Combined Modified Induced Membrane and Tibial Transport for Diabetic Foot Ulcers: A Controlled Study

Combined Modified Induced Membrane and Tibial Transport for Diabetic Foot Ulcers: A Controlled Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Combined Modified Induced Membrane and Tibial Transport for Diabetic Foot Ulcers: A Controlled Study Zhou Min, Shi Shouyin, An Xingwei, Huang Ying, Sun Jungang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9151446/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: Diabetic foot ulcer (DFU), a common and severe complication among diabetic patients, has become a global healthcare challenge due to its high incidence rate and associated amputation risk. The cornerstone of DFU management lies in improving local blood circulation, promoting wound healing, and controlling infection. However, conventional treatment methods often suffer from prolonged healing periods, relatively high invasiveness, or frequent complications. In this context, innovative research on combining a modified induced membrane technique with tibial transverse transport (TTT) offers a novel therapeutic approach for the clinical management of DFU.Objective: To investigate the efficacy of combining modified induced membrane technique with tibial transverse transport (TTT) in treating DFU. Methods: A retrospective analysis was conducted on 60 DFU patients treated at the Orthopedic Center of Xinjiang Uygur Autonomous Region Peoples Hospital between June 2020 and June 2024. Based on surgical approaches, patients were divided into a treatment group (modified induced membrane technique + TTT, 30 patients) and a control group (traditional transverse bone transport technique, 30 patients). Key clinical outcomes were compared postoperatively, including Visual Analogue Scale (VAS) pain scores, Michigan Neuropathy Screening Instrument (MNSI) scores, American Orthopaedic Foot & Ankle Society (AOFAS) scores, wound healing time, amputation rate, ulcer recurrence rate, and average hospital stay. Results: All patients completed follow-up (range: 6-18 months; mean: 11.0 ± 1.5 months). At final follow-up, the treatment group exhibited significantly higher AOFAS scores ( P <0.05), while demonstrating significantly lower VAS scores, MNSI scores, wound healing time, amputation rate, ulcer recurrence rate, and average hospital stay compared to the control group ( P <0.05). Conclusion: Modified induced membrane technique combined with TTT significantly improves clinical symptoms, shortens wound healing time and hospitalization duration, and reduces amputation and recurrence rates in DFU patients, demonstrating considerable clinical value. Modified Induced Membrane Technique Tibial Transverse Transport Diabetic Foot Ulcer Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 INTRODUCTION Diabetic foot ulcer (DFU) is one of the most common complications in diabetic patients. Its development involves multiple factors, including lower extremity neuropathy, peripheral vascular disease, and infection, leading to damage of the skin and deeper tissues of the foot [ 1 , 2 ] . These ulcers frequently occur in areas prone to friction and pressure, such as the plantar surface, dorsum of the foot, or toes, clinically presenting as skin breakdown, ulceration, and potential infection. DFU not only severely impairs patients quality of life but may also lead to amputation and even life-threatening conditions. Therefore, improving DFU wound perfusion, controlling infection, and reducing amputation rates have become the core objectives of DFU treatment [ 3 ] . Since June 2020, the Orthopedic Center of the People's Hospital of Xinjiang Uygur Autonomous Region has adopted a modified induced membrane technique combined with tibial transverse transport (TTT) for the treatment of DFU. Postoperative follow-up observations have demonstrated significant clinical efficacy and a low recurrence rate with this treatment protocol. The research results are reported as follows: MATERIALS AND METHODS 1.1 Patient Selection Criteria (1) Inclusion criteria: ① Good patient compliance and stable cardiopulmonary function; ② Clinically diagnosed as diabetic foot and meeting the "China Diabetic Foot Diagnosis and Treatment Guidelines" [ 4 ] of DFU-related diagnostic criteria; ③ patients aged 45 to 70 years, with diabetic foot Wagner staging [ 5 ] Grade 2–4; ④ Dual lower extremity computed tomography angiography (CTA) revealed no significant occlusion in the popliteal artery or its main branches. (2) Exclusion criteria: ① Poor general condition that cannot tolerate surgery and anesthesia; ② Patients with mental disorders or inability to cooperate with surgery; ③ Severe systemic or local infections that would endanger life safety with limb-sparing treatment. 1.2 Clinical Data This study conducted a retrospective analysis of data from 60 diabetic foot ulcers (DFU) patients admitted to the Orthopedic Center of Xinjiang Uygur Autonomous Region Peoples Hospital between June 2020 and June 2024. Based on surgical techniques, patients were divided into a treatment group (modified induction membrane technique combined with TTT) and a control group (traditional TTT), with 30 cases in each group. Postoperative follow-up ranged from 6 to 18 months (mean: 11.0 ± 1.5 months). Observation indicators, including VAS scores, MNSI scores, AOFAS scores, wound healing time, amputation rate, ulcer recurrence rate, and average hospital stay, were recorded and compared between the two groups to evaluate clinical outcomes multidimensionally. No statistically significant differences were observed between the two groups in terms of gender, age, duration of diabetic foot disease, or Wagner classification (P > 0.05), indicating comparability (see Table 1 ). 1.3 Surgical Approach 1.3.1 Surgical Procedure Steps in the Treatment Group (1) Anesthesia and positioning: The patient was placed in the supine position under general anesthesia, with routine preoperative disinfection and draping. ⑵ Installation of transverse tibial bone transfer frame: ① First, implant 1–2 self-tapping screws (4.5 mm diameter) on the medial plane of the proximal and distal tibia to complete the external fixation frame (TTT). ② Subsequently, temporarily remove the middle section of the frame while retaining the screws at both tibial ends. ③ Next, make a 6 cm arc-shaped incision 2 cm below the tibial tuberosity, extending to the periosteum. Turn the periosteum and soft tissue flap outward, and use a 2.5 mm low-speed drill to continuously bore along the osteotomy guide plate, creating a 2.5 cm × 6 cm single cortical tibial bone window. Sequentially drill bone holes with a fine bone knife. Then, reinstall the external fixation frame and sequentially lock the screw clamps. ④ Finally, suture the periosteum continuously with 3 − 0 absorbable sutures and intermittently suture the incision with 2 − 0 silk sutures. Upon completion, cover and bandage the incision with sterile dressing. ⑶ Thorough wound debridement: ① Employ sharp surgical techniques to excise infected and necrotic (gangrenous) tissues of the foot, and use bone-biting forceps to remove necrotic bone lesions until fresh blood exudes from the wound. ② After completing thorough debridement of the surgical area, if the extent of soft tissue defect is large enough to prevent full wound coverage, moderate shortening of the phalanges or metatarsal bones may be performed intraoperatively to effectively reduce the wound area. Efforts should be made to minimize the wound size. ③ During intraoperative debridement, repeatedly irrigate the wound with diluted povidone-iodine saline solution. After achieving hemostasis, apply pressure dressing with sterile gauze. ⑷ Drug-loaded bone cement coverage: ① First, mix 40g of gentamicin bone cement (PMMA) with 2g of vancomycin (Wan Gu Xian) and stir evenly. Add specialized curing solution and knead until the mixture forms a soft dough-like consistency. Shape it into 2–3mm thick sheets according to the wound size and temporarily cover the wound. ② Second, during the heat generation from bone cement curing, continuously rinse with running normal saline to cool the area and prevent burns to soft tissues. ③ After the bone cement cools and takes shape, use a 2.5mm drill bit to make intermittent holes between the center and edges of the drug-loaded bone cement sheet. Ensure the cement fully covers the wound and suture it with 2 − 0 silk thread for fixation. ④ Finally, apply sterile dressing with pressure bandaging. 1.3.2 Surgical procedure steps for the control group The debridement of the wound and the transverse tibial bone grafting procedure in the control group were identical to those in the treatment group, with the sole difference being that the control group did not receive drug-loaded bone cement coverage for the wound. 