SLR - February 2019 - Michael McCann
Reference: Tricot M, Deleu PA, Detrembleur C, Leemriise T. "Clinical Assessment of 115 Cases of Hindfoot Fusion with Two Different Types of Graft: Allograft + DBM + Bone Marrow Aspirate Versus Autograft + DBM." Orthop Traumatol Surg Res. 2017 Sep; 103(5); 697–702.
Scientific Literature Review
Reviewed By: Michael McCann, DPM
Residency Program: Wake Forest Baptist Hospital, Winston-Salem, NC
Podiatric Relevance: An essential component of ankle and hindfoot arthrodesis procedures is achieving bony union. Nonunion rates are approximately 15 percent when patients undergo this complex procedure [3]. Commonly, bone grafting is utilized to facilitate fusion. Corticocancellous autograft bone graft is the gold standard due to its mechanical, functional and structural properties. Nevertheless, harvesting autograft lengthens case times, increases both indirect cost to patient and donor site morbidity and varies in biological quality and availability. To determine if an alternative bone graft was a viable option, the authors compared the effectiveness of allograft-demineralized bone matrix (DBM)-bone marrow aspirate (BMA) to autograft-demineralized bone graft in terms of fusion time, fusion rates and number of surgical revisions. They hypothesized allograft-DBM-BMA is equivalent to autograft-DBM in its effectiveness while simplifying clinical practice.
Methods: A level III retrospective study was performed on 82 patients (115 joints) who underwent ankle or hindfoot arthrodesis with the addition of bone graft. All procedures were performed by a single surgeon, between 2010 and 2015, at St. Luc University Clinic. Two cohorts were formed based on type of bone graft used, autograft-DBM (n= 45 joints) and allograft-DBM-BMA (n=70 joints). Fusion time and fusion rates were assessed through standard X-ray imaging when applicable. In instances when fusion could not be determined, CT scans were assessed. A rank test determined if cohorts were equal in indication terms, fusion type, age, BMI, male-female ratio, percentage of smokers, amount of DMB used, length of postop follow-up, effect of graft type on fusion time and fusion rate, and revision rate. A contingency table the determined effects of comorbidities on nonunion. Complication rates were expressed as a percentage.
Results: The mean follow-up time for autograft group was 17 months and 12.5 months for the allograft group. Complication rates occurred in the autograft group at 29 percent, which included nonunion at 18 percent, infection rate of 11 percent and a 25 percent surgical revision rate of failed arthrodesis. Nonunion at osteonecrosis joints occurred at 60 percent and 27 percent in revision joints of failed arthrodesis. Complication rates occurred in the allograft group at 17 percent, which included nonunion at 13 percent, infection rate of 4 percent and a 14 percent surgical revision of failed arthrodesis. The authors determined fusion at osteonecrosis joints occurred “well” but saw a 27 percent nonunion rate in revision joints. Fusion time, fusion rates, revision rates and heterotopic ossifications were equal in both cohorts. DBM was used more in allograft then autograft cohort but was at the limit of significance.
Conclusion: In both cohorts, there was no significant difference found in terms of fusion rate, fusion time, heterotopic ossifications, revision rate and quantity of DBM used. The allograft-DBM-BMA cohort showed similar effectiveness with a 10 percent reduction in complications when compared to the autograft-DBM cohort. Based on these outcomes, utilizing allograft-DBM-BMA to facilitate fusion in rearfoot arthrodesis is a viable option to reduce indirect patient cost, the time length of the case and patient morbidity.