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Hindfoot and ankle arthrodesis are invasive procedures performed for the treatment of ankle arthritis and deformities as a measure to alleviate pain and functional disability caused by the damaged joint. Hindfoot and ankle arthrodesis are often resultant of trauma, fractures, infection, osteonecrosis, osteopenia, arthritis, Charcot, clubfoot deformity, or paralytic disorders.1,2 In trauma cases, tibial pilon, talus, and calcaneus fractures are common injuries that result in the need for hindfoot and/or ankle arthrodesis procedures.3,4 Ankle arthrodesis is often a secondary, delayed salvage procedure performed as an alternative to nonsurgical care, arthroplasty, or below the knee amputation to treat posttraumatic infection, malalignment, nonunion, or end-stage ankle arthritis.
Bone grafts used to aid in hindfoot and/or ankle arthrodesis procedures have been shown to contribute to successful fusion and favorable outcomes. Graft materials available to supplement hindfoot and ankle arthrodesis procedures include autologous (autograft) or allogeneic bone graft (allograft) but also bone graft substitutes, such as demineralized bone matrix, calcium sulfate, calcium phosphate, and tricalcium phosphate/hydroxyapatite. In addition, biologic agents, such as recombinant human bone morphogenetic protein-2 or recombinant human platelet-derived growth factor-BB with beta-tricalcium phosphate (rhPDGF-BB/β-TCP; Augment Bone Graft, Biomimetics Therapeutics—a subsidiary of Stryker, Franklin), bone morphogenetic protein (BMP)-2 growth factor analog (B2A)–coated ceramic granules (Amplex, BioSurface Engineering Technologies Inc—BioSET, Rockville), and preparations, including platelet-rich plasma or concentrated bone marrow aspirate, have been used to facilitate bone healing in ankle or hindfoot arthrodesis.
The clinical outcomes of ankle or hindfoot arthrodesis procedures have been documented with variable parameters as the primary outcome including fusion rate using CT fusion rate, radiographic fusion rate, nonunion rate, time to union, American Orthopedic Foot and Ankle Society (AOFAS) score, Foot Function Index (FFI) score, SF-12 (Short form-12) score, fusion site pain, weight-bearing pain, harvest site pain, and postoperative complications. As a result, the clinical interpretation of the existing evidence on this topic remains a challenge.
The purpose of this review was to summarize the available clinical evidence on the efficacy of bone grafts, bone graft substitutes, and biologic agents in ankle or foot arthrodesis procedures.
Given the high heterogeneity in the literature and the rapidly expanding research on this topic,5–7 we only included comparative studies analyzing the outcomes after ankle or foot arthrodesis using different types of bone grafts, with primary focus on articles comparing newer biologic evidence against autograft, which remains the current benchmark.
Randomized Controlled TrialsRandomized controlled trials (RCTs), or Level I studies, for graft materials in foot and ankle arthrodesis procedures are rare. Only autograft, rhPDGF-BB/β-TCP and B2A peptide-coated ceramic granules have this level of evidence (Table 1). Of these materials, only autograft and rhPDGF-BB/β-TCP have Level I studies that are not pilot studies with greater than 25 subjects.
Table 1 - Level I/Noninferiority Trials Comparing the Outcomes of Autologous Bone Graft (ABG), Recombinant Human Platelet-derived Growth Factor BB-homodimer With Beta Tricalcium Phosphate (rhPDGF-BB/β-TCP), and Bone Morphogenetic Protein (BMP)-2 Growth Factor Analog (B2A)–coated Ceramic Granules in Patients Undergoing Ankle or Hindfoot Arthrodesis. Study (first author, year) Graft Comparison Groups Population (Number of Patients or Joints) Primary Outcome Latest Follow-up Time CT Fusion Rates (N, %) Radiographic Union Rates (N, %) Clinical Healing Rate (N,%) Median/Mean VAS Median/Mean AOFAS score Median/Mean FFI Median/Mean SF-12 Physical Summary Digiovanni et al.,10 2011 rhPDGF-BB/β-TCP versus ABG rhPDGF-BB/β-TCP: 14 patientsVAS = visual analog scale, AOFAS = American Orthopaedic Foot & Ankle Society, FFI = Foot Function Index, ABG = autologous bone graft
The functional outcomes represent the values recorded at the latest follow-up for each study; American Orthopaedic Foot & Ankle Society (AOFAS) score, Foot Function Index (FFI) score, Short-form 12 (SF-12), Physical Component Summary (PCS), score; and visual analog scale (VAS).