1.4 Postoperative Management (1) Strengthen comprehensive treatment of underlying medical conditions: ① Maintain stable blood glucose levels throughout the postoperative period (fasting blood glucose < 8 mmol/L). ② Select appropriate antibiotics for anti-infection therapy based on results of wound bacterial culture and antimicrobial susceptibility testing. (2) Routine anticoagulation therapy was administered for 8–12 weeks during the perioperative period (during hospitalization, low molecular weight heparin injection 4000 IU was administered subcutaneously every 12 hours; after discharge, the regimen was adjusted to oral administration of aspirin 100 mg once daily). ⑶External fixation frame adjustment protocol: On postoperative day 3, initiate transverse tibial bone realignment therapy (the osteotomy block is displaced 1 mm daily in four 0.25 mm increments). After 14 days of displacement, pause for 5 days and perform X-ray re-examination to evaluate the exact displacement position. Subsequently, repeat the same procedure in the opposite direction for 14 days, followed by another X-ray re-examination to confirm reduction status (this process may be repeated 2–3 times based on patient condition). ⑷Precautions during perioperative period: ①During bone grafting, avoid strenuous exercise to prevent fracture at the osteotomy site. ②Disinfect and clean the surgical area and nail tunnel every 3–5 days. ③After bone grafting, perform X-ray follow-up every two months and remove external fixation devices as appropriate based on the healing status of the transplanted bone. ④For bone cement coverage of the wound, no special treatment is generally required; removal may be performed as needed based on wound size and outpatient follow-up (no treatment required in the control group). 1.5 Observation Indicators Postoperative follow-up was conducted by comparing the VAS scores of patients before and after surgery in both groups [ 6 ] 、MNSI grade [ 7 ] 、AOFAS score [ 8 ] , The treatment efficacy was comprehensively evaluated based on observation indicators such as wound healing time, amputation rate, ulcer recurrence rate, and average hospital stay. 1.6 Statistical Methods Independent samples t-test (for normally distributed data) and the χ2-test (for categorical variates) were carried out to compared demographic characteristics and clinical data between two groups. Statistical analyses were performed using SPSS20.0 (SPSS Inc., Chicago, IL, USA) and P ˂ 0.05 is considered as statistical significance. RESULTS All 60 patients completed postoperative follow-up, with a follow-up duration ranging from 6 to 18 months, averaging (11.0 ± 1.5) months. At the final follow-up, the AOFAS score in the treatment group was significantly higher than that in the control group, while the VAS score, MNSI score, wound healing time, amputation rate, ulcer recurrence rate, and average length of hospital stay were significantly lower than those in the control group ( P < 0.05) (see Table 2 and Table 3 ). DISCUSSION Diabetic foot ulcers (DFU) are common complications in advanced diabetes. The formation of DFU involves complex pathological processes, not only causing systemic vascular and neuropathic damage but also potentially leading to organ impairment. In patients with diabetic foot at Wagner stages 2–4, some infections have invaded muscle tissue, resulting in poor wound healing and even limb necrosis. Without aggressive treatment, patients face risks of amputation or even death. However, traditional therapies often suffer from limited efficacy, significant trauma, or multiple complications. This study conducted a retrospective comparative analysis of clinical data from 60 patients with diabetic foot ulcers (DFU). Postoperative follow-up data demonstrated that the treatment group (modified induction membrane technique combined with TTT) significantly outperformed the control group (transverse tibial bone grafting) in multiple evaluation criteria, including improvement of foot and ankle function, alleviation of pain and neuropathy symptoms, promotion of wound healing, reduction of severe complication incidence, and optimization of medical resource utilization. The therapeutic experience is summarized as follows: 3.1 Theoretical Basis of Modified Induced Membrane Technology for Treating DFU (1) Induction membrane technique, also known as Masquelet technique, was first proposed by French orthopedic surgeon Alain-Charles Masquelet in 1986. [9 ， 10] This technique involves surgical debridement of the infected lesion, followed by the application of antibiotic-cemented bone filler to form an inducible membrane. The inducible membrane secretes multiple growth factors, which nourish surrounding tissues, improve local blood supply to soft tissues, thereby enhancing anti-infection and tissue healing capabilities, and promoting the healing of bone and soft tissue wounds. ⑵Compared to traditional dressings, the induced membrane technology demonstrates superior biocompatibility. ① Firstly, the induced membrane technology effectively isolates infection sources by establishing a biological barrier around the wound. ② Secondly, the modified induced membrane technology promotes the migration of epidermal cells and soft tissue regeneration by fully covering the wound with drug-loaded bone cement, thereby creating an induced membrane environment that shortens the healing time of ulcerated wounds. ③ Dai et al. [11 ， 12] The research report indicates that the application of Masquelet technology in treating diabetic foot ulcers (DFU) can reduce the frequency of wound debridement, shorten wound healing time, and lower the amputation rate. 3.2 Theoretical Basis of Tibial Transverse Bone Transfer for DFU Treatment (1) Transverse tibial transfer (TTT) is based on the principles of Ilizarov limb regeneration theory. [13 ， 14] By transversely displacing a small segment of the tibial bone, the bodys traumatic healing response is triggered. This not only reduces intramedullary pressure in the tibia and alleviates limb pain, but also significantly improves microcirculation within and around the bone marrow, enhances the neuroischemic and hypoxic state, and indirectly promotes ulcer wound healing. ⑵TTT stimulates the high expression of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF). These bioactive substances possess potent angiogenic and microcirculatory improvement capabilities, thereby significantly increasing blood supply to the lower extremities, particularly the feet, promoting tissue cell regeneration and repair, and accelerating ulcer wound healing. [15 ～ 18] Hua Qikai et al. [19 ， 20] Studies have shown that the application of TTT in the treatment of diabetic foot ulcers results in faster wound healing and a lower recurrence rate. 3.3 Advantages of Modified Induction Membrane Technique Combined with Transverse Tibial Bone Transfer for DFU Treatment (1) Promoting neovascular regeneration and shortening wound healing time: ① Firstly, the modified induction membrane effectively isolates infection sources by establishing a biological barrier around the wound surface, while promoting the orderly growth of granulation tissue, thereby reducing the healing time of ulcerated wounds. ② Secondly, TTT activates tissue regeneration capacity through the tension-stress principle, stimulating the high expression of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF), inducing the regeneration of the lower limb microvascular network, increasing local blood supply, and shortening the healing time of ulcerated wounds. [21] ③ Finally, the combined use of the two can enhance the bioactivity of the induced membrane, further promote neovascularization and epidermal cell growth, and accelerate the healing process of ulcer wounds. [22] 。 ⑵ Establishing a positive feedback loop for angiogenesis and tissue repair to overcome the efficacy limitations of single therapies: ① Firstly, TTT utilizes an external fixator to perform "accordion" bone grafting. [23] ① Traction stimulation promotes the release of bone marrow stem cells, thereby facilitating the establishment of collateral circulation and increasing microvascular density, which improves ischemic conditions in the extremities. ② Secondly, the modified induction membrane technology creates a more favorable repair environment for wound healing. ③ Under the synergistic effect of these two mechanisms, angiogenesis and tissue repair form a positive feedback loop, thereby overcoming the efficacy limitations of single therapies. ⑶ Shortening treatment duration and improving patients quality of life: ① After thorough debridement of infected wounds, primary application of drug-loaded bone cement for wound coverage can significantly reduce hospitalization time. ② Postoperative adjustment of external fixation braces and wound care procedures are simple, facilitating early ambulation. ③ Removal of external fixation braces and bone cement can be completed in outpatient settings, reducing hospital visits and saving treatment costs. In conclusion, the modified induction membrane technique combined with TTT for DFU treatment can significantly improve therapeutic outcomes, shorten wound healing time and hospital stay, and reduce the risk of amputation and ulcer recurrence. However, due to the small sample size and short follow-up period in this study, the results may be biased. Therefore, future research should expand the sample size and conduct multicenter, randomized controlled trials to verify the stability and efficacy of the results. Declarations Ethic Approval and consent to publication This study complies with the requirements of the Declaration of Helsinki, and all family members of the patients signed informed consent forms prior to surgery. Additionally, the study was approved by the Ethics Committee of Xinjiang Uygur Autonomous Region Peoples Hospital (Approval No.: KY2025100902). Conflict of interest All authors declare that there is no conflict of interest. Acknowledgment None. Funding This study received no special research funding; all expenses were covered by the authors and their research team. Clinical Trial Registration Number Not applicable for routine clinical surgical treatment. Author contributions Zhou Min: In charge of data statistical analysis, literature retrieval, assisting in organizing research materials, and completing the paper writing. Shi Shouyin: Responsible for screening research subjects, performing surgical procedures, collecting and organizing follow - up data, and assisting in completing the paper writing. An Xingwei: Responsible for the overall design and coordination of the research protocol. Huang Ying and Sun Jungang: Responsible for the overall design and coordination of the research protocol, reviewing research data and reports, and providing guidance to ensure the smooth implementation of the study. References Zhang Z, Chen C, Wu PP, et al. Study on the pathological mechanisms of delayed wound healing in diabetic foot ulcers [J]. Journal of Clinical Dermatology, 2025,54(01):48-51. Luo Fuqiang, Yu Dianbai, Xie Kangqi, et al. Research progress on the mechanisms of diabetic foot ulcer wound repair[J]. Journal of Practical Medicine, 2023,39(02):158-163. Pandey G, [3]Pandey G, et al. Navigating the complexities of diabetic foot ulcers: From pathophysiology to advanced treatment strategies[J]. Journal of Drug Delivery Science and Technology, 2025, 107:106852. Gu Yongquan, Ran Xingwu, Guo Lianrui, et al. China Diabetes Foot Diagnosis and Treatment Guidelines [J]. China Journal of Clinical Physicians, 2024,52(11):1287-1296. WAGNER F W Jr. ThE dysvascular foot:a systEm for diagnosis and trEatmEnt [J]. Foot AnklE ,1981 ,2(2):64-122. Wan Li, Zhao Qing, Chen Jun, et al. Expert consensus on the application of pain assessment scales in China (2020 edition) [J]. Chinese Journal of Pain Medicine, 2020,16(3):11-13. Xiong Q, Zhang Y, Chen X, [7]Xiong Q, Zhang Y, Chen X, et al. The diagnostic value of neuropathy symptom and change score, neuropathy impairment score and Michigan neuropathy screening instrument for diabetic peripheral neuropathy. Eur Neurol 2015; 74(5-6): 323-327. Frank VJ, et al. Comparison of the European Foot and Ankle Score (EFAS) and the American Orthopedic Foot and Ankle Society Score (AOFAS) in patients with foot and ankle surgery [J]. Foot Ankle Surg, 2025, 35(5): 278-284. Alford AI, Nicolaou D, Hake M, [9]Alford AI, Nicolaou D, Hake M, et al. Masquelets induced membrane technique: Review of current concepts and future directions [J]. J Orthop Res, 2021, 39(4): 707-718. Tanner MC, Boxriker S, Haubruck P, [10]Tanner MC, Boxriker S, Haubruck P, et al. Expression of VEGF in peripheral serum is a possible prognostic factor in bone-regeneration via Masquelet-Technique-A pilot study [J]. J Clin Med, 2021, 10(4): 776-778. Dai J, Zhou Y, Mei S, [11]Dai J, Zhou Y, Mei S, et al. Application of antibiotic bone cement in the treatment of infected diabetic foot ulcers in type 2 diabetes [J]. BMC Musculoskelet Disord, 2023, 24(1): 135-137. Cao T, et al. [A prospective randomized controlled study of antibiotic bone cement in the treatment of diabetic foot ulcer] [J]. Chin J Burns, 2023, 39(4): 311-318. Guan SS, [13]Guan SS, et al. The Ilizarov technique: a dynamic solution for orthopaedic challenges [J]. Orthop Surg, 2024, 16(9): 2111-2114. Zheng XJ, et al. [Preliminary study of Ilizarov technique in treatment of lower limb deformity caused by achondroplasia] [J]. Chin J Repar Reconstr Surg, 2023, 37(2): 157-161. Li C, Li J, Wang D, et al. Research progress on tibial transverse bone grafting for reconstruction of diabetic foot microcirculation[J]. Chinese Journal of Bone and Joint Surgery, 2025,18(04):362-367. Zhou HD, [16]Zhou HD, et al. Research progress of tibial transverse transport in the treatment of DFU [J]. J Biosci Med, 2025, 13(3): 217-228. Mukherjee S, Im SS. Impact of tibial transverse transport in tissue regeneration and wound healing with perspective on diabetic foot ulcers [J]. World J Diabetes, 2024, 15(5): 810-813. Daeschler SC, Pennekamp A, Tsilingiris D, [18] Daeschler SC, Pennekamp A, Tsilingiris D, et al. Effect of surgical release of entrapped peripheral nerves in sensorimotor diabetic neuropathy on pain and sensory dysfunction-study protocol of a prospective, controlled clinical trial [J]. J Pers Med, 2023, 13(2): 1045-1050. Hua Qikai, Qin Sihe, Kuang Xiaocong, et al. Summary of experience in treating 516 cases of diabetic foot with transverse tibial bone grafting technique [J]. China Journal of Reconstructive Surgery, 2020,34(08):959-963. Ou S, Xu C, Yang Y, [20]Ou S, Xu C, Yang Y, et al. Transverse tibial bone transport enhances distraction osteogenesis and vascularization in the treatment of diabetic foot [J]. Orthop Surg, 2022, 14(9): 2170-2179. Xu Daofei, Hu Rong, Yu Qinglong, et al. Clinical application of transverse tibial transfer technique and research progress on its induced vascular regeneration mechanism [J]. Chinese Journal of Bone and Joint Surgery, 2023,16(09):854-859. Zhao Yamei, Chen Yan, Xie Bin, et al. Advances in the application of induced membrane technology in chronic non-healing wounds [J]. China Journal of Burn and Wound, 2025,37(01):9-12. Liu K, Shi L, Wang S, et al. Experimental study on the effect of "accordion" technique and deironing amine on promoting bone regeneration in distraction osteogenesis zone [J]. China Journal of Reconstructive Surgery, 2024,38(08):1001-1009. TYPICAL CASE A 52-year-old female patient presented with a chief complaint of "recurrent ulceration and infection of the right foot for over 5 months." The patient reported: "She has a 15-year history of type 2 diabetes mellitus (T2DM) and has been receiving insulin therapy (details unspecified), but glycemic control has been suboptimal. Over the past two years, she has experienced hypoesthesia in the skin below the knee joints of both lower limbs, with multiple chronic ulcers appearing on the right foot. Local hospital treatments, including wound dressing changes and symptomatic management, have shown limited efficacy." For further treatment, she was transferred to our hospital. After completing outpatient examinations, she was diagnosed with "1. Right diabetic foot ulcer (Wagner stage 2); 2. T2DM; 3. Diabetic peripheral neuropathy" and admitted for inpatient treatment. She underwent surgical intervention with "modified induction membrane combined with TTT." Postoperative follow-up for 12 months showed good wound healing at the affected foot, with no recurrence of ulcerative wounds (see Figures A–H). Tables Table 1 Comparison of preoperative general data between the two groups group Number of cases （ human being ） sex age （ year ） course of disease （ year ） Wagner classify （ example ） man woman treatment group 30 14 16 45～70 (Average 62.5) 5.0～20 (Average 4.8) Grade 2: 7 cases Grade 3: 11 cases Grade 4: 12 cases control group 30 15 15 43～71 (average 61.8) 5.2～21 (Average 5.2) Grade 2: 7 cases Grade 3: 10 cases Grade 4: 13 cases Note: There were no significant differences between the two groups in terms of gender, age, duration of diabetic foot disease, and Wagner classification ( P >0.05). Table 2 Comparison of VAS scores, MNSI scores, and AOFAS scores before and after surgery between the two groups ( ± s) group Number of cases (people) Time (month) VAS score (points) MNSI score (points) AOFAS score (points) Preoperative 6.5±0.5 4.2±0.5 54.5±5.0 treatment group 30 6 months postoperatively 12 months postoperatively 4.5±0.5 3.8±0.4 3.0±0.4 1.0±0.4 77.0±3.5 89.5±2.8 