The long-term clinical efficacy of transverse tibial bone transfer in the treatment of diabetic foot ulcers: more than 4 years of follow-up in a single center

The long-term clinical efficacy of transverse tibial bone transfer in the treatment of diabetic foot ulcers: more than 4 years of follow-up in a single center | 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 long-term clinical efficacy of transverse tibial bone transfer in the treatment of diabetic foot ulcers: more than 4 years of follow-up in a single center Yuanmeng Ren, Hong Liu, Xianyan Yan, Baona Wang, Yonghong Zhang, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7661681/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 Objective : To conduct long-term follow-up on patients who underwent transverse tibial bone transfer for the treatment of diabetic foot ulcers and evaluate the long-term efficacy. Methods : The clinical data of patients with diabetic foot ulcers who underwent transverse tibial bone transfer in our hospital from 2019 to 2021 were retrospectively collected. The last centralized follow-up was conducted on April 30, 2025. The recovery status of diabetic foot in the patients was collected, and the self-management ability and satisfaction of the patients were evaluated. Results : A total of 51 patients (52 with affected feet) were followed up, and the recovery rate was 67.3%. Among them, the recovery rates at 4, 5, and 6 years after the operation were 73.9%, 73.6%, and 40%, respectively. A total of 23 self-management scoring scales were collected. The scores at 4, 5, and 6 years after the operation were (42.40±3.34) points,(40.29±2.69)points,and(36.00±4.42) points, respectively. The self-management ability level of the recovered patients was higher than that of the non-recovered patients, P < 0.05; A total of 31 satisfaction survey forms were collected, with a score of (3.23±0.42) points. Among them, 7 cases were very satisfied and 24 cases were satisfied, with a satisfaction rate of 100%. Conclusion : The long-term efficacy of tibial transverse bone transfer in the treatment of diabetic foot ulcers is good. Patients have a relatively good level of self-management ability and high patient satisfaction. Diabetic foot ulcer Transverse tibial bone transport Follow-up Figures Figure 1 Introduction Diabetic foot ulcer (DFU) is an ulcer that develops in diabetic patients as a result of lower extremity nerve and microvascular lesions. It is one of the common and severe chronic complications of diabetes. The foot soft tissue initially experiences local damage and gradually progresses to deep necrosis. The sluggish vascular regeneration results in a prolonged healing period [ 1 ] . Consequently, DFU is characterized by a high incidence, high amputation rate, high mortality rate, and low healing rate [ 2 ] . The transverse tibial bone transport technique, which can reconstruct the lower extremity microcirculation, offers favorable conditions for foot tissue repair. By slowly enhancing and gradually reconstructing the damaged microcirculation, this technique has significantly reduced the amputation rate among DFU patients since its application in DFU treatment. It has also greatly improved patient prognosis and addressed the issue of lower extremity ischemia caused by diabetes [ 3 ] . Nevertheless, the long-term efficacy of this technique remains a subject of controversy [ 4 ] . Therefore, this study carried out a follow-up of DFU patients for at least four years. The aim was to explore the long-term efficacy and associated factors, identify evidence-based predictive factors for adverse outcomes, and provide a basis for formulating the optimal treatment plan. Methods/design Research Object Patients who underwent transverse tibial bone repositioning surgery for diabetic foot between January 2019 and December 2021 were recruited. The inclusion criteria were as follows:① Wagner grade III or above; ② At least one of the anterior tibial artery, posterior tibial artery or peroneal artery of the affected limb was unobstructed; ③ Positive bacterial culture results from foot wound secretions; ④ Treated with transverse tibial bone repositioning surgery; ⑤ The patient and their family members gave informed consent for the surgical plan, had good compliance, and cooperated with follow-up. The exclusion criteria were as follows:① Severe peripheral vascular disease (80% or more occlusion of the anterior tibial artery, posterior tibial artery or peroneal artery); ② Non-diabetic foot ulcers; ③ Abnormal heart or kidney function that could not tolerate anesthesia; ④ Complicated with severe diabetic complications, such as uncontrolled infectious shock in diabetic foot. Methods Surgical strategy All cases were surgically treated by the same experienced