The bone graft alternative, rhPDGF-BB/β-TCP was introduced in 2010 as a bone regeneration device.8 rhPDGF-BB/β-TCP is composed of beta tricalcium phosphate (β-TCP) and 0.3 mg/mL recombinant human platelet-derived growth factor-BB rhPDGF-BB in a sodium acetate buffer.8 In this formulation, the β-TCP serves as the scaffold with osteoconductive properties to deliver the rhPDGF-BB to the fusion site which has an osteoinductive effect.8 The safety of rhPDGF-BB/β-TCP was evaluated in a phase 2 human trial including 60 patients requiring hindfoot or midfoot fusion with a follow-up time of 36 weeks.8 No patient had a serious adverse event in the latest study, and moderate or complete osseous bridging was achieved in 75% (44/59) of patients at 36 weeks postoperatively, using CT imaging with a high benchmark (≥50% osseous bridging) for successful fusion.8 In the paper of Barlet et al,9 the odds of fusion success were compared among subjects older or younger than age thresholds of 55, 60, 65, 70, and 75 years and comparisons were made based on the use of autograft versus rhPDGF-BB/β-TCP among subjects older than each age threshold. In this last article, age above and below 60 years, and ages above and below 65 years had odd ratio of fusion 2.24 and 2.74, respectively, of fusion (>50% osseous bridging on CT).9
Four clinical trials (469 total patients) have compared the rates of CT or radiographic fusion in patients undergoing ankle and hindfoot fusion using autograft (autologous bone graft) tissue versus rhPDGF-BB/β-TCP and showed noninferiority.10–13 CT fusion was defined as ≥50% osseous bridging or >50% healing across the fused articulation. Secondary outcomes in these four studies included radiographic fusion rate, clinical healing status, visual analog scale pain score, AOFAS score, FFI score, and SF-12 score (Table 1).
B2A is a synthetic peptide that enhances osteoblastic differentiation and has been studied as a bone graft expander in spinal fusion animal models with positive outcomes. The biologic action of B2A on osteoblastic differentiation has been associated with the upregulation of endogenous BMP2. B2A ceramic granules appeared in a pilot RCT conducted by Glazebrook et al14 who reported similar fusion rates and improvement in clinical outcomes between 24 patients who underwent foot and ankle fusion using either B2A ceramic granule or autograft. In this last study, radiographic fusion success was defined as a percentage joint fusion greater than 50%.15 More research is necessary to investigate the clinical efficacy of B2A-coated ceramic granule in foot and ankle fusion surgery given the limited amount of current evidence.15
The results of the above mentioned RCTs are summarized in Table 1.
Retrospective and Prospective Comparative Studies (Non-RCT)Additional bone graft alternatives that are not supported by RCTs are discussed below. The literature is characterized by notable variability in studies reporting the outcomes after foot or ankle fusion using different bone augmentation materials such as allograft, autograft, or other biologics. Multiple case series and a limited number of comparative studies have been conducted, and the latter will be discussed below. Given the notable variability of surgical techniques and biologics used and the challenges in clinical interpretation, noncomparative studies were out of scope of this review.
