Reconstructive procedures for segmental resection of bone in giant cell tumors around the knee

Background:

Segmental resection of bone in Giant Cell Tumor (GCT) around the knee, in indicated cases, leaves a gap which requires a complex reconstructive procedure. The present study analyzes various reconstructive procedures in terms of morbidity and various complications encountered.

Materials and Methods:

Thirteen cases (M-six and F-seven; lower end femur-six and upper end tibia -seven) of GCT around the knee, radiologically either Campanacci Grade II, Grade II with pathological fracture or Grade III were included. Mean age was 25.6 years (range 19-30 years).Resection arthrodesis with telescoping (shortening) over intramedullary nail (n=5), resection arthrodesis with an intercalary allograft threaded over a long intramedullary nail (n=3) and resection arthrodesis with intercalary fibular autograft and simultaneous limb lengthening (n=5) were the procedure performed.

Results:

Shortening was the major problem following resection arthrodesis with telescoping (shortening) over intramedullary nail. Only two patients agreed for subsequent limb lengthening. The rest continued to walk with shortening. Infection was the major problem in all cases of resection arthrodesis with an intercalary allograft threaded over a long intramedullary nail and required multiple drainage procedures. Fusion was achieved after two years in two patients. In the third patient the allograft sequestrated. The patient underwent sequestrectomy, telescoping of fragments and ilizarov fixator application with subsequent limb lengthening. The patient was finally given an ischial weight relieving orthosis, 54 months after the index procedure.After resection arthrodesis with intercalary autograft and simultaneous lengthening the resultant gap (∼15cm) was partially bridged by intercalary nonvascularized dual fibular strut graft (6-7cm) and additional corticocancellous bone graft from ipsilateral patella. Simultaneous limb lengthening with a distal tibial corticotomy was performed on an ilizarov fixator. The complications were superficial infection (n=5), stress fracture of fibula (n=2). The stress fracture fibula required DCP fixation and bone grafting. The usual time taken for union and limb length equalization was approximately one year.

Conclusion:

Resection arthrodesis with intercalary dual fibular autograft and cortico-cancellous bone grafting with simultaneous limb lengthening achieved limb length equalization with relatively short morbidity.     

Randomized prospective study comparing tri-cortical iliac crest autograft to allograft in the lateral column lengthening component for operative correction of adult acquired flatfoot deformity

BACKGROUND: Operative treatment of stage II posterior tibial tendon insufficiency (PTTI) is controversial. Many soft-tissue and bony procedures and various combinations of the two have been reported for treatment of stage II PTTI. Orthopaedists recognize the lateral column lengthening component of the procedure as a successful reconstructive technique. The use of cortical allograft for lateral column lengthening in the correction of pes planus in the pediatric patient population has been routine. In the adult population, however, tricortical iliac crest autograft has been the bone graft of choice. Harvest of this autograft can precipitate significant morbidity and cost. Therefore, we undertook this randomized controlled trial to compare graft incorporation and healing of allograft and autograft in the lateral column lengthening component of adult flatfoot reconstruction. METHODS: Lateral column lengthening was done as a component of operative correction for stage II PTTI in adult patients (older than 18 years) by two surgeons using similar procedures. The patients were randomized to either the allograft or autograft procedures. The primary endpoint was graft incorporation and healing as assessed by radiographs. RESULTS: The study included 33 randomized feet in 31 patients. We followed 18 feet in the allograft group and 15 in the autograft group to the point of union. There were 21 women and 10 men. There were no delayed unions, nonunions, or hardware failures. All patients in both groups achieved bony union by the 12-week followup evaluation. Two superficial foot infections were successfully treated with oral antibiotics. Two patients in the autograft group continued to have hip donor site pain at 3 months. CONCLUSIONS: This study suggests that union rates of allograft and autograft (iliac crest bone graft) are equal. The use of allograft in the lateral column lengthening component of operative correction of adult stage II PTTI appears to be a viable alternative to the use of iliac crest autograft and eliminates the morbidity and increased cost associated with autograft harvest.     