orthopedic surgeons at the Second Hospital of Shanxi Medical University.Make 2 to 3 incisions each about 1cm long on the anterolateral side of the tibia.Utilizing minimally invasive osteotomy instruments, a bone block measuring 10–12 cm in length was longitudinally incised along the long axis of the tibia. Subsequently, the incisions were sutured closed. All patients were equipped with a transverse bone repositioning external fixator. Two threaded pins with diameters of 4.5 mm and 5.5 mm were respectively implanted at both ends of the osteotomized block. Additionally, the osteotomized block was secured with 4 threaded half - pins. At the wound site, antibiotic - loaded bone cement technology was employed. The choice of antibiotics carried by the bone cement was based on the results of preoperative bacterial culture and drug sensitivity tests. These antibiotics were thoroughly mixed with the bone cement to form a bead chain or a long strip, which was then filled into the infected and tissue - defect areas. In cases where it was challenging to position the bone cement at the wound surface, ligament threads could be utilized to temporarily fix the bone cement. Data collection Including general information (gender, age, marital status, payment method, place of residence, occupation, contact information, length of hospital stay, hospitalization cost), clinical manifestations (duration of diabetes, duration of diabetic foot disease, location of wound, etc.), and treatment plans. The follow-up method is by phone/video. The last centralized follow-up was conducted for the patients included in the study on April 30, 2025. The follow-up content included diabetes foot-related conditions (including healing, recurrence, amputation, death), the diabetes patient self-management behavior scale, and satisfaction. Recurrence refers to the occurrence of a new diabetic foot ulcer during the follow-up period, regardless of whether it heals later, it is recorded as recurrence. The deceased are recorded with their death time and cause. The satisfaction of patients was evaluated using a 4-point Likert scale, including very satisfied (4 points), satisfied (3 points), dissatisfied (2 points), and very dissatisfied (1 point). A score of 3 points and 4 points are considered as satisfactory for the surgical outcome. The Summery of Diabetes Self-care Activities (SDSCA) assesses the self-management ability of patients in five aspects: diet, exercise, blood sugar, medication, and foot care. The total score is 77 points, and the score is positively correlated with self-management ability [ 5 ] . Statistical method Statistical analysis was performed using SPSS 27.0 software. Measurement data were expressed as mean ± standard deviation. Comparisons between groups were conducted using the independent sample t-test, and multiple group comparisons were analyzed using one-way ANOVA. Count data were presented as percentages. A difference was considered statistically significant when P < 0.05. Outcomes General Information A total of 62 patients (63 affected feet) were included. Among them, 51 patients (52 affected feet) achieved the follow-up outcome in the final centralized follow-up. The patient selection process is shown in Figure 1, and the general information of the patients is presented in Table 1. Table 1 General information form Items Category Number/Mean Rate(%)/standard deviation Gender male 33 63.5% female 19 36.5% Age 64.1 13.5 Profession peasant 24 46.2% retirement 22 42.3% professional 2 3.8% freelance 2 3.8% Office clerk 1 1.9% worker 1 1.9% Degree of education Illiterate and semi-literate individuals 6 11.5% Primary school 12 23.1% Junior high school 19 36.5% Senior high school 9 17.3% Technical secondary school 2 3.8% Junior college 1 1.9% regular college course 3 5.8% Marital status discoverture 4 7.7% married 43 82.7% divorce 1 1.9% widowed 3 5.8% else 1 1.9% Residence city 22 42.3% country 30 57.7% Payment medical insurance 45 86.5% self-paying 7 13.5% Length of stay 20.8 9.5 position left 32 61.5% right 20 38.5% Long-term clinical effect analysis 52 affected feet were included in the analysis. Among them, 23 cases had surgery lasting for up to 4 years, of which 17 cases recovered, 3 cases relapsed. The relapse occurred at the 2nd and 3rd years after surgery respectively. With active improvement of lifestyle and dressing changes, these cases recovered. 1 case underwent amputation due to persistent non-healing of the ulcer, and 2 cases died due to sudden accidents and pulmonary infection leading to multiple organ failure. Another 19 cases had surgery lasting for up to 5 years, among which 14 cases recovered, 2 cases relapsed. The relapse occurred at the 3rd and 4th years after surgery respectively. With active dressing changes and surgical debridement, these cases recovered. 