Bone Morphogenetic ProteinBone morphogenetic protein (BMP-2) has been studied more extensively compared with other biologic agents; however, all through lower level of evidence studies.15–17 DeVries et al15 compared the fusion rates and time to fusion after revision tibiotalocalcaneal arthrodesis (TTC) with the use of BMP-2 versus without BMP-2. Although the results did not reach statistical significance likely due to the limited study population (7 patients in the BMP-2 group and 16 patients in the non–BMP-2 group), biologic augmentation of revision TTC with BMP-2 was associated with slightly increased salvage rates compared with revision TTC without BMP-2 augmentation.15
Another study evaluated the outcomes of patients who underwent complex ankle fusion with the Ilizarov technique and who received recombinant human BMP-2 (rh-BMP2/Infuse; Medtronic, Minneapolis) versus those who did not; patients treated with recombinant human bone morphogenetic protein-2 were more likely to obtain fusion after the initial surgery (93% versus 53%, P < 0.001; OR, 11.76; 95% CI, 3.12 to 44.41), spent less total time wearing the frame (124 versus 161 days, P < 0.01), and demonstrated more bone bridging on CT scans (48% versus 32%, P < 0.05).16 The results of this study supported the use of rh-BMP2 in the setting of complex ankle arthrodesis; however, the data were limited by their retrospective nature (obtained through a chart review) as well notable difference in the baseline characteristics of the included patients.16
Autograft TissueIn comparative studies using autograft, Nodzo et al18 compared the radiographic fusion rate and complications in patients who underwent ankle arthrodesis augmented with iliac crest bone graft (ICBG) versus femoral reamer-irrigator aspirator (RIA) bone graft for ankle fusion. These authors found similar radiographic bony fusion rates between the groups with a mean time to fusion of 12 weeks; however, the ICBG group had a markedly higher nonunion rate which the authors attributed to previous research showing higher levels of transcription factors associated with vascular, skeletal, and hematopoietic tissues in the RIA sample compared with ICBG in the same patient.19 Furthermore, ankle fusion rates and clinical outcomes in patients with osteoarthritis secondary to osteonecrosis of the talus were markedly higher in patients who received vascularized autografts compared with nonvascularized autografts (76% in the vascularized group versus 40% in the nonvascularized group) based on a small population study by Kodama et al.20
El Hawary et al21 showed no difference in clinical and radiographic outcome between patients who underwent subtalar arthrodesis for calcaneal nonunion using local calcaneal bone graft versus iliac crest bone graft. These authors highly recommend the usage of local autograft to avoid complications associated with the possibility of donor site morbidity.21
Other Biologic AgentsDemineralized bone matrix consists of concentrated bone growth factors and known for its osteoconductive and osteoinductive properties.22 Tricot et al23 evaluated the clinical and radiographic fusion rates and time to fusion in a total of 82 patients who underwent hindfoot arthrodesis supplemented with autograft and DBM versus combined allograft, DBM and bone marrow aspirate and found no notable differences between the groups.
A retrospective study compared the radiographic and clinical fusion rates of patients who underwent ankle fusion using mesenchymal stem cell (MSC) bone allografts (44 patients) versus proximal tibia autograft (41 patients) and demonstrated a statistically significant delay in radiographic and clinical fusion in patients with the MSC allograft (13 ± 2.5 weeks in the MSC group versus 11 + 3 ± 2.8 in the proximal tibia autograft group).24 However, at final follow-up (minimal 2 years), the radiographic fusion rates and clinical fusion rates as well as the functional outcomes were similar between the two groups.24 The authors hypothesized that the delayed fusion in the MSC groups may be related to the variability of MSC bone allograft preparations used within their study population, which mostly represents differences in the amount of viable MSCs included in the preparation; this may have affected the healing rate.24
Teriparatide is a synthetic human parathyroid hormone that activates osteoblastic activity that has been approved for the treatment of osteoporosis. Based on the previously reported benefit of teriparatide on bone healing in patients with fractures or those undergoing spinal fusion, Lee et al conducted a comparative study to evaluate the effect of teriparatide on fusion rates in a small population (16 patients) undergoing foot and ankle arthrodesis and who were at high risk of nonunion (had at least one of the following risk factors for nonunion: deformity, bone defects, osteonecrosis, or nonunion after previous foot and ankle arthrodesis).25 Patients who received teriparatide treatment had a markedly higher fusion rate compared with those who did not (100% vs 50%). In addition, three of the patients in the control group had nonunion. These patients subsequently received teriparatide after their revision surgery and subsequently achieved union.26
In a different study including 68 patients, Devries et al found similar nonunion rates between patients who underwent ankle and hindfoot arthrodesis using allograft morphogenetic protein (AMP; OSTEOAMP; Bioventus LLC) versus those without AMP.17 In this study, patients in the AMP group had a significantly lower complication rate compared with patients in the non-AMP group (13.8% vs 35.9%, P = 0.04). Complications in the non-AMP group included nonunion (17.9%), deep vein thrombosis (5.1%), plantar fasciitis (5.1%), persistent pain (2.6%), periprosthetic fracture (2.6%), and painful hardware (2.6%). Complications in the AMP group included nonunion (10.3%) and wound complication requiring irrigation and debridement (3.4%).