Experimental study on vascularized bone allografts for reconstruction of massive bone defects

To study the healing mechanism of vascularized bone allografts under short-term as well as long-term immunosuppression with cyclosporin A, experimental vascularized intercalary bone allograft transplantation was carried out between inbred rats using the tibiofibula graft model. Bone scintigram and radiographs were used as an indicator for early detection of rejection after transplantation and bone union. In vascularized bone allografts under long-term immunosuppression with cyclosporin A, early bone union and continuous incorporation were similar to that observed in vascularized bone autograft transplantation. When administration of cyclosporin A was discontinued before completion of bone union, the graft was rejected and bone union was delayed. Apparent swelling on the operated limb associated with a decrease in bone scintigram uptake suggested the occurrence of rejection of the allograft. Vascularized bone allograft transplantation is useful for reconstruction of massive bone defects only if immunosuppressants are used and maintained at least until bone union is obtained. © 1994 Wiley-Liss, Inc.     

Intercalary reconstruction following resection of diaphyseal bone tumors: A systematic review

IntroductionThe options for the reconstruction of diaphyseal defects following the resection of bone tumors include biological or prosthetic implants. The purpose of our study was to evaluate different types of intercalary reconstruction techniques, including massive bone allograft, extracorporeal devitalized autograft, vascularized free fibula, and modular prosthesis.MethodsWe performed a systematic review of articles using the terms diaphyseal bone tumor and intercalary reconstruction. All the studies reporting the non-oncological complications such as infection, nonunion and fracture of the intercalary reconstructions were included. We excluded articles published before 2000 or did not involve humans in the study. Case reports, reviews, technique notes and opinion articles were also excluded based on the abstracts. Thirty-three articles included in this review were then studied to evaluate failure rates, complications and functional outcome of different surgical intercalary reconstruction techniques.ResultsNonunion rates of allograft ranged 6%–43%, while aseptic loosening rates of modular prosthesis ranged 0%–33%. Nonunion rates of allograft alone and allograft with a vascularized fibula graft ranged 6%–43% and 0%–33%, respectively. Fracture rates of allograft alone and allograft with a vascularized fibula graft ranged 7%–45% and 0%–44%, respectively. Infection rates of allograft alone and allograft with a vascularized fibula graft ranged 0%–28% and 0%–17%, respectively. All of the allograft (range: 67%–92%), extracorporeal devitalized autograft including irradiation (87%), autoclaving (70%), pasteurization (88%), low-heat (90%) or freezing with liquid nitrogen (90%), and modular prosthesis (range: 77%–93%) had similar Musculoskeletal Tumor Society functional scores. Addition of a vascularized fibula graft to allograft did not affect functional outcome [allograft with a vascularized fibula graft (range: 86%–94%) vs. allograft alone (range: 67%–92%)].ConclusionAseptic loosening rates of modular prosthesis seem to be less than nonunion rates of allograft. Adding a vascularized fibula graft to allograft seems to increase bone union rate and reduce the risk of fractures and infections, though a vascularized fibula graft needs longer surgical time and has the disadvantage of donor site morbidity. These various intercalary reconstruction techniques with or without a vascularized fibula autograft had similar functional outcome.     

Effects of a New Allograft Processing Procedure on Graft Healing in a Canine Model: A Preliminary Study

Graft healing in vivo can be affected by allograft processing. We asked whether a new processing technique influenced graft-host healing compared with autograft and a standard processing technique in a canine ulna model. We used bilateral intercalary allografts or autografts in the ulna of 13 skeletally mature male coonhounds. Each animal received two allografts, either one autograft and one allograft, or two autografts. At term (90 days), the graft sites were harvested. We assessed union with high-resolution xray imaging. Each specimen was processed for nondecalcified histologic analysis to assess the graft-host interface. Quantitative histomorphometric analysis was performed to determine spatial location and area of bone. Radiographic analysis, histologic analysis, and histomorphometric measures revealed no differences in union, mean total bone area, or total endosteal/intramedullary bone for the new process, standard process, and autografts. Our preliminary data suggest the new processing techniques may increase the safety of allograft transplantation without adversely affecting union when compared with standard processing techniques and autograft in a canine model.     

