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J Bone Joint Surg Am. 2016 Aug 3;98(15):1260-7. doi: 10.2106/JBJS.15.00879.

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

Author information

Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
North Jersey Orthopaedics Institute, Rutgers, New Jersey Medical School, Newark, New Jersey.
Division of Orthopaedic Surgery, St. Michael's Hospital, Toronto, and Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
Dalhousie University, Halifax, and Queen Elizabeth II Health Science Center, Halifax, Nova Scotia, Canada.
Department of Diagnostic Imaging, Rhode Island Hospital, the Warren Alpert School of Medicine at Brown University, Providence, Rhode Island.
Wright Medical Technology, Inc., Franklin, Tennessee.
Department of Orthopaedics, University of Rochester School of Medicine and Dentistry, Rochester, New York.



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.


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.


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).


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.


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

[Indexed for MEDLINE]

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