Clinical Study of Modified Tibial Transverse Transport Combined with the Masquelet Technique for the Treatment of Diabetic Foot with Ulcers.

Abstract

Objective and background: To analyze the clinical effect of modified tibial transverse transport combined with the Masquelet technique in treating diabetic foot with ulcers (Wagner stages 2-4). This study was conducted to explore a novel combined surgical strategy for Wagner 2-4 diabetic foot ulcers that respond poorly to conventional treatments.

Methods: A total of 46 patients with Wagner 2-4 diabetic foot ulcers were enrolled (23 per group). Both groups received standardized preoperative glycemic control and infection management. The intervention group underwent modified tibial transverse transport (10 × 1.8 cm bone window; distraction starting on day 7 at 1 mm/day for 3 weeks, followed by reverse transport) combined with the Masquelet technique (PMMA spacer implantation at stage I, followed by autologous bone grafting at 6-8 weeks). The control group received conventional treatment, including debridement, VSD, and systemic antibiotics, without bone transport or induced membrane procedures. The primary outcome was limb salvage rate at 6 months. Secondary outcomes included wound healing rate, time to wound healing, MRI-confirmed edema resolution, changes in inflammatory markers, and 6-month recurrence rate. The hierarchical testing procedure was applied with limb salvage as the first endpoint; only if significant would subsequent endpoints be formally tested.

Results: With a median follow-up of 6.5 months (range 3-12 months), the complete wound healing rate (defined as complete epithelialization without drainage sustained for ≥ 2 weeks, achieved without or after minor amputation) was 82.6% (19/23) versus 69.6% (16/23) (P = 0.289). The limb salvage rate (avoidance of major amputation above ankle) was 100% (23/23) in both groups (P = 1.000). Among the 19 healed patients in the intervention group, 15 achieved healing without amputation, and 4 achieved healing after minor amputation (toe/ray); among the 16 healed control patients, 9 achieved healing without amputation and 7 achieved healing after minor amputation. Four intervention patients and seven control patients did not achieve wound healing within the study period. Among healed patients with complete 6-month post-healing follow-up (n = 19 intervention, n = 16 control), recurrence rates were 15.8% (3/19) and 31.3% (5/16), respectively (P = 0.113). Four intervention patients and seven control patients did not achieve wound healing or were lost to follow-up before 6 months and were excluded from recurrence analysis. Four patients in the intervention group and seven in the control group did not achieve wound healing within the study period and were excluded from recurrence analysis. Wound healing time showed a trend toward a shorter duration in the intervention group (4.2 ± 2.1 vs. 5.8 ± 2.4 months, P = 0.056). Postoperative inflammatory markers (ESR, CRP), affected foot skin temperature, toe oxygen saturation, and clinical scores (VAS) showed significantly greater improvement in the intervention group compared with control (P < 0.05), while WBC, HbA1c, and TCSS scores improved in both groups without a significant between-group difference. CTA-demonstrated dorsal foot artery recanalization was observed in 78% (18/23) of the intervention group versus 52% (12/23) of the control group (P = 0.068). Clinical dorsal foot artery palpability normalization was observed in 48% (11/23) versus 17% (4/23) (P = 0.068).

Conclusion: As an exploratory pilot study, modified tibial transverse transport combined with the Masquelet technique presents potential clinical benefits for the treatment of diabetic foot with ulcers, including tentative trends toward improved limb salvage and accelerated wound healing, without definitive causal associations established.