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Objective:To analyze the application value of tibial transverse transport (TTT) microvascular reconstruction combined with antibiotic bone cement in the limb salvage of diabetic foot.Methods:Seventy-seven patients with diabetic foot admitted to the Traditional Chinese Medicine Hospital of Zhongshan from January 2018 to January 2021 were enrolled retrospectively, and they were divided into the control group (performed TTT microvascular reconstruction, 47 cases) and the combined group (performed TTT microvascular reconstruction combined with antibiotic bone cement, 30 cases) according to the surgical method. Wound healing rate, limb salvage rate, the ulcer healing time, bone window healing time, wound infection control status, affected side lower limb vascular blood supply situation, and peripheral nerve function recovery were compared between the two groups.Results:The amputation rate between the two groups had no significant difference ( P>0.05), but the healing rate in the combined group was higher than that in the control group: 90.00%(27/30) vs. 68.08%(32/47); and the ulcer healing time, bone window healing time in the combined group were shorter than those in the control group: (12.55 ± 2.14) weeks vs. (15.01 ± 3.17) weeks, (17.47 ± 2.09) weeks vs. (19.00 ± 2.58) weeks, there were statistical differences ( P<0.05). The positive percentage of bacteria culture in wound secretions in the combined group after the surgery for 6 d was lower than that in the control group: 20.00%(6/30) vs. 44.68%(21/47), there was statistical difference ( P<0.05). After the surgery for 3 months, the dorsal skin temperature and ankle brachial index in the combined group were higher than those in the control group: (31.05 ± 1.74) ℃ vs. (29.27 ± 1.66) ℃, 0.93 ± 0.29 vs. 0.80 ± 0.19, there were statistical differences ( P<0.05), but the scores of visual analog scale (VAS) and 10 g nylon line test values between the two groups had no significant differences ( P>0.05). Conclusions:TTT combined with antibiotic bone cement can achieve better wound healing and infection control effect in the limb salvage of diabetic foot, and the blood supply improvement of the affected limb is more significant.
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OBJECTIVE@#To investigate the effectiveness of tibial transverse transport (TTT) combined with modified neurolysis in treatment of diabetic foot ulcer (DFU) through a prospective randomized controlled study.@*METHODS@#The patients with DFU and diabetic peripheral neuropathy, who were admitted between February 2020 and February 2022, were selected as the research objects, of which 31 cases met the selection criteria and were included in the study. The patients were divided into two groups by random number table method. The 15 patients in the trial group were treated with TTT combined with modified neurolysis, and the 16 patients in the control group received treatment with TTT alone. There was no significant difference in gender, age, duration of DFU, ulcer area, Wagner classification, as well as preoperative foot skin temperature, visual analogue scale (VAS) score, ankle-brachial index (ABI), motor nerve conduction velocity (MNCV) of the common peroneal nerve, MNCV of the tibial nerve, MNCV of the deep peroneal nerve, two-point discrimination (2-PD) of heel, and cross-sectional area (CSA) of the common peroneal nerve between the two groups ( P>0.05). The time for ulcer healing, foot skin temperature, VAS scores, ABI, 2-PD of heel, and CSA of the common peroneal nerve before operation and at 6 and 12 months after operation were recorded and compared between groups. The differences in MNCV of the common peroneal nerve, MNCV of the tibial nerve, and MNCV of the deep peroneal nerve between pre-operation and 12 months after operation were calculated.@*RESULTS@#All patients in both groups were followed up 12-24 months (mean, 13.9 months). The surgical incisions in both groups healed by first intention and no needle tract infections occurred during the bone transport phase. Ulcer wounds in both groups healed successfully, and there was no significant difference in the healing time ( P>0.05). During the follow-up, there was no ulcer recurrences. At 12 months after operation, the MNCV of the common peroneal nerve, the MNCV of the tibial nerve, and the MNCV of the deep peroneal nerve in both groups accelerated when compared to preoperative values ( P<0.05). Furthermore, the trial group exhibited a greater acceleration in MNCV compared to the control group, and the difference was significant ( P<0.05). The foot skin temperature, VAS score, ABI, 2-PD of heel, and CSA of the common peroneal nerve at 6 and 12 months after operation significantly improved when compared with those before operation in both groups ( P<0.05). The 2-PD gradually improved over time, showing significant difference ( P<0.05). The 2-PD of heel and VAS score of the trial group were superior to the control group, and the differences were significant ( P<0.05). There was no significant difference in ABI, foot skin temperature, and CSA of the common peroneal nerve between groups after operation ( P>0.05).@*CONCLUSION@#Compared with TTT alone, the TTT combined with modified neurolysis for DFU can simultaneously solve both microcirculatory disorders and nerve compression, improve the quality of nerve function recovery, and enhance the patient's quality of life.
