SLR - January 2020 - Andrew Robitaille
Reference: Pedro Diniz, Jácome Pacheco, Miguel Flora, Diego Quintero, Sjoerd Stufkens, Gino Kerkhoffs, Jorge Batista, Jon Karlsson, Hélder Pereira. Clinical Applications of Allografts in Foot and Ankle Surgery. Knee Surgery, Sports Traumatology, Arthroscopy (2019) 27:1847–1872Scientific Literature Review
Reviewed By: Andrew Robitaille, DPM
Residency Program: Beaumont Wayne Hospital, Wayne, MI
Podiatric Relevance: Allografts are a valuable treatment option in podiatric surgery. Allografts can improve surgical results by avoiding donor site morbidity, reduce operative time, and help fill large defects in bone, osteochondral defects, and ligamets/tendons. Limitations of allografts include lower biological activity compared to autografts, possible transmission of infectious diseases, graft-host reactions. Allografts allow the treatment of large bone defects that otherwise have few treatment options when compared to autografts. The goal of this review is to analyze current literature regarding the use of allografts in the surgical treatment of foot and ankle disorders in adult patients and provide evidence-based recommendations.
Methods: The database for PubMed was searched for all published articles. No timeframe restrictions were applied. Clinical studies eligible for inclusion met the following criteria: patients over 18 years old, surgical treatment of foot and ankle, reported outcome of the use of allografts, assessment of pain and function, and minimum follow-up of one year. Two reviewers independently selected studies for analysis. 107 studies were included from 1113 records. Studies were grouped according to surgical indications into ten categories: musculoskeletal tumours (n=16), chronic ankle instability (n=15), ankle arthritis (n=14), osteochondral lesions of the talus (n=12), Achilles tendon defects (n=11), other tendon defects (n=9), fusions (n=9), fractures (n=8), hallux rigidus (n=3) and other indications (n=10).
Results: Most studies displayed evidence level of IV (n=57) and V (n=39). There was one level I, one level II and nine level III studies. Most studies reported allografting as a good option (n=99; 92.5 percent). The most commonly used allograft was ankle ( n =247), followed by hamstring tendons (n=186), talus (n=94), femoral head (n=59), tibialis anterior (n=35), iliac crest (n=32), skin (n=16), fascia lata (n=15), Achilles tendon (n=14), tibia (n=11), meniscus (n=7), first metatarsophalangeal joint (n=4), patella tendon (n=2), calcaneus (n=1), fibula (n=1), first metatarsal (n=1), peroneus brevis tendon (n=1) and placenta (n=1). Thirty-seven studies reported complications, divided into minor and major complications. Failure was considered a major complication. Simple removal of hardware was considered a minor complication. Overall complication rate was 17 percent (n =202). Minor complications occurred in 100 patients. Major complications were reported in 102 patients, with 67 from ankle arthritis group (65.7 percent).
Discussion: The present study found that fair evidence (Grade B) was found supporting the use of allografts in lateral ankle ligament reconstructions and repair of intra-articular calcaneal fractures. Grade B evidence was found against the use of allogeneic mesenchymal stem cells in ankle fusions. The use of allogeneic grafts is an attractive option in foot and ankle surgery. When compared to autografts, their use avoids donor site morbidity and reduces surgery time, but should be used with caution as there are possible complications such as: failure of implant, graft-host reactions, and potential for infection transmission.