Editor’s note: With the June cover story, “A Guide To Orthobiologics In Podiatric Surgery,” leading surgeons discussed indications and their use of orthobiologics in a roundtable format. Unfortunately, due to space constrictions, one of the questions posed by Mark Dollard, DPM, wound up on the cutting room floor. In this online exclusive, here is the remaining question from the roundtable and the panelist responses.
Mark Dollard, DPM: You are performing a talonavicular arthrodesis on a desert island. You have limited instrumentation and only one screw. Which orthobiologic material would you chose and why?
A: D. Scot Malay, DPM, says a single screw, usually a 6.5 mm interfragmental compression screw, should be sufficient. He uses it routinely when fusing the talonavicular joint as an isolated procedure or as a component of triple arthrodesis. If the fusion interface is flush and well coapted, and there are no cystic changes or cancellous voids, he does not see an indication for the use of a bioceramic conductor material in the isolated fusion. When performing a triple arthrodesis, Dr. Malay does pack the sinus tarsi with a combination of calcium phosphate and DBM. For an isolated fusion in a healthy adult, he adds DBM paste to the arthrodesis interface. If a patient has any other risk factors (such as tobacco use, neuropathy or a previous nonunion) for delayed union or nonunion, he adds a bone marrow aspirate and DBM to the construct.
“I think that judicial use of any and all of these agents is less expensive than dealing with a nonunion,” says Dr. Malay. “Moreover, use of orthobiological materials decreases the need to harvest as much, or any, autogenous bone graft, thereby reducing operating time, blood loss, complications and costs related to the additional procedure.”
Dr. Malay says the synthetic and demineralized materials are very safe, aside from a low risk of an immunological or infectious complication related to allogenicity. Although harvesting autogenous marrow cells carries some surgical risks, he notes the risks are small and complications are not likely if the procedures are performed properly. As he says, the risk of complications is far smaller than the risk associated with harvesting a corticocancellous bone graft.
If Glenn Weinraub, DPM, had to choose one material, he would use Platelet Gel Concentrate. He says the material is cost effective and provides a large amount of growth factors to create an inductive cascade.
Opteform (Exatech) is the choice for Thomas Zgonis, DPM. The allograft, he notes, has corticocancellous bone chips for osteoconduction and demineralized bone matrix (DBM) for induction. He says such one’s choice would need to accept the compression from the single screw and become solid at body temperature. In addition, Dr. Zgonis says such a product should not wash out after irrigation, must be firmed at the surgeon’s needs and provide mechanical integrity at the arthrodesis site.
Kieran Mahan, DPM, would use a large fragment solid screw with the Healos bone substitute/autogenous marrow combination. As an alternative, he chooses autogenous cancellous bone.
In contrast, Luis Leal, DPM, would not choose a product, saying such a procedure, when performed in a concentric fashion with minimal cartilage resection, should produce little to no bony deficit. If there is bony deficit or Dr. Leal wants to add a stress relief graft, the navicular tuberosity is readily available. However, if he had to choose one product, he would use the Therics graft (Therics), which he says one can easily shape and pack around the joint space that requires fusion. He says the Therics graft has a defined shape and internal architecture that provides for controlled graft resorption, which he notes is critical in fusion procedures where remodeling is important for a stable bony mass.