1 case underwent amputation due to acute lower extremity vascular embolism and acute gangrene, and 2 cases died due to complications. The patients' basic conditions were all poor. Another 10 cases had surgery lasting for up to 6 years, among which 4 cases recovered, 1 case relapsed. The relapse occurred at the 3rd year after surgery. After active dressing changes, this case recovered. 2 cases underwent amputation due to persistent non-healing of ulcers after poor postoperative blood sugar control, and 3 cases died due to complications. The death ages were all over 75 years old. See Table 2. For 1 special patient, left foot ulcer treatment was performed in 2020, and there was no recurrence of the left foot ulcer. However, a right foot ulcer occurred in 2021, which was treated and recovered without recurrence. The records for all cases were that they recovered. Table 2 curative effect Number （ % ） Follow-up outcome Follow-up time Total 4 years 5 years 6 years Recovery 17（73.9） 14（73.6） 4（40.0） 35（67.3） Recurrence 3（13.0） 2（10.5） 1（10.0） 6（11.5） Amputation 1（4.3） 1（5.2） 2（20.0） 4（7.7） Died 2（8.7） 2（10.5） 3（30.0） 7（13.4） Total 23（100.0） 19（100.0） 10（100.0） 52（100.0） Self-management Ability The self-management behavior scale for diabetic patients was completed in 23 cases. The scores at 4 years, 5 years, and 6 years after surgery were (42.40 ± 3.34) points, (40.29 ± 2.69) points, and (36.00 ± 4.42) points, respectively. The comparison between groups showed significant differences in scores between 4 years and 6 years after surgery, and between 5 years and 6 years after surgery (P < 0.05), as shown in Table 3. 29 cases did not complete the assessment of the scale due to time constraints or their own conditions. Table 3 Self-management Ability Outcome （ ` x±s ） Items Four years after the operation Five years after the operation Six years after the operation SDSCA score 42.40±3.34 40.29±2.69 36.00±4.42 *# Diet 18.50±2.27 17.43±0.97 16.67±1.75 Movement 7.10±2.55 5.86±1.06 5.83±0.40 Blood glucose 5.50±1.90 5.57±0.97 4.33±1.86 Foot care 4.80±1.61 5.14±1.46 4.17±1.47 Pharmacy 6.50±0.52 6.29±0.48 5.67±0.51 Compared with the operation time of 4 years， * P＜0.05；Compared with the operation time of 5 years， # P＜0.05 Follow-up outcomes and self-management ability Among the 23 patients who completed the self-management behavior scale for diabetic patients, 17 were cured, 3 relapsed, and 3 underwent amputation. The outcomes of relapse and amputation were both defined as non-recovery. The results showed that there was a significant difference in scores between recovery and non-recovery (P < 0.05), as shown in Table 4. Table 4 Follow-up outcomes and self-management ability Items Recovery Unhealed SDSCA score 41.65±3.02 35.67±4.27 * Diet 18.35±1.57 15.83±1.60 Movement 6.82±1.91 5.17±0.98 Blood glucose 5.47±1.32 4.50±2.42 Foot care 4.94±1.29 4.17±2.04 Pharmacy 6.29±0.47 6.00±0.89 Compared with the outcome of recovery， * P＜0.05 Analysis of satisfaction degree Among the 51 patients who had follow-up outcomes, 31 patients received the satisfaction survey, with a score of (3.23 ± 0.42) points. Among them, 7 cases were very satisfied and 24 cases were satisfied, resulting in a satisfaction rate of 100%. 20 cases did not receive the satisfaction survey results due to time constraints or their own conditions. Discussion Long-term clinical effect The recovery rate within 3 years or more after the surgery is a key indicator for evaluating long-term efficacy [ 6 ][ 7 ] , representing whether the treatment plan is effective and whether it can reduce the risk of disability. It is of great significance for delaying disease progression and reducing the consumption of medical resources. The current research follow-up periods are mostly around 2 years (24 months), and the clinical effects are generally good. However, there are relatively few studies on the long-term clinical effects, especially those lasting for 4 years (48 months) or more. Professor Qu and Hua and others applied the transverse tibial bone repositioning surgery to patients with diabetic foot and achieved good therapeutic effects. All 40 patients were followed up, with the longest follow-up period reaching 34 months. The ulcer healing rate reached 100% [ 8 ] . Others, such as Ou, used a percutaneous minimally invasive surgical method to further improve the transverse tibial bone repositioning surgery, and the results were also satisfactory. Among the 23 cases, 21 cases of affected feet were cured, and the cure rate within 19 months reached 91%. The remaining 2 cases had poor basic conditions and ended up with amputation and death [ 9 ] .Wang and others treated diabetic foot patients using the combined bone cement method. Within 21 