Preoperative 6.0±1.0 4.0±0.5 54.6±5.1 control group 30 6 months postoperatively 12 months postoperatively 5.5±0.5 4.8±0.6 3.5±0.6 2.5±0.5 65.5±5.5 82.0±3.0 t pric e 6 months postoperatively 7.75 3.82 9.68 12 months postoperatively 7.59 12.83 10.01 P price 6 months postoperatively <0.001 <0.001 <0.001 12 months postoperatively <0.001 <0.001 <0.001 Note: The between-group comparison was performed using an independent samples t-test with a significance level of α=0.05. Table 3 Comparison of wound healing time, amputation rate, ulcer recurrence rate, and mean length of hospital stay between the two groups group Number of cases （ human being ） Wound healing time （ sky ） amputation rate （%） Ulcer recurrence rate （%） Average length of hospital stay （ sky ） treatment group 30 38.5±4.3 1（3.3%) 1（3.3%) 7.0±1.0 control group 30 45.7±5.8 3（10%) 2（6.7%) 10.0±1.5 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 10 May, 2026 Reviews received at journal 20 Apr, 2026 Reviewers agreed at journal 19 Apr, 2026 Reviewers agreed at journal 18 Apr, 2026 Reviewers invited by journal 17 Apr, 2026 Editor assigned by journal 21 Mar, 2026 Submission checks completed at journal 21 Mar, 2026 First submitted to journal 17 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9151446","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":628487690,"identity":"5377d62a-e34a-48e2-a0e2-591a461ecd2c","order_by":0,"name":"Zhou Min","email":"","orcid":"","institution":"Tianjin University","correspondingAuthor":false,"prefix":"","firstName":"Zhou","middleName":"","lastName":"Min","suffix":""},{"id":628487692,"identity":"72b1dc2e-efd2-4b32-aa8c-621f52d8cd82","order_by":1,"name":"Shi Shouyin","email":"","orcid":"","institution":"Peoples Hospital of Xinjiang Uygur Autonomous 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University","correspondingAuthor":true,"prefix":"","firstName":"Huang","middleName":"","lastName":"Ying","suffix":""},{"id":628487695,"identity":"05f4976b-9192-486a-b773-9cb67d95f299","order_by":4,"name":"Sun Jungang","email":"","orcid":"","institution":"Peoples Hospital of Xinjiang Uygur Autonomous Region","correspondingAuthor":false,"prefix":"","firstName":"Sun","middleName":"","lastName":"Jungang","suffix":""}],"badges":[],"createdAt":"2026-03-17 17:24:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9151446/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9151446/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107965912,"identity":"5eb1d934-118b-48e3-bb30-18d781c2325d","added_by":"auto","created_at":"2026-04-28 05:41:52","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":3902568,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure A\u003c/strong\u003e: Preoperative photographs demonstrate significant swelling of the patients right foot, with chronic ulceration and infection present on the dorsum and lateral skin of the foot.\u003c/p\u003e","description":"","filename":"FiguresA.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9151446/v1/92e85dee3cdeb907f1f31a4d.jpeg"},{"id":107965892,"identity":"51b5c7ef-d593-4f20-bd97-8113761fea6a","added_by":"auto","created_at":"2026-04-28 05:41:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":5713,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure B\u003c/strong\u003e: Intraoperative photographs show that the patient has undergone transverse tibial transport (TTT) surgery.\u003c/p\u003e","description":"","filename":"placeholderimageCopy.png","url":"https://assets-eu.researchsquare.com/files/rs-9151446/v1/daf35be66a0af6ecd6cee24c.png"},{"id":107965874,"identity":"703f2680-8f79-46de-9859-51fca32b7238","added_by":"auto","created_at":"2026-04-28 05:41:41","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":3656503,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure C\u003c/strong\u003e: Intraoperative photographs indicate that vancomycin has been mixed with bone cement to form a paste for intraoperative use.\u003c/p\u003e","description":"","filename":"FiguresC.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9151446/v1/c8a298fa5a37b2bf5563c6e8.jpeg"},{"id":107965823,"identity":"b2ab33fb-452d-4824-a86d-33065ed2ed51","added_by":"auto","created_at":"2026-04-28 05:41:33","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":3698326,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure D\u003c/strong\u003e: The drug-loaded bone cement is prepared in sheet form and covered over the wound, followed by cooling and shaping.\u003c/p\u003e","description":"","filename":"FiguresD.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9151446/v1/6388555917378ab32718445d.jpg"},{"id":107965911,"identity":"24900a44-4398-4bfc-a291-ab0c99daa892","added_by":"auto","created_at":"2026-04-28 05:41:51","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":2647678,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure E\u003c/strong\u003e: Intraoperative photographs show that the shaped drug-loaded bone cement sheet is drilled and then covered over the wound, with fixation achieved through sutures.\u003c/p\u003e","description":"","filename":"FiguresE.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9151446/v1/1687bab582a1e5570d17345d.jpeg"},{"id":107965957,"identity":"cf08eb7b-5854-4cec-998a-077b29a4a785","added_by":"auto","created_at":"2026-04-28 05:42:05","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":5713,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure F\u003c/strong\u003e: Postoperative follow-up evaluation at 3 months shows good healing of the ulcerated wound on the affected foot.\u003c/p\u003e","description":"","filename":"placeholderimage.png","url":"https://assets-eu.researchsquare.com/files/rs-9151446/v1/7f01acc7f2e40d59972d1959.png"},{"id":107965820,"identity":"2babfed2-dee8-4fe9-b89d-43df2ec439eb","added_by":"auto","created_at":"2026-04-28 05:41:33","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":56735992,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigures G–H\u003c/strong\u003e: Follow-up observations at 6 months and 12 months postoperatively reveal that the patients foot skin appears rosy, with good wound healing and no signs of ulcer recurrence.\u003c/p\u003e","description":"","filename":"GH.png","url":"https://assets-eu.researchsquare.com/files/rs-9151446/v1/daac47ea0cfbed97f244c2d2.png"},{"id":108010336,"identity":"c6b21718-f899-4e7b-a25b-9d9624a098a9","added_by":"auto","created_at":"2026-04-28 13:13:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":70488876,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9151446/v1/b40d7ade-f04e-4c70-95cf-76980b1b3a27.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Combined Modified Induced Membrane and Tibial Transport for Diabetic Foot Ulcers: A Controlled Study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eDiabetic foot ulcer (DFU) is one of the most common complications in diabetic patients. Its development involves multiple factors, including lower extremity neuropathy, peripheral vascular disease, and infection, leading to damage of the skin and deeper tissues of the foot \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. These ulcers frequently occur in areas prone to friction and pressure, such as the plantar surface, dorsum of the foot, or toes, clinically presenting as skin breakdown, ulceration, and potential infection.\u003c/p\u003e \u003cp\u003eDFU not only severely impairs patients quality of life but may also lead to amputation and even life-threatening conditions. Therefore, improving DFU wound perfusion, controlling infection, and reducing amputation rates have become the core objectives of DFU treatment \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSince June 2020, the Orthopedic Center of the People's Hospital of Xinjiang Uygur Autonomous Region has adopted a modified induced membrane technique combined with tibial transverse transport (TTT) for the treatment of DFU. Postoperative follow-up observations have demonstrated significant clinical efficacy and a low recurrence rate with this treatment protocol. The research results are reported as follows:\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003e1.1 Patient Selection Criteria\u003c/h2\u003e\n \u003cp\u003e(1) Inclusion criteria: ① Good patient compliance and stable cardiopulmonary function; ② Clinically diagnosed as diabetic foot and meeting the \u0026quot;China Diabetic Foot Diagnosis and Treatment Guidelines\u0026quot;\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003eof DFU-related diagnostic criteria; ③ patients aged 45 to 70 years, with diabetic foot Wagner staging\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003eGrade 2\u0026ndash;4; ④ Dual lower extremity computed tomography angiography (CTA) revealed no significant occlusion in the popliteal artery or its main branches.