异体松质骨移植治疗骨肿瘤切除后骨缺损

目的：探讨应用异体松质骨移植治疗肿瘤切除后骨缺损的生物材料填充方法。方法：总结应用深低温冷冻保存异体松质骨移植治疗骨肿瘤切除后骨缺损57例。年龄6－56岁,平均年龄17．4岁。结果：除1例因感染异体骨取出外,其余56例均取得满意的骨愈合,愈合时间平均为4．5个月。依骨腔大小或植骨量的不同愈合时间 亦有所不同。单纯异体松质骨移植与异体松质骨加自体松质骨混合移植相比,愈合时间没有明显不同。植骨量越大,骨愈合时间越长。此组患者中未见明显排异反应及并发感染者。肿瘤复发率为7％。结论：同其他骨缺损填充方法和大块异体骨的使用相比,此种方法可行性较好,安全性较高。在骨愈合率,骨愈合时间上及复发以外并发症的发生上同自体松质骨植骨无明显差异。     

A study of the mechanical strength of long bone defects treated with various bone autograft substitutes: an experimental investigation in the rabbit

This study was designed to determine which of several bone grafting materials would be the most efficacious substitute for autogenous bone graft in the treatment of segmental long bone defects. The experimental model was a 1-cm defect in the rabbit ulna. The control group had nothing implanted in the defect. The six grafts tested were: (a) autogenous iliac crest bone, (b) autogenous cortical bone (ulna), (c) hydroxylapatite, (d) hydroxylapatite-demineralized bone matrix (allograft) composite graft, (e) freeze-dried bone (allograft), and (f) demineralized bone matrix (allograft). At 6 weeks postoperatively, the ulnas were harvested, examined radiographically, and tested mechanically in torsion. The radiographic examination proved to be of little value because some materials were radiodense at the time of implantation. The rates (percentage) of union, torques at failure, and energy to failure values were statistically significantly higher than control for all groups except hydroxylapatite. We concluded that demineralized bone matrix and hydroxylapatite-demineralized bone matrix composite graft compare favorably with cortical replacement (autograft) in mechanical strength and rate of union and therefore may be satisfactory substitutes for bone grafting. Freeze-dried bone did not appear to be as satisfactory because of its low mean energy to failure, but statistical analysis failed to confirm this opinion. Hydroxylapatite graft, when used alone, does not appear to be a suitable material for grafting segmental bone defects.     

异体DBM复合rhBMP-2修复兔桡骨缺损的实验研究

目的探讨异体脱钙骨基质（demineralized bonematrix，DBM）复合重组人骨形态发生蛋白2（reconstruction humn bonemorphology protein-2，rhBMP-2）修复节段性骨缺损的能力。方法48只新西兰大白兔采用桡骨15mm节段性骨缺损模型，随机分为3组，A组植入异体DBM与rhBMP-2复合材料，B组植入异体DBM，C组为空白对照组。术后4周、8周、12周、16周．进行放射学和组织学检查。结果A组：术后4周宿主结缔组织长入植骨材料内的骨小梁间，并有岛状新生软骨、骨组织形成；术后8周，新生软骨及骨形成并融合成片；术后12周，新骨改建成熟，但仍能见到植骨材料；术后16周，管状骨结构形成，髓腔再通。B组：术后4周，植骨材料周围有软骨形成；术后8周，大量软骨形成；术后12周，大片状骨形成；术后16周，有髓腔形成。C组：各时问点仅见有纤维结缔组织，只在两端有新骨形成。X片示A组成骨量大，新骨改建、成熟迅速，术后16周全部达骨性愈合。B组成骨量少，仅2例达骨性愈合。C组未见骨性愈合。结论异体DBM复合rhBMP-2材料通过骨诱导和骨传导两种方式修复骨缺损，是一种较理想、具有高效成骨活性的植骨材料。     

