16.8% vs. 11.5%, p = 0.85), reoperation (42.2% vs. 42.9%, p = 1.00), and overall complications (53.3% vs. 48.9%, p = 0.70). Union and weight bearing times were 9.4/11.6 months (Capanna) vs. 8.5/14.1 months (VFG). In adults, Capanna had fewer fibula fractures (17.2% vs. 35.0%, p = 0.03) but more reoperations (49.6% vs. 26.5%, p = 0.005); non-union (14.8% vs. 20.6%, p = 0.35), infection (8.5% vs. 19.5%, p = 0.15), and overall complications (53.4% vs. 40.9%, p = 0.15) were not significantly different. Across all groups, adjuvant chemotherapy was associated with significantly increased odds of non-union (OR: 10.1, 95% CI: 3.3–30.6; p < 0.0001). Conclusion: The Capanna technique and VFG alone offer comparable overall complication rates and functional outcomes in both pediatric and adult patients. However, the Capanna construct is associated with higher reoperation rates in adults, despite a lower incidence of fibula fractures. Adjuvant chemotherapy significantly increases the risk of non-union and should be carefully considered during surgical planning.