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

Table 1 Inclusion and exclusion criteria

Inclusion criteria	Exclusion criteria
At least 1 year follow-up	Less than 1 year follow-up
Human participants	Cadaver or animal studies
Minimum 5 patients per cohort	Less than five patients per cohort
Outcomes following demineralized bone matrix for foot and ankle surgical procedures	Systematic reviews or case reports
Written in English	Written in foreign language

Table 2 Study characteristics and patient characteristics

Ref.	LOE	Patients (N)	Ankles/Hindfoot/Joints (N)	Follow up (months)	Age	M/F	R/L	Surgical procedure	DBM utilized	DBM volume (cc)
Tricot et al[6]	3	30	45	17	56.5	16/14	n/r	TT arthrodesis = 6, TT + ST arthrodesis = 11, ST arthrodesis = 8, ST + TN arthrodesis = 2, ST + TN + CC arthrodesis = 2, CC arthrodesis = 0, TT + ST + TN + CC arthrodesis = 1	DBM was supplied by the tissue bank at the Saint-Luc University Clinic in Brussels and made from allogenic cortical bone	6
Tricot et al[6]	3	52	70	12.5	56	27/27	n/r	TT arthrodesis = 9, TT + ST arthrodesis = 8, ST arthrodesis = 19, ST + TN arthrodesis = 6, ST + TN + CC arthrodesis = 6, CC arthrodesis = 2, TT + ST + TN + CC arthrodesis = 2	DBM was supplied by the tissue bank at the Saint-Luc University Clinic in Brussels and made from allogenic cortical bone	9
Schlickewei et al[5]	4	31	31	43	58.2	10/21	16/15	Arthroscopic ankle arthrodesis = 31	DBX Inject (Depuy Synthes, Solothurn, Switzerland)	2-5
Bibbo and Patel[7]	3	33	33	22.4	42.2	23/10	20/13	Calcaneal fracture ORIF = 31	Allomatrix (Wright Medical, Arlington, TN)	5-10
Brigido et al[19]	4	13	13	12	43.2	6/7	10/3	Demineralized subchondral allograft = 13	SC Plug (Bacterin International, Belgrade, MT)	n/r
Crosby and Fitzgibbons[8]	4	42	42	27	46	25/16	n/r	Arthroscopic ankle arthrodesis = 42	n/r	n/r
Galli et al[9]	4	12	12	24	43.9	5/7	9/3	Demineralized Allograft Subchondral Bone = 12	OsteoSponge SC (Bacterin, MT)	n/r
Hunt and Anderson[10]	4	8	8	27.3	27	6/2	2/6	Intramedullary screw fixation for Jones fracture = 8	Ignite (Wright Medical, Arlington, TN)	1-2
Hunt and Anderson[10]	4	1	1	14	15	0/1	0/1	Intramedullary screw fixation for Jones fracture = 1	Ignite (Wright Medical, Arlington, TN)	1-2
Iyer et al[20]	4	17	17	28.8	47.7	3/14	8/9	Akin osteotomy = 10, Second hammertoe correction = 6, Medial sesamoidectomy = 1	Bonus DBM (Biomet, IN)	n/r
Lareau et al[11]	4	25	25	6	24	25/0	10/15	Intramedullary screw fixation for Jones fracture = 25	Mini-Ignite (Wright Medical, Arlington, TN)	n/r
Park et al[18]	3	9	10	33.7	18.9	6/3	3/5	Cyst debridement and resection = 10	Injecta Bone TR (Modumedi Ltd., Daegu, Korea)	n/r
Thordarson and Latteier[12]	3	37	37	12 to 78	50.8	17/20	n/r	TT arthrodesis = 5, ST arthrodesis = 6, ST + TN + CC arthrodesis = 20, CC arthrodesis = 1, TT + ST + TN + CC arthrodesis = 1, TTC arthrodesis = 3, TT + CC arthrodesis = 1	Grafton Putty (Osteotech, NJ)	n/r
Thordarson and Latteier[12]	3	26	26	12 to 78	49.9	12/14	n/r	TT arthrodesis = 1, ST arthrodesis = 6, ST + TN + CC arthrodesis = 14, CC arthrodesis = 0, TT + ST + TN + CC arthrodesis = 1, TTC arthrodesis = 4, TT + CC arthrodesis = 0	Orthoblast (SeaSpine, CA)	n/r
Weinraub and Cheung[13]	3	1	1	10	62	n/r	n/r	TN + ST + CC arthrodesis = 1	n/r (MTF, NJ)	n/r
Weinraub and Cheung[13]	3	12	12	10	43.9	n/r	n/r	TN arthrodesis = 1, MCJ arthrodesis = 4, Evans osteotomy = 1, Evans + Cotton osteotomy = 1, ST arthrodesis = 2, 1st MTPJ arthrodesis = 1, ST + NC + 1st MTPJ arthrodesis = 1	n/r (MTF, NJ)	n/r
Sherman et al[14]	4	14	14	22.6	52.1	5/9	n/r	TTC arthrodesis augmented with fresh-frozen femoral head allograft, cBMA, DBM = 14	n/r	n/r

