Does autogenous bone graft work? A logistic regression analysis of data from 159 papers in the foot and ankle literature

Nitinol Staple Use in Primary Arthrodesis of Lisfranc Fracture-Dislocations

BACKGROUND

Primary arthrodesis of Lisfranc fracture-dislocations is a reliable treatment option, yet concerns remain about nonunion. Nitinol staple use has recently proliferated in midfoot arthrodesis. The purpose of this study is to examine the union rate of primary arthrodesis of acute Lisfranc fracture-dislocations treated with nitinol staples compared with traditional plate-and-screw fixation. The secondary objective is to assess the difference in operative times and reoperation rates.

METHODS

Midfoot fracture-dislocations treated with primary arthrodesis by 7 foot and ankle orthopaedic surgeons were reviewed. Of 160 eligible patients, 121 patients (305 joints) met the required 4-month minimum radiographic follow-up. Radiographic outcomes were analyzed at the individual joint level. Each joint was classified as either staples alone (45 patients, 154 joints), staples plus plates and screws (hybrid) (45 patients, 40 joints), or plates and screws alone (31 patients, 111 joints). The primary outcome was arthrodesis union at each joint fused.

RESULTS

Nonunion was more common (9.0%, 10/111) among joints fixed with plate and screws than with hybrid (2.5%, 1/40) or staples only (1.3%, 2/154) (P = .0085). Multivariable regression demonstrated that autograft use was independent associated with union (P = .0035) and plate-and-screw only fixation was an independent risk factor for nonunion (P = .0407). Median operating room and tourniquet times were shorter for hybrid (92 and 83 minutes) and staple only (67 and 63 minutes) constructs compared to plate-and-screw only fixation (105 and 95 minutes) (P ≤ .0001 and .0003). There was no difference in reoperation rates among patients with different fixation types.

CONCLUSION

We found that use of nitinol compression staple and bone autograft in primary arthrodesis of Lisfranc and midfoot fracture-dislocations was associated with both improved union rates and shorter tourniquet and operative times compared to traditional plate-and-screw fixation techniques.

LEVEL OF EVIDENCE

Level III, therapeutic.

Radiographical outcomes of a cellular based allograft following foot/ankle arthrodesis in patients with risk for non-union

Morbidity associated with autograft harvest has led to the need for alternative bone grafts during fusion surgical procedures. The purpose of this study is to evaluate the efficacy of a cellular bone allograft (CBA) in patients who underwent foot/ankle fusion surgery. Retrospective data of patients who underwent foot/ankle arthrodesis using a CBA between XXXX and XXXX were collected from a single site. Patients were at least 18 years of age at the time of surgery and had ankle/foot surgery with Trinity ELITE CBA as the primary or only bone graft. Patients' radiographic union was assessed at three (3) months, six (6) months, nine (9) months, and twelve (12) months. Twenty-two (22) patients and 29 joints were evaluated. The mean age and BMI of the cohort were 54±9yrs and 30.5±6kg/m2, respectively. The surgical indications were degenerative joint diseases, trauma, and arthritis. All patients except one had at least one risk factor for non-union. At 12 months, 21 of the 22 patients (95%) attained successful fusion with an average time of 6 months. In addition, there was a 100% fusion among patients with prior failed fusion, nicotine use, diabetes, neuropathy, and osteoporosis. There was no significant difference in time to fusion between patients with non-union risk factor(s) ≤ 1 and ≥ 2 (p=0.71). No complication or adverse event was reported following the surgery. The use of CBA resulted in high fusion among patients with the risk of non-union. CBA is a viable bone graft substitute for autograft in foot/ankle arthrodesis procedures.

Non-Union Treatment in the Foot, Ankle, and Lower Leg: A Multicenter Retrospective Study Comparing Conventional Treatment with the Human Allogeneic Cortical Bone Screw (Shark Screw®)

Addressing non-unions involves stabilizing the affected area through osteosynthesis and improving bone biology using bone grafts. However, there is no consensus on the optimal treatment method. This study aims to compare outcomes of non-union surgery using conventional treatment methods (metal hardware ± graft) versus osteosynthesis with the human allogeneic cortical bone screw (Shark Screw®) alone or in combination with a metallic plate. Thirty-four patients underwent conventional treatment, while twenty-eight cases received one or more Shark Screws®. Patient demographics, bone healing, time to bone healing, and complications were assessed. Results revealed a healing rate of 96.4% for the Shark Screw® group, compared to 82.3% for the conventionally treated group. The Shark Screw® group exhibited a tendency for faster bone healing (9.4 ± 3.2 vs. 12.9 ± 8.5 weeks, p = 0.05061). Hardware irritations led to six metal removals in the conventional group versus two in the Shark Screw® group. The Shark Screw® emerges as a promising option for personalized non-union treatment in the foot, ankle, and select lower leg cases, facilitating effective osteosynthesis and grafting within a single construct and promoting high union rates, low complications, and a rapid healing process.

The Efficiency of Highly Porous β-Tricalcium Phosphate With Bone Marrow Aspirate Concentrate in Midfoot Joint Arthrodesis

BACKGROUND

Nonunion is one of the most common and devastating complications following midfoot joint arthrodesis. Many different types of bone grafts and bone substitutes have been used to promote osseous fusion. However, there is no consensus on the gold standard bone grafting material and whether biologic materials should be used alone or in combination. The purpose of this study is to investigate the efficiency of highly porous β-tricalcium phosphate (β-TCP) with bone marrow aspirate concentrate (BMAC) in midfoot joint arthrodesis.

METHODS

This retrospective comparative study included patients who underwent midfoot joint arthrodesis using compression screws. Patients were classified into 2 groups: arthrodesis with highly porous β-TCP and BMAC (group A) and arthrodesis without them (group B). The osseous union rate was compared between the 2 groups. A total of 44 patients (46 feet) including 89 joints were included in this study.

RESULTS

There was a significant difference in the union rate between the 2 groups: 91.5% (43/47 joints) in arthrodesis with highly porous β-TCP and BMAC (group A) and 76.2% (32/42 joints) in arthrodesis without highly porous β-TCP and BMAC (group B; P = .048).

CONCLUSION

This study investigated the efficiency of highly porous β-TCP and BMAC to promote bony healing in midfoot joint arthrodesis. A significantly higher union rate was shown when arthrodesis was performed with highly porous β-TCP and BMAC, compared with arthrodesis performed without them. We suggest that highly porous β-TCP and BMAC can be a viable and effective adjunct to the fixation in midfoot joint arthrodesis.

