The choice of single bone flap TTT and double bone flaps TTT to treat severe diabetic foot ulcer: a clinical exploration

The choice of single bone flap TTT and double bone flaps TTT to treat severe diabetic foot ulcer: a clinical exploration | 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 The choice of single bone flap TTT and double bone flaps TTT to treat severe diabetic foot ulcer: a clinical exploration Guicheng Li, Yusong Yuan, Ying Chen, Hailin Xu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7931428/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Aims This study aimed to compare the differences between single and double flap TTT (hereafter, sTTT and dTTT, respectively) for treatment of severe chronic diabetic foot ulcer in terms of biomechanics, safety, and efficacy. Methods The retrospectively conducted clinical study analyzed the basic epidemiological data, therapeutic effect, and safety of patients in the sTTT and dTTT cohorts. Results The clinical results showed that the operation time of sTTT was significantly longer than that of dTTT (p = 0.001). The mean healing time was 32.1 ± 3.9 and 29.7 ± 1.7 weeks in the sTTT and dTTT groups, respectively (p = 0.532). There was no significant difference in foot microcirculation indicators and VAS between the two groups at 12 months after the operation, but the complication rate of sTTT was significantly higher than that of dTTT (p < 0.001). Conclusion Both dTTT and sTTT can effectively treat severe chronic diabetic foot ulcers. However, the operation time of dTTT is shorter and safer. diabetic foot ulcer sTTT dTTT Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1. Introduction Currently, China has the largest number of diabetes patients in the world. Diabetic foot ulcer (DFU) is one of the main chronic complications of diabetes and is characterized by a long course of treatment, high disability rate, difficult cure, and heavy psychological and economic burden, which seriously threaten the prognosis and quality of life of patients[ 1 ].Amputation is the most common therapeutic outcome of DFU. According to relevant statistics, about 40%–70% of all low distal limbs amputations, even up to 90% in many geographical regions, in patients were related to diabetes, while about 85% of all diabetes-related low distal amputation were caused by foot ulcers[ 2 , 3 ] , [ 4 ]. Despite evidence to show that mortality has decreased with the introduction of aggressive cardiovascular risk management protocols 5 , the 5-year overall average survival rate for patients with diabetic foot after major amputations is only 29% 4 . Therefore, the most effective and optimal treatment choice for DFU to preserve the patients’ limbs is still debatable among endocrinologists, vascular surgeons, and orthopedic surgeons. At the beginning of the 21th century, Chinese orthopedic surgeons invented the transverse tibial transport (TTT) technique to treat severe DFU according to the stress tension rule proposed by Professor Ilizarov. The operation could improve the blood supply of the lower extremities by periodically carrying the tibial bones to promote ulcer healing. The DFU healing rate could reach > 95% after TTT treatment, significantly reducing the large amputation rate of DFU patients[ 5 ]. At present, there is no systematic evaluation of TTT. There might be many improvements could be done to TTT, especially because of its destruction of the integrity of the tibia, which may cause mechanical instability and iatrogenic fractures of the tibia. According to the number of transported bones, the reported TTT procedures can be divided into single flap TTT (sTTT)[ 5 – 7 ] and double flap TTT (dTTT)[ 8 ]. Although the therapeutic effects of these two surgical methods were similar, the incidence of complications was different. In particular, iatrogenic tibial fractures have become the main complication of sTTT in the treatment of DFU after infection. In the reported cases of DFU treated with dTTT, iatrogenic fractures seemed rare. To evaluate the biomechanical stability and effectiveness of these two surgical methods in an all-round way, this study explored the two surgical methods through cadaver bone biomechanical testing and historical cohort clinical data. 2. Materials and methods 2.1 Patients Patients with DFU who were hospitalized in Beijing Longfu Hospital from January 2017 to June 2021 were selected. There were 82 patients in the sTTT group (61 male and 21 female; mean age: 68.7 ± 7.8 years) and 204 patients in the dTTT group (141 male and 63 female, mean age: 68.1 ± 8.1 years) (Table 2 ). All research procedures were approved by the Ethics Committee of Beijing Longfu Hospital (no. LFYYLL-2021-24). Table 1 Biomechanical results of two groups Group a (Nm/deg) stiffness (N/mm) a (N/mm) sTTT 3.61 ± 2.03 1540.78 ± 991.38 1052.21 ± 375.31 dTTT 4.13 ± 2.26 2341.77 ± 766.27 1074.36 ± 462.17 P value 0.008 0.038 0.869 Table 2 Demographics of patients Characters sTTT dTTT P value Gender, n 0.168 Male 61 141 Female 21 63 Age, years 68.7 ± 7.8 68.1 ± 8.1 0.478 BMI 27.2 ± 1.7 25.2 ± 2.3 1.754 HbA1c, % 14.5 ± 1.9 13.9 ± 2.1 0.996 duration of diabetes, years 8.9 ± 1.2 10.8 ± 0.81.267 1.267 duration of ulcer, weeks 4.9 ± 1.1 5.1 ± 0.6 0.478 TAXAS classification, n 0.391 3B 0 2 3C 3 5 3D 18 71 4D 51 126 BMI: body mass index; HbA1C: haemoglobin A1c. 2.2 Inclusion criteria Diabetic foot Texas University grade 3C or 3D; ultrasound Doppler examination of popliteal artery patency rate > 50%; and follow-up time was ≥ 12 months. 2.3 Exclusion criteria Patients with mental illnesses who could not cooperate with treatment; those with other uncontrollable severe diabetic complications diagnosed by an endocrinologist; those who could not tolerate anesthesia due to cardiovascular complications or renal failure; those with non-diabetic ulcers; those in whom the skin condition of the leg could not meet the surgical requirements; those with active Charcot foot; those with a history of cerebral or myocardial infarction, heart failure, cancer, or kidney failure in the past 3 months; those on treatment with corticosteroids, immunosuppressive drugs, and/or chemotherapy. 2.4 Treatments 2.4.1 General treatments All patients were consulted by endocrinologists and vascular surgeons for evaluation of blood glucose levels and lower extremity vascular status after admission. The blood glucose control standard of patients was rapid blood glucose < 7 mmol/L before a meal and rapid blood glucose < 11 mmol/L, 2 h after a meal. Ward nurses performed routine foot care for patients. If DFU patients had underlying infection, the wound secretion exudate was taken for bacterial culture and drug sensitivity identification testing was carried out; appropriate antibiotics were then selected for intravenous application according to the drug sensitivity results. All patients underwent emergency surgery with complete debridement of foot necrotic tissue, incision negative pressure drainage, and wound treatment. 2.4.2 Surgery 2.4.2.1 sTTT The surgeon disinfected the affected limb and spread sterile towels after nerve block anesthesia was administered to the affected limb. The osteotomy area was located 5 cm distal to the tibial tubercle on the medial side of the tibia. An arc incision measuring about 5 cm in length was made, and the tissue was separated to the superficial surface of the periosteum (without cutting the periosteum). A closed osteotomy device was used to drill continuously along the osteotomy guide plate on the medial tibial crest to form a tibial cortical bone window of about 15 mm×50 mm. Next, two traction needles were implanted on the bone window flap, and a fixed needle was implanted at the distal and proximal ends of the bone window. After the external fixator was installed, the bone flap of the bone window was cut off using a bone knife along the borehole around the bone window. Finally, the tibial transverse bone transport device was installed, and each bone needle was firmly locked. The subcutaneous tissue and skin were sutured. The incision was bandaged with dressing after disinfection by medical alcohol (Fig. 3 ). 