\u003c/p\u003e\n \u003cp\u003e(2) Exclusion criteria: ① Poor general condition that cannot tolerate surgery and anesthesia; ② Patients with mental disorders or inability to cooperate with surgery; ③ Severe systemic or local infections that would endanger life safety with limb-sparing treatment.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003e1.2 Clinical Data\u003c/h2\u003e\n \u003cp\u003eThis study conducted a retrospective analysis of data from 60 diabetic foot ulcers (DFU) patients admitted to the Orthopedic Center of Xinjiang Uygur Autonomous Region Peoples Hospital between June 2020 and June 2024. Based on surgical techniques, patients were divided into a treatment group (modified induction membrane technique combined with TTT) and a control group (traditional TTT), with 30 cases in each group. Postoperative follow-up ranged from 6 to 18 months (mean: 11.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 months). Observation indicators, including VAS scores, MNSI scores, AOFAS scores, wound healing time, amputation rate, ulcer recurrence rate, and average hospital stay, were recorded and compared between the two groups to evaluate clinical outcomes multidimensionally. No statistically significant differences were observed between the two groups in terms of gender, age, duration of diabetic foot disease, or Wagner classification \u003cem\u003e(P\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), indicating comparability (see Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003e1.3 Surgical Approach\u003c/h2\u003e\n \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\n \u003ch2\u003e1.3.1 Surgical Procedure Steps in the Treatment Group\u003c/h2\u003e\n \u003cp\u003e(1) Anesthesia and positioning: The patient was placed in the supine position under general anesthesia, with routine preoperative disinfection and draping.\u003c/p\u003e\n \u003cp\u003e⑵ Installation of transverse tibial bone transfer frame: ① First, implant 1\u0026ndash;2 self-tapping screws (4.5 mm diameter) on the medial plane of the proximal and distal tibia to complete the external fixation frame (TTT). ② Subsequently, temporarily remove the middle section of the frame while retaining the screws at both tibial ends. ③ Next, make a 6 cm arc-shaped incision 2 cm below the tibial tuberosity, extending to the periosteum. Turn the periosteum and soft tissue flap outward, and use a 2.5 mm low-speed drill to continuously bore along the osteotomy guide plate, creating a 2.5 cm \u0026times; 6 cm single cortical tibial bone window. Sequentially drill bone holes with a fine bone knife. Then, reinstall the external fixation frame and sequentially lock the screw clamps. ④ Finally, suture the periosteum continuously with 3\u0026thinsp;\u0026minus;\u0026thinsp;0 absorbable sutures and intermittently suture the incision with 2\u0026thinsp;\u0026minus;\u0026thinsp;0 silk sutures. Upon completion, cover and bandage the incision with sterile dressing.\u003c/p\u003e\n \u003cp\u003e⑶ Thorough wound debridement: ① Employ sharp surgical techniques to excise infected and necrotic (gangrenous) tissues of the foot, and use bone-biting forceps to remove necrotic bone lesions until fresh blood exudes from the wound. ② After completing thorough debridement of the surgical area, if the extent of soft tissue defect is large enough to prevent full wound coverage, moderate shortening of the phalanges or metatarsal bones may be performed intraoperatively to effectively reduce the wound area. Efforts should be made to minimize the wound size. ③ During intraoperative debridement, repeatedly irrigate the wound with diluted povidone-iodine saline solution. After achieving hemostasis, apply pressure dressing with sterile gauze.\u003c/p\u003e\n \u003cp\u003e⑷ Drug-loaded bone cement coverage: ① First, mix 40g of gentamicin bone cement (PMMA) with 2g of vancomycin (Wan Gu Xian) and stir evenly. Add specialized curing solution and knead until the mixture forms a soft dough-like consistency. Shape it into 2\u0026ndash;3mm thick sheets according to the wound size and temporarily cover the wound. ② Second, during the heat generation from bone cement curing, continuously rinse with running normal saline to cool the area and prevent burns to soft tissues. ③ After the bone cement cools and takes shape, use a 2.5mm drill bit to make intermittent holes between the center and edges of the drug-loaded bone cement sheet. Ensure the cement fully covers the wound and suture it with 2\u0026thinsp;\u0026minus;\u0026thinsp;0 silk thread for fixation. ④ Finally, apply sterile dressing with pressure bandaging.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\n \u003ch2\u003e1.3.2 Surgical procedure steps for the control group\u003c/h2\u003e\n \u003cp\u003eThe debridement of the wound and the transverse tibial bone grafting procedure in the control group were identical to those in the treatment group, with the sole difference being that the control group did not receive drug-loaded bone cement coverage for the wound.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003e1.4 Postoperative Management\u003c/h2\u003e\n \u003cp\u003e(1) Strengthen comprehensive treatment of underlying medical conditions: ① Maintain stable blood glucose levels throughout the postoperative period (fasting blood glucose\u0026thinsp;\u0026lt;\u0026thinsp;8 mmol/L). ② Select appropriate antibiotics for anti-infection therapy based on results of wound bacterial culture and antimicrobial susceptibility testing.\u003c/p\u003e\n \u003cp\u003e(2) Routine anticoagulation therapy was administered for 8\u0026ndash;12 weeks during the perioperative period (during hospitalization, low molecular weight heparin injection 4000 IU was administered subcutaneously every 12 hours; after discharge, the regimen was adjusted to oral administration of aspirin 100 mg once daily).\u003c/p\u003e\n \u003cp\u003e⑶External fixation frame adjustment protocol: On postoperative day 3, initiate transverse tibial bone realignment therapy (the osteotomy block is displaced 1 mm daily in four 0.25 mm increments). After 14 days of displacement, pause for 5 days and perform X-ray re-examination to evaluate the exact displacement position. Subsequently, repeat the same procedure in the opposite direction for 14 days, followed by another X-ray re-examination to confirm reduction status (this process may be repeated 2\u0026ndash;3 times based on patient condition).\u003c/p\u003e\n \u003cp\u003e⑷Precautions during perioperative period: ①During bone grafting, avoid strenuous exercise to prevent fracture at the osteotomy site. ②Disinfect and clean the surgical area and nail tunnel every 3\u0026ndash;5 days. ③After bone grafting, perform X-ray follow-up every two months and remove external fixation devices as appropriate based on the healing status of the transplanted bone. ④For bone cement coverage of the wound, no special treatment is generally required; removal may be performed as needed based on wound size and outpatient follow-up (no treatment required in the control group).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003e1.5 Observation Indicators\u003c/h2\u003e\n \u003cp\u003ePostoperative follow-up was conducted by comparing the VAS scores of patients before and after surgery in both groups\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e、MNSI grade\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e、AOFAS score\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e, The treatment efficacy was comprehensively evaluated based on observation indicators such as wound healing time, amputation rate, ulcer recurrence rate, and average hospital stay.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003e1.6 Statistical Methods\u003c/h2\u003e\n \u003cp\u003eIndependent samples t-test (for normally distributed data) and the \u0026chi;2-test (for categorical variates) were carried out to compared demographic characteristics and clinical data between two groups. Statistical analyses were performed using SPSS20.0 (SPSS Inc., Chicago, IL, USA) and \u003cem\u003eP\u003c/em\u003e ˂ 0.05 is considered as statistical significance.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eAll 60 patients completed postoperative follow-up, with a follow-up duration ranging from 6 to 18 months, averaging (11.