SLR - November 2016 - David Farnen

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

Reference: Digiovanni CW, Lin SS, Daniels TR, Glazebrook M, Evangelista P, Donahue R, Beasley W, Baumhauer JF. The Importance of Sufficient Graft Material in Achieving Foot or Ankle Fusion. J Bone Joint Surg Am. 2016 Aug 3;98(15): 1260–267.

Reviewed By: David Farnen, DPM
Residency Program: Eastern Virginia Medical School Podiatric Medicine and Surgery Residency Program

Podiatric Relevance: Foot and ankle arthrodeses are commonly performed by podiatric surgeons. Adequate preparation, apposition and fixation is necessary to avoid nonunions. Nonunions can cause significant morbidity and disability. To aid in successful arthrodeses, surgeons may use graft materials. The purpose of the study was to determine the importance of adequate graft material to achieve fusion in ankle and hindfoot surgery.

Methods: This study used retrospective data from a previously published clinical trial of grafting material for healing in hindfoot and ankle fusions.  Between April 2007 and January 2010, 379 patients with 573 joints were studied (383 with recombinant human platelet-derived growth factor with beta tricalcium phosphate vs 190 managed with autograft). Patients were first stratified by nonunion risk factors. All arthrodesis sites used rigid internal fixation. Graft fill was considered adequate if the graft material occupied > or equal to 50 percent of the cross-sectional area of the fusion space on CT scan made at nine weeks. Fusion was defined as osseous bridging of greater than or equal to 50 percent of each articulation seen on a CT scan at 24 weeks.

Results: Overall, 472 of 573 (82 percent) of patients had adequate graft fill. Three hundred eighty-three were successfully fused at 24 weeks compared to 21 of 101 joints without adequate graft fill.

Conclusions: This study demonstrates the association between amount of graft material and successful hindfoot and ankle arthrodesis. Irrespective of type of graft material, if the fusion site was occupied with 50 percent of graft, successful fusion was seen at 24 weeks. This study further confirmed my training in the importance of adequate preparation, apposition and grafting to aid in successful ankle and hindfoot fusion. 

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