2.4.2.1 dTTT After nerve block anesthesia was administered to affected limb, the patient was placed in the supine position, and the affected limb was routinely disinfected. Two 3.0-mm Steinmann pins were implanted along the midline of the medial longitudinal axis of the proximal tibia of the affected limb. Then, the skin was cut along the long axis with a 3.0-mm Steinmann pin as the center, and the subcutaneous tissue was bluntly separated to expose the periosteum. With the implanted Steinmann pin as the center, two square bone windows with a side length of 2.5 cm were drilled with a rapid osteotomy device. Then, subperiosteal osteotomy was performed with a narrow bone knife with a diameter of 5 mm at an angle of 15°–30° to the bone surface. Finally, the external fixator was installed and fixed with 4.0-mm Kirschner wire at the distal and proximal ends of the osteotomy area, respectively. Subcutaneous tissue and skin were sutured layer-by-layer and bandaged with dressing after disinfection by medical alcohol (Fig. 3 ). 2.4.3 Post-Surgery The patients’ blood glucose was strictly controlled with nutrition support after surgery. Endocrinologists were invited to assist in treatment if necessary. According to the results of bacterial culture and identification of preoperative wound secretions and intraoperative deep tissue biopsy, appropriate antibiotics were continuously selected for intravenous drip. After three postoperative days, the bone flaps were transported outwards perpendicular to the long axis of the tibia at the rate of 1 mm/day, which was divided into four timepoints: morning, mid-day, evening, and bedtime for a total of 14 days. Then, the bone flaps were reset and transported 2 mm every day, which was also completed four times with a total of 7 days (Fig. 4 ). If the patient experienced intolerable pain during the bone transport or if the local skin color became darker and the blood supply became worse, the outward movement was stopped and a gradual inward movement was attempted to avoid flap necrosis. After the bone flaps were completely reduced, they was transported perpendicular to the long axis of the tibia, and 1 mm was transported every 2 days. After the pain was significantly relieved, it was changed to 1 mm per day as mentioned above. After the bone was completely reset, the external fixator was removed and a tibia brace was worn. At this time, the affected limb could be partial weight-bearing. The radiographic films of the affected limbs were reviewed monthly to observe healing of the bone window. Early ulcer wounds after the first debridement might still have secondary necrosis, and the necrotic sites may involve the skin, fascia, muscle, tendon, and bone tissue. Physicians could use the following wound treatment methods when changing the wound dressing: physical debridement under local anesthesia, antibiotic bone cement covering surface, and vacuum sealing drainage. After removal of the tibial external fixator, patients with unhealed wounds continued to undergo debridement and received dressing changes. 2.5 Follow-up Outpatient follow-up was performed at 1, 6, and 12 months postoperatively. The follow-up included evaluation of wound healing and healing time, amputation, ulcer recurrence rate, visual analogue scale (VAS), ankle-brachial index (ABI), dorsal pedis temperature (DPT), transcutaneous oxygen pressure (TCPO 2 ), and related complications. Ulcers were considered healed when complete epithelialization was observed without drainage and maintained for at least 2 weeks[ 9 ]. 3. Statistical analysis SPSS 19.0 statistical software (IBM Corporation, Armonk, NY, USA) was used to analyze the data. Data that did not conform to normal distribution were tested by rank sum test. Normally distributed biomechanical data and clinical data of patients were tested by paired t -test and independent sample t -test, respectively. P < 0.05 was considered to indicate statistically significant differences. Test level α is 0.05. 3. Results 3.1 Both dTTT and sTTT could effectively treat severe DFU There was no significant difference in BMI, duration of diabetes, duration of DFU, and Texas stage between the sTTT group and dTTT group (Table 2 ) and all diabetic foot ulcers patients had been healed (Fig. 5 ). The preoperative skin temperature, ABI, and TCPO 2 of the patients in the sTTT group were 29.5 ± 1.98°C, 0.31 ± 0.51, and 28.4 ± 2.14 mmHg, respectively, which were significantly lower than 34.8 ± 1.35°C, 0.77 ± 0.35, and 41.2 ± 2.78 mmHg at 6 months post-surgery (Table 3 ). Dorsal foot skin temperature, ABI, and TCPO 2 were also significantly higher at 12 months postoperatively than preoperatively in the dTTT group (p < 0.001) (Table 4 ). Table 3 Therapeutic effects of sTTT Characters Pre-op 12 months post-op P value dorsum pedis temperature, ℃ 29.5 ± 1.98 34.8 ± 1.35 < 0.001 ABI 0.31 ± 0.51 0.77 ± 0.35 < 0.001 TCPO 2 , mmHg 28.4 ± 2.14 41.2 ± 2.78 < 0.001 VAS 7.4 ± 0.36 1.2 ± 0.67 < 0.001 ABI: ankle brachial index; TCPO 2 : percutaneous oxygen partial pressure; VAS: visual analogue scale; pre-op: pre-operation; post-op: post-operation. Table 4 Therapeutic effects of dTTT Characters Pre-op 12 months post-op P value dorsum pedis temperature, ℃ 27.8 ± 0.79 35.1 ± 1.24 < 0.001 ABI 0.33 ± 0.69 0.92 ± 0.15 < 0.001 PTCO 2 , mmHg 28.9 ± 1.85 40.1 ± 1.96 < 0.001 VAS 7.1 ± 0.39 0.7 ± 0.56 < 0.001 ABI: ankle brachial index; PTCO 2 : percutaneous oxygen partial pressure; VAS: visual analogue scale; pre-op: pre-operation; post-op: post-operation. The VAS of the sTTT group and dTTT group at 12 months post-surgery was 1.2 ± 0.67 and 0.7 ± 0.56, respectively, which was significantly lower than that of the two groups before operation (p < 0.001) (Tables 3 , 4 ). 3.2 There was no difference between dTTT and sTTT in the treatment of severe DFU At 12 months postoperatively, there was no significant difference in dorsal skin temperature, VAS, ABI, and PCO2 between the two groups (p = 0.268, 0.432, 0.842, and 0.764, respectively) (Table 5 ). Table 5 comparison of therapeutic effects of two technique. Characters sTTT dTTT P value dorsum pedis temperature, ℃ 34.8 ± 1.35 35.1 ± 1.24 0.268 ABI 0.77 ± 0.35 0.92 ± 0.15 0.842 PTCO 2 , mmHg 41.2 ± 2.78 40.1 ± 1.96 0.764 VAS 1.2 ± 0.67 0.7 ± 0.56 0.432 healing period, weeks 32.1 ± 3.9 29.7 ± 1.7 0.532 ABI: ankle brachial index; PTCO 2 : percutaneous oxygen partial pressure; VAS: visual analogue scale. Table 6 Advantages of dTTT sTTT dTTT P value complications 12 1 < 0.001 infection 7 1 < 0.001 osteomyelitis 2 0 < 0.001 fracture 3 0 < 0.001 op time, min 48.7 ± 5.6 26.1 ± 1.31 0.0011 Op: operation. 3.3 dTTT was safer and faster than sTTT Twelve months after the surgery, there were 13 cases of postoperative complications in the sTTT group, including incision infection (n = 7, 8.6%), osteomyelitis (n = 2, 2.4%), and iatrogenic fracture (n = 3, 3.6%). By contrast, only one case of incision infection was found in the dTTT group 12 months postoperatively (0.46%), and the incidence of complications was significantly lower than in the sTTT group (14.6% vs. 0.46%, p < 0.001). The mean operation time of sTTT was 48.7 ± 5.6 min, which was significantly longer than the 26.1 ± 1.31 min required for dTTT (p = 0.0011). 