The viable cellular allograft contains viable stem cells and bone scaffold in a gel base and has been recently studied as a potential alternative to autograft in foot arthrodesis.23 The rate of fusion, time to fusion, and rate of revision surgery after forefoot, midfoot, and hindfoot arthrodesis were compared between patients who received autograft, viable cellular bone allograft, or both and found no statistically significant difference between the three groups for all variables. Based on these results, the authors suggested that the viable cellular allograft may serve as an alternative to autograft.27
DiscussionFoot and ankle arthrodesis remains the benchmark procedure for end-stage arthritis of the foot and ankle or other conditions that result in notable distortion of the normal anatomy and function of the distal lower extremity.7 Nonunion is a potential complication of foot and ankle fusion surgery, and it has been associated with poor functional outcomes. Patients who are at high risk of nonunion such as those with medical comorbidities (diabetes, neuropathy, and osteonecrosis) and/or history of smoking or alcohol use can have nonunion rates up to 40%.25 Bone autograft or allograft tissue with or without biologic augmentation can be used to facilitate fusion in patients with foot and ankle arthrodesis, and research evidence on this topic has been growing exponentially.6,28,29
This review focused on studies comparing the clinical and radiographic outcomes in patients undergoing foot and ankle fusion surgery and who received various types of bone grafts with or without orthobiologics. The main advantage of the present review is that it focused on the comparative studies available on this topic, and therefore, it can be useful for surgeons exploring the different options for biologic augmentation of foot and ankle fusion.7,30 We purposely excluded the case reports and noncomparative studies given that comparing two or more surgical techniques and/or biologic agents provides more insight into the advantages and disadvantages of each treatment option, and it is useful for preoperative patient counseling. As highlighted in the systematic review by Greer et al,7 the quality of evidence on this topic can be characterized as poor given that is limited by small study populations, lack of reporting factors of nonunion, and variations in orthobiologics and surgical techniques but also the outcome measures used but also selection bias. By eliminating noncomparative series in this review and by categorizing the different techniques based on the biologic agent, we are hoping the reader can focus on the biologic agent of their interest and review results of techniques using that specific agent.
The osteoinductive, osteoconductive, osteogenic, and angiogenetic properties of the bone graft preparation used are responsible for the biologic effect to facilitate bone fusion.6 Based on these principles, autologous bone graft has been considered the benchmark graft used in foot and ankle arthrodesis procedures because it provides all four aspects of an ideal bone graft. Disadvantages associated with the use of autograft include donor site complications, need for additional surgical incision, and variability of the quality of autograft harvested based on host factors and anatomic location used as the source, which can all affect clinical outcomes.31 Based on previous data, the combined rate of complication associated with autograft harvest procedures ranges between 15% and 49%.31 For example, harvesting bone graft from the iliac crest can result in injury to the lateral femoral cutaneous nerve, infection, severe postoperative pain, bowel complications, abdominal hernia, or hematoma.31 Autograft harvest can result in long-term (up to 10 years) chronic, clinically significant pain.4 The use of the RIA device to obtain autograft tissue has been popularized; however, this procedure is associated with increased cost and surgical time.7,31 This current review provides evidence that the use of allograft tissue and/or orthobiologics to enhance bone healing can result in comparative clinical and radiographic outcomes as autograft in foot and ankle fusion surgery.7
Allograft bone tissue is mainly used for its osteoconductive properties in patients undergoing foot and ankle fusion procedures. Allograft tissue is readily available and can be provided in different forms such as powder, patty, bone chips, and pellets, facilitating its application. Calcium sulfate has been widely used to augment foot/ankle fusion surgery over the years; however, due to its rapid resorption rate which can result in seromas or wound drainage, it has largely been replaced by calcium phosphate. Coralline hydroxyapatite comprises the “bone chips,” and it is widely used in ankle/foot fusion surgery due to its compressive strength that approximates that of cancellous bone.7,31 Demineralized bone matrix is another allograft that is available in multiple formulations including paste, gel, sheets, and cubes and has mainly osteoconductive properties, but recent studies have isolated osteoinductive molecules from DBM, such as IGF, TGF-β, osteocalcin, and osteopontin.31 The use of allograft tissue has been associated with increased cost and the potential risk of immune reaction from the host that may result in catastrophic complications after foot or ankle fusion.7
