Demineralized Bone Matrix in Foot and Ankle Surgery: Products,Mechanisms,and Clinical Outcomes

Abstract

Background

Bone grafting is a commonly used adjunct in foot and ankle surgery to enhance osseous healing in fracture fixation and arthrodesis. Although autologous corticocancellous bone is commonly used, donor site morbidity and limited graft availability have driven the development of allogenic alternatives such as demineralized bone matrix (DBM).

Formulations

Demineralized bone matrix is produced through decalcification of donor bone, preserving a collagen-rich scaffold and biologically active proteins that support osteoconduction and osteoinduction. Commercial formulations vary in carrier systems, structural properties, and quality control processes. Products such as DBX (DePuy Synthes/MTF Biologics) and AlloSync (Arthrex) incorporate lot-specific osteoinductivity testing, whereas others including AlloMatrix (Stryker), OrthoBlast II (SeaSpine/Orthofix), and Grafton (Medtronic) use carriers to improve handling. Carrier-free and structural grafts, as well as injectable systems, further expand available options.

Clinical Applications

The strongest clinical evidence for DBM exists in fracture fixation, where high union rates have been consistently reported. In arthrodesis procedures, DBM demonstrates union rates comparable to autograft, though without evidence of superiority. Applications in osteochondral lesions of the talus and hallux valgus correction remain less clearly defined, with variable outcomes reported in predominantly small case series. Limited evidence also suggests a potential role in calcaneal bone cysts.

Conclusion

Demineralized bone matrix is a safe and versatile adjunct that avoids donor site morbidity and provides favorable handling characteristics. However, the current literature is dominated by level III-IV evidence, with no high-quality comparative studies demonstrating superiority over autograft. Demineralized bone matrix is best used in fracture fixation and selective arthrodesis, while further studies are required to define its role in cartilage-related and forefoot procedures.