4. Discussion The pathogenesis of DFU is complex and has not yet been fully elucidated. Studies have found that 25–44% of DFU is caused by neuropathy, 10% by limb ischemia, and 45–60% by neuropathy combined with ischemia. The patients’ nutritional status, vascular condition, and infection have been shown to play a major role in ulcer healing[ 10 ] , [ 11 ]. Russian Professor Ilizarov proposed the “tension-stress rule,” wherein the periodic transport of bone mass could reshape microcirculation[ 12 , 13 ]. Anatomical studies have found that long bones have dense transcortical vessels (TCV) closed blood circulation system (60% arteries, 40% veins)[ 14 ] , [ 15 ], which may be one of the anatomical basis by which TTT promotes microcirculation reconstruction. Iliopoulos et al. found that slow traction stimulation of the tibial bone marrow can not only accelerate mitosis of vascular endothelial cells to continue tissue regeneration and reconstruction of local blood circulation[ 16 ] but also effectively reduce bone pressure and ease the occurrence of small vasospasm and improve local ischemic symptoms and skin color. Li et al. speculated that the mechanism of TTT promoting microcirculation regeneration may be attributed to the following reasons: (i) tibial fenestration can reduce intramedullary pressure and improve microcirculation; (ii) tension stress stimulation can promote capillary regeneration and accelerate the formation of new TCV network; and (iii) systemic stem cell mobilization, reduce local inflammatory response[ 17 ]. To the best of our knowledge, no TTT-related biomechanical study has yet been reported. This study is the first biomechanical analysis of TTT surgery. The biomechanical study of cadaver bones found that the mechanical stability of the tibia after dTTT surgery was better than that after sTTT surgery, indicating that patients with DFU treated with dTTT can move early after surgery, thereby being able to establish lower limb circulation. The tibial anti-axial compression and torsion ability is stronger after dTTT surgery than sTTT surgery. We used a three-point lateral bending test to characterize the ability of the tibia to resist lateral stress after surgery. Because the tibia is similar to a triangular prism, and the body resources are limited, we only detected the ability to resist lateral stress on one surface. The experimental results showed the same trend as the axial compression and torsion experiments. Researchers believe that similar to the field of construction engineering, the mechanical stability of the 工-shaped support structure is better than that of the 口 shape, and the bone window shape of dTTT could resist stronger stress than sTTT. Regarding the efficacy of TTT, our study’s results were consistent with those of other reports on the two TTT methods, in that that both techniques could effectively treat severe DFU. At the same time, the therapeutic effects of both treatment methods had no significant difference in the immediate future. Based on the positive results of TTT in the treatment of ischemic foot ulcers, Hua et al. recommend that it should be used for ulcers with a grade of Texas 2B and above (i.e., wounds that penetrate tendons, joint capsules, bones, or joints with infection and/or ischemia) [18] . At present, the method reported more often is sTTT. The effective rate of sTTT in the treatment of DFU ranged between 88.24% and 94.9% [19, 20] , which might be related to the surgeon’s skill and experience. Appropriate surgical instruments could also reduce the difficulty of surgery and help in patient recovery. In this study, although the incidence of complications of sTTT was only 14.63%, it was still significantly higher than that of dTTT, especially iatrogenic infection and fracture. The reason might be that the biomechanical stability of dTTT was better than that of sTTT, which was consistent with our biomechanical results. This study has some limitations. First, because both sTTT and dTTT have been proven safe and effective in retrospective studies, the purpose of this study was only to evaluate the differences between these two treatment methods. More in-depth biomechanical research should be carried out for standardized TTT treatment of DFU. Second, given the limited source of cadaver bones, this study was unable to use fresh cadaver bones for research. However, we classified the tibiae on both sides of the same cadaver into two different groups and performed the same test to maximize the extrapolation and comparability of data and consistency of the baseline data. Last, our clinical data were analyzed using a retrospective cohort study which is inherently prone to information bias. In the future, we aim to conduct a prospective study to standardize the clinical application of TTT in the treatment of DFU. Conclusion Both sTTT and dTTT could effectively treat severe DFU. The mechanical stability and safety of the tibia after dTTT osteotomy were better than after sTTT. Abbreviations sTTT: single bone flap transverse tibial transport; dTTT: double bone flaps transverse tibial transport; ABI: ankle brachial index; TCPO 2 : percutaneous oxygen partial pressure; VAS: visual analogue scale; pre-op: pre-operation; post-op: post-operation; BMI: body mass index; HbA1C: haemoglobin A1c. Declarations Consent of publication The study was performed in accordance with ethical standards, with the protocol approved by the hospital’s ethics committee, ensuring data privacy and confidentiality Ethics approval and consent to participate All research procedures were approved by the Ethics Committee of Beijing Longfu Hospital (no. LFYYLL-2021-24 and no. LFYYLL-2021-23). Informed consent to participation was obtained from all study participants.This study complied with the provisions of the Declaration of Helsinki. Funding This study was supported by Elite Medical Professionals Project of China-Japan Friendship Hospital, No. ZRJY2023-QM29; Capital`s Funds for Health Improvement and Research, No. 2020-2-4086; Beijing Health Science and Technology Achievements and Appropriate Technology Promotion Project, No. BHTPP2022015; National Key R&D Program of China, No. 2022YFC2504302; Beijing Natural Science Foundation, No. L234015. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest withrespect to the research, authorship, and/or publication of this article. Only the language has been revised by ChatGPT. Contribution statement Guicheng li and Yusong Yuan performed experiments, analyzed results, and prepared the draft. Hailin Xu and Ying Chen provided data interpretation, collected human samples, accounted for clinical practice, designed and supervised the study, revised the manuscript, and obtained funding support. All authors contributed to the final article. 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Modified tibial transverse transport technique for the treatment of ischemic diabetic foot ulcer in patients with type 2 diabetes. J Orthop Translat. 2021; 29:100-105. van Netten JJ, Bus SA, Apelqvist J, Lipsky BA, Hinchliffe RJ, Game F, Rayman G, Lazzarini PA, Forsythe RO, Peters EJG, Senneville E, Vas P, Monteiro-Soares M, et al. Definitions and criteria for diabetic foot disease. Diabetes Metab Res Rev. 2020; 36 Suppl 1:e3268. Guo S and Dipietro LA. Factors affecting wound healing. J Dent Res. 2010; 89(3):219-229. Apelqvist J. The foot in perspective. Diabetes Metab Res Rev. 2008; 24 Suppl 1:S110-115. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res. 1989; (238):249-281. Ilizarov GA. The principles of the Ilizarov method. 1988. Bull Hosp Jt Dis. 1997; 56(1):49-53. Gruneboom A, Hawwari I, Weidner D, Culemann S, Muller S, Henneberg S, Brenzel A, Merz S, Bornemann L, Zec K, Wuelling M, Kling L, Hasenberg M, et al. A network of trans-cortical capillaries as mainstay for blood circulation in long bones. Nat Metab. 2019; 1(2):236-250. da Silva LP, Santos TC, Rodrigues DB, Pirraco RP, Cerqueira MT, Reis RL, Correlo VM and Marques AP. Stem Cell-Containing Hyaluronic Acid-Based Spongy Hydrogels for Integrated Diabetic Wound Healing. J Invest Dermatol. 2017; 137(7):1541-1551. Iliopoulos E, Morrissey N, Cho S and Khaleel A. Outcomes of the Ilizarov frame use in elderly patients. J Orthop Sci. 2017; 22(4):783-786. Yang Y and Li G. [Biological mechanisms of tibial transverse transport for promoting microcirculation and tissue repair]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2020; 34(8):964-968. Nie X, Kuang X, Liu G, Zhong Z, Ding Y, Yu J, Liu J, Li S, He L, Su H, Qin W, Zhao J, Hua Q, et al. Tibial cortex transverse transport facilitating healing in patients with recalcitrant non-diabetic leg ulcers. J Orthop Translat. 2021; 27:1-7. Li H, You J, Liu C and Ma Y. [Effectiveness of transverse tibial bone transport in treatment of diabetic foot ulcer]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2019; 33(1):23-27. Chen Y, Ding X, Zhu Y, Jia Z, Qi Y, Chen M, Lu J, Kuang X, Zhou J, Su Y, Zhao Y, Lu W, Zhao J, et al. Effect of tibial cortex transverse transport in patients with recalcitrant diabetic foot ulcers: A prospective multicenter cohort study. J Orthop Translat. 