Complication Rates in Open Ankle Arthrodesis with Autologous Tissue Substitute vs Non-Autologous Tissue Substitute: A Comparative Analysis

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Open ankle arthrodesis remains the definitive treatment for advanced ankle arthritis and deformities that fail conservative management. Bone graft selection can critically influence postoperative outcomes, as graft choice affects both biomechanical stability and biological healing capacity. Autologous grafts possess superior osteogenic properties but entail donor-site morbidity and extended operative time. Non-autologous grafts circumvent secondary harvesting but may yield suboptimal integration or higher complication rates. Despite increasing clinical use of both graft types, comparative data on complication profiles in ankle fusion remain scarce. This study analyzed a large national database to determine whether autologous or non-autologous grafts confer distinct rates of key complications, including infection, malunion, wound dehiscence, and mechanical failure. Methods: A retrospective cohort analysis was performed using data from the National Readmissions Database (NRD) from 2016 to 2021. Patients were stratified by graft type — autologous or non-autologous — using relevant ICD-10 procedure codes. Outcomes assessed included malunion/nonunion, infection, wound complications, aseptic mechanical loosening, and readmissions within 90 days. Propensity score matching was conducted to control for confounders, incorporating variables such as age, sex, and comorbidities. Pearson’s chi-squared tests and logistic regression were used to compare complication rates, and significance was set at P< 0.05. Results: A total of 6,957 patients were included for analysis, with 5,285 autologous and 1,672 non-autologous graft recipients. Following 1:1 propensity score matching (n = 1,655), non-autologous grafts were associated with a higher overall complication rate (17.7% vs. 12.3%, P < 0.001), cellulitis (3.8% vs 2.0%; p = 0.002), wound dehiscence (1.1% vs. 0.4%; p = 0.002), malunion/nonunion (8.1% vs. 6.1%; p = 0.031), aseptic mechanical loosening (3.6% vs. 2.2%; p = 0.018). Conversely, autologous grafts had higher incidences of acute infection (0.8% vs. 0.1%; p = 0.001). Binomial regression indicated that autologous arthrodesis lowered the odds of cellulitis (OR = 0.442; 95% CI 0.198-0.988; p = 0.047) but had higher odds of developing acute infection (OR = 28.9; 95% CI 2.828-295.636; p = 0.005). Conclusion: Non-autologous grafts, while sparing patients the morbidity of donor-site harvesting, demonstrated a higher incidence of mechanical and wound complications, likely due to reduced osteogenic potential. In contrast, autologous grafts conferred enhanced biological integration yet increased the risk of acute infection likely associated with additional operative sites. Surgeons should weigh these trade-offs, particularly in patients with significant comorbidities that may predispose them to poor healing or infection. Tailoring graft selection to individual risk factors and employing stringent perioperative protocols could optimize outcomes. These findings reinforce the need for further prospective studies to refine graft strategies in open ankle arthrodesis. Table 1. Propensity-Matched Comparative Complication Rates