LEVEL OF EVIDENCE

Level III: Retrospective comparative analysis.

Canine ex vivo tarsal arthrodesis: fixation by using a new bone tissue glue

Introduction

Arthrodesis, performed as a salvage surgical procedure to treat intractable joint conditions in dogs and cats, is associated with a high incidence of complications intra and postoperative, proving the need for improved and new techniques in arthrodesis surgery. Adding a new resorbable bone glue to the arthrodesis could potentially add fixation strength and lower complications. The objectives of this experimental ex vivo biomechanical study were therefore to develop a biomechanical test model of partial tarsal arthrodesis and to determine whether the new resorbable bone glue (phosphoserine modified cement) produced measurable fixation strength in canine calcaneoquartal arthrodesis, without orthopedic implants.

Methods

Four biomechanical test models with a total of 35 canine tarsal joints were used. Soft tissues were dissected to 4 different test models with variable contributions from soft tissues. The calcaneoquartal joint was prepared as in vivo arthrodesis and the glue was applied to joint surfaces as a liquid/putty (0.4 cc). After curing for 24 h, a shear force was applied to the joint (1 mm per minute) and the failure strength was recorded.

Results

Calcaneoquartal joints, where all soft tissues had been completely resected and fixated with glue (1-1.5 cm2 joint surface), withstood 2-5 mm of displacement and an average of 100 ± 58 N/cm2 of shear force (Model 1). Similar adhesive fixation strengths were obtained in Model 2 and 3 with increasing contributions from soft tissues (80 ± 44 and 63 ± 23 N/cm2, p = 0.39, ANOVA).

Conclusion

The developed biomechanical model was sensitive enough to measure differences in fixation strengths between different glue formulations. The average fixation strength (60-100 N/cm2) should be strong enough to support short-term load bearing in medium sized canines (20 kg). The developed cadaver biomechanical test model is of potential use for other arthrodesis studies. The new resorbable glue can potentially contribute to stability at arthrodesis surgery, acting as a complement to today's standard fixation, metal implants.

Talonavicular arthrodesis: Does the IOFiX system provide safe and reliable fixation?

AIMS

Talonavicular (TN) arthrodesis is a common procedure to treat arthritis of the TN joint.It can also form part of a wider triple fusion to restore the architecture of the foot.Traditional methods of arthrodesis are not universally successful. The aim of this study was to evaluate the clinical and radiological outcomes of those who had a TN fusion using the IOFiX system. Data was collected retrospectively from the hospital operation database. Inclusion criteria included patients who underwent a TN fusion between 2012 and 19 with the IOFiX system. All patients were over 16 years of age and at least one year post operation.Patient demographics were obtained, as well as rate of union and rate of re-operation for analysis.

RESULTS

35 patients were identified. The mean age was 58 years (range 34-85). The most common indication was osteoarthritis of the TN joint (n = 19), followed by acquired adult flat foot (n = 8), rheumatoid arthritis (n = 3), avascular necrosis (n = 2) and a previous nonunion.(n = 1). 9 % (n = 3) of patients did not achieve union by one year and 14 % (n = 5) required another operation subsequent to their initial surgery: four to remove metalwork, and one to treat non-union of the arthrodesis. The use of bone graft did not affect complication rates. TN fusion, when performed as part of a triple fusion, showed a tendency for reducing the rate of non-union, however this did not achieve statical significance.

CONCLUSION

This study suggests that the IOFiX system offers a reliable and acceptable alternative technique for patients undergoing a TN fusion. Further work is required to assess if early signs of improved outcome when used in triple fusion, over isolated TN fusion,are significant.

Factors influencing successful bone union of isolated subtalar arthrodesis for posttraumatic subtalar arthritis: a multicenter case series

BACKGROUND

The purpose of this study was to find the factors influencing successful bone union for isolated subtalar arthrodesis in posttraumatic subtalar arthritis following calcaneal fracture.

MATERIAL AND METHODS

We retrospectively analyzed the rate of successful bone union of 119 cases of isolated subtalar arthrodesis for posttraumatic subtalar arthritis performed at five university hospitals between January 2010 and December 2019. Multivariate logistic regression analysis was used to find the factors associated with successful bone union. Successful bone union was defined as resolution of hindfoot pain with the presence of osseous trabecular bridging involving more than 50% of the posterior facet within 6 months postoperatively.

RESULTS

There were 77 (64.7%) cases of successful bone union, 11 (9.2%) cases of delayed union, 8 (6.7%) cases of questionable union, and 23 (19.3%) cases of nonunion. Use of fully threaded screws was 5.90 times [odds ratio (OR) = 5.90, 95% confidence interval (CI) = 1.42-24.49, p = 0.02] more likely to achieve successful bone union compared to the use of partially threaded screws. Use of two parallel screws or the two divergent screws were 3.71 times (OR = 3.71, 95% CI = 1.05-13.14, p = 0.04) and 4.65 times (OR = 4.65, 95% CI = 1.23-17.53, p = 0.02) more likely to achieve successful bone union compared to the use of a single screw. Use of cancellous autograft or structural autograft was 4.72 times (OR = 4.72, 95% CI = 1.17-19.06, p = 0.03) and 7.12 times (OR = 7.12, 95% CI = 1.46-34.68, p = 0.02) more likely to achieve successful bone union compared to no graft use.

CONCLUSION

Use of fully threaded screws, autograft, and two screws compared to a single screw were the factors associated with successful bone union within six postoperative months after subtalar arthrodesis for the posttraumatic arthritis.

General Considerations About Foot and Ankle Arthrodesis. Any Way to Improve Our Results?

Nonunion and adjacent joint osteoarthritis (OA) are known complications after a fusion procedure, and foot and ankle surgeons are commonly exposed to such disabling complications. Determining who is at risk of developing nonunion is essential to reducing nonunion rates and improving patient outcomes. Several evidenced-based modifiable risk factors related to adverse outcomes after foot and ankle arthrodesis have been identified. Patient-related risk factors that can be improved before surgery include smoking cessation, good diabetic control (HbAc1 <7%) and vitamin D supplementation. Intraoperatively, using less invasive techniques, avoiding joint preparation with power tools, using bone grafts or orthobiologics in more complex cases, high-risk patients, nonunion revision surgeries, and filling in bone voids at the arthrodesis site should be considered. Postoperatively, pain management with NSAIDs should be limited to a short period (<2 weeks) and avoided in high-risk patients. Furthermore, early postoperative weight-bearing has shown to be beneficial, and it does not seem to increase postoperative complications. The incidence of surrounding joint OA after foot and ankle fusion seems to increase progressively with time. Owing to its progression and high probability of being symptomatic, patients must be informed consequently, as they may require additional joint fusions, resulting in further loss of ankle/foot motion. In patients with symptomatic adjacent joint OA and unsatisfactory results after an ankle arthrodesis, conversion to total ankle arthroplasty (TAA) has become a potential option in managing these complex and challenging situations.