2022; 36:194-204. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. 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13:56:22","extension":"png","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":22067,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7931428/v1/0c17e882caed2f57a228aae0.png"},{"id":97260058,"identity":"0a71f6ec-ffab-4faf-8682-0f3c5580ceef","added_by":"auto","created_at":"2025-12-02 13:56:22","extension":"png","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":59109,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7931428/v1/9a7ee2282045c8249e5e54d9.png"},{"id":97260060,"identity":"796a10ce-e09d-471b-9044-49188ddfef45","added_by":"auto","created_at":"2025-12-02 13:56:22","extension":"xml","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":83994,"visible":true,"origin":"","legend":"","description":"","filename":"e8441e46756444f08892f357ecc3ea9f1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7931428/v1/0061dce985b2627b098e73c2.xml"},{"id":97367284,"identity":"b8acacf2-a009-4db4-a6a2-ded210a00206","added_by":"auto","created_at":"2025-12-03 16:17:56","extension":"html","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":92372,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7931428/v1/a2392ccd4fd45dde4bfa2653.html"},{"id":97368370,"identity":"545eb699-6aaa-4f25-8d38-2a5c88d8e7e6","added_by":"auto","created_at":"2025-12-03 16:22:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":232625,"visible":true,"origin":"","legend":"\u003cp\u003eAppearance of tibia after bone removal. The left side was the tibia of the sTTT group with a bone window size of 5.0 cm * 1.5 cm, and the right side was the tibia of the dTTT group with a bone window size of 2.5 cm * 2.5 cm * 2.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7931428/v1/a24791fa78d299a15522827d.png"},{"id":97260047,"identity":"ad34d04c-c9de-44ad-b2f1-b44769bae01e","added_by":"auto","created_at":"2025-12-02 13:56:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":459686,"visible":true,"origin":"","legend":"\u003cp\u003eBiomechanical experiment diagram. A, B and C are the images of axial compression experiment, torsion experiment and three-point bending experiment respectively. The arrow points to the position of the bone window.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7931428/v1/d8bc26e513c9f9b290d50bb5.png"},{"id":97260043,"identity":"e874b010-79e9-42e2-9847-cd6b5aa31274","added_by":"auto","created_at":"2025-12-02 13:56:22","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":580528,"visible":true,"origin":"","legend":"\u003cp\u003eBone flap cutting operation diagram. A and B were the tibial bone resection methods of sTTT. The 15 mm × 50 mm tibial cortical bone flap was cut off. C and D were the tibial bone flaps of dTTT. Two 25 mm × 25 mm bone flaps were cut off.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7931428/v1/87d9713ec5a1dbacf087d7c3.png"},{"id":97260044,"identity":"01e284ed-b3e8-4252-83ad-0d04ae3c23b8","added_by":"auto","created_at":"2025-12-02 13:56:22","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":72123,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative bone transport diagram.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7931428/v1/4f1bc77b61b2442446182403.png"},{"id":97367600,"identity":"2afe2698-bf48-4186-b962-de682305783f","added_by":"auto","created_at":"2025-12-03 16:19:42","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":573357,"visible":true,"origin":"","legend":"\u003cp\u003eAppearance of ulcer surface. A and B are the wound conditions before and 16 weeks after sTTT; C, D are the wound conditions before and 16 weeks after dTTT.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7931428/v1/90875768b29475b061adce54.png"},{"id":102296698,"identity":"bb66365b-bce2-4b60-85e9-3fa20f8d36d8","added_by":"auto","created_at":"2026-02-10 10:20:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3392796,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7931428/v1/f6bf5f10-58d9-4723-a2ad-5a1e18d31ae0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The choice of single bone flap TTT and double bone flaps TTT to treat severe diabetic foot ulcer: a clinical exploration","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eCurrently, China has the largest number of diabetes patients in the world. Diabetic foot ulcer (DFU) is one of the main chronic complications of diabetes and is characterized by a long course of treatment, high disability rate, difficult cure, and heavy psychological and economic burden, which seriously threaten the prognosis and quality of life of patients[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].Amputation is the most common therapeutic outcome of DFU. According to relevant statistics, about 40%\u0026ndash;70% of all low distal limbs amputations, even up to 90% in many geographical regions, in patients were related to diabetes, while about 85% of all diabetes-related low distal amputation were caused by foot ulcers[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite evidence to show that mortality has decreased with the introduction of aggressive cardiovascular risk management protocols\u003csup\u003e5\u003c/sup\u003e, the 5-year overall average survival rate for patients with diabetic foot after major amputations is only 29%\u003csup\u003e4\u003c/sup\u003e. Therefore, the most effective and optimal treatment choice for DFU to preserve the patients\u0026rsquo; limbs is still debatable among endocrinologists, vascular surgeons, and orthopedic surgeons.\u003c/p\u003e\u003cp\u003eAt the beginning of the 21th century, Chinese orthopedic surgeons invented the transverse tibial transport (TTT) technique to treat severe DFU according to the stress tension rule proposed by Professor Ilizarov. The operation could improve the blood supply of the lower extremities by periodically carrying the tibial bones to promote ulcer healing. The DFU healing rate could reach\u0026thinsp;\u0026gt;\u0026thinsp;95% after TTT treatment, significantly reducing the large amputation rate of DFU patients[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAt present, there is no systematic evaluation of TTT. There might be many improvements could be done to TTT, especially because of its destruction of the integrity of the tibia, which may cause mechanical instability and iatrogenic fractures of the tibia. According to the number of transported bones, the reported TTT procedures can be divided into single flap TTT (sTTT)[\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and double flap TTT (dTTT)[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Although the therapeutic effects of these two surgical methods were similar, the incidence of complications was different. In particular, iatrogenic tibial fractures have become the main complication of sTTT in the treatment of DFU after infection. In the reported cases of DFU treated with dTTT, iatrogenic fractures seemed rare.\u003c/p\u003e\u003cp\u003eTo evaluate the biomechanical stability and effectiveness of these two surgical methods in an all-round way, this study explored the two surgical methods through cadaver bone biomechanical testing and historical cohort clinical data.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Patients\u003c/h2\u003e\u003cp\u003ePatients with DFU who were hospitalized in Beijing Longfu Hospital from January 2017 to June 2021 were selected. There were 82 patients in the sTTT group (61 male and 21 female; mean age: 68.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8 years) and 204 patients in the dTTT group (141 male and 63 female, mean age: 68.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1 years) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). All research procedures were approved by the Ethics Committee of Beijing Longfu Hospital (no. LFYYLL-2021-24).