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5) months. At the final follow-up, the AOFAS score in the treatment group was significantly higher than that in the control group, while the VAS score, MNSI score, wound healing time, amputation rate, ulcer recurrence rate, and average length of hospital stay were significantly lower than those in the control group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (see Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eDiabetic foot ulcers (DFU) are common complications in advanced diabetes. The formation of DFU involves complex pathological processes, not only causing systemic vascular and neuropathic damage but also potentially leading to organ impairment. In patients with diabetic foot at Wagner stages 2\u0026ndash;4, some infections have invaded muscle tissue, resulting in poor wound healing and even limb necrosis. Without aggressive treatment, patients face risks of amputation or even death. However, traditional therapies often suffer from limited efficacy, significant trauma, or multiple complications.\u003c/p\u003e\n\u003cp\u003eThis study conducted a retrospective comparative analysis of clinical data from 60 patients with diabetic foot ulcers (DFU). Postoperative follow-up data demonstrated that the treatment group (modified induction membrane technique combined with TTT) significantly outperformed the control group (transverse tibial bone grafting) in multiple evaluation criteria, including improvement of foot and ankle function, alleviation of pain and neuropathy symptoms, promotion of wound healing, reduction of severe complication incidence, and optimization of medical resource utilization. The therapeutic experience is summarized as follows:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1 Theoretical Basis of Modified Induced Membrane Technology for Treating DFU\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(1) Induction membrane technique, also known as Masquelet technique, was first proposed by French orthopedic surgeon Alain-Charles Masquelet in 1986.\u003csup\u003e[9\u003c/sup\u003e\u003csup\u003e，\u003c/sup\u003e\u003csup\u003e10]\u003c/sup\u003eThis technique involves surgical debridement of the infected lesion, followed by the application of antibiotic-cemented bone filler to form an inducible membrane. The inducible membrane secretes multiple growth factors, which nourish surrounding tissues, improve local blood supply to soft tissues, thereby enhancing anti-infection and tissue healing capabilities, and promoting the healing of bone and soft tissue wounds.\u003c/p\u003e\n\u003cp\u003e⑵Compared to traditional dressings, the induced membrane technology demonstrates superior biocompatibility. ① Firstly, the induced membrane technology effectively isolates infection sources by establishing a biological barrier around the wound. ② Secondly, the modified induced membrane technology promotes the migration of epidermal cells and soft tissue regeneration by fully covering the wound with drug-loaded bone cement, thereby creating an induced membrane environment that shortens the healing time of ulcerated wounds. ③ Dai et al.\u003csup\u003e[11\u003c/sup\u003e\u003csup\u003e，\u003c/sup\u003e\u003csup\u003e12]\u003c/sup\u003eThe research report indicates that the application of Masquelet technology in treating diabetic foot ulcers (DFU) can reduce the frequency of wound debridement, shorten wound healing time, and lower the amputation rate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Theoretical Basis of Tibial Transverse Bone Transfer for DFU Treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(1) Transverse tibial transfer (TTT) is based on the principles of Ilizarov limb regeneration theory.\u003csup\u003e[13\u003c/sup\u003e\u003csup\u003e，\u003c/sup\u003e\u003csup\u003e14]\u003c/sup\u003eBy transversely displacing a small segment of the tibial bone, the bodys traumatic healing response is triggered. This not only reduces intramedullary pressure in the tibia and alleviates limb pain, but also significantly improves microcirculation within and around the bone marrow, enhances the neuroischemic and hypoxic state, and indirectly promotes ulcer wound healing.\u003c/p\u003e\n\u003cp\u003e⑵TTT stimulates the high expression of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF). These bioactive substances possess potent angiogenic and microcirculatory improvement capabilities, thereby significantly increasing blood supply to the lower extremities, particularly the feet, promoting tissue cell regeneration and repair, and accelerating ulcer wound healing.\u003csup\u003e[15\u003c/sup\u003e\u003csup\u003e～\u003c/sup\u003e\u003csup\u003e18]\u003c/sup\u003eHua Qikai et al.\u003csup\u003e[19\u003c/sup\u003e\u003csup\u003e，\u003c/sup\u003e\u003csup\u003e20]\u003c/sup\u003eStudies have shown that the application of TTT in the treatment of diabetic foot ulcers results in faster wound healing and a lower recurrence rate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Advantages of Modified Induction Membrane Technique Combined with Transverse Tibial Bone Transfer for DFU Treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(1) Promoting neovascular regeneration and shortening wound healing time: ① Firstly, the modified induction membrane effectively isolates infection sources by establishing a biological barrier around the wound surface, while promoting the orderly growth of granulation tissue, thereby reducing the healing time of ulcerated wounds. ② Secondly, TTT activates tissue regeneration capacity through the tension-stress principle, stimulating the high expression of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF), inducing the regeneration of the lower limb microvascular network, increasing local blood supply, and shortening the healing time of ulcerated wounds.\u003csup\u003e[21]\u003c/sup\u003e③ Finally, the combined use of the two can enhance the bioactivity of the induced membrane, further promote neovascularization and epidermal cell growth, and accelerate the healing process of ulcer wounds.\u003csup\u003e[22]\u003c/sup\u003e。\u003c/p\u003e\n\u003cp\u003e⑵ Establishing a positive feedback loop for angiogenesis and tissue repair to overcome the efficacy limitations of single therapies: ① Firstly, TTT utilizes an external fixator to perform \u0026quot;accordion\u0026quot; bone grafting.\u003csup\u003e[23]\u003c/sup\u003e① Traction stimulation promotes the release of bone marrow stem cells, thereby facilitating the establishment of collateral circulation and increasing microvascular density, which improves ischemic conditions in the extremities. ② Secondly, the modified induction membrane technology creates a more favorable repair environment for wound healing. ③ Under the synergistic effect of these two mechanisms, angiogenesis and tissue repair form a positive feedback loop, thereby overcoming the efficacy limitations of single therapies.\u003c/p\u003e\n\u003cp\u003e⑶ Shortening treatment duration and improving patients quality of life: ① After thorough debridement of infected wounds, primary application of drug-loaded bone cement for wound coverage can significantly reduce hospitalization time. ② Postoperative adjustment of external fixation braces and wound care procedures are simple, facilitating early ambulation. ③ Removal of external fixation braces and bone cement can be completed in outpatient settings, reducing hospital visits and saving treatment costs.\u003c/p\u003e\n\u003cp\u003eIn conclusion, the modified induction membrane technique combined with TTT for DFU treatment can significantly improve therapeutic outcomes, shorten wound healing time and hospital stay, and reduce the risk of amputation and ulcer recurrence. However, due to the small sample size and short follow-up period in this study, the results may be biased. Therefore, future research should expand the sample size and conduct multicenter, randomized controlled trials to verify the stability and efficacy of the results.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthic Approval and consent to publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study complies with the requirements of the Declaration of Helsinki, and all family members of the patients signed informed consent forms prior to surgery. Additionally, the study was approved by the Ethics Committee of Xinjiang Uygur Autonomous Region Peoples Hospital (Approval No.: KY2025100902).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare that there is no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no special research funding; all expenses were covered by the authors and their research team.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Registration Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable for routine clinical surgical treatment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZhou Min: In charge of data statistical analysis, literature retrieval, assisting in organizing research materials, and completing the paper writing.\u003c/p\u003e\n\u003cp\u003eShi Shouyin: Responsible for screening research subjects, performing surgical procedures, collecting and organizing follow - up data, and assisting in completing the paper writing.