SLR - March 2022 - Maria Begum
References: Yuan, Yusong, Xiaofang Ding, Zhengwei Jing, Hao Lu, Kun Yang, Yuanli Wang, and Hailin Xu. " Modified Tibial Transverse Transport Technique for the Treatment of Ischemic Diabetic Foot Ulcer In Patients with Type 2 Diabetes." Journal of Orthopaedic Translation 29 (2021): 100-105.Level of Evidence: III Cohort Retrospective Study
Scientific Literature Review
Reviewed By: Maria Begum, DPM
Residency Program: Our Lady of Lourdes Memorial Hospital – Binghamton, NY
Podiatric Relevance: Foot ulcer is one of the fetal complications for diabetic patient. Ischemia as well as hypoxia caused by microvascular injury can further increase complication for those patients. However, not all patients can undergo vascular surgery due to complete occlusion of blood vessels in the lower extremity or other combabilities. This study introduces a new technique called modified tibial transport (mTTT) to treat ischemic diabetic foot ulcer by increasing microcirculation of damaged tissue who are unable to undergo vascular interventions.
Methods: The retrospective study included patients who were diagnosed and treated for diabetic foot ulcers at Peking University People’s Hospital and Beijing Longfu Hospital from January 2016 to October 2019. Patients were selected based on The University of Texas Staging System for Diabetic Foot Ulcers grades 2C, 2D, 3C and 3D.
Surgical procedure: Two Steinman pins were fixated on the anterior medial aspect of the affected lower extremity of the tibia for stabilization of the bone osteotomy. Osteotomy was performed at 15-30 degrees to the tibia bone surface and a mono-rail external fixator was applied. Transverse bone transportation was initiated three days after the surgery. A 1mm transportation was performed four times daily for fourteen days followed by 2mm reverse transportation of the bone was performed four times daily for total of seven days. X-rays of the tibia were reviewed monthly to observe bone healing.
Outcomes were measured at one, three, six and 12 months following the surgery. Wound healing time, limb salvage rate, skin temperature, transcutaneous oxygen pressure (TCPO), ankle brachial index (ABI), and ulcer recurrence rate were measured to determine the efficacy of mTTT for ischemic diabetic foot ulcer.
Results: A total of 201 patients were included in this study. All patients were followed up for one year after the surgery. Diabetic foot ulcers that were included in this study noted to be completely healed. The mean healing time was 4.6+/- 1.6 months. The longest heal time was eight months. More importantly, there was no recurrence of ulcer or amputation after the procedure. The skin temperature (℃) (pre-op 29.50 to post op 35.50), TCPO (mmHg) (pre-op 31.00 to post op 43.00) and ABI (Pre-op 0.20 to Post-op 0.80) all improved significantly.
Conclusions: Based on the significant findings of this study the authors of the article concluded that mTTT is a useful surgical method for ischemic diabetic foot ulcer patients. It is widely used in China, however, has not been introduced in US The concept of reconstruction of microcirculation by creating stress to the bone has been around since 1989 when Ilizarov conducted a traction osteogenesis experiment on a dog, and this was confirmed by many studies. It is critical in our profession to investigate this novel technique and the efficacy of this treatment choice by high-quality clinical controlled trials in the U.S. The mTTT should be part of our toolbox as viable options for treatment of diabetic foot ulcers who have compromised blood supply and unable to receive vascular interventions.