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBiomechanical results of two groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ea (Nm/deg)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003estiffness (N/mm)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ea (N/mm)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003esTTT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.61\u0026thinsp;\u0026plusmn;\u0026thinsp;2.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1540.78\u0026thinsp;\u0026plusmn;\u0026thinsp;991.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1052.21\u0026thinsp;\u0026plusmn;\u0026thinsp;375.31\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003edTTT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.13\u0026thinsp;\u0026plusmn;\u0026thinsp;2.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2341.77\u0026thinsp;\u0026plusmn;\u0026thinsp;766.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1074.36\u0026thinsp;\u0026plusmn;\u0026thinsp;462.17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.038\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.869\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographics of patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003esTTT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003edTTT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.168\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e141\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e68.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.478\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.754\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHbA1c, %\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.996\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eduration of diabetes, years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81.267\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.267\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eduration of ulcer, weeks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.478\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTAXAS classification, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.391\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3B\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3C\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3D\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4D\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e126\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eBMI: body mass index; HbA1C: haemoglobin A1c.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Inclusion criteria\u003c/h2\u003e\u003cp\u003eDiabetic foot Texas University grade 3C or 3D; ultrasound Doppler examination of popliteal artery patency rate\u0026thinsp;\u0026gt;\u0026thinsp;50%; and follow-up time was \u0026ge;\u0026thinsp;12 months.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Exclusion criteria\u003c/h2\u003e\u003cp\u003ePatients with mental illnesses who could not cooperate with treatment; those with other uncontrollable severe diabetic complications diagnosed by an endocrinologist; those who could not tolerate anesthesia due to cardiovascular complications or renal failure; those with non-diabetic ulcers; those in whom the skin condition of the leg could not meet the surgical requirements; those with active Charcot foot; those with a history of cerebral or myocardial infarction, heart failure, cancer, or kidney failure in the past 3 months; those on treatment with corticosteroids, immunosuppressive drugs, and/or chemotherapy.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Treatments\u003c/h2\u003e\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\u003ch2\u003e2.4.1 General treatments\u003c/h2\u003e\u003cp\u003eAll patients were consulted by endocrinologists and vascular surgeons for evaluation of blood glucose levels and lower extremity vascular status after admission. The blood glucose control standard of patients was rapid blood glucose\u0026thinsp;\u0026lt;\u0026thinsp;7 mmol/L before a meal and rapid blood glucose\u0026thinsp;\u0026lt;\u0026thinsp;11 mmol/L, 2 h after a meal. Ward nurses performed routine foot care for patients. If DFU patients had underlying infection, the wound secretion exudate was taken for bacterial culture and drug sensitivity identification testing was carried out; appropriate antibiotics were then selected for intravenous application according to the drug sensitivity results. All patients underwent emergency surgery with complete debridement of foot necrotic tissue, incision negative pressure drainage, and wound treatment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\u003ch2\u003e2.4.2 Surgery\u003c/h2\u003e\u003cdiv id=\"Sec9\" class=\"Section4\"\u003e\u003ch2\u003e2.4.2.1 sTTT\u003c/h2\u003e\u003cp\u003eThe surgeon disinfected the affected limb and spread sterile towels after nerve block anesthesia was administered to the affected limb. The osteotomy area was located 5 cm distal to the tibial tubercle on the medial side of the tibia. An arc incision measuring about 5 cm in length was made, and the tissue was separated to the superficial surface of the periosteum (without cutting the periosteum). A closed osteotomy device was used to drill continuously along the osteotomy guide plate on the medial tibial crest to form a tibial cortical bone window of about 15 mm\u0026times;50 mm. Next, two traction needles were implanted on the bone window flap, and a fixed needle was implanted at the distal and proximal ends of the bone window. After the external fixator was installed, the bone flap of the bone window was cut off using a bone knife along the borehole around the bone window. Finally, the tibial transverse bone transport device was installed, and each bone needle was firmly locked. The subcutaneous tissue and skin were sutured. The incision was bandaged with dressing after disinfection by medical alcohol (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section4\"\u003e\u003ch2\u003e2.4.2.1 dTTT\u003c/h2\u003e\u003cp\u003eAfter nerve block anesthesia was administered to affected limb, the patient was placed in the supine position, and the affected limb was routinely disinfected. Two 3.0-mm Steinmann pins were implanted along the midline of the medial longitudinal axis of the proximal tibia of the affected limb. Then, the skin was cut along the long axis with a 3.0-mm Steinmann pin as the center, and the subcutaneous tissue was bluntly separated to expose the periosteum. With the implanted Steinmann pin as the center, two square bone windows with a side length of 2.5 cm were drilled with a rapid osteotomy device. Then, subperiosteal osteotomy was performed with a narrow bone knife with a diameter of 5 mm at an angle of 15\u0026deg;\u0026ndash;30\u0026deg; to the bone surface. Finally, the external fixator was installed and fixed with 4.0-mm Kirschner wire at the distal and proximal ends of the osteotomy area, respectively. Subcutaneous tissue and skin were sutured layer-by-layer and bandaged with dressing after disinfection by medical alcohol (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\u003ch2\u003e2.4.3 Post-Surgery\u003c/h2\u003e\u003cp\u003eThe patients\u0026rsquo; blood glucose was strictly controlled with nutrition support after surgery. Endocrinologists were invited to assist in treatment if necessary. According to the results of bacterial culture and identification of preoperative wound secretions and intraoperative deep tissue biopsy, appropriate antibiotics were continuously selected for intravenous drip.\u003c/p\u003e\u003cp\u003eAfter three postoperative days, the bone flaps were transported outwards perpendicular to the long axis of the tibia at the rate of 1 mm/day, which was divided into four timepoints: morning, mid-day, evening, and bedtime for a total of 14 days. Then, the bone flaps were reset and transported 2 mm every day, which was also completed four times with a total of 7 days (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIf the patient experienced intolerable pain during the bone transport or if the local skin color became darker and the blood supply became worse, the outward movement was stopped and a gradual inward movement was attempted to avoid flap necrosis. After the bone flaps were completely reduced, they was transported perpendicular to the long axis of the tibia, and 1 mm was transported every 2 days. After the pain was significantly relieved, it was changed to 1 mm per day as mentioned above.\u003c/p\u003e\u003cp\u003eAfter the bone was completely reset, the external fixator was removed and a tibia brace was worn. At this time, the affected limb could be partial weight-bearing. The radiographic films of the affected limbs were reviewed monthly to observe healing of the bone window.\u003c/p\u003e\u003cp\u003eEarly ulcer wounds after the first debridement might still have secondary necrosis, and the necrotic sites may involve the skin, fascia, muscle, tendon, and bone tissue. Physicians could use the following wound treatment methods when changing the wound dressing: physical debridement under local anesthesia, antibiotic bone cement covering surface, and vacuum sealing drainage. After removal of the tibial external fixator, patients with unhealed wounds continued to undergo debridement and received dressing changes.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Follow-up\u003c/h2\u003e\u003cp\u003eOutpatient follow-up was performed at 1, 6, and 12 months postoperatively. The follow-up included evaluation of wound healing and healing time, amputation, ulcer recurrence rate, visual analogue scale (VAS), ankle-brachial index (ABI), dorsal pedis temperature (DPT), transcutaneous oxygen pressure (TCPO\u003csub\u003e2\u003c/sub\u003e), and related complications. Ulcers were considered healed when complete epithelialization was observed without drainage and maintained for at least 2 weeks[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e3. Statistical analysis\u003c/h3\u003e\n\u003cp\u003eSPSS 19.0 statistical software (IBM Corporation, Armonk, NY, USA) was used to analyze the data. Data that did not conform to normal distribution were tested by rank sum test. Normally distributed biomechanical data and clinical data of patients were tested by paired \u003cem\u003et\u003c/em\u003e-test and independent sample \u003cem\u003et\u003c/em\u003e-test, respectively. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate statistically significant differences. Test level α is 0.05.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Both dTTT and sTTT could effectively treat severe DFU\u003c/h2\u003e\u003cp\u003eThere was no significant difference in BMI, duration of diabetes, duration of DFU, and Texas stage between the sTTT group and dTTT group (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) and all diabetic foot ulcers patients had been healed (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe preoperative skin temperature, ABI, and TCPO\u003csub\u003e2\u003c/sub\u003e of the patients in the sTTT group were 29.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.98\u0026deg;C, 0.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51, and 28.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.14 mmHg, respectively, which were significantly lower than 34.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35\u0026deg;C, 0.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35, and 41.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.78 mmHg at 6 months post-surgery (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Dorsal foot skin temperature, ABI, and TCPO\u003csub\u003e2\u003c/sub\u003e were also significantly higher at 12 months postoperatively than preoperatively in the dTTT group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTherapeutic effects of sTTT\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-op\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 months post-op\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003edorsum pedis temperature, ℃\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e29.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e34.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eABI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e0.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTCPO\u003csub\u003e2\u003c/sub\u003e, mmHg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e28.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e41.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVAS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e7.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eABI: ankle brachial index; TCPO\u003csub\u003e2\u003c/sub\u003e: percutaneous oxygen partial pressure; VAS: visual analogue scale; pre-op: pre-operation; post-op: post-operation.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTherapeutic effects of dTTT\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-op\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 months post-op\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003edorsum pedis temperature, ℃\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e27.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e35.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eABI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e0.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePTCO\u003csub\u003e2\u003c/sub\u003e, mmHg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e28.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e40.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVAS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e7.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e0.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eABI: ankle brachial index; PTCO\u003csub\u003e2\u003c/sub\u003e: percutaneous oxygen partial pressure; VAS: visual analogue scale; pre-op: pre-operation; post-op: post-operation.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe VAS of the sTTT group and dTTT group at 12 months post-surgery was 1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67 and 0.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56, respectively, which was significantly lower than that of the two groups before operation (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e3.2 There was no difference between dTTT and sTTT in the treatment of severe DFU\u003c/h2\u003e\u003cp\u003eAt 12 months postoperatively, there was no significant difference in dorsal skin temperature, VAS, ABI, and PCO2 between the two groups (p\u0026thinsp;=\u0026thinsp;0.268, 0.432, 0.842, and 0.764, respectively) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ecomparison of therapeutic effects of two technique.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003esTTT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003edTTT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003edorsum pedis temperature, ℃\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e34.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e35.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.268\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eABI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e0.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.842\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePTCO\u003csub\u003e2\u003c/sub\u003e, mmHg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e41.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e40.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.764\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVAS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e0.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.432\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ehealing period, weeks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e32.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e29.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.532\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eABI: ankle brachial index; PTCO\u003csub\u003e2\u003c/sub\u003e: percutaneous oxygen partial pressure; VAS: visual analogue scale.