Synthetic grafts such as the rhPDGF-BB/β-TCP or B2A products have been used in foot and ankle fusion surgery during the last decade in an effort to overcome the limitations associated with the use of autograft such as tissue availability and variability, prolonged surgical time, and complications associated with donor site morbidity. In the largest trial comparing the results between patients who underwent ankle/hindfoot fusion using rhPDGF-BB/β-TCP versus autograft, the radiographic and clinical fusion rates using rhPDGF-BB/β-TCP were deemed noninferior compared with autograft.11 Secondary outcomes that favored the use of rhPDGF-BB/β-TCP included a lower therapeutic failure rate at 24 weeks and 52 weeks postoperatively, lower weight-bearing pain at 52 weeks postoperatively, and an improved safety profile. Furthermore, in a multicenter, retrospective, case series of 98 patients with Charcot neuropathy patients who underwent Charcot reconstruction using rhPDGF-BB/β-TCP, the fusion rate (≥50% osseous bridging based on CT and/or radiographic consolidation) was 97% and the mean time to fusion was 13 weeks.30 In this last study by Loveland et al, the complication rate in this high-risk population was 26.5%; complications included hardware failure, wound problems, amputation, and death. However, no complications or adverse events were related to the graft material.29
The surgical methods used in the included studies in this review and the indications for fusion were variable, and this constitutes a major limitation.7,23,25,26,32 Posttraumatic osteoarthritis or primary osteoarthritis was likely the most common indication for ankle fusion; however, patients with other diagnosis such as rheumatoid arthritis or Charcot disease were also included in the included studies, but the outcomes were not analyzed by surgical indication.4,11,15–17,31,32 In the surgical techniques, there was variability in the fixation construct used among the included articles and occasionally among the patients included in the same study population such as plate and screws, screws only, or intramedullary nails and/or combination of the above. The latter can have a notable effect on the interpretation of outcomes, and this review categorizes the study based on the types of biologic agents used in comparative series with somewhat similar surgical fixation technique between the study groups.26,27,30,32 Again, the heterogeneity among patient characteristics, surgical fixation method, indication for fusion, and biologic agent used are factors that need to be taken into account when interpreting the results of this review.
The interpretation of the outcomes in clinical trials can be challenging given multiple follow-up points and the utilization of functional outcomes scores in combination with the corresponding variable minimal clinically important difference values that have not always be validated for the diagnosis of interest.32 As an example, most of the reported minimal clinically important difference values for FFI or AOFAS stemmed from study populations undergoing common procedures such as correction of hallux valgus and not necessarily ankle/hindfoot fusion.33,34 In addition, there was a lack of consistency in the time interval and definition of nonunion versus delayed-union, and the defined benchmark for successful fusion varied greatly, as well as the level of accuracy in the imaging method used to assess fusion (CT versus plain radiograph). In general, plain radiographic analysis was the most common method used for joint evaluation; however, plain radiographs may overestimate the degree of consolidation and therefore is less sensitive in identifying nonunions.2 These are limitations that should always be taken into consideration when analyzing the results of clinical research.
Notable heterogeneity was noticed among the non-RCT studies comparing the effectiveness of various bone graft options and orthobiologics in the healing rates and functional outcomes after foot and ankle arthrodesis.15–18,20,21,23–26,30,32 The heterogeneity among those studies can be attributed to the different types of bone grafts reported, the various combinations of autograft or allograft tissue with biologic molecules, lack of more than one study analyzing the effect of a certain biologic agent or medication on bone healing in ankle/foot fusion surgery (except for the BMP, see section above), and inconsistency in the reported clinical outcomes.15–18,20,21,23,24,27,30,32 More research is necessary to understand the role of allograft bone tissue and/or orthobiologics as alternatives to autograft use to facilitate bone healing in patients undergoing foot and ankle arthrodesis.
