Why Morbidity, Not Fusion Rates, Separates Winners in Foot and Ankle Surgery

by Vince Vacketta, DPM

The allograft space in foot and ankle fusion is crowded and confusing. Every company has a portfolio of products, and every product claims to be “best.” But what moves the needle in fusion?

The evidence

An April 2026 propensity-matched TriNetX study compared iliac crest autograft to rhPDGF-BB. Consistent with existing literature, key findings included:

• rhPDGF-BB is noninferior to autograft, meaning it demonstrates equivalent performance.

• There was no difference in union rates, revision, infection, or complications.

Counterpoint: Why not BMP-2?

BMP-2 has no foot and ankle products. It is used off-label and carries risks, including ectopic bone formation, swelling, and wound issues.

Why don’t more grafts contain rhPDGF-BB?

rhPDGF-BB requires drug–device biologic approval at the PMA level, requiring expensive trials and specialized manufacturing. Few companies enter this space.

Final points

What moves the needle in fusion success isn’t fusion rates; they’re equivalent across options. It’s morbidity. rhPDGF-BB wins because it eliminates donor site complications without sacrificing outcomes. However, new rhPDGF-BB products are expensive to create, while me-too products are easier to make and can market to surgeons unfamiliar with the science.