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAdvantages of dTTT\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003esTTT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003edTTT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ecomplications\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003einfection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eosteomyelitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003efracture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eop time, min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0011\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eOp: operation.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e3.3 dTTT was safer and faster than sTTT\u003c/h2\u003e\u003cp\u003eTwelve months after the surgery, there were 13 cases of postoperative complications in the sTTT group, including incision infection (n\u0026thinsp;=\u0026thinsp;7, 8.6%), osteomyelitis (n\u0026thinsp;=\u0026thinsp;2, 2.4%), and iatrogenic fracture (n\u0026thinsp;=\u0026thinsp;3, 3.6%). By contrast, only one case of incision infection was found in the dTTT group 12 months postoperatively (0.46%), and the incidence of complications was significantly lower than in the sTTT group (14.6% vs. 0.46%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003eThe mean operation time of sTTT was 48.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6 min, which was significantly longer than the 26.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.31 min required for dTTT (p\u0026thinsp;=\u0026thinsp;0.0011).\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe pathogenesis of DFU is complex and has not yet been fully elucidated. Studies have found that 25\u0026ndash;44% of DFU is caused by neuropathy, 10% by limb ischemia, and 45\u0026ndash;60% by neuropathy combined with ischemia. The patients\u0026rsquo; nutritional status, vascular condition, and infection have been shown to play a major role in ulcer healing[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRussian Professor Ilizarov proposed the \u0026ldquo;tension-stress rule,\u0026rdquo; wherein the periodic transport of bone mass could reshape microcirculation[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Anatomical studies have found that long bones have dense transcortical vessels (TCV) closed blood circulation system (60% arteries, 40% veins)[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], which may be one of the anatomical basis by which TTT promotes microcirculation reconstruction. Iliopoulos et al. found that slow traction stimulation of the tibial bone marrow can not only accelerate mitosis of vascular endothelial cells to continue tissue regeneration and reconstruction of local blood circulation[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] but also effectively reduce bone pressure and ease the occurrence of small vasospasm and improve local ischemic symptoms and skin color. Li et al. speculated that the mechanism of TTT promoting microcirculation regeneration may be attributed to the following reasons: (i) tibial fenestration can reduce intramedullary pressure and improve microcirculation; (ii) tension stress stimulation can promote capillary regeneration and accelerate the formation of new TCV network; and (iii) systemic stem cell mobilization, reduce local inflammatory response[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo the best of our knowledge, no TTT-related biomechanical study has yet been reported. This study is the first biomechanical analysis of TTT surgery. The biomechanical study of cadaver bones found that the mechanical stability of the tibia after dTTT surgery was better than that after sTTT surgery, indicating that patients with DFU treated with dTTT can move early after surgery, thereby being able to establish lower limb circulation. The tibial anti-axial compression and torsion ability is stronger after dTTT surgery than sTTT surgery. We used a three-point lateral bending test to characterize the ability of the tibia to resist lateral stress after surgery. Because the tibia is similar to a triangular prism, and the body resources are limited, we only detected the ability to resist lateral stress on one surface. The experimental results showed the same trend as the axial compression and torsion experiments. Researchers believe that similar to the field of construction engineering, the mechanical stability of the 工-shaped support structure is better than that of the 口 shape, and the bone window shape of dTTT could resist stronger stress than sTTT.\u003c/p\u003e\u003cp\u003eRegarding the efficacy of TTT, our study\u0026rsquo;s results were consistent with those of other reports on the two TTT methods, in that that both techniques could effectively treat severe DFU. At the same time, the therapeutic effects of both treatment methods had no significant difference in the immediate future. Based on the positive results of TTT in the treatment of ischemic foot ulcers, Hua et al. recommend that it should be used for ulcers with a grade of Texas 2B and above (i.e., wounds that penetrate tendons, joint capsules, bones, or joints with infection and/or ischemia)\u003csup\u003e[18]\u003c/sup\u003e. At present, the method reported more often is sTTT. The effective rate of sTTT in the treatment of DFU ranged between 88.24% and 94.9%\u003csup\u003e[19, 20]\u003c/sup\u003e, which might be related to the surgeon\u0026rsquo;s skill and experience. Appropriate surgical instruments could also reduce the difficulty of surgery and help in patient recovery.\u003c/p\u003e\u003cp\u003eIn this study, although the incidence of complications of sTTT was only 14.63%, it was still significantly higher than that of dTTT, especially iatrogenic infection and fracture. The reason might be that the biomechanical stability of dTTT was better than that of sTTT, which was consistent with our biomechanical results.\u003c/p\u003e\u003cp\u003eThis study has some limitations. First, because both sTTT and dTTT have been proven safe and effective in retrospective studies, the purpose of this study was only to evaluate the differences between these two treatment methods. More in-depth biomechanical research should be carried out for standardized TTT treatment of DFU. Second, given the limited source of cadaver bones, this study was unable to use fresh cadaver bones for research. However, we classified the tibiae on both sides of the same cadaver into two different groups and performed the same test to maximize the extrapolation and comparability of data and consistency of the baseline data. Last, our clinical data were analyzed using a retrospective cohort study which is inherently prone to information bias. In the future, we aim to conduct a prospective study to standardize the clinical application of TTT in the treatment of DFU.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBoth sTTT and dTTT could effectively treat severe DFU. The mechanical stability and safety of the tibia after dTTT osteotomy were better than after sTTT.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003esTTT: single bone flap transverse tibial transport; dTTT: double bone flaps transverse tibial transport; ABI: ankle brachial index; TCPO\u003csub\u003e2\u003c/sub\u003e: percutaneous oxygen partial pressure; VAS: visual analogue scale; pre-op: pre-operation; post-op: post-operation; BMI: body mass index; HbA1C: haemoglobin A1c.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent of publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was performed in accordance with ethical standards, with the protocol approved by the hospital’s ethics committee, ensuring data privacy and confidentiality\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll research procedures were approved by the Ethics Committee of Beijing Longfu Hospital (no. LFYYLL-2021-24 and no. LFYYLL-2021-23).