Proximal Tibial Cortex Transverse Distraction Facilitating Healing and Limb Salvage in Severe and Recalcitrant Diabetic Foot Ulcers

Abstract

Category: Diabetes; Diabetes Introduction/Purpose: The management of severe and recalcitrant diabetic foot ulcers is challenging. Distraction osteogenesis is accompanied by vascularization and regeneration of the surrounding tissues. The longitudinal distraction of the proximal tibia stimulates increased and prolonged blood flow to the distal tibia. However, the effects of the transverse distraction of the proximal tibia cortex on severe and recalcitrant diabetic foot ulcers are largely unknown. Methods: Between July 2014 and March 2017, we treated 136 patients with diabetes and severe ulcers (University of Texas Grade 2B to 3D) that had not responded to treatment for at least 6 months. and their ulcers had a mean ± SD area of 44 cm2 ± 10 cm2. All 136 patients underwent tibial cortex transverse distraction. We compared these patients with the last 136 consecutive patients we treated with standard surgical treatment between May 2011 and June 2013; All patients received standard off-loading and wound care. We compared the groups with respect to ulcer healing (complete epithelialization without discharge, maintained for at least 2 weeks) in a 2-year follow-up, the proportion of ulcers that healed by 6 months, major amputation, recurrence, and complications in the 2-year follow-up. Foot arterial status and perfusion were assessed in the TCTD group using CT angiography and perfusion imaging. Results: The tibial cortex transverse distraction group had a higher proportion of ulcers that healed in the 2-year follow-up than the control group (96% versus 68% ; p < 0.001). By 6 months, a higher proportion of ulcers healed in the TCTD group than in the control group (93% versus 41% ; p < 0.001). Lower proportions of patients in the TCTD group underwent major amputation (2.9% versus 23%; p < 0.001) or had recurrences 2.9% versus 17%, OR 0.20 [95% CI 0.05 to 0.45]; p < 0.001) than the control group in 2-year follow-up. In the feet of the patients in the TCTD group, there was a higher density of small vessels and higher blood flow and blood volume 12 weeks postoperatively than preoperatively. Conclusion: Proximal tibial cortex transverse distraction substantially facilitated healing and limb salvage and decreased the recurrence of severe and recalcitrant diabetic foot ulcers. The surgical techniques were relatively straightforward although the treatment was unorthodox, and the complications were few and minor. These findings suggest that tibial cortex transverse distraction is an effective procedure to treat severe and recalcitrant diabetic foot ulcers compared with standard surgical therapy. Randomized controlled trials are required to confirm these findings.