ConclusionThe utilization of bone graft and orthobiologics in foot and ankle fusion surgery continues to expand. Existing trials showed noninferiority of newer products compared with autologous bone graft in fusion rates at short-term follow-up. Overall, there is a clear lack of high-quality evidence available for most graft materials used in hindfoot and ankle fusion. Autograft is the most studied graft material, followed by rhPDGF-BB/β-TCP. The use of BMP, MSC, calcaneal autograft tissue, RIA, ICBG, teriparatide, and viable cellular allograft to facilitate bone healing in foot and ankle arthrodesis has also been studied in lower quality comparative studies that were greatly heterogeneous precluding the generation of cumulative outcomes. Future research will continue to shed more light on the role of orthobiologics and allograft tissue in foot and ankle fusion surgery and their potential to replace autograft to avoid donor site complications.
References 1. Abidi NA, Gruen GS, Conti SF: Ankle arthrodesis: Indications and techniques. J Am Acad Orthop Surg 2000;8:200-209. 2. Bibbo C, Anderson RB, Davis WH: Complications of midfoot and hindfoot arthrodesis. Clin Orthop Relat Res 2001;391:45-58. 3. Beaman DN, Gellman R: Fracture reduction and primary ankle arthrodesis: A reliable approach for severely comminuted tibial pilon fracture. Clin Orthop Relat Res 2014;472:3823-3834. 4. Rammelt S, Zwipp H: Corrective arthrodeses and osteotomies for post-traumatic hindfoot malalignment: Indications, techniques, results. Int Orthop2013;37:1707-1717. 5. Wee J, Thevendran G: The role of orthobiologics in foot and ankle surgery: Allogenic bone grafts and bone graft substitutes. Efort Open Rev 2017;2:272-280, 6. Peterson JR, Chen F, Nwankwo E, Dekker TJ, Adams SB: The use of bone grafts, bone graft substitutes, and orthobiologics for osseous healing in foot and ankle surgery. Foot Ankle Orthop 2019;4:2473011419849019 7. Greer N, Yoon P, Majeski B, Wilt TJ: Orthobiologics in foot and ankle arthrodesis: A systematic review. J Foot Ankle Surg 2021;60:1029-1037 8. Daniels T, DiGiovanni C, Lau JT, Wing K, Younger A: Prospective clinical pilot trial in a single cohort group of rhPDGF in foot arthrodeses. Foot Ankle Int 2010;31:473-479 9. Berlet GC, Baumhauer JF, et al.: The impact of patient age on foot and ankle arthrodesis supplemented with autograft or an autograft alternative (rhPDGF-BB/β-TCP). JBJS Open Access 2020 17;e20.00056 10. Digiovanni CW, Baumhauer J, Lin SS, et al.: Prospective, randomized, multi-center feasibility trial of rhPDGF-BB versus autologous bone graft in a foot and ankle fusion model. Foot Ankle Int 2011;32:344-354 11. DiGiovanni CW, Lin SS, Baumhauer JF, et al.: Recombinant human platelet-derived growth factor-BB and beta-tricalcium phosphate (rhPDGF-BB/β-TCP): An alternative to autogenous bone graft. J Bone Joint Surg Am 2013;95:1184-1192 12. Daniels TR, Younger AS, Penner MJ, et al.: Prospective randomized controlled trial of hindfoot and ankle fusions treated with rhPDGF-BB in combination with a β-TCP-collagen matrix. Foot Ankle Int 2015;36:739-748 13. Daniels TR, Anderson J, Swords MP, et al.: Recombinant human platelet-derived growth factor BB in combination with a beta-tricalcium phosphate (rhPDGF-BB/β-TCP)-Collagen matrix as an alternative to autograft. Foot Ankle Int 2019;40:1068-1078 14. Glazebrook M, Younger A, Wing K, Lalonde KA: A prospective pilot study of B2A-coated ceramic granules (Amplex) compared to autograft for ankle and hindfoot arthrodesis. Foot Ankle Int 2013;34:1055-1063 15. DeVries JG, Nguyen M, Berlet GC, Hyer CF: The effect of recombinant bone morphogenetic protein-2 in revision tibiotalocalcaneal arthrodesis: Utilization of the retrograde arthrodesis intramedullary nail database. J Foot Ankle Surg 2012;51:426-432. 16. Fourman MS, Borst EW, Bogner E, Rozbruch SR, Fragomen AT: Recombinant human BMP-2 increases the incidence and rate of healing in complex ankle arthrodesis. Clin Orthop Relat Res 2014;472:732-739. 17. DeVries JG, Scharer B: Comparison and use of allograft bone morphogenetic protein versus other materials in ankle and hindfoot fusions. J Foot Ankle Surg 2018;57:707-711. 18. Nodzo SR, Kaplan NB, Hohman DW, Ritter CA: A radiographic and clinical comparison of reamer–irrigator–aspirator versus iliac crest bone graft in ankle arthrodesis. Int Orthop 2014;38:1199-1203. 19. Sagi HC, Young ML, Gerstenfeld L, Einhorn TA, Tornetta P: Qualitative and quantitative differences between bone graft obtained from the medullary canal (with a Reamer/Irrigator/Aspirator) and the iliac crest of the same patient. JBJS 2012;94:2128-2135. 20. Kodama N, Takemura Y, Shioji S, Imai S: Arthrodesis of the ankle using an anterior sliding tibial graft for osteoarthritis secondary to osteonecrosis of the talus: A comparison of vascularised non-vascularised grafts. Bone Joint J 2016;98:359-364. 21. El-Hawary A, Kandil Y, Ahmed M, Elgeidi A, El-Mowafi H: Distraction subtalar arthrodesis for calcaneal malunion: Comparison of local versus iliac bone graft. Bone Joint J 2019;101:596-602. 22. Pietrzak WS, Woodell-May J, McDonald N: Assay of bone morphogenetic protein-2,-4, and-7 in human demineralized bone matrix. J Craniofac Surg 2006;17:84-90. 23. Tricot M, Deleu P-A, Detrembleur C, Leemrijse 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;103:697-702. 24. Anderson JJ, Boone JJ, Hansen M, Brady C, Gough A, Swayzee Z: Ankle arthrodesis fusion rates for mesenchymal stem cell bone allograft versus proximal tibia autograft. J Foot Ankle Surg 2014/11/01/2014;53:683-686. 25. Perlman MH, Thordarson DB: Ankle fusion in a high risk population: An assessment of nonunion risk factors. Foot Ankle Int 1999;20:491-496 26. Lee HS, Park JH, Suh DH, et al.: Effects of teriparatide on fusion rates in patients undergoing complex foot and ankle arthrodesis. Foot Ankle Surg 2020;26:766-770 27. Frederick RM, Sarfani S, Chiu CY, et al.: Comparing rates of fusion and time to fusion in viable cellular allograft and autograft. Foot Ankle Int 2022;43:1548-1553 28. Baumhauer JF, Pinzur MS, Daniels TR, et al.: Survey on the need for bone graft in foot and ankle fusion surgery. Foot Ankle Int 2013;34:1629-1633 29. Loveland JD, McMillen RL, Cala MA: A multicenter, retrospective, case series of patients with Charcot neuroarthropathy deformities undergoing arthrodesis utilizing recombinant human platelet-derived growth factor with beta-tricalcium phosphate. J Foot Ankle Surg 2021;60:74-79 30. Wan J, Liu L, Zeng Y, Ren H, Zhang S: Comparison of different bone graft with arthroscopy-assisted arthrodesis for the treatment of traumatic arthritis of the subtalar joint. Int Orthop 2020;44:2719-2725 31. Miller CP, Chiodo CP: Autologous bone graft in foot and ankle surgery. Foot Ankle Clin 2016;21:825-837. 32. Schlickewei C, Neumann JA, Yarar-Schlickewei S, et al.: Does demineralized bone matrix affect the nonunion rate in arthroscopic ankle arthrodesis? J Clin Med 2022;11:3893 33. Shazadeh Safavi P, Janney C, Jupiter D, Kunzler D, Bui R, Panchbhavi VK: A systematic review of the outcome evaluation tools for the foot and ankle. Foot Ankle Special 2019;12:461-470. 34. Sutton RM, McDonald EL, Shakked RJ, Fuchs D, Raikin SM: Determination of minimum clinically important difference (MCID) in visual analog scale (VAS) pain and foot and ankle ability measure (FAAM) scores after hallux valgus surgery. Foot Ankle Int 2019;40:687-693
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