\u0026nbsp;Informed consent to participation was obtained from all study participants.This study complied with the provisions of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by Elite Medical Professionals Project of China-Japan Friendship Hospital, No. ZRJY2023-QM29; Capital`s Funds for Health Improvement and Research, No. 2020-2-4086; Beijing Health Science and Technology Achievements and Appropriate Technology Promotion Project, No. BHTPP2022015; National Key R\u0026amp;D Program of China, No. 2022YFC2504302; Beijing Natural Science Foundation, No. L234015.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Conflicting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declared no potential conflicts of interest withrespect to the research, authorship, and/or publication of this article. Only the language has been revised by ChatGPT.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContribution statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGuicheng li and Yusong Yuan performed experiments, analyzed results, and prepared the draft. \u0026nbsp;Hailin Xu and Ying Chen provided data interpretation, collected human samples, accounted for clinical practice, designed and supervised the study, revised the manuscript, and obtained funding support. All authors contributed to the final article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data collected for this study can be obtained by correspondence with the corresponding authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWang L, Gao P, Zhang M, Huang Z, Zhang D, Deng Q, Li Y, Zhao Z, Qin X, Jin D, Zhou M, Tang X, Hu Y, et al. Prevalence and Ethnic Pattern of Diabetes and Prediabetes in China in 2013. JAMA. 2017; 317(24):2515-2523.\u003c/li\u003e\n\u003cli\u003eDi Giovanni P, Scampoli P, Meo F, Cedrone F, D\u0026apos;Addezio M, Di Martino G, Valente A, Romano F and Staniscia T. The impact of gender on diabetes-related lower extremity amputations: An Italian regional analysis on trends and predictors. Foot Ankle Surg. 2021; 27(1):25-29.\u003c/li\u003e\n\u003cli\u003eAmerican Diabetes A. Screening for type 2 diabetes. Diabetes Care. 2004; 27 Suppl 1:S11-14.\u003c/li\u003e\n\u003cli\u003eBrennan MB, Hess TM, Bartle B, Cooper JM, Kang J, Huang ES, Smith M, Sohn MW and Crnich C. Diabetic foot ulcer severity predicts mortality among veterans with type 2 diabetes. J Diabetes Complications. 2017; 31(3):556-561.\u003c/li\u003e\n\u003cli\u003eChen Y, Kuang X, Zhou J, Zhen P, Zeng Z, Lin Z, Gao W, He L, Ding Y, Liu G, Qiu S, Qin A, Lu W, et al. Proximal Tibial Cortex Transverse Distraction Facilitating Healing and Limb Salvage in Severe and Recalcitrant Diabetic Foot Ulcers. Clin Orthop Relat Res. 2020; 478(4):836-851.\u003c/li\u003e\n\u003cli\u003eHua QK, Zhang YH, Wan CY, Zhang DW, Xie QP, Zhu YL, Bai LB, Liu J, Yang YK, Pan XH, Qin SH, Qu L, Ma XL, et al. Chinese Association of Orthopaedic Surgeons (CAOS) clinical guideline for the treatment of diabetic foot ulcers using tibial cortex transverse transport technique (version 2020). J Orthop Transl. 2020; 25:11-16.\u003c/li\u003e\n\u003cli\u003eLiu GW, Li SL, Kuang XC, Zhou J, Zhong ZW, Ding Y, Lu W, Zhao JM, Chen Y and Hua QK. The emerging role of tibial cortex transverse transport in the treatment of chronic limb ischemic diseases. J Orthop Transl. 2020; 25:17-24.\u003c/li\u003e\n\u003cli\u003eYuan Y, Ding X, Jing Z, Lu H, Yang K, Wang Y and Xu H. Modified tibial transverse transport technique for the treatment of ischemic diabetic foot ulcer in patients with type 2 diabetes. J Orthop Translat. 2021; 29:100-105.\u003c/li\u003e\n\u003cli\u003evan Netten JJ, Bus SA, Apelqvist J, Lipsky BA, Hinchliffe RJ, Game F, Rayman G, Lazzarini PA, Forsythe RO, Peters EJG, Senneville E, Vas P, Monteiro-Soares M, et al. Definitions and criteria for diabetic foot disease. Diabetes Metab Res Rev. 2020; 36 Suppl 1:e3268.\u003c/li\u003e\n\u003cli\u003eGuo S and Dipietro LA. Factors affecting wound healing. J Dent Res. 2010; 89(3):219-229.\u003c/li\u003e\n\u003cli\u003eApelqvist J. The foot in perspective. Diabetes Metab Res Rev. 2008; 24 Suppl 1:S110-115.\u003c/li\u003e\n\u003cli\u003eIlizarov GA. The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res. 1989; (238):249-281.\u003c/li\u003e\n\u003cli\u003eIlizarov GA. The principles of the Ilizarov method. 1988. Bull Hosp Jt Dis. 1997; 56(1):49-53.\u003c/li\u003e\n\u003cli\u003eGruneboom A, Hawwari I, Weidner D, Culemann S, Muller S, Henneberg S, Brenzel A, Merz S, Bornemann L, Zec K, Wuelling M, Kling L, Hasenberg M, et al. A network of trans-cortical capillaries as mainstay for blood circulation in long bones. Nat Metab. 2019; 1(2):236-250.\u003c/li\u003e\n\u003cli\u003eda Silva LP, Santos TC, Rodrigues DB, Pirraco RP, Cerqueira MT, Reis RL, Correlo VM and Marques AP. Stem Cell-Containing Hyaluronic Acid-Based Spongy Hydrogels for Integrated Diabetic Wound Healing. J Invest Dermatol. 2017; 137(7):1541-1551.\u003c/li\u003e\n\u003cli\u003eIliopoulos E, Morrissey N, Cho S and Khaleel A. Outcomes of the Ilizarov frame use in elderly patients. J Orthop Sci. 2017; 22(4):783-786.\u003c/li\u003e\n\u003cli\u003eYang Y and Li G. [Biological mechanisms of tibial transverse transport for promoting microcirculation and tissue repair]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2020; 34(8):964-968.\u003c/li\u003e\n\u003cli\u003eNie X, Kuang X, Liu G, Zhong Z, Ding Y, Yu J, Liu J, Li S, He L, Su H, Qin W, Zhao J, Hua Q, et al. Tibial cortex transverse transport facilitating healing in patients with recalcitrant non-diabetic leg ulcers. J Orthop Translat. 2021; 27:1-7.\u003c/li\u003e\n\u003cli\u003eLi H, You J, Liu C and Ma Y. [Effectiveness of transverse tibial bone transport in treatment of diabetic foot ulcer]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2019; 33(1):23-27.\u003c/li\u003e\n\u003cli\u003eChen Y, Ding X, Zhu Y, Jia Z, Qi Y, Chen M, Lu J, Kuang X, Zhou J, Su Y, Zhao Y, Lu W, Zhao J, et al. Effect of tibial cortex transverse transport in patients with recalcitrant diabetic foot ulcers: A prospective multicenter cohort study. J Orthop Translat. 2022; 36:194-204.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"diabetic foot ulcer, sTTT, dTTT","lastPublishedDoi":"10.21203/rs.3.rs-7931428/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7931428/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eAims\u003c/h2\u003e\u003cp\u003eThis study aimed to compare the differences between single and double flap TTT (hereafter, sTTT and dTTT, respectively) for treatment of severe chronic diabetic foot ulcer in terms of biomechanics, safety, and efficacy.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThe retrospectively conducted clinical study analyzed the basic epidemiological data, therapeutic effect, and safety of patients in the sTTT and dTTT cohorts.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe clinical results showed that the operation time of sTTT was significantly longer than that of dTTT (p\u0026thinsp;=\u0026thinsp;0.001). The mean healing time was 32.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9 and 29.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7 weeks in the sTTT and dTTT groups, respectively (p\u0026thinsp;=\u0026thinsp;0.532). There was no significant difference in foot microcirculation indicators and VAS between the two groups at 12 months after the operation, but the complication rate of sTTT was significantly higher than that of dTTT (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eBoth dTTT and sTTT can effectively treat severe chronic diabetic foot ulcers. However, the operation time of dTTT is shorter and safer.\u003c/p\u003e","manuscriptTitle":"The choice of single bone flap TTT and double bone flaps TTT to treat severe diabetic foot ulcer: a clinical exploration","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-02 13:56:17","doi":"10.21203/rs.3.rs-7931428/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1e68f6a2-31a2-4f4f-8d01-304dc6e12955","owner":[],"postedDate":"December 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-08T14:39:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-02 13:56:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7931428","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7931428","identity":"rs-7931428","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}