ON Path: outpatient nonunion pathway for lower-extremity nonunions

Objectives

The purpose of this study was to assess the safety and efficacy of outpatient and short-stay surgical nonunion treatment by incorporating minimally invasive surgical techniques, multimodal pain control, and a modernized postoperative protocol.

Design

Retrospective case series.

Setting

Tertiary referral hospital and hospital outpatient department.

Patients

All consecutive nonunion surgeries performed by 1 surgeon between 2014 and 2019 were identified. Outpatient and short-stay surgeries for patients with nonunion of the tibia and femur were eligible (n = 50).

Intervention

Outpatient and short-stay surgical nonunion treatment by incorporating minimally invasive surgical techniques, multimodal pain control, and a modernized postoperative protocol.

Main Outcome Measurements

Length of stay, postoperative emergency department visits, all complications, reoperations, and time to union.

Results

Fifty patients were eligible, with 32 male patients (64%) and an average age of 46.5 years. The patient cohort consisted of 28 femur (56%) and 22 tibia (44%) nonunions. The average length of stay was 0.36 days. Seven patients (14%) required reoperation, 6 patients because of deep infection and 1 patient because of painful implant removal. Four patients (8%) presented to the emergency department within 1 week of surgery. One patient requiring amputation and patients lost to follow-up were excluded from the union rate calculation. For the remaining patients (46/50), 100% (46/46) united their nonunion. The average time to radiographic union was 7.82 months.

Conclusions

An outpatient pathway is safe and effective for medically appropriate patients undergoing nonunion surgery. Outpatient nonunion surgery is a reasonable alternative that achieves similar outcomes compared with inpatient nonunion studies in the published literature.

Level of Evidence

IV.

Midfoot Joint Arthrodesis Using Compression Plate With Lag Screw Augmenting With Highly Porous β-Tricalcium Phosphate and Bone Marrow Aspirate Concentrate

BACKGROUND

There is still a controversy regarding the most optimal fixation instruments and bone graft materials for midfoot joint arthrodesis. We present the results of midfoot joint arthrodesis using compression plate with lag screw augmenting with highly porous β-tricalcium phosphate (β-TCP) and bone marrow aspirate concentrate (BMAC).

METHODS

We performed a retrospective review of patients undergoing midfoot joint arthrodesis using compression plate with lag screw augmenting with highly porous β-TCP and BMAC from January 2014 to May 2019. The radiographic bony union rate was investigated. Postoperative complications and reoperations were also reviewed. A total of 36 patients (37 feet) including 75 joints were available in this study.

RESULTS

A high union rate was achieved as of 97.3% in 73 of 75 joints. Nonunion occurred in 2 patients including 2 joints. Other than nonunion, there were no major complications such as deep infection. Minor complications (5 of 75 joints, 6.7%) included hardware irritations. Reoperations were required in 1 patient for revision of arthrodesis and symptomatic hardware removal was performed in all 5 hardware irritation cases.

CONCLUSION

Based on our results, the fixation construct of compression plate with lag screw augmenting with highly porous β-TCP and BMAC is safe and effective for midfoot joint arthrodesis with an excellent union rate and a low complication rate.

LEVEL OF EVIDENCE

IV, retrospective case series.

A Retrospective Analysis of Outcomes From Foot and Ankle Arthrodesis and Open Reduction and Internal Fixation Using Cellular Bone Allograft Augmentation

BACKGROUND

ViviGen is an allogeneic cellular bone matrix product containing lineage-committed bone cells, and can be used as an alternative to autograft bone or other augments to aid in arthrodesis or to enhance bony healing in open reduction and internal fixation (ORIF) procedures.

METHODS

This study included 153 consecutive patients undergoing ankle, midfoot, or hindfoot arthrodesis or ORIF procedures from January 2017 to October 2018, in which an allogeneic cellular bone matrix product was used to aid in bony healing. Retrospective chart review identified patient demographic factors and medical comorbidities and evaluated clinical and radiographic data to determine fusion/union rate and complications.

RESULTS

The overall fusion rate for the arthrodesis cohort was 97/113 (85.8%). The overall complication rate in this cohort was 22/113 (19.5%). Smokers had significantly lower rates of fusion compared with nonsmokers (P = .01). The observed bony healing rate for the ORIF cohort was 19/22 (86.4%), with a complication rate of 3/22 (13.6%).

CONCLUSION

With satisfactory fusion rates and relatively few complications, our findings suggest that ViviGen is a safe and efficacious alternative to other forms of bone graft augmentation for fusion and ORIF procedures about the foot and ankle. Further study is needed to compare the efficacy of ViviGen with autograft bone and other augments.

LEVELS OF EVIDENCE

Level IV: Case series.

Surgical Management of Jones Fractures in Athletes: Orthobiologic Augmentation: A Systematic Review and Meta-analysis of 718 Fractures

BACKGROUND

The use of orthobiologics is expanding. However, the use of orthobiologic augmentation in primary fracture fixation surgery remains limited. Primary fracture fixation of the fifth metatarsal (Jones) in athletes is one of the rare situations where primary orthobiologic augmentation has been advocated.

PURPOSE

To determine the effect of orthobiologic augmentation on the outcome of surgically managed Jones fractures in athletes.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases including PubMed, MEDLINE, Embase, Google Scholar, Web of Science, Cochrane Library, and ClinicalTrials.gov through March 2021 to identify studies reporting on surgically managed Jones fractures of the fifth metatarsal exclusively in athletes. The primary outcomes were the return to play (RTP) rate and time to RTP, whereas the secondary outcomes were time to union, union rate, and refractures. Data were presented by type of treatment (biologically augmented fixation or fixation alone).

