Hartman H, Butler JJ, Calton M, Lin CC, Rettig S, Tishelman JC, Krebsbach S, Randall GW, Kennedy JG. Limited evidence to support demineralized bone matrix in foot and ankle surgical procedures: A systematic review. World J Orthop 2025; 16(1): 97848 [PMID: 39850040 DOI: 10.5312/wjo.v16.i1.97848]
Corresponding Author of This Article
John G Kennedy, FRCS, MCh, MD, MSc, Chief, Professor, Department of Orthopedic Surgery, NYU Langone Health, 171 Delancey Street, New York, NY 10002, United States. john.kennedy@nyulangone.org
Research Domain of This Article
Orthopedics
Article-Type of This Article
Systematic Reviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Orthop. Jan 18, 2025; 16(1): 97848 Published online Jan 18, 2025. doi: 10.5312/wjo.v16.i1.97848
Limited evidence to support demineralized bone matrix in foot and ankle surgical procedures: A systematic review
Hayden Hartman, James J Butler, Megan Calton, Charles C Lin, Samantha Rettig, Jared C Tishelman, Sebastian Krebsbach, Grace W Randall, John G Kennedy
Hayden Hartman, Department of Medicine, Lincoln Memorial University, Knoxville, TN 37752, United States
James J Butler, Charles C Lin, Samantha Rettig, Jared C Tishelman, Sebastian Krebsbach, Grace W Randall, John G Kennedy, Department of Orthopedic Surgery, NYU Langone Health, New York, NY 10002, United States
Megan Calton, Department of Medicine, Royal College of Surgeons in Ireland, Dublin D02 YN77, Leinster, Ireland
Author contributions: Hartman H was involved in data analysis, concept creation, and writing of the first draft of the manuscript, and editing of the first draft of the manuscript; Butler JJ was involved in search term generation, data analysis, writing of the first draft of the manuscript, and table creation; Lin CC was involved in data extraction, data analysis, editing of the first draft of the manuscript, and figure creation; Rettig S was involved in data analysis, figure creation, and writing of the first draft of the manuscript; Tishelman JC was involved in data extraction, table creation, and editing of the first and second draft of the manuscript; Krebsbach S was involved in data extraction, table creation, and editing of the second draft of the manuscript; Randall GW was involved in data extraction and figure/table creation; Kennedy JG was involved in concept creation, data analysis, writing of the first draft of the manuscript, and editing of the first and second draft of the manuscript.
Conflict-of-interest statement: The authors deny any conflict of interest.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: John G Kennedy, FRCS, MCh, MD, MSc, Chief, Professor, Department of Orthopedic Surgery, NYU Langone Health, 171 Delancey Street, New York, NY 10002, United States. john.kennedy@nyulangone.org
Received: June 10, 2024 Revised: October 28, 2024 Accepted: December 25, 2024 Published online: January 18, 2025 Processing time: 216 Days and 9.9 Hours
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 5th 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.
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.