months, the recovery rate of affected feet reached 92%. One patient died due to pulmonary infection and multiple organ failure, and another was amputated due to acute lower extremity vascular embolism [ 1 ] . Liu conducted a retrospective study at two centers, including 43 affected feet. The recovery rate one year after surgery was 95% [ 10 ] . Chen carried out a multicenter study, including 1175 affected feet. This study broke through the limitations of previous single-center studies with a smaller sample size and followed up for 2 years. A total of 1157 affected feet were included, with a recovery rate of 85%, a mortality rate of 7.2%, an amputation rate of 4.5%, and a recurrence rate of 2.8%. These results strongly demonstrated the value of TTT in the treatment of diabetic foot [ 11 ] . The shortest follow-up period in this study was 4 years, and the longest was 6 years. The recovery rate of the 52 included affected feet was 67.3%. The recovery rates in the 4th, 5th, and 6th years after surgery were 73.9%, 73.6%, and 40.0% respectively. The recovery rate was significantly different from the results of other scholars' studies. The reasons may be as follows: Firstly, diabetic foot is a chronic disease. During the long-term treatment process, patients not only bear economic burdens but also suffer from psychological problems such as anxiety, depression, and physical symptoms such as pain and insomnia [ 12 ] . As the disease progresses, the long-term and slow pain will gradually lead patients to develop stubborn and incorrect cognition, even questioning the professional guidance of medical staff, and then adopting some inappropriate treatment methods, ultimately resulting in improper disease management.The series of problems caused by the chronic course of diabetic foot disease may be an important reason for the decline in the recovery rate. Secondly, for patients whose surgery was performed 6 years ago, the surgery was conducted in 2019, and the surgical techniques and nursing plans at that time had certain differences from the current ones [ 4 ] . Moreover, the patients included in this study were all relatively old, especially those whose follow-up outcomes were death, whose ages were basically above 75 years old, and the oldest was 90 years old. The causes of death were mainly the underlying diseases and complications, and only one patient was 31 years old and died due to an accident rather than the disease itself. The causes of death were mainly the underlying diseases and complications. Therefore, the mortality rate of this study may lack certain representativeness, and the recovery rate discussed in this study is the recovery rate of all patients who could be followed up to the outcome, that is, the death patients will also be included, which means the number of death patients will directly affect the recovery rate, leading to a decrease in the recovery rate. Finally, the Wagner classification of the patients included in this study at admission was all at level 3 or above, the patients' conditions were severe, and the duration of diabetic foot disease was long. Even without other diabetes-related complications, there were many risk factors [ 13 ] . And the other studies compared and discussed in this study included more patients with Wagner classification of level 1. This difference in the severity of the included study subjects' conditions may also be one of the reasons for the significant gap in the healing rates between the two. In conclusion, it is not appropriate to simply equate the lower recovery rate in this study with poor surgical efficacy. The results more reflect the diversity of influencing factors, which suggests that we should focus on the factors affecting surgical efficacy in the future and provide targeted improvement measures to maintain the long-term efficacy of the surgery. It is worth noting that the recurrence rate, amputation rate, and mortality rate of the patients in this study were 11.5%, 7.7%, and 13.4% respectively, which were significantly lower than the results of previous related studies. This indicates the long-term effectiveness of TTT in treating DFU, and its safety and operability are good, and it has the value of being widely promoted in clinical practice [ 14 ][ 15 ][ 16 ] . Self-management skills TTT can treat diabetic foot but not diabetes itself. Therefore, the long-term maintenance of surgical effects depends on the continuous maintenance and active cooperation of the patients. Currently, in the research on diabetes self-management, the self-management ability of patients is mainly evaluated through aspects such as diet, exercise, blood sugar monitoring, medication, and foot care. Based on previous related studies, there are many tools for assessing the