RESULTS

In the biologically augmented fixation group, successful RTP was reported in 195 (98.98%) of 197 fractures (odds ratio [OR], 97.5%; 95% CI, 95.8%-100%; I² = 0), with a mean time to RTP of 10.3 weeks (95% CI, 9.5-11.1 weeks; I² = 99%). In the group that received fixation without biological augmentation, successful RTP was reported in 516 (99.04%) of 521 fractures (OR, 98.7%; 95% CI, 97.8%-99.7%; I² = 0], with a mean time to RTP of 9.7 weeks (95% CI, 7.84-11.53 weeks; I² = 98.64%]. In the biologically augmented fixation group, fracture union was achieved in 194 (98.48%) of 197 fractures (OR, 97.6%; 95% CI, 95.5%-99.7%; I² = 0%), with a mean time to fracture union of 9.28 weeks (95% CI, 7.23-11.34 weeks; I² = 98.18%). In the group that received fixation without biological augmentation, fracture union was achieved in 407 (93.78%) of 434 fractures (OR, 97.4%; 95% CI, 96%-98.9%; I² = 0%), with a mean time to fracture union of 8.57 weeks (95% CI, 6.82-10.32 weeks; I² = 98.81%).

CONCLUSION

Orthobiologically augmented surgical fixation of Jones fractures in athletes is becoming increasingly common, despite the lack of comparative studies to support this practice. Biologically augmented fixation of Jones fractures results in higher fracture union rates than fixation alone but similar rates of RTP and time to RTP. Although the current evidence recommends primary surgical fixation for the management of Jones fractures in athletes, further high quality comparative studies are required to establish the indication for orthobiologic augmentation.

Patient and Surgical Factors Affecting Fusion Rates After Arthroscopic and Open Ankle Fusion: A Review of a High-Risk Cohort

ABSTRACT

We present a case series with the objective of identifying risk factors for nonunion after open and arthroscopic primary ankle arthrodesis. Eighty-seven patients who underwent primary ankle arthrodesis and met inclusion criteria were divided into open (N = 46) and arthroscopic (N = 41) groups. Patient and operative characteristics were retrospectively analyzed as possible risk factors for nonunion within each technique. The nonunion rate was 11% in the open and 12% in the arthroscopic group. Obesity, smoking, and ASA class 3 were highly prevalent in both groups. In the arthroscopic group, a remote history of infection and the use of headed screws had notably higher risk of nonunion, though not statistically significant. In the open group, use of bone graft trended toward lower risk of nonunion, though also not statistically significant. The results of this study demonstrated, nonunion rates are comparable between open and arthroscopic ankle arthrodesis in high-risk patients. For patients with a remote history of infection, open ankle arthrodesis may be preferable, and bone graft importance may vary with open versus arthroscopic technique.

LEVEL OF EVIDENCE

III.

Early results and complication rate of the LapiCotton procedure in the treatment of medial longitudinal arch collapse: a prospective cohort study

INTRODUCTION

Instability/collapse of the medial column has been associated with many conditions, particularly progressive collapsing foot deformity (PCFD), hallux valgus (HV), and midfoot arthritis (MA). Restoration of first ray length and sagittal plane alignment to restore the foot tripod is essential when treating these deformities. This study aimed to assess early results, healing, and complication rate of a distraction dorsal opening plantarflexion wedge allograft first tarsometatarsal joint fusion (LapiCotton Procedure) in patients with collapse/instability of the medial column.

METHODS

In this prospective cohort study, we included PCFD, HV, and MA patients that underwent a LapiCotton procedure. Fusion site healing was defined by > 50% bone bridging in both interfaces between allograft wedge and host bone using weight-bearing computed tomography (WBCT) after 3 months. First ray collapse radiographic correction and minor and major complications (deep dehiscence, deep infection, and reoperation) were assessed.

RESULTS

A total of 22 patients (22 feet) were included (11 PCFD, 6 MA, and 5 of HV patients). Mean follow-up was 5.9 months (range 3-12) and median allograft size was 8 mm (range 5-19 mm). Bone healing was observed in 91% of cases. Two minor complications (9%, both superficial dehiscence) and one major complication (4.5%, deep infection) were observed. Statistically significant improvement of the sagittal plane talus-first metatarsal angle was observed, with mean improvement of 9.4° (95% CI 6.7-12.1°; p < 0.0001).

CONCLUSION

In this prospective cohort study of 22 patients treated with the LapiCotton procedure for medial longitudinal arch collapse/instability, we observed a low complication rate (9% minor, 4.5% major), high healing rate after 3 months (91%), one clinically stable radiographic non-union (4.5%) and one unstable non-union (4.5%) needing reoperation. Our results demonstrate promising initial results for LapiCotton technique in treating collapse of the medial longitudinal arch in patients with PCFD, MA and HV deformities. Long-term results are needed to confirm these promising results.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Phalangeal autologous bone graft for flail digit subluxation: A case report

A 70-year-old patient was referred for a surgical opinion with a flail digit. Flail digit occurs as a result of over resection to the head of the proximal phalanx beyond the surgical neck and proximally into the shaft. The patient was complaining of a symptomatic right fourth digit (pain 7/10 on a Visual Analogue Scale) that had previously undergone two failed hammer toe surgeries resulting in symptomatic plantar hyperkeratosis with no history of ulceration or infection. The patient was surgically managed with autologous bone graft harvested from an adjacent digit biphalangic phalanx. Six months postoperative, the patient presented asymptomatic. Anatomical alignment, digital stabilisation and function were achieved. Full autologous graft consolidation was confirmed radiographically. Favourable patient-reported outcomes using the Manchester–Oxford Foot Questionnaire showed improvement in all domains. Currently, there is no published case study or description utilising our surgical technique to treat flail digit deformity.

Orthobiologics in Foot and Ankle Arthrodesis: A Systematic Review

Orthobiologics are biologically-derived materials intended to promote bone formation and union. We review evidence on effectiveness and harms of orthobiologics compared to no orthobiologics for foot and ankle arthrodesis. We searched multiple databases (1995-2019) and included clinical trials and other studies with concurrent controls, English language, and reporting patient-centered outcomes, union/time to union, costs/resource utilization, or harms. Studies were organized by orthobiologic used. We describe quality and limitations of available evidence but did not formally rate risk of bias or certainty of evidence. Most of the 21 studies included were retrospective chart reviews with orthobiologics used at surgeon's discretion for patients considered at higher risk for nonunion. Ten studies compared autologous bone graft versus no graft and 2 compared remote versus local graft with few studies of other orthobiologics. All studies reported a measure of fusion and about half reported on function/quality of life. Few studies reported harms. Due to limited reporting, we were unable to assess whether effectiveness varies by risk factors for nonunion (eg, age, gender, smoking status, obesity, diabetes) or whether orthobiologics were cost-effective. Available evidence is of poor quality with small sample sizes, inadequate reporting of risk factors for nonunion, variations in orthobiologics, surgical techniques used, and outcome assessment, and potential selection bias. Research is needed to adequately inform surgeons about benefits and harms and guide patient selection for use, or type, of orthobiologics. Careful assessment of individual patient risk for nonunion is critical prior to orthobiologic use.