LOE: Level of evidence; R: Right; L: left; M: Male; F: Female; cc: Cubic centimeters; TT: Tibiotalar; ST: Subtalar; CC: Calcaneocuboid; BMA: Bone marrow aspirate; MTPJ: Metatarsophalangeal joint; NC: Naviculocuneiform; TTC: tibiotalarcalcaneal; cBMA: Concentrated bone marrow aspirate; TN: Talonavicular, MTF: Musculoskeletal transplantation foundation; MCJ: Metatarsalcuneiform joint; DBP: Demineralized bone powder; ORIF: Open reduction internal fixation; n/r: Not recorded.

Table 3 Osseous union, complications, failures and secondary procedures

Ref.	Patients (N)	Ankles/Hindfoot/Joints (N)	Union (%)	Non-union (%)	Complications	Failures	Secondary procedures
Tricot et al[6]	30	45	37 (82.2)	8 (17.8)	Nonunion = 8, heterotopic ossification = 2	11	Repeat procedure = 11
Tricot et al[6]	52	70	62 (88.6)	8 (11.4)	Nonunion = 8, heterotopic ossification = 4, infection = 3	10	Repeat procedure = 10
Schlickewei et al[5]	31	31	27 (87.1)	4 (12.9)	Nonunion = 4, superficial wound infection = 2, symptomatic hardware = 6	9	Revision arthrodesis due to nonunion = 3, hardware removal = 6
Bibbo and Patel[7]	33	33	33 (100)	0 (0)	Incisional nonhealing = 5, full-length wound dehiscense = 1, skin sloughing = 1	n/r	n/r
Brigido et al[19]	13	13	n/r	n/r	DVT = 1	0	0
Crosby and Fitzgibbons[8]	42	42	31 (73.8)	3 (7)	Nonunion = 3, delayed union = 2, infection = 5, symptomatic hardware = 10, stress fracture = 2, progressive symptomatic subtalar arthritis = 4, guide pin shear = 1	n/r	Hardware removal = 4, open procedure = 1, electrical stimulation = 1, debridement = 1
Galli et al[9]	12	12	n/r	n/r	DVT = 1	0	n/r
Hunt and Anderson[10]	8	8	8 (100)	0 (0)	0	0	n/r
Hunt and Anderson[10]	1	1	1 (100)	0 (0)	0	0	n/r
Iyer et al[20]	17	17	17 (100)	0 (0)	Symptomatic hardware = 2, Arthritis = 3, 2nd toe hammering = 1, stiffness = 1, MTPJ pain = 3, prominent hardware = 1	11	Modified lapidus = 4, hardware removal = 2
Lareau et al[11]	25	25	25 (100)	0 (0)	0	n/r	n/r
Park et al[18]	9	10	n/r	n/r	Residual defect = 5, Healed cyst = 5	n/r	n/r
Thordarson and Latteier[12]	37	37	32 (86.5)	5 (13.5)	Nonunion = 5	5	n/r
Thordarson and Latteier[12]	26	26	24 (92.3)	2 (7.7)	Nonunion = 2	2	n/r
Weinraub and Cheung[13]	1	1	0 (0)	1 (100)	Nonunion = 1	1	n/r
Weinraub and Cheung[13]	12	12	12 (100)	0 (0)	0	0	n/r
Sherman et al[14]	14	14	13 (92.9)	1 (7.1)	Nonunion = 1, infection = 1	1	n/r

DBM: Demineralized bone matrix; BMA: Bone marrow aspirate; MTPJ: Metatarsophalangeal joint; n/r: Not recorded.