self-management ability of diabetic patients. Among them, the SDSCA and the Morisky Medication Adherence Scale are widely used and verified in multiple countries, and the SDSCA scale, as a comprehensive measurement tool, has fewer items and meets the requirements of this study [ 17 ] .In the research conducted by Wang [ 18 ] , the SDSCA scale was used to assess the self-management practice ability of rural patients with type 2 diabetes. The results showed that rural patients lacked the ability in blood glucose monitoring and foot care, which was consistent with the results of this study. This might be related to the poorer economic conditions of rural patients, as well as their insufficient attention to foot care and lack of nursing skills. The study also proved that knowledge has a positive impact on improving patients' self-management. This suggests the importance of health education for patients by medical staff. However, it should be noted that the effectiveness of health education decreases gradually over time after discharge [ 19 ] . This highlights the importance of follow-up. During the follow-up process, strengthening patients' mastery of health education knowledge can further improve their self-management ability [ 20 ] . This study also revealed that while patients' self-management ability tends to decline over time in general, a closer look at individual cases shows that even those who underwent surgery 6 years ago may have a higher level of self-management ability than those with only 4 years post-surgery. The reasons for this might be as follows: Firstly, it is related to the patient's living environment. Patients with higher self-management ability often have higher economic and knowledge levels, enabling them to obtain health knowledge and implement healthy behaviors. Secondly, some patients have had hospitalizations in other departments during the follow-up period, and each hospitalization may provide health education for the patients, thereby increasing their awareness of the disease. This also reminds us of the importance of postoperative follow-up. During each follow-up, timely detection of patients' unhealthy behaviors and correction are necessary to maintain the surgical efficacy. Follow-up outcomes and self-management ability The results of this study show that there is a difference in the self-management scale scores between patients with a follow-up outcome of recovery and those without recovery. The former has higher scores than the latter. From the perspective of disease management, the higher scores of the recovered patients in the self-management scale indicate that they exhibit more standardized and systematic behavioral patterns in aspects such as blood glucose monitoring, foot care, diet control, and exercise management. Good self-management can, to a certain extent, prevent ulcer recurrence and sustain the efficacy of TTT surgery. In contrast, the lower scale scores of the non-recovered patients suggest that there may be knowledge gaps and behavioral deficiencies during the disease management process, such as lacking regular foot examinations and blood glucose monitoring behaviors, neglecting the importance of exercise, and these factors collectively contribute to the occurrence of non-healing outcomes, thereby weakening the efficacy of TTT surgery. This difference further corroborates the importance of establishing a sound follow-up supervision mechanism to enhance patients' self-management efficacy, improve clinical outcomes, especially for patients with longer surgical durations. Satisfaction Satisfaction is the overall perception of the quality of life of patients with diabetic foot disease, including their acceptance and adaptation to the impacts brought by diabetic foot. Patients with higher satisfaction tend to have a more positive attitude towards life, which helps them better manage the disease and maintain the therapeutic effect [ 12 ] . Although the transverse tibial bone repositioning surgery has achieved good results in the healing of diabetic foot ulcers, consistent with the research results of Zhou [ 21 ] , some studies have found that there is still room for improvement in the satisfaction of patients with diabetic foot. The research by Yin [ 22 ] shows that the satisfaction of 120 patients was 90.8%, and after effective intervention, the satisfaction of the patients improved. Therefore, clinical practice should attach importance to the management of satisfaction of patients with diabetic foot, by establishing a multi-dimensional intervention system, continuously improving the quality of life and disease self-management ability of patients, and promoting the coordinated improvement of the therapeutic effect and patient satisfaction of diabetic foot treatment. Conclusions