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Humanos , Pie Diabético/cirugía , Microcirculación , Estudios Prospectivos , Calidad de Vida , Resultado del Tratamiento , Diabetes MellitusRESUMEN
Objective:To evaluate superb microvascular imaging used to monitor the hemodynamic changes in lower limb arteries in the treatment of diabetic foot by tibial transverse transport.Methods:From December 2019 to December 2021, 17 patients with diabetic foot were treated by tibial transverse transport at Department of Orthopedics, The Second Hospital of Shanxi Medical University. Superb microvascular imaging was used to observe the vascular index of the first dorsal metatarsal artery, the total blood flow of the anterior tibial artery and the posterior tibial artery, and the Wagner classification in the patients before surgery, one week and one month after surgery. Complications were documented.Results:After treatment, neovascularization was observed in all the 17 patients and detected on both the ipsilateral and contralateral sides of the surgery. At the last follow-up, the number of newborn collaterals was 7.0 (3.5, 9.0), significantly larger than that before surgery [1.0 (0, 1.5)] ( P<0.05). The vascular index of the first dorsal metatarsal artery at one week (9.70±10.88) and one month (9.22±5.46) after surgery was significantly higher than that before surgery (5.65±4.36) ( P<0.05). There was no significant difference in the total blood flow between the anterior tibial artery and the posterior tibial artery before surgery, one week or one month after surgery ( P>0.05). The Wagner classification at one month after surgery (grade 1 in 4, grade 2 in 11 and grade 3 in 2) was significantly better than that before surgery (grade 2 in one, grade 3 in 2 and grade 4 in 14) and one week after surgery (grade 2 in one, grade 3 in 5 and grade 1 in 11) ( P<0.05). One patient underwent amputation due to acute lower extremity arterial embolism 2 months after operation, and another patient underwent toe amputation due to blackening of the toes. Conclusion:Superb microvascular imaging is a valuable means of monitoring in tibial transverse transport because it can objectively reflect the hemodynamic changes and microcirculation in lower limb arteries and provide valuable information for prognosis of the condition in the treatment of diabetic foot by tibial transverse transport.
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Tibial transverse transport (TTT) was firstly applied to treat thromboangiitis obliterans successfully by Professor QU Long in China in 2000. Based on this, the team of Professor HUA Qikai in the First Affiliated Hospital of Guangxi Medical University applied this technique to treat diabetic foot since 2013, and until now, more than 500 patients underwent this treatment with excellent effectiveness including a salvage rate as high as 96.1%. Our team also improved this technique in many aspects, and developed a TTT-based classification system and treatment for diabetic foot. We also explored the underlying mechanism of TTT treatment using imaging, histology, and other basic research methods. To further promote the application of this technique in clinic, we reported the findings from our cases and reviewed our previous findings in this study.
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Objective: To study the effectiveness of tibial transverse transport combined with the antibiotics embedded bone cement in the treatment of chronic infection of foot and ankle with lower extremity ischemic diseases. Methods: A retrospective analysis was performed on 28 patients with ischemic diseases of lower extremities associated with chronic foot and ankle infection who were treated with tibial transverse transport combined with antibiotic bone cement between August 2015 and October 2019. There were 22 males and 6 females, with an average age of 65.6 years (range, 41-86 years). There were 25 cases of diabetic foot, 2 cases of arteriosclerosis obliterans, and 1 case of thromboangiitis obliterans. The course of infection ranged from 1 to 27 years, with an average of 14.9 years. The healing condition and time of foot and ankle in all patients were recorded and compared, and the Wagner grading and WIFi (W: lower extremity wound classification; I: ischemic classification; Fi: foot infection classification) grading were compared before and at last follow-up. Results: The wound surface of 1 diabetic foot patient improved at 111 days after operation, without purulent secretion, and lost follow-up. The remaining 27 cases were followed up 5 to 21 months (mean, 8.4 months). There was no necrosis in the tibial osteotomy incision and the local flap. After operation, 21 cases showed needle reaction of external fixator, but the needle infection gradually improved after the corresponding treatment. Among the 24 patients with diabetic foot, 1 died of multiple organ failure due to pulmonary infection. Acute lower extremity vascular embolism occurred in 1 case, and the foot was amputated due to acute gangrene. In the remaining 22 cases, the wound healing time of foot and ankle was 2.5-11.0 months (mean, 4.6 months). At last follow-up, Wagner grading and WIFi grading of the patients were significantly improved when compared with those before operation ( P<0.05). One patient with thromboangiitis obliterans had foot and ankle healing at 6 months after operation. Two patients with lower extremity arteriosclerosis obliterans had foot and ankle healing at 16 and 18 months after operation, respectively. Conclusion: Tibial transverse transport combined with the antibiotics embedded bone cement is effective in treating chronic infection of foot and ankle with lower extremity ischemic diseases.