Open Curettage With Bone Augmentation for Symptomatic Tumors and Tumor-like Lesions of Calcaneus: A Comparison of Bioactive Glass Versus Allogeneic Bone

Few studies have characterized the clinical outcomes of 45S5 Bioglass® applied as a bone graft to that of allogeneic bone applied in calcaneal open curettage. Therefore, the purpose of the present investigation was to compare the outcomes of patients with calcaneal tumors and tumor-like lesions treated by open curettage with 45S5 Bioglass® or allogeneic bone. Of the 31 patients who underwent open curettage (18 cases of unicameral bone cysts, 7 cases of aneurysmal bone cysts, and 6 cases of intraosseous lipoma), 16 (52%) received grafts with 45S5 Bioglass® and 15 (48%) with allogeneic bone. All the feet achieved bone fusion according to the modified Neer radiographic classification system at the last follow-up examination. The mean bone ingrowth time for the grafts with 45S5 Bioglass® versus allogeneic bone was 3.71 ± 0.86 versus 4.46 ± 1.04 months (p = .038), the mean bone healing time was 4.86 ± 0.93 versus 5.73 ± 1.07 months (p = .021), and the mean incision drying time was 7.2 ± 1.8 versus 8.2 ± 1.5 days (p = .047), respectively. No differences were found in the postoperative American Orthopaedic Foot and Ankle Society ankle-hindfoot scale scores between the 2 groups (p = .213). These results show that 45S5 Bioglass® can better facilitate the formation of new bone with a faster drying time of the incision than allogeneic bone. Although both materials can benefit the clinical outcomes of calcaneal tumors and tumor-like lesions, further studies are needed to observe the long-term complications and lesion recurrence rates.

Bone Graft Harvesting From the Calcaneus Using Lateral Wall Corticotomy Technique by an Osteotome

Background: The aim of this study was to evaluate the complications following calcaneal autologous bone graft harvesting using an osteotome in patients who underwent foot and ankle surgery with follow-up of at least 1 year. Methods: In a cohort study, all consecutive patients underwent forefoot or midfoot surgeries in conjunction with harvesting bone graft from the calcaneus using lateral wall corticotomy technique by an osteotome from 2015 till 2018 were asked to follow. The outcome and morbidity were assessed by visual analogue scale (VAS) pain, numbness in territory of the sural nerve, surgical site numbness or tenderness, infection, hematoma formation, or pathologic fracture. Also any possible restrictions on wearing desired shoes were asked. Results: Totally, 50 patients (11 males, 39 females; 29 right foot, 21 left foot) with the mean age of 48.2 ± 13.8 years (range 8-66 years) were assessed. There were no major complications on donor site such as infection, hematoma formation, or pathologic fracture. The following results were seen; 90% without any pain (VAS 0/10), 96% without numbness at the incision site, 96% without point tenderness on lateral of heel, 98% without paresthesia or numbness in the sural nerve territory, and 84% were able to wear their favorite shoes. Forty-one (82%) cases said if they need another foot surgery, they would permit to harvest bone graft from their heel. Conclusions: Autologous bone graft harvesting from the calcaneus using lateral wall corticotomy technique by an osteotome could be a useful method with very low complications.Levels of Evidence: Therapeutic, level IV: cohort, case series.

Surgical Reconstruction of Nonunion after Iatrogenic Scarf Osteotomy

We present the case of a young patient, 32 years old, with nonunion in the diaphysis of the first metatarsal after scarf osteotomy for correction of hallux valgus. After removal of the failed osteosynthesis material and preparation of the bone fragments, a calcaneal bone autograft, previously extracted from the patient, was placed in the nonunion area. The new physiological position of the first metatarsal in the three planes was checked intraoperatively, and autograft and fragment fixation was performed using a combination of a low-profile plate with six screws and two interfragmentary screws. The advantage of using an autogenous graft is that it provides corticocancellous bone and great osteogenic capacity with little antigenic capacity. This makes it an excellent option in many situations in foot and ankle surgery. Regarding the fixation method, we used the two most commonly used techniques for osteosynthesis of bone grafts in cases of bone nonunion, combining plates with locking screws and two interfragmentary screws. This provides greater stability of the bone fragments in the three planes and makes it possible to bring forward when the patient starts postsurgical loading.

Arthroscopic Contribution of Synthetic Graft in Tibiotalocalcaneal Arthroscopic Fusions

Nonunion is a frequent complication of tibiotalocalcaneal arthrodesis. The risk of nonunion increases significantly for those patients with systemic comorbidities and smokers. The purpose of this article is to show the proper way to supplement our arthroscopic fusion surgeries with biomaterial (peptide-15) graft. We have achieved an increase in consolidation rates in complex patient cases. We can conclude that this is a simple and reproducible technique.

Do Patient Positioning and Portal Placement for Arthroscopic Subtalar Arthrodesis Matter?

Background

Arthroscopic subtalar arthrodesis was first described over 2 decades ago and originally performed in the lateral decubitus or supine position using anterolateral and posterolateral portals situated about the fibula. More recently, several authors have advocated for prone positioning utilizing posteromedial and posterolateral portals with an optional accessory lateral portal. To date, a comparison of these techniques has been limited.

Purpose

To determine the effect of patient positioning and portal placement on complication rates after arthroscopic subtalar arthrodesis.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Patients were placed into 1 of 3 groups: the lateral group if they were positioned lateral or supine with lateral-based portals; the 2-portal prone group if they were positioned prone with posteromedial and posterolateral portals; or the 3-portal prone group if posteromedial, posterolateral, and accessory lateral portals were utilized in the prone position. Inverse variance-weighted fixed-effects models were used to evaluate pooled estimates.