Allograft bone for metacarpal reconstruction

Banked allograft bone has been used for metacarpal reconstruction in 10 patients. In one patient, allograft replaced the shafts of the fourth and fifth metacarpals that were lost as the result of an injury from an explosion. In the remaining nine, allograft was used as an intercalary bone after distraction lengthening of the metacarpal. The first metacarpal was lengthened in seven patients; four had hypoplasia of the thumb and three had partial thumb amputation. One patient with hypoplasia of the ulnar side of the hand had the fourth and fifth metacarpals lengthened, and the fifth metacarpal was lengthened in another. Of the 12 allografts used, radiographic and clinical evidence of bone union occurred at 23 of the 24 allograft/recipient bone interface sites. Most patients had no callus formation. This suggested primary bone healing. Recipient new bone appeared to cross the recipient/donor interface and replace the allograft by "creeping substitution" within 6 months to 1 year. The density and trabecular pattern of the allograft bone gradually assumed that of the recipient's bone. There was no clinical or radiographic evidence of rejection and no evidence of infection, abnormal swelling, or bone resorption. Nine of the 10 patients had improved function as determined by objective and subjective evaluation. Banked allograft bone offers two advantages over autogenous bone for reconstructive hand surgery: There is no donor site morbidity, and large defects can be filled with cylindric cortical bone of appropriate size and shape, which offers excellent stability as an intercalary graft.     

The effect of osteogenic protein-1 on the healing of segmental bone defects treated with autograft or allograft bone.

BACKGROUND: Large amounts of bone graft are frequently used to elicit the healing of bone defects resulting from reconstructive procedures. Autograft and allograft bone are often used, but each has its limitations. Bone morphogenetic proteins (BMPs) improve the healing of segmental bone defects treated with autograft or allograft. The objective of the present study was to determine the effect of implantation of a recombinant osteogenic protein-1 (OP-1) in combination with bone graft on the healing of a critical-sized (2.5-cm) segmental defect in canine ulnae. METHODS: Either autograft bone, allograft bone, osteogenic protein-1 (OP-1) mixed with type-1 bovine collagen, or various combinations of OP-1 and collagen (OP-1 device) mixed with allograft or autograft were implanted in the segmental bone defects. The combinations included 67% bone graft with 33% OP-1 device and 33% bone graft with 67% OP-1 device. The healing of the defects was assessed with radiographic, biomechanical, and histological studies. The animals were killed at twelve weeks postoperatively. RESULTS: The use of the OP-1 device alone or any combination of autograft or allograft bone and the OP-1 device demonstrated improved healing on radiographic, mechanical, and histological studies compared with that demonstrated after use of autograft or allograft bone alone. The highest radiographic and histological grades and the greatest mechanical strength were achieved with the use of 33% allograft and 67% OP-1 device, although no significant differences were observed among the different groups containing the OP-1 device. At twelve weeks postoperatively, the defects treated with any amount of the OP-1 device obtained greater mechanical strength than that obtained by autograft bone alone. CONCLUSIONS: Major bone defects may be treated with allograft bone combined with the OP-1 device, instead of autograft alone, to avoid complications associated with the use of autograft. The combination of allograft bone and the OP-1 device resulted in optimum healing of the defect, according to the radiographic, mechanical, and histological parameters measured in this study. CLINICAL RELEVANCE: The combination of freeze-dried allograft bone with the OP-1 device is an attractive graft material for the treatment of large bone defects. Although similar results were observed when autogenous bone graft was used in combination with the OP-1 device, the results of the present study suggest that allograft, because of its relatively unlimited supply, can be substituted without reduced efficacy. In addition, avoiding the need to harvest autogenous bone eliminates the additional operative time and risk associated with a second surgical procedure.     