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Objective: To explore the causes and management of the complications in diabetic foot treated with tibial transverse transport (TTT). Methods: Between September 2015 and September 2019, 196 patients with diabetic foot were treated with TTT. There were 109 males and 87 females, with an average age of 67.6 years (range, 45-86 years). According to Wagner's classification, there were 124 cases of grade 3, 62 cases of grade 4, and 10 cases of grade 5; the course of disease was 1-12 months, with an average of 2.6 months. All patients underwent the minimally invasive tibial osteotomy. The osteotomy site was the middle and lower tibia in 62 cases and the middle and upper tibia in 134 cases. The area of osteotomy was 20 cm 2 in 83 cases and 7.5 cm 2 in 113 cases. The osteotomy block was moved back and forth once in 92 cases and twice in 104 cases. The complications were recorded, including secondary fracture at tibial osteotomy, skin necrosis in osteotomy area, and pin tract infection. Results: Among 196 patients, 41 cases (20.9%) had complications. Nine cases (4.6%) had secondary fracture at tibial osteotomy, among which 6 cases (9.6%) of middle and lower segment osteotomies and 3 cases (2.2%) of middle and upper segment osteotomies. The incidence between the patients with different osteotomy sites was significant ( χ2=5.354, P=0.021). The area of osteotomy was 20 cm 2 in 5 cases (6.0%) and 7.5 cm 2 in 4 cases (3.5%). There was no significant difference in the incidence between patients with different areas ( χ2=0.457, P=0.499). Skin necrosis occurred in the osteotomy area in 12 cases (6.1%), all of which were moved back and forth once. There was a significant difference in the incidence between patients who were treated with transport once and twice ( P=0.001). There were 18 cases (9.1%) with pin tract infection, including 12 cases (6.1%) with mild infection and 6 cases (3.0%) with severe infection. There was no significant difference in the incidence between the patients with mild and severe infections ( P=0.107). Conclusion: TTT is an effective method to treat diabetic foot, but there are complications such as secondary fracture at tibial osteotomy, skin necrosis in osteotomy area, and pin tract infection during transport. Preoperative evaluation of indication, standardization of osteotomy mode, size and position of osteotomy block, establishment of individualized removal plan, and strengthening of pin track nursing after operation can effectively reduce complications.
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Objective: To summarize the research progress of tibial transverse transport (TTT) in treatment of chronic ischemic diseases of the lower extremities. Methods: The related literature was systematically searched and the mechanisms, clinical treatment methods, clinical efficacy, indications, contraindications, and complications of TTT were discussed. Results: Based on the law of tension-stress, TTT is a new method in the treatment of chronic ischemic diseases of the lower extremities. It can relieve the ischemic symptoms, promote the wound healing, and increase the limb salvage rate. The clinical application in recent years has shown good effectiveness, and the scope of application is expanding. Conclusion: Due to the current limited clinical application, the sample size of the TTT for the chronic ischemic diseases of the lower extremities is relatively small, and the follow-up time is limited. So its validity, long-term effectiveness, and bone transport standards are need further research.
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Objective: To summarize the research progress of tibial transverse transport in the treatment of diabetic foot. Methods: The domestic and foreign literature on the tibial transverse transport for diabetic foot in recent years was summarized, and the advantages and disadvantages of the technique were analyzed. Results: The tibial transverse transport was an innovation based on Ilizarov technique. At present, the treatment of diabetic foot by the tibial transverse transport is in the initial stage and has achieved good results, but there are also problems such as ulcer recurrence and re-fracture. And its biological mechanism to promote tissue regeneration, clinical technical points (such as the selection of incision and bone window size), the technical parameters of postoperative removal program, and the postoperative effectiveness are still in dispute and exploration. More clinical studies and practices are needed in the future to develop a standard protocol for this technique. Conclusion: Tibial transverse transport is a hot spot for microcirculation reconstruction of lower extremity. Significant progress has been made in the treatment of diabetic foot, which provides a new direction for limb salvage treatment. However, the technique is not mature, there are still many disputes and difficulties to be further studied clearly.
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Objective: To explore the biological mechanisms of tibial transverse transport (TTT) for promoting microcirculation and tissue repair. Methods: The clinical application and animal model study of TTT were reviewed. Results: The possible biological mechanisms of TTT for promoting microvascular network formation and tissue repair: ① Tibial corticotomy reduces intramedullary pressure and improves microcirculation; ② Tension stress stimulation promotes microvascular regeneration and accelerates the formation of new "transcortical vessels" network; ③ Systemic mobilization of stem cells, mediating local inflammation, etc. Conclusion: TTT has been clinically proven to be effective for the management of lower limb ischemia and diabetic foot ulcers. The surgical procedure is relatively easy with little adverse effects on bone structures. The TTT has good application prospects despite the biological mechanisms of which still need further exploration.