Results

A total of 20 studies examining 484 feet in 468 patients with a mean follow-up of 36.1 months were included for analysis. Overall, 8 studies examined patients in the prone position with 2 posterior portals (n = 111; 22.9%), 7 articles evaluated lateral portals (n = 182; 37.6%), and 5 studies examined patients in the prone position with 3 portals (n = 191; 39.5%). The total complication rate was similar (P = .620) between the 2-portal prone (18.9%), 3-portal prone (17.8%), and lateral (17.6%) groups. There was no difference observed in the rate of complications secondary to portal placement (P ≥ .334), rate of painful hardware (P ≥ .497), and rate of repeat surgery (P ≥ .304). The 2-portal prone group had a significantly higher rate of nonunion than the lateral group (8.1% vs 1.1%, respectively; P = .020) but not the 3-portal prone group (5.8%; P = .198).

Conclusion

The current study demonstrated a higher rate of nonunion following arthroscopic subtalar arthrodesis with prone patient positioning using posteromedial and posterolateral portals without an accessory lateral portal.

Citation Classics in the Journal of Endodontics and a Comparative Bibliometric Analysis with the Most Downloaded Articles in 2017 and 2018

INTRODUCTION

Bibliometric analysis is the quantitative measure of the impact of a scientific article in its respective field of research. The aim of this study was to identify and analyze the main features of the top 50 most cited articles published in the Journal of Endodontics since its inception as well as the top 50 most downloaded articles in 2017 and 2018 in order to evaluate the changing trends and other bibliometric parameters of the contemporary literature compared with the classic literature.

METHODS

An electronic search was conducted on the Clarivate Analytics Web of Science "All Databases" to identify and analyze the top 50 most frequently cited scientific articles. After ranking the articles in a descending order based on their citation counts, each article was then crossmatched with the citation counts in Scopus, Google Scholar, and PubMed.

RESULTS

The citation counts of the 50 selected most cited articles ranged between 218 and 731 (Clarivate Analytics Web of Science). The years in which most top 50 articles were published were 2004 and 2008 (n = 5). Among 131 authors, the greatest contribution was made by M. Torabinejad (n = 14). Most of the articles originated from the United States (n = 38) with the greatest contributions from the School of Dentistry, Loma Linda University, Loma Linda, CA (n = 15). Basic research-technology was the most frequent study design (n = 18). A negative, significant correlation occurred between citation density and publication age (correlation coefficient = -0.708, P < .01).

CONCLUSIONS

Several interesting differences were found between the main characteristics of the most cited articles and the most downloaded articles.

The Role of Allograft Bone in Foot and Ankle Arthrodesis and High-Risk Fracture Management

Allogenic bone graft has long been accepted as a standard of care in the surgical arthrodesis of the foot and ankle and treatment of certain high-risk, comminuted fracture types that have greater potential for delayed union or nonunion. It has been shown in multiple studies to be equivalent to autograft in regard to union rates without the morbidity associated with bone graft harvest. We present a retrospective study on the efficacy of an allogenic cancellous/periosteal cellular bone matrix with mesenchymal stem cells and angiogenic growth factors. The study includes a cohort of 41 procedures and 40 patients who underwent foot and ankle arthrodesis, fracture fixation, or a simultaneous combination of both. Radiographic consolidation of the fracture/fusion site was reviewed at regular intervals (first postoperative visit at 1 week and 4, 8, and 12 weeks and at regular intervals until healing was confirmed). Age, workmen's compensation insurance, diabetes, and nicotine use were evaluated as potential risk factors. Our retrospective study indicated that allograft bone has the potential to positively affect union rates in foot and ankle arthrodesis and certain high-risk fracture types that have potential for delayed union/nonunion. Levels of Evidence: Level IV.

Biopolymers as bone substitutes: a review

Human bones have unique structures and characteristics, and replacing a natural bone in the case of bone fracture or bone diseases is a very complicated problem. The main goal of this paper was to summarize the recent research on polymer materials as bone substitutes and for bone repair. Bone treatment methods, bone substitute materials as well as their advantages and drawbacks, and manufacturing methods were reviewed. Biopolymers are the most promising materials in the field of artificial bones and using biopolymers with the shape memory effect can improve the integration of an artificial bone into the human body by better mimicking the structure and properties of natural bones, decreasing the invasiveness of surgical procedures by producing deployable implants. It has been shown that the application of the rapid prototyping technology for artificial bones allows the customization of bone substitutes for a patient and the creation of artificial bones with a complex structure.

Effect of Fixation Type and Bone Graft on Tarsometatarsal Fusion

BACKGROUND:

End-stage tarsometatarsal (TMT) arthritis is commonly treated with arthrodesis of involved joints. Fixation hardware can consist of varying combinations of screws, plates, and staples with or without supplemental bone graft. There are limited data to demonstrate either superiority of a given fixation method or the impact of bone graft on fusion rates. The purpose of this study, therefore, was to determine whether nonunion rates after TMT arthrodesis were influenced by either the use of screw vs plate fixation or the addition of bone graft vs no bone graft.

METHODS:

All patients older than 18 years undergoing arthrodesis for TMT arthritis between July 1991 and July 2016 were identified retrospectively. Exclusion criteria included less than 12 months follow-up, prior midfoot surgery, any added procedure beyond TMT arthrodesis using plates or screws, and acute foot trauma. All patients with radiographic or clinical nonunion, including those requiring revision surgery, were identified. Demographic data and associated risk factors were recorded via chart and radiographic image review. Eighty-eight patients (88 feet, mean follow-up: 75.1 ± 51.4; range, 12-179), with a total of 189 joints and who met enrollment criteria were treated by 9 different surgeons with arthrodesis.

RESULTS:

The overall nonunion rate was 11.4%. Significant independent risk factors associated with nonunion were (1) arthrodesis using plate fixation with all screws through the plate (odds ratio [OR], 6.2; 95% confidence interval [CI], 1.8-21.3; P = .004), (2) smoking during the perioperative period (OR, 7.9; 95% CI, 2.1-30.2; P = .002), and (3) postoperative nonanatomic alignment (OR, 11.2; 95% CI, 2.1-60.8; P = .005). Bone graft utilization was found to significantly lower the rate of nonunion (OR, 0.2; 95% CI, 0.1-0.6; P = .006).

CONCLUSION:

Isolated plate fixation, smoking, and postoperative nonanatomic alignment appear to significantly increase the rate of nonunion among patients undergoing TMT arthrodesis for midfoot arthritis. Concomitant use of autogenous bone graft significantly decreased this risk.

LEVEL OF EVIDENCE:

Level III, retrospective comparative study.