Autograft and Allograft Unite Similarly in Lateral Column Lengthening for Adult Acquired Flatfoot Deformity

Background

Lateral column lengthening (LCL) is used to address the forefoot abduction associated with the adult acquired flatfoot. This opening wedge osteotomy can be filled with either allograft or autograft bone.

Questions/Purposes

The investigators sought to determine union rates and any loss of correction in patients undergoing LCL with autograft versus allograft.

Methods

Over a 3-year period, 126 LCLs performed by five surgeons in 120 patients were reviewed. Autograft was used in 51 patients, allograft in 75 patients. Times to clinical and radiographic union were established for these patients. Any loss of correction of forefoot abduction as manifested by talonavicular uncoverage was recorded for those grafts that healed. Failure was defined as nonunion or loss of 50% or greater correction. The size of the implanted graft was assessed as a risk factor for failure.

Results

There were 20 total failures: seven in patients with autograft and 13 in patients with allograft (p?=?0.63). The size of the implanted graft was larger in those patients that did fail (p?=?0.04).

Conclusions

The rate of nonunion and loss of correction for LCL was not significantly different between allograft and autograft. The overall rate of nonunion may be higher than has previously been reported.     

Massive bone allograft reconstruction in high-grade osteosarcoma

From 1986 to 1994, 112 bone allograft reconstructions were performed in patients with high-grade osteosarcoma in whom neoadjuvant chemotherapy was administered. The allograft reconstruction was used in arthrodesis in 44 cases (41 knees, three ankles), as an intercalary graft in 39 (28 femurs, 11 tibias), as an osteoarticular graft in 22 (three proximal and/or distal humeri, six distal femurs, 13 proximal tibias), and as an allograft and prosthesis composite in seven (two proximal humeri, one proximal femurs, four proximal tibias). In 20 patients an autologous vascularized fibula was used to augment the allograft. Functional results were excellent or good in 74% of the patients after the primary surgery, and in 83% of the patients after secondary surgery. Complications include delayed union (49%) and fracture (27%), although there were no cases of deep infection. The incidence of delayed union, but not infection or fracture, was increased by the use of chemotherapy.     

The effect of recombinant human bone morphogenetic protein-2 on femoral reconstruction with an intercalary allograft in a dog model.

This study compared the effect of augmentation of allograft host bone junctions with recombinant human bone morphogenetic protein-2 (rhBMP-2) on an absorbable collagen sponge (ACS), autogenous cancellous bone graft (CBG), and a collagen sponge alone in a canine intercalary femoral defect model repaired with a frozen allograft. Outcome assessment included serial radiographs, dual energy X-ray absorptiometry scans, and gait analyses, and mechanical testing and histology of post-mortem specimens. The distal junction healed more quickly and completely with rhBMP-2 than ACS alone based on qualitative radiography and histologic evaluations. The primary tissue in the unhealed gaps in the ACS group was fibrous connective tissue. The proximal allograft host bone junction had complete bone union in the three treatment groups. There was significantly greater new bone callus formation at both junctions with rhBMP-2 than with CBG or ACS alone that resulted in increased bone density around the allograft host bone junctions. All dogs shifted their weight from the treated leg to the contralateral pelvic limb immediately after surgery. Weight bearing forces were redistributed equally between the pelvic limbs at 12 weeks after surgery with rhBMP-2, at 16 weeks after surgery with CBG, and at 24 weeks after surgery with ACS alone. Bending and compressive stiffnesses of the whole treated femora were equal to the contralateral control femora in all treatment groups, whereas torsional rigidities of the whole treated femora for the CBG and ACS groups were significantly less than the control. Both the proximal and distal junctions the treated with rhBMP-2 had torsional stiffnesses and strengths equal to intact control bones. Ultimate failure torques of the proximal junctions of the CBG group and of both junctions of the ACS group were significantly less than the BMP-treated bones. Augmentation of the allograft host bone junctions with rhBMP-2 on an ACS gave results for all parameters measured that equaled or exceeded autogenous graft in this canine intercalary femoral defect model.     

