Limited evidence to support demineralized bone matrix in foot and ankle surgical procedures: A systematic review

Abstract

BACKGROUND

Demineralized bone matrix (DBM) is a commonly utilized allogenic bone graft substitute to promote osseous union. However, little is known regarding outcomes following DBM utilization in foot and ankle surgical procedures.

AIM

To evaluate the clinical and radiographic outcomes following DBM as a biological adjunct in foot and ankle surgical procedures.

METHODS

During May 2023, the PubMed, EMBASE and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following DBM for the management of various foot and ankle pathologies. Data regarding study characteristics, patient demographics, subjective clinical outcomes, radiological outcomes, complications, and failure rates were extracted and analyzed. In addition, the level of evidence (LOE) and quality of evidence (QOE) for each individual study was also assessed. Thirteen studies were included in this review.

RESULTS

In total, 363 patients (397 ankles and feet) received DBM as part of their surgical procedure at a weighted mean follow-up time of 20.8 ± 9.2 months. The most common procedure performed was ankle arthrodesis in 94 patients (25.9%). Other procedures performed included hindfoot fusion, 1st metatarsophalangeal joint arthrodesis, 5th metatarsal intramedullary screw fixation, hallux valgus correction, osteochondral lesion of the talus repair and unicameral talar cyst resection. The osseous union rate in the ankle and hindfoot arthrodesis cohort, base of the 5^th metatarsal cohort, and calcaneal fracture cohort was 85.6%, 100%, and 100%, respectively. The weighted mean visual analog scale in the osteochondral lesions of the talus cohort improved from a pre-operative score of 7.6 ± 0.1 to a post-operative score of 0.4 ± 0.1. The overall complication rate was 27.2%, the most common of which was non-union (8.8%). There were 43 failures (10.8%) all of which warranted a further surgical procedure.

CONCLUSION

This current systematic review demonstrated that the utilization of DBM in foot and ankle surgical procedures led to satisfactory osseous union rates with favorable wound complication rates. Excellent outcomes were observed in patients undergoing fracture fixation augmented with DBM, with mixed evidence supporting the routine use of DBM in fusion procedures of the ankle and hindfoot. However, the low LOE together with the low QOE and significant heterogeneity between the included studies reinforces the need for randomized control trials to be conducted to identify the optimal role of DBM in the setting of foot and ankle surgical procedures.

Keywords: Demineralized bone matrix; Allogenic bone graft; osseous union; Biological adjunct; Systematic review; Bone morphogenetic proteins; Lower limb fusion; Arthrodesis

Core Tip: Despite the prevalent use of demineralized bone matrix in foot and ankle surgeries, this systematic review uncovers a lack of robust evidence supporting its efficacy. While it demonstrates satisfactory osseous union rates and favorable complication profiles, the insufficiency of high-quality studies and significant heterogeneity across research call for caution in its clinical application, emphasizing the need for further well-designed investigations to establish its effectiveness definitively.