In conclusion, this study aimed to explore the long-term efficacy of the transverse tibial bone repositioning surgery in the treatment of diabetic foot ulcers. We collected the medical records of patients who underwent TTT surgery for DFU in our department from 2019, sorted them out, and conducted centralized follow-up. The main analysis focused on the healing rate, recurrence rate, amputation rate, mortality rate, and their related factors of DFU over the long term. The results showed that the healing rate in patients with a surgery duration of up to 4 years was lower than that at around 2 years after surgery, and the healing rate tended to decrease as the surgery duration increased. This study also found that the follow-up outcomes were related to the patients' self-management ability to some extent. Therefore, it is necessary to strengthen postoperative care for patients and attach importance to the follow-up work. During the follow-up, problems existing in patients should be promptly identified to maximize the quality of the surgery and reduce the burden on patients and society. In the future, the sample size can be further increased, and the potential relationship between the surgery duration and the patients' self-management ability can be explored. Declarations Author Contribution H.L. , Y.Z., J.G.,J.X.：Conception and design of the research.B.W. ,X.Y. , P.Z. ,C.H.,J.X. :Acquisition of dataB.W. ,X.Y. , P.Z. ,D.W. ,C.H. ,Q.W. ,B.W. :Statistical analysisD.W. ,Y.Z. :guided the surgeryY.R. , H.L. :Writing of the manuscriptY.R. ,J.G. :Critical revision of the manuscript for intellectual content Acknowledgement I acknowledge anyone who contributed towards the article that does not meet the criteria for authorship, including anyone who gave professional writing services or materials.This study received ethical approval and informed consent. References Wang D, Zhang Y, He G, et al. Tibial transverse bone repositioning technique combined with antibiotic bone cement for the treatment of chronic ischemic diseases of the lower extremities accompanied by chronic infections of the foot and ankle [J]. Chin J Reconstr Aesthetic Surg. 2020;34(08):979–84. 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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-7661681","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":526936853,"identity":"4063ea7b-5e99-4adb-9dc0-094fbdc13d57","order_by":0,"name":"Yuanmeng Ren","email":"","orcid":"","institution":"Shanxi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yuanmeng","middleName":"","lastName":"Ren","suffix":""},{"id":526936854,"identity":"4798a762-024f-4640-8d55-6d562517f51c","order_by":1,"name":"Hong Liu","email":"","orcid":"","institution":"Second Hospital of Shanxi Medical 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14:04:34","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":88965,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7661681/v1/759b20bfca05fdbad543cc89.html"},{"id":93336268,"identity":"6733d14e-aca6-4f1c-995c-45f9fd395fac","added_by":"auto","created_at":"2025-10-12 14:04:33","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":218733,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7661681/v1/4561e6e4378fcd42316ead23.jpeg"},{"id":93836712,"identity":"e67eba4f-78cb-4e10-8aa5-b2ae48cb4e06","added_by":"auto","created_at":"2025-10-18 11:31:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":968093,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7661681/v1/01dce042-b91e-431c-ac9d-6b13fc4ddd55.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The long-term clinical efficacy of transverse tibial bone transfer in the treatment of diabetic foot ulcers: more than 4 years of follow-up in a single center","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDiabetic foot ulcer (DFU) is an ulcer that develops in diabetic patients as a result of lower extremity nerve and microvascular lesions. It is one of the common and severe chronic complications of diabetes. The foot soft tissue initially experiences local damage and gradually progresses to deep necrosis. The sluggish vascular regeneration results in a prolonged healing period\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Consequently, DFU is characterized by a high incidence, high amputation rate, high mortality rate, and low healing rate\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe transverse tibial bone transport technique, which can reconstruct the lower extremity microcirculation, offers favorable conditions for foot tissue repair. By slowly enhancing and gradually reconstructing the damaged microcirculation, this technique has significantly reduced the amputation rate among DFU patients since its application in DFU treatment. It has also greatly improved patient prognosis and addressed the issue of lower extremity ischemia caused by diabetes\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Nevertheless, the long-term efficacy of this technique remains a subject of controversy\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eTherefore, this study carried out a follow-up of DFU patients for at least four years. The aim was to explore the long-term efficacy and associated factors, identify evidence-based predictive factors for adverse outcomes, and provide a basis for formulating the optimal treatment plan.