The 'Ziran' wrap: reconstruction of critical-sized long bone defects using a fascial autograft and reamer-irrigator-aspirator autograft

Reconstruction of critical-size bony defects remains a challenge to surgeons despite recent technological advances. Current treatments include distraction osteogenesis, cancellous autograft, induced membranes (Masquelet procedure), polymeric membranes, and titanium-mesh cages filled with bone graft. In this article, the authors presents two cases in which critical-sized defects were reconstructed using a meshed fascial autograft encasing reamer-irrigator-aspirator (RIA) autograft and cancellous allograft. This article will discuss the clinical outcomes of the technique, comparison to other current techniques, and technical insight into the potential biological mechanism.     

Treatment of chronic osteomyelitis with one-stage allograft

Objective: To avoid disadvantages of two-stage cancellus bone autograft, we investigated the feasibility of one-stage allograft for reconstructing the bone defect resulting from debridement of chronic osteomyelitis in limbs. Methods: Between Feb. 1999 and Apr. 2004, 35 cases of chronic osteomyelitis ( 8 cases of nonunion) underwent one-stage allograft after debridement in our hospital. Results: Thirty-five cases were followed up for an average period of 28 months (range, 13 to 55 months), in which 32 cases (91.43%) were found no infection, and 3 cases (8.57%) were confirmed recurrence of infection. Four out of 8 cases of bone nonunion healed in 9.5 months on average (range, 3 to 12 months), and another case also acquired union after redebridement and autograft of ilium due to infection recurrence 35 days after surgery. Renonunion occurred in 3 cases, 2 out of whom healed after secondary operation with autograft. One case of renonunion and 2 cases of infection recurrence refused further treatment. Conclusions: A high rate of infection arrest can be attained when one-stage allograft is used to reconstruct the bone defect of chronic osteomyelitis after debridement in limbs. Therefore, chronic osteomyelitis should not be regarded as a contraindication to one-stage aliogeneic bone grafting. Renonuion, however, achieves a relatively high rate, especially in cases of segmental bone defect.     

混合植骨技术结合髋臼加强杯或钛网杯重建髋臼严重骨缺损

 目的 探讨自体骨和异体冷冻干燥骨混合植骨方法在治疗髋臼严重骨缺损中恢复髋臼骨量的作用,评价混合植骨技术结合髋臼加强杯或钛网杯重建髋臼的临床效果。方法 1999年4月至2007年12月,采用自体骨和异体冷冻干燥骨混合打压植骨结合髋臼加强杯或钛网杯对髋臼严重骨缺损18例19髋进行重建。男8例,女10例;年龄33~76岁,平均64.7岁。全髋关节置换术后髋臼周围骨溶解导致髋臼假体松动而行翻修术17例,髋臼发育不良行髋臼截骨术后继发髋关节骨关节炎行全髋关节置换1例。Paprosky ⅡB型骨缺损5髋,Paprosky ⅡC型2髋,Paprosky ⅢA型6髋,Paprosky ⅢB型6髋。结果 全部病例随访3.6~12.3年,平均6.5年。Harris髋关节评分由术前平均(38.7±9.6)分提高至末次随访(87.6±7.8)分。术后3~6个月X线检查可见髋臼植骨区骨长入,1年后植骨区骨整合良好。随访期间未发现髋臼再松动病例。1例出现髋臼聚乙烯明显磨损,髋关节旋转中心上移。结论 自体骨和异体冷冻干燥骨混合打压植骨可有效恢复髋臼骨量,植骨中加入的自体骨可促进植骨区骨长入,混合植骨方法结合髋臼加强杯或钛网杯固定治疗髋臼严重骨缺损疗效确切。     

