Tibial cortex transverse distraction in treating diabetic foot ulcers: what are we concerned about?

Modified tibial cortex transverse transport for diabetic foot ulcers with Wagner grade ≥ II: a study of 98 patients

Background

Diabetic foot ulcers constitute a substantial healthcare burden on a global scale and present challenges in achieving healing. Our objective was to assess the efficacy of modified tibial cortex transverse transport surgery in managing refractory diabetic foot ulcers.

Methods

We retrospectively analyzed clinical data from 98 patients suffering from diabetic foot ulcers classified as Wagner grade ≥II who were admitted to our medical facility between January 2020 and June 2022. All the patients were treated by modified tibial cortex transverse transport surgery, wherein the osteotomy scope was reduced to two rectangular bone windows measuring 1.5cm × 1.5cm each. Record the patient's general information and ulcer healing time; ulcer area, ankle-brachial index, WIFi classification, and visual analogue scale before and 3 months following the surgical intervention.

Results

The average duration of diabetes of 98 patients with diabetic foot ulcer was 20.22 ± 8.02 years, 52 patients had more than one toe gangrene on admission. The postoperative wound healing rate was 95.83% and the average healing time was 53.18 ± 20.18 days. The patients showed significant improvement in ankle-brachial index, WIFi classification, and visual analogue scale at 3 months postoperatively compared to preoperatively, with statistically significant differences (P< 0.05). Eight patients experienced complications, and the incidence of complications was 8.16%. Throughout the follow-up period, there were no instances of ulcer recurrence noted.

Conclusion

Modified tibial cortex transverse transport surgery demonstrates effectiveness in the management of diabetic foot ulcers by enhancing lower limb microcirculation and facilitating the process of wound healing.

An novel and alternative treatment method for large heel ulceration in diabetic patients: Proximal tibial cortex transverse distraction

Heel ulceration in patients with diabetes mellitus (DM) is a major clinical challenge, manifesting with a protracted and uncertain healing process. The prefer treatment of heel ulceration is still controversial. This study aims at describing a newly alternative surgical method with the proximal transverse tibial bone transport technique, as an attempt to achieve wound healing in diabetic patients with large heel ulceration. Retrospective clinical study. A total of 21 diabetic patients with large heel ulceration were enrolled and followed up at least 6 months. The following parameters were assessed: Visual analogue scale (VAS), healing time, ulcer healing rate, ulcer recurrence rate and limb salvage rate. All patients got fully follow-up and achieved wound healing uneventfully. Eighteen patients returned to independent walking without any helper while three patients walked using a crutch. Limb salvage was achieved in all 21 patients (100%). The mean wound area was 67.43 ± 13.31 cm2 (range: 46-97 cm2 ). The mean healing time was 128.62 ± 16.76 days (range: 91-160 days). 16 out of 21 patients without calcaneal osteomyelitis achieved ulcer healing with a mean duration of 124.69 ± 14.42 days (range: 91-143 days), while the other five patients with calcaneal osteomyelitis were 141.20 ± 19.12 days (range: 110-160 days). 2 out of 21 patients got superficial rupture at the previous wounds and healed after outpatient dressing change combined with oral antibiotics. The novel technique described is particularly applicable for large heel ulceration in diabetic patients. It offers a better alternative for achieving wound healing with a favourable encouraging outcome.

Anterior superior iliac spine distraction for severe and recalcitrant diabetic foot ulcers

PURPOSE

The study aimed to introduce anterior superior iliac spine distraction to treat severe and recalcitrant diabetic foot ulcers. For comparison, we also included another group of diabetic foot ulcers treated with proximal tibial cortex transverse distraction.

METHODS

From February 1998 to February 2020, 87 patients (87 feet) with severe and recalcitrant diabetic foot ulcers were treated. The mean age of patients at surgery was 64 years (range, 47 to 87 years). The severity of the narrowed artery was assessed using the ankle-brachial index test. For comparison, another group of 91 patients (91 diabetic foot ulcers) treated with proximal tibial cortex transverse distraction was included.

RESULTS

The mean preoperative ankle-brachial indexes of the two groups were 0.41±0.07 and 0.39±0.05 (OR 0.65 [95% CI -0.77 to 1.58]; P=0.62), respectively. The mean preoperative limb pain was 3.42±2.84 cm and 3.52±3.11 cm (OR 1.54 [95% CI -077 to 1.35]; P=0.083), respectively. At the 2-year follow-up visit, ulcers healed in 72 (83%) and 74 (81%) patients, respectively (P=0.188). The mean postoperative limb pain was 0.52±0.23 cm and 0.49±0.41 cm (OR 2.32 [95% CI -0.27 to 1.66]; P=0.078), respectively. Pin-site infection occurred in 2 patients and 8 patients (P=0.09), respectively. Ulcer recurrence occurred in 13 (15%) patients and 15 (16%) patients (P=0.205), respectively.

CONCLUSIONS

Anterior superior iliac spine transverse distraction may be an effective alternative treatment for severe and recalcitrant diabetic foot ulcers. It may be associated with fewer distraction-site complications than proximal tibial cortex transverse distraction.

LEVEL OF EVIDENCE

Therapeutic study, Level IIa.

Effectiveness of transverse tibial bone transport in treatment of diabetic foot ulcer: A systematic review and meta-analysis

Background

Diabetic foot ulcerations (DFUs) are a common but highly morbid complication of long-standing diabetes, carrying high rates of associated major amputation and mortality. Transverse tibial bone transport (TTT) has recently been applied for treatment of DFUs with the aim of accelerating wound healing. This study was performed to evaluate the effectiveness and safety of TTT in patients with DFUs.

Methods

Two authors independently retrieved the platforms of PubMed, Embase and CENTRAL, to identify studies associated with treatment of DFUs with TTT. Quantitative meta-analyses were performed to pool all available outcomes about the effectiveness and complications of TTT operation, with fixed- (I2<50%) or random-effect (I2>50%) model according to I2.

Results

A total of 7 studies, involving 818 participants, were included, with 661 participants treated with TTT operation. The pooled healing rate and limb salvage rate were 0.96 (95%CI: 0.93~0.98) and 0.98 (95%CI: 0.95~1.00) respectively after treatment with TTT. The pooled mean healing time was 15.03 (95%CI: 9.05~21.00) months. When compared with the pre-operative baseline values, the ankle-brachial index (ABI, MD: 0.23; 95%CI: 0.03~0.44; p<0.001), skin temperature (MD: 1.56; 95%CI: 0.30~2.81; p<0.001), and visual analogue scale (VAS, MD: 3.70; 95%CI: 1.97~5.44; p<0.001) were significantly improved at the final follow-up. When compared with non-TTT group, the TTT group was associated with higher healing rate (OR: 10.43; 95%CI: 3.96~27.43; p<0.001) and limb salvage rate (OR: 9.65; 95%CI: 3.30~28.20; p<0.001). Concerning the complications of the TTT process, the pooled risks of fracture at transportation site and pin-site infection were 0.02 (95%CI: 0.00~0.04) and 0.08 (95%CI: 0.00~0.22), respectively; and the DFU recurrence rate in TTT group was significantly lowered comparing to that of the non-TTT group (RR: 0.18; 95%CI: 0.06~0.49; p=0.001).

Conclusions

TTT operation was associated with high healing rate and limb salvage rate, and could significantly improve the ABI, skin temperature, and VAS after operation. When compared with the control group, TTT group provided significantly higher healing rate and limb salvage rate. However, TTT operation should be conducted with caution concerning the incidences of fracture at tibia, infection at pin channels and necrosis of skin overlying the anterior tibia.

Twenty Years Development of Tibial Cortex Transverse Transport Surgery in PR China

Tibial cortex transverse transport (TTT) surgery is an extension of the Ilizarov technique. Based on the law of tension‐stress, its primary function is to rebuild microcirculation which can relieve ischemic symptoms and promote wound healing. It has received more and more scholars' attention and has experienced a series of changes for 20 years since it entered PR China. The mechanisms involved have gradually become clear, such as the reconstruction of the polarization balance of macrophages, the promotion of vascular tissue regeneration, and the mobilization and regulation of bone marrow‐derived stem cells. TTT technique is mainly used in the treatment of chronic ischemic diseases of the lower extremities. It has recently been successfully used in the treatment of primary lymphedema of the lower extremities. A series of improvements have been made in the external fixator's style, the size of skin incision and osteotomy, and distraction method. For example, the annular external fixator has been redesigned as a unilateral external fixator, and accordion technology has been introduced. For distraction methods after surgery, there was no uniform standard in the past. The technique can also be used in combination with other treatments to achieve better effects, such as interventional therapy, negative pressure sealed drainage, 3D printing technology, traditional Chinese medicine. Nevertheless, the surgery may bring some complications, such as secondary fracture, nail infection, skin necrosis at the surgical site, etc. Reports of complications and doubts about the technique have made the TTT technique controversial. In 2020, the relevant expert consensus was published with treatment and management principles, which might guide the better application and development of this technique.

Impairment characteristics of static balance and plantar load distribution of patients undergoing tibial cortex transverse distraction for diabetic foot ulcers

Objective

Tibial cortex transverse distraction (TCTD) has been recently reported for the treatment of diabetic foot ulcers. Herein, we explored the characteristics of the impairments in static balance and plantar load distribution in patients.

Methods

We performed a retrospective study of 21 patients with diabetic foot ulcers who underwent TCTD, who were regularly followed up for > 1 year after surgery, and 20 healthy individuals (control group). A pressure platform was used to assess the standing balance functions of the lower extremities and the plantar load distribution.

Results

One patient underwent amputation because of severe infection. In patient group, center of pressure (COP) ellipse sway area, COP path length and angle θ were all larger, compared with those of control group (250.15 ± 98.36 mm² vs. 135.67 ± 53.21 mm², 145.15 ± 67.43 mm vs. 78.47 ± 34.15 mm, 39.75 ± 17.61° vs. 22.17 ± 14.15°), with statistically significant differences (P < 0.01). The average plantar load and backfoot load of the unaffected side was significantly larger than that of the affected side (58.4 ± 5.5% vs. 41.6 ± 5.5%, 45.3 ± 6.4% vs. 36.5 ± 5.6%), but they were similar for the two feet of members of the control group.

Conclusions

Although TCTD may represent an appropriate method for the treatment of diabetic foot ulcers, postoperative impairments in static balance and plantar load distribution remain in the long term. These potential long-term problems should be taken into account in further rehabilitation planning.

Type of study/level of evidence: Therapeutic III.