Collagen as Coating Material for 45S5 Bioactive Glass-Based Scaffolds for Bone Tissue Engineering

Highly porous 45S5 bioactive glass-based scaffolds were fabricated by the foam replica technique and coated with collagen by a novel method. After an initial cleaning step of the bioactive glass surface to expose reactive –OH groups, samples were surface functionalized by (3-aminopropyl)triethoxysilane (APTS). Functionalized scaffolds were immersed in a collagen solution, left for gelling at 37 °C, and dried at room temperature. The collagen coating was further stabilized by crosslinking with 1-ethyl-3-(3-dimethylaminopropyl)carbodiimide (EDC) and N-hydroxysuccinimide (NHS). Applying this coating method, a layer thickness of a few micrometers was obtained without affecting the overall scaffold macroporosity. In addition, values of compressive strength were enhanced by a factor of five, increasing from 0.04 ± 0.02 MPa for uncoated scaffolds to 0.18 ± 0.03 MPa for crosslinked collagen-coated scaffolds. The composite material developed in this study exhibited positive cell (MG-63) viability as well as suitable cell attachment and proliferation on the surface. The combination of bioactivity, mechanical competence, and cellular response makes this novel scaffold system attractive for bone tissue engineering.

Poor outcomes of fusion with Trabecular Metal implants after failed total ankle replacement: Early results in 11 patients

INTRODUCTION

One of the reasons for revision of total ankle replacement (TAR) implants is loosening due to subchondral cysts. Reconstruction and fusion of the ankle is often the first choice for revision procedures due to the large bone defects, which are typically filled with autograft and/or allograft. Filling the defect with a trabecular metal tantalum implant is a potential alternative given the biomechanical properties of this component.

HYPOTHESIS

Using tantalum as a spacer provides primary stability and contributes to fusion of the ankle joint after removal of failed TAR implants.

METHODS

Eleven patients underwent arthrodesis an average of 6.9 years after TAR. The mean height of the bone defect was 32mm. It was filled with a specially designed quadrangular implant (Trabecular Metal™, Zimmer/Biomet) combined with an iliac crest graft. Ten patients underwent tibio-talo-calcaneal (TTC) arthrodesis fixed with an angled retrograde nail and one patient underwent talocrural arthrodesis fixed with two plates (anterolateral and anteromedial). The clinical, functional (AOFAS and SF36 scores) and radiological (plain X-rays and CT scan) outcomes were determined.

RESULTS

At a mean follow-up of 19.3 months, the mean total AOFAS score was 56 (21-78) and the mean SF36 score was 60.5 (19-84). One patient was lost to follow-up and four patients still had pain. The tantalum implant was integrated in six patients. Five patients achieved fusion of the subtalar joint and 8 achieved fusion of the talocrural joint. Three patients required surgical revision.

DISCUSSION

Our hypothesis was not confirmed. The clinical outcomes after more than 1 year of follow-up are disappointing, as was the large number of nonunion cases and the lack of tantalum integration. These technical failures can be explained by insufficient construct stability and/or insufficient implant porosity.

LEVEL OF EVIDENCE

IV (retrospective cohort study).

Open Ankle Arthrodesis

First described in 1879, ankle arthrodesis is a procedure that has undergone significant advancements not only in technique but also in technology and fixation. Surgeon preference has often dictated those changes with regard to incisional approaches, fixation methods, and use of bone graft and biologics but one constant has always remained: open ankle arthrodesis is a predictable, time-tested procedure with consistent results when performed in appropriate patients. This article highlights the changes that have occurred since the introduction of this procedure and provides a brief overview of the preferred technique.

Antimicrobial Hydroxyapatite-Gelatin-Silica Composite Pastes with Tunable Setting Properties

Bone grafting is one of the commonest surgical procedures, yet all bone substitutes developed so far suffer from specific weaknesses and the search for a bone graft material with ideal physical and biological properties is still ongoing. Calcium phosphate pastes are the most frequently used synthetic bone grafts, yet they (a) often take an impractically long time to set, (b) release the drug content too fast, and (c) do not form pores large enough to accommodate host cells and foster osseointegration. To make up for these deficiencies, we introduced gelatin and silica to pastes composed of 5-15 nm sized hydroxyapatite nanoparticles and yielded a bioresorbable composite that is compact, yet flowing upon injection; that prevents setting at room temperature, but sets promptly, in minutes, at 37 °C; that displays an increase in surface porosity following immersion in physiological fluids; that allows for sustained release of antibiotics; and that sets in a tunable manner and in clinically relevant time windows: 1-3 minutes at its fastest. Timelapse, in situ X-ray diffraction analysis demonstrated that the setting process is accompanied by an increase in crystallinity of the initially amorphous hydroxyapatite, involving no polymorphic phase transitions in its course. Setting time can be tuned by controlling the weight content of gelatin or powder-to-liquid ratio. The release of vancomycin was slow, ~ 8 % after 2 weeks, and unaffected by the gelatin content. While vancomycin-loaded pastes were effective in reducing the concentration of all bacterial species analyzed, the bacteriostatic effects of the antibiotic-free pastes were pronounced against S. liquefaciens and E. coli. S. liquefaciens bacilli underwent beading and filamentation during the treatment, suggesting that the antimicrobial effects are attributable to cell wall disruption by hydroxyapatite nanoparticles. Vancomycin-loaded pastes augmented the activity of the antibiotic against P. aeruginosa and S. liquefaciens, while exhibiting no negative effects against human mesenchymal stem cells. They were also uptaken three times more abundantly than pure hydroxyapatite, indicating the theoretical favorability of their use for intracellular delivery of therapeutics. This selectivity, toxic for bacteria and harmless for primary stem cells, is promising for application as bone grafts for osteomyelitis.

Osseous Healing in Foot and Ankle Surgery with Autograft, Allograft, and Other Orthobiologics

In the surgical treatment of foot and ankle abnormality, many problems require bone grafting for successful osseous union. Nonunion, reconstruction, and arthrodesis procedures pose specific challenges due to bony defects secondary to trauma, malunions, or previous surgery. Nonunion in foot and ankle arthrodesis is a significant risk and is well documented in recent literature. This article is a review of the recent literature regarding the use of bone graft and orthobiologics in foot and ankle surgery.

The available evidence on demineralised bone matrix in trauma and orthopaedic surgery: A systematic review

Objectives

The aim of this systematic literature review was to assess the clinical level of evidence of commercially available demineralised bone matrix (DBM) products for their use in trauma and orthopaedic related surgery.

