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Nonunion remains the most impactful complication following ankle and hindfoot arthrodesis. Historically, surgeons have relied on autologous bone graft (ABG) to combat nonunion risk. Although effective, ABG remains limited in quantity, varies in quality, and can be associated with harvest site pain and morbidity. Use of alternative bone-stimulating agents, however, avoids harvesting an autograft, and provides a more predictable dose-response efficacy. This article highlights findings from basic science, animal, and human clinical research that led to the approval of Augment Bone Graft. We present an adaptation of the surgical techniques described for investigators participating in the pivotal trial.

In the absence of bony deformity, ankle equinus is generally the result of shortening within the gastrocnemius-soleus complex. Restriction of ankle dorsiflexion as a proxy for equinus contracture has been linked to increased mechanical strains and resultant foot and ankle pathology for a long time. This entity has many known causes, and data suggest it can manifest as either an isolated gastrocnemius or combined (Achilles) contracture. Numerous disorders of the foot and ankle have been linked with such "equinus disease", and although some of these relationships remain controversial, a reasonably convincing relationship between equinus contracture and the development of flatfoot exists. What is still perhaps most misunderstood is the temporal association between these two pathologies, and hence higher levels of evidence are needed in the future to define more precisely the interplay between flatfoot deformity and gastrocnemius-soleus tightness.

Tibial malunion, a fracture healed in a position that affects the mechanical function of the limb, can be difficult to assess and to correct surgically. Precise definition of malunion has yet to be determined, and the limits of deformity which are associated with arthritic change also remain imprecise. Surgical intervention is therefore primarily indicated in symptomatic patients or those with relatively severe deformity. The several described techniques for correction of tibial malunion can achieve excellent results, although the surgery is not without substantial risk and recovery time. These issues should be discussed at length with patients before surgery.

Nonunions of the tibia represent challenging orthopedic problems, which require the surgeon to analyze numerous factors and choose an appropriate treatment. Tibial nonunion treatment requires establishing its existence and cause. The treatment algorithm necessitates consideration of a wide variety of factors: the location of the nonunion, the presence or absence of infection, and any angular or rotational deformity. Given advances in implant design and biologic agents, a wide variety of management options exist for the treatment of tibial nonunions. This article reviews surgical treatments for tibial nonunions.

Generally, large or significantly displaced intra-articular navicular fractures are treated best by surgical intervention. Open reduction and internal fixation of these injuries allow anatomic restoration of adjacent joint surfaces and preservation of length and stability along the medial column of the foot; intervention must not disrupt the already tenuous blood Supply of the tarsal navicular because of the associated risks of avascular necrosis and nonunion. The unique morphology and vital role of the navicular as a cornerstone of the talonavicular joint require every effort to maintain the congruity and motion of this joint to avoid later fusion. The likelihood for successful reduction decreases with increasing grades of injury. The naviculo-cuneiform joint, alternatively, requires stability for proper foot function and can be fused, if necessary, to improve fixation or enhance vascularity to the navicular. External fixation, bone grafting (often and early), and limited peritarsal fusion also have evolved into useful aids, under certain circumstances, to facilitate the goals of navicular fracture management. Early postoperative range of motion, prolonged protected weight bearing, and aggressive patient counseling as to the severity and long-term implications of these injuries also are paramount to success. Caution also must be exercised in managing navicular dislocations because of the potential long-term complications of redislocation or painful flatfoot deformity if alignment is not maintained. Navicular fracture care remains a challenge to the orthopedic surgeon; successful surgical intervention continues to hinge upon a careful balance between an operative exposure that is limited enough to avoid further devascularization but extensive enough to permit anatomic reduction and rigid internal fixation.

This article summarizes the various alternatives for direct gastrocnemius lengthening and elucidates the relative strengths and tradeoffs of each as a means of providing balanced perspective in selecting the appropriate procedure for any given patient.

Calcaneal osteotomy is a commonly used tool in cavovarus foot reconstructions. Understanding the indications and limitations of such an osteotomy is critical to success in reconstruction. We present a comprehensive review of surgical calcaneal osteotomy techniques and the currently available state of literature for their indications and limitations.

Platelet-derived growth factor (PDGF) is one of the most thoroughly studied proteins in the body. Research has progressively highlighted the role of PDGF during wound healing and in the bone repair cascade. This research has resulted in FDA approval of 2 products containing a recombinant version of the protein, rhPDGF-BB, for treating chronic diabetic foot ulcers and periodontal bone defects. This article reviews the applicable basic science and mechanisms of action of PDGF, with attention to the increasingly defined role of rhPDGF-BB in initiating bone regeneration. The most recent data from prospective clinical trials evaluating the use of rhPDGF-BB in combination with beta tricalcium phosphate as a substitute for autogenous bone graft in hindfoot and ankle arthrodesis are also summarized.