\u003c/p\u003e\n\u003cp\u003eAn Xingwei: Responsible for the overall design and coordination of the research protocol.\u003c/p\u003e\n\u003cp\u003eHuang Ying and Sun Jungang: Responsible for the overall design and coordination of the research protocol, reviewing research data and reports, and providing guidance to ensure the smooth implementation of the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eZhang Z, Chen C, Wu PP, et al. Study on the pathological mechanisms of delayed wound healing in diabetic foot ulcers [J]. Journal of Clinical Dermatology, 2025,54(01):48-51.\u003c/li\u003e\n\u003cli\u003eLuo Fuqiang, Yu Dianbai, Xie Kangqi, et al. Research progress on the mechanisms of diabetic foot ulcer wound repair[J]. Journal of Practical Medicine, 2023,39(02):158-163.\u003c/li\u003e\n\u003cli\u003ePandey G, [3]Pandey G, et al. Navigating the complexities of diabetic foot ulcers: From pathophysiology to advanced treatment strategies[J]. Journal of Drug Delivery Science and Technology, 2025, 107:106852.\u003c/li\u003e\n\u003cli\u003eGu Yongquan, Ran Xingwu, Guo Lianrui, et al. China Diabetes Foot Diagnosis and Treatment Guidelines [J]. China Journal of Clinical Physicians, 2024,52(11):1287-1296.\u003c/li\u003e\n\u003cli\u003eWAGNER F W Jr. ThE dysvascular foot:a systEm for diagnosis and trEatmEnt [J]. Foot AnklE ,1981 ,2(2):64-122.\u003c/li\u003e\n\u003cli\u003eWan Li, Zhao Qing, Chen Jun, et al. Expert consensus on the application of pain assessment scales in China (2020 edition) [J]. Chinese Journal of Pain Medicine, 2020,16(3):11-13.\u003c/li\u003e\n\u003cli\u003eXiong Q, Zhang Y, Chen X, [7]Xiong Q, Zhang Y, Chen X, et al. The diagnostic value of neuropathy symptom and change score, neuropathy impairment score and Michigan neuropathy screening instrument for diabetic peripheral neuropathy. Eur Neurol 2015; 74(5-6): 323-327.\u003c/li\u003e\n\u003cli\u003eFrank VJ, et al. Comparison of the European Foot and Ankle Score (EFAS) and the American Orthopedic Foot and Ankle Society Score (AOFAS) in patients with foot and ankle surgery [J]. Foot Ankle Surg, 2025, 35(5): 278-284.\u003c/li\u003e\n\u003cli\u003eAlford AI, Nicolaou D, Hake M, [9]Alford AI, Nicolaou D, Hake M, et al. Masquelets induced membrane technique: Review of current concepts and future directions [J]. J Orthop Res, 2021, 39(4): 707-718.\u003c/li\u003e\n\u003cli\u003eTanner MC, Boxriker S, Haubruck P, [10]Tanner MC, Boxriker S, Haubruck P, et al. Expression of VEGF in peripheral serum is a possible prognostic factor in bone-regeneration via Masquelet-Technique-A pilot study [J]. J Clin Med, 2021, 10(4): 776-778.\u003c/li\u003e\n\u003cli\u003eDai J, Zhou Y, Mei S, [11]Dai J, Zhou Y, Mei S, et al. Application of antibiotic bone cement in the treatment of infected diabetic foot ulcers in type 2 diabetes [J]. BMC Musculoskelet Disord, 2023, 24(1): 135-137.\u003c/li\u003e\n\u003cli\u003eCao T, et al. [A prospective randomized controlled study of antibiotic bone cement in the treatment of diabetic foot ulcer] [J]. Chin J Burns, 2023, 39(4): 311-318.\u003c/li\u003e\n\u003cli\u003eGuan SS, [13]Guan SS, et al. The Ilizarov technique: a dynamic solution for orthopaedic challenges [J]. Orthop Surg, 2024, 16(9): 2111-2114.\u003c/li\u003e\n\u003cli\u003eZheng XJ, et al. [Preliminary study of Ilizarov technique in treatment of lower limb deformity caused by achondroplasia] [J]. Chin J Repar Reconstr Surg, 2023, 37(2): 157-161.\u003c/li\u003e\n\u003cli\u003eLi C, Li J, Wang D, et al. Research progress on tibial transverse bone grafting for reconstruction of diabetic foot microcirculation[J]. Chinese Journal of Bone and Joint Surgery, 2025,18(04):362-367.\u003c/li\u003e\n\u003cli\u003eZhou HD, [16]Zhou HD, et al. Research progress of tibial transverse transport in the treatment of DFU [J]. J Biosci Med, 2025, 13(3): 217-228.\u003c/li\u003e\n\u003cli\u003eMukherjee S, Im SS. Impact of tibial transverse transport in tissue regeneration and wound healing with perspective on diabetic foot ulcers [J]. World J Diabetes, 2024, 15(5): 810-813.\u003c/li\u003e\n\u003cli\u003eDaeschler SC, Pennekamp A, Tsilingiris D, [18] Daeschler SC, Pennekamp A, Tsilingiris D, et al. Effect of surgical release of entrapped peripheral nerves in sensorimotor diabetic neuropathy on pain and sensory dysfunction-study protocol of a prospective, controlled clinical trial [J]. J Pers Med, 2023, 13(2): 1045-1050.\u003c/li\u003e\n\u003cli\u003eHua Qikai, Qin Sihe, Kuang Xiaocong, et al. Summary of experience in treating 516 cases of diabetic foot with transverse tibial bone grafting technique [J]. China Journal of Reconstructive Surgery, 2020,34(08):959-963.\u003c/li\u003e\n\u003cli\u003eOu S, Xu C, Yang Y, [20]Ou S, Xu C, Yang Y, et al. Transverse tibial bone transport enhances distraction osteogenesis and vascularization in the treatment of diabetic foot [J]. Orthop Surg, 2022, 14(9): 2170-2179.\u003c/li\u003e\n\u003cli\u003eXu Daofei, Hu Rong, Yu Qinglong, et al. Clinical application of transverse tibial transfer technique and research progress on its induced vascular regeneration mechanism [J]. Chinese Journal of Bone and Joint Surgery, 2023,16(09):854-859.\u003c/li\u003e\n\u003cli\u003eZhao Yamei, Chen Yan, Xie Bin, et al. Advances in the application of induced membrane technology in chronic non-healing wounds [J]. China Journal of Burn and Wound, 2025,37(01):9-12.\u003c/li\u003e\n\u003cli\u003eLiu K, Shi L, Wang S, et al. Experimental study on the effect of \u0026quot;accordion\u0026quot; technique and deironing amine on promoting bone regeneration in distraction osteogenesis zone [J]. China Journal of Reconstructive Surgery, 2024,38(08):1001-1009.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"TYPICAL CASE","content":"\u003cp\u003eA 52-year-old female patient presented with a chief complaint of \u0026quot;recurrent ulceration and infection of the right foot for over 5 months.\u0026quot; The patient reported: \u0026quot;She has a 15-year history of type 2 diabetes mellitus (T2DM) and has been receiving insulin therapy (details unspecified), but glycemic control has been suboptimal. Over the past two years, she has experienced hypoesthesia in the skin below the knee joints of both lower limbs, with multiple chronic ulcers appearing on the right foot. Local hospital treatments, including wound dressing changes and symptomatic management, have shown limited efficacy.\u0026quot; For further treatment, she was transferred to our hospital. After completing outpatient examinations, she was diagnosed with \u0026quot;1. Right diabetic foot ulcer (Wagner stage 2); 2. T2DM; 3. Diabetic peripheral neuropathy\u0026quot; and admitted for inpatient treatment. She underwent surgical intervention with \u0026quot;modified induction membrane combined with TTT.\u0026quot; Postoperative follow-up for 12 months showed good wound healing at the affected foot, with no recurrence of ulcerative wounds (see Figures A\u0026ndash;H).\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1 Comparison of preoperative general data between the two groups\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003egroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of cases\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e（\u0026nbsp;human being\u0026nbsp;）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u003cstrong\u003esex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eage\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e（\u0026nbsp;year\u0026nbsp;）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ecourse of disease\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e（\u0026nbsp;year\u0026nbsp;）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWagner classify\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e（\u0026nbsp;example\u0026nbsp;）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003ewoman\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003etreatment group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e45～70\u003c/p\u003e\n \u003cp\u003e(Average 62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e5.0～20\u003c/p\u003e\n \u003cp\u003e(Average 4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003eGrade 2: 7 cases\u003c/p\u003e\n \u003cp\u003eGrade 3: 11 cases\u003c/p\u003e\n \u003cp\u003eGrade 4: 12 cases\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003econtrol group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e43～71\u003c/p\u003e\n \u003cp\u003e(average 61.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e5.2～21\u003c/p\u003e\n \u003cp\u003e(Average 5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003eGrade 2: 7 cases\u003c/p\u003e\n \u003cp\u003eGrade 3: 10 cases\u003c/p\u003e\n \u003cp\u003eGrade 4: 13 cases\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e There were no significant differences between the two groups in terms of gender, age, duration of diabetic foot disease, and Wagner classification (\u003cem\u003eP\u003c/em\u003e\u0026gt;0.05).