A new technique for reconstructions of large metadiaphyseal bone defects

Surgical Principles Tumors involving the metadiaphyseal region around the knee are often treated by intraarticular resection (and reconstructed by prosthesis or osteoarticular allografts) even when the subchondral bone could be saved and an intercalary reconstruction applied. This is due to problems associated with the reconstruction of the subarticular diaphyseal bone defects by conventional methods. Intercalary allografts (as well as cortical autografts) have significant complication rates in terms of delayed union or graft fracture: these would be significantly increased in those patients in whom an adequate osteosynthesis for support is not feasible. The use of a vascularized fibula alone is contraindicated because it cannot provide sufficient stability for the epiphysis and is too weak to allow early weight bearing. The Ilizarov technique (bone transportation) is extremely time consuming and it may be at risk in patients under aggressive chemotherapy (pin tract infection, possible interference with callus formation). Furthermore, the thin subarticular segment requires an additional ring across the joint, causing knee stiffness. The authors describe a new surgical technique to manage this surgical problem. The basic idea consists to bridge the bone defect using a massive allograft as a peripheral shell supporting a centrally placed micro-vascular fibular autograft. This technique was introduced by the first author in 1988 and preliminary results first described by Capanna et al. in 1989 and in 1991 [1, 2]. Supported by Comitato Nazionale delle Ricerche (Applicazioni Cliniche Ricerca Oncologica) and by Ricerca Finalizzata Ministerio Sanita.     

Intercalary reconstructions after bone tumor resections: a review of treatments

An intercalary reconstruction is defined as replacement of the diaphyseal portion of a long bone after segmental skeletal resection (diaphysectomy). Intercalary reconstructions typically result in superior function compared to other limb-sparing procedures as the patient’s native joints above and below the reconstruction are left undisturbed. The most popular reconstructive options after segmental resection of a bone sarcoma include allografts, vascularized fibula graft, combined allograft and vascularized fibula, segmental endoprostheses, extracorporeal devitalized autograft, and segmental transport using the principles of distraction osteogenesis. This article aims to review the indications, techniques, limitations, pros and cons, and complications of the aforementioned methods of intercalary bone tumor resections and reconstructions in the context of the ever-growing, brave new field of limb-salvage surgery.     

A Retrospective Analysis of Anterior Calcaneal Osteotomy with Allogenic Bone Graft

Anterior calcaneal osteotomy (ACO) with extension bone graft is commonly employed in the treatment of symptomatic supple, hypermobile flatfoot in adolescent as well as adult (≥ 18 years of age) patients. Although autogenous bone graft has been considered the gold standard, allogenic bone is widely used for this procedure because it is readily available, requires no additional procedure for procurement and has incorporation rates similar to autogenous bone graft. There is increasing agreement among surgeons that the union rates with allograft bone are comparable with that observed with autograft bone when used in the ACO. We reviewed the medical records of 51 consecutive patients who had undergone 53 ACO with allogenic bone graft for the repair of flatfoot deformity in an effort to further evaluate outcomes associated with the use of allogenic bone graft. All of the patients had at least 12 months of follow-up. The mean time to graft incorporation was 9.10 ± 1.54 weeks for adolescents and 9.81 ± 2.13 weeks for adults (P = .0149), The incidence of graft incorporation (bone union) was 100% and 90% (P = .1391) in the adolescent and adult groups, respectively. Complications included lateral column pain, sinus tarsitis, nonunion, calcaneocuboid capsulitis, complex regional pain syndrome, incisional dehiscence, and sural neuritis; and all of the complications occurred in the adult group. The results support the understanding that ACO with allogenic bone graft is a reasonable alternative to autograft bone graft in the treatment of flexible flatfoot in adolescent and adult patients.