Methods

A total of 17 DBM products were used as search terms in two available databases: Embase and PubMed according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses statement. All articles that reported the clinical use of a DBM-product in trauma and orthopaedic related surgery were included.

Results

The literature search resulted in 823 manuscripts of which 64 manuscripts met the final inclusion criteria. The included manuscripts consisted of four randomised controlled trials (level I), eight cohort studies (level III) and 49 case-series (level IV). No clinical studies were found for ten DBM products, and most DBM products were only used in combination with other grafting materials. DBM products were most extensively investigated in spinal surgery, showing limited level I evidence that supports the use Grafton DBM (Osteotech, Eatontown, New Jersey) as a bone graft extender in posterolateral lumbar fusion surgery. DBM products are not thoroughly investigated in trauma surgery, showing mainly level IV evidence that supports the use of Allomatrix (Wright Medical, London, United Kingdom), DBX (DePuy Synthes, Zuchwil, Switzerland), Grafton DBM, or OrthoBlast (Citagenix Laval, Canada) as bone graft extenders.

Conclusions

The clinical level of evidence that supports the use of DBM in trauma and orthopaedic surgery is limited and consists mainly of poor quality and retrospective case-series. More prospective, randomised controlled trials are needed to understand the clinical effect and impact of DBM in trauma and orthopaedic surgery.

Cite this article: J. van der Stok, K. A. Hartholt, D. A. L. Schoenmakers, J. J. C. Arts. The available evidence on demineralised bone matrix in trauma and orthopaedic surgery: A systemati c review. Bone Joint Res 2017;6:423–432. DOI: 10.1302/2046-3758.67.BJR-2017-0027.R1.

First Metatarsal-Phalangeal Joint Arthrodesis: Primary, Revision, and Salvage of Complications

Arthrodesis of the first metatarsal-phalangeal joint has been proposed for treatment of severe hallux valgus, end-stage hallux rigidus, rheumatoid arthritis, and revision of failed surgery due to the perceived safety and efficacy. This article discusses the principles of first metatarsal-phalangeal joint arthrodesis in primary and revision situations, joint preparation, configurations of osteosynthesis, and common complications, including salvage of nonunion and revision of malunion with realignment osteotomy.

The Efficacy of Platelet-Derived Growth Factor as a Bone-Stimulating Agent

Nonunion remains the most impactful complication following ankle and hindfoot arthrodesis. Historically, surgeons have relied on autologous bone graft (ABG) to combat nonunion risk. Although effective, ABG remains limited in quantity, varies in quality, and can be associated with harvest site pain and morbidity. Use of alternative bone-stimulating agents, however, avoids harvesting an autograft, and provides a more predictable dose-response efficacy. This article highlights findings from basic science, animal, and human clinical research that led to the approval of Augment Bone Graft. We present an adaptation of the surgical techniques described for investigators participating in the pivotal trial.

The Role of Orthobiologics in Fracture Healing and Arthrodesis

Nonunion after tibial shaft fracture and hindfoot arthrodesis remains a major problem. Known risk factors include advanced age, immunosuppression, smoking, and diabetes. Several factors must be considered in the fracture healing process. This review evaluates the efficacy of orthobiologics in improving union rates after fracture or arthrodesis. Use of compounds have shown increased cellular proliferation experimentally. Percutaneous autologous bone marrow has shown increased cellular proliferation. Matrix supplementation has shown significant improvements in bone healing. Several studies have highlighted the importance of adequate graft fill over graft type. Patients at increased risk for nonunion would benefit most from these adjuvant therapies.

Delayed Reconstruction by Total Calcaneal Allograft following Calcanectomy: Is It an Option?

Many options are available in literature for the management of delayed reconstruction following calcanectomy. In cases of low-grade tumor lesions, conservative surgery can be considered. We describe a case of delayed reconstruction by calcaneal allograft after calcanectomy for low-grade chondrosarcoma. At 12-month follow-up, the patient had no pain; MSTS score and AOFAS score were satisfactory. Subtalar nonunion was observed with no secondary displacement or graft necrosis. The aim of conservative treatment for this patient was to restore normal gait with plantigrade locomotion and function of the Achilles tendon. Calcaneal reconstruction by total allograft is an alternative approach following calcanectomy for calcaneal tumors. We also discussed other options of calcaneal reconstruction.

The Importance of Sufficient Graft Material in Achieving Foot or Ankle Fusion

BACKGROUND

Nonunion, an important complication following foot and ankle arthrodesis, causes substantial morbidity and disability. In patients undergoing hindfoot and ankle arthrodesis, autogenous bone graft (autograft) or a suitable alternative is often used to promote osseous fusion across the joint. This study assessed the importance of adequate graft material in the fusion space to achieve joint fusion during ankle and hindfoot arthrodesis.

METHODS

This study used data from a previously published clinical trial of grafting material (recombinant human platelet-derived growth factor-BB with beta-tricalcium phosphate [rhPDGF-BB/β-TCP] or autograft) for healing in hindfoot and ankle arthrodesis to correlate the amount of graft fill at 9 weeks with ultimate healing. Patients who received supplemental graft material for ankle or hindfoot arthrodesis for end-stage ankle or hindfoot arthritis were stratified according to nonunion risk factors and surgical fusion site. Patients underwent arthrodesis using standard rigid internal fixation. Graft fill was defined as "adequate" if the material occupied ≥50% of the cross-sectional area of the fusion space on a computed tomography (CT) scan made at 9 weeks. Fusion was defined as osseous bridging of ≥50% of each articulation on a CT scan made at 24 weeks. Three hundred and seventy-nine patients with 573 joints (383 managed with rhPDGF-BB/β-TCP and 190 managed with autograft) that underwent arthrodesis had complete follow-up with 9-week and 24-week CT scans available.

RESULTS

Overall, 472 (82%) of 573 joints had adequate graft fill; of those, 383 (81%) were successfully fused at 24 weeks compared with 21 (21%) of 101 joints without adequate graft fill (p < 0.0001). Absolute fusion rate differences (joints with adequate fill minus those without adequate fill) were consistent across joints (61% to 63%) and for graft materials. The overall odds ratio (OR) of successful fusion in joints with adequate graft fill compared with those without adequate graft fill was 16.4 (95% confidence interval, 9.6 to 27.9).

CONCLUSIONS

This study demonstrates an association between the amount of graft material and successful hindfoot and ankle arthrodesis. Graft material filling of ≥50% of the fusion space at 9 weeks, regardless of type or origin, was associated with significantly higher fusion rates at 24 weeks.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.