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;Comparison of VAS scores, MNSI scores, and AOFAS scores before and after surgery between the two groups ( \u0026plusmn; s)\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003egroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of cases\u0026nbsp;\u003c/strong\u003e(people)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(month)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVAS score\u0026nbsp;\u003c/strong\u003e(points)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMNSI score\u003c/strong\u003e (points)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAOFAS score\u0026nbsp;\u003c/strong\u003e(points)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.5\u0026plusmn;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.2\u0026plusmn;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54.5\u0026plusmn;5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003etreatment\u003c/strong\u003e group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 months postoperatively\u003c/p\u003e\n \u003cp\u003e12 months postoperatively\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.5\u0026plusmn;0.5\u003c/p\u003e\n \u003cp\u003e3.8\u0026plusmn;0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.0\u0026plusmn;0.4\u003c/p\u003e\n \u003cp\u003e1.0\u0026plusmn;0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e77.0\u0026plusmn;3.5\u003c/p\u003e\n \u003cp\u003e89.5\u0026plusmn;2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.0\u0026plusmn;1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.0\u0026plusmn;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54.6\u0026plusmn;5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003econtrol\u0026nbsp;\u003c/strong\u003egroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 months postoperatively\u003c/p\u003e\n \u003cp\u003e12 months postoperatively\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.5\u0026plusmn;0.5\u003c/p\u003e\n \u003cp\u003e4.8\u0026plusmn;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.5\u0026plusmn;0.6\u003c/p\u003e\n \u003cp\u003e2.5\u0026plusmn;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e65.5\u0026plusmn;5.5\u003c/p\u003e\n \u003cp\u003e82.0\u0026plusmn;3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003et\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003epric\u003c/strong\u003e\u003cstrong\u003ee\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 months postoperatively\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12 months postoperatively\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eprice\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 months postoperatively\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12 months postoperatively\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNote: The between-group comparison was performed using an independent samples t-test with a significance level of \u0026alpha;=0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3 Comparison of wound healing time, amputation rate, ulcer recurrence rate, and mean length of hospital stay between the two groups\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003egroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of cases\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e（\u0026nbsp;human being\u0026nbsp;）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWound healing time\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e（\u0026nbsp;sky\u0026nbsp;）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eamputation rate\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e（%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUlcer recurrence rate\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e（%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAverage length of hospital stay\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e（\u0026nbsp;sky\u0026nbsp;）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003etreatment\u0026nbsp;group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e38.5\u0026plusmn;4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1（3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1（3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.0\u0026plusmn;1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003econtrol group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e45.7\u0026plusmn;5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3（10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2（6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.0\u0026plusmn;1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Modified Induced Membrane Technique, Tibial Transverse Transport, Diabetic Foot Ulcer","lastPublishedDoi":"10.21203/rs.3.rs-9151446/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9151446/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eDiabetic foot ulcer (DFU), a common and severe complication among diabetic patients, has become a global healthcare challenge due to its high incidence rate and associated amputation risk. The cornerstone of DFU management lies in improving local blood circulation, promoting wound healing, and controlling infection. However, conventional treatment methods often suffer from prolonged healing periods, relatively high invasiveness, or frequent complications. In this context, innovative research on combining a modified induced membrane technique with tibial transverse transport (TTT) offers a novel therapeutic approach for the clinical management of DFU.Objective: \u0026nbsp;To investigate the efficacy of combining modified induced membrane technique with tibial transverse transport (TTT) in treating DFU.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A retrospective analysis was conducted on 60 DFU patients treated at the Orthopedic Center of Xinjiang Uygur Autonomous Region Peoples Hospital between June 2020 and June 2024. Based on surgical approaches, patients were divided into a treatment group (modified induced membrane technique + TTT, 30 patients) and a control group (traditional transverse bone transport technique, 30 patients). Key clinical outcomes were compared postoperatively, including Visual Analogue Scale (VAS) pain scores, Michigan Neuropathy Screening Instrument (MNSI) scores, American Orthopaedic Foot \u0026amp; Ankle Society (AOFAS) scores, wound healing time, amputation rate, ulcer recurrence rate, and average hospital stay.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003eAll patients completed follow-up (range: 6-18 months; mean: 11.0 ± 1.5 months). At final follow-up, the treatment group exhibited significantly higher AOFAS scores ( \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05), while demonstrating significantly lower VAS scores, MNSI scores, wound healing time, amputation rate, ulcer recurrence rate, and average hospital stay compared to the control group ( \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eModified induced membrane technique combined with TTT significantly improves clinical symptoms, shortens wound healing time and hospitalization duration, and reduces amputation and recurrence rates in DFU patients, demonstrating considerable clinical value.\u003c/p\u003e","manuscriptTitle":"Combined Modified Induced Membrane and Tibial Transport for Diabetic Foot Ulcers: A Controlled Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-28 05:39:36","doi":"10.21203/rs.3.rs-9151446/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-10T18:47:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-20T09:47:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"254339268542854194920869692201548533193","date":"2026-04-19T16:59:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180551062542158478382767473691621386192","date":"2026-04-18T07:17:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-17T15:32:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-21T08:24:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-21T08:24:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Medical Research","date":"2026-03-17T17:19:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6fe4f1df-78c2-4824-ba7d-6ad976784dc1","owner":[],"postedDate":"April 28th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-10T18:47:37+00:00","index":40,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-28T05:39:42+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-28 05:39:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9151446","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9151446","identity":"rs-9151446","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}