\u003c/p\u003e"},{"header":"Methods/design","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eResearch Object\u003c/h2\u003e\n \u003cp\u003ePatients who underwent transverse tibial bone repositioning surgery for diabetic foot between January 2019 and December 2021 were recruited.\u003c/p\u003e\n \u003cp\u003eThe inclusion criteria were as follows:① Wagner grade III or above; ② At least one of the anterior tibial artery, posterior tibial artery or peroneal artery of the affected limb was unobstructed; ③ Positive bacterial culture results from foot wound secretions; ④ Treated with transverse tibial bone repositioning surgery; ⑤ The patient and their family members gave informed consent for the surgical plan, had good compliance, and cooperated with follow-up.\u003c/p\u003e\n \u003cp\u003eThe exclusion criteria were as follows:① Severe peripheral vascular disease (80% or more occlusion of the anterior tibial artery, posterior tibial artery or peroneal artery); ② Non-diabetic foot ulcers; ③ Abnormal heart or kidney function that could not tolerate anesthesia; ④ Complicated with severe diabetic complications, such as uncontrolled infectious shock in diabetic foot.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eMethods\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eSurgical strategy\u003c/h2\u003e\n \u003cp\u003eAll cases were surgically treated by the same experienced orthopedic surgeons at the Second Hospital of Shanxi Medical University.Make 2 to 3 incisions each about 1cm long on the anterolateral side of the tibia.Utilizing minimally invasive osteotomy instruments, a bone block measuring 10\u0026ndash;12 cm in length was longitudinally incised along the long axis of the tibia. Subsequently, the incisions were sutured closed.\u003c/p\u003e\n \u003cp\u003eAll patients were equipped with a transverse bone repositioning external fixator. Two threaded pins with diameters of 4.5 mm and 5.5 mm were respectively implanted at both ends of the osteotomized block. Additionally, the osteotomized block was secured with 4 threaded half - pins.\u003c/p\u003e\n \u003cp\u003eAt the wound site, antibiotic - loaded bone cement technology was employed. The choice of antibiotics carried by the bone cement was based on the results of preoperative bacterial culture and drug sensitivity tests. These antibiotics were thoroughly mixed with the bone cement to form a bead chain or a long strip, which was then filled into the infected and tissue - defect areas. In cases where it was challenging to position the bone cement at the wound surface, ligament threads could be utilized to temporarily fix the bone cement.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eIncluding general information (gender, age, marital status, payment method, place of residence, occupation, contact information, length of hospital stay, hospitalization cost), clinical manifestations (duration of diabetes, duration of diabetic foot disease, location of wound, etc.), and treatment plans. The follow-up method is by phone/video. The last centralized follow-up was conducted for the patients included in the study on April 30, 2025. The follow-up content included diabetes foot-related conditions (including healing, recurrence, amputation, death), the diabetes patient self-management behavior scale, and satisfaction. Recurrence refers to the occurrence of a new diabetic foot ulcer during the follow-up period, regardless of whether it heals later, it is recorded as recurrence. The deceased are recorded with their death time and cause. The satisfaction of patients was evaluated using a 4-point Likert scale, including very satisfied (4 points), satisfied (3 points), dissatisfied (2 points), and very dissatisfied (1 point). A score of 3 points and 4 points are considered as satisfactory for the surgical outcome. The Summery of Diabetes Self-care Activities (SDSCA) assesses the self-management ability of patients in five aspects: diet, exercise, blood sugar, medication, and foot care. The total score is 77 points, and the score is positively correlated with self-management ability\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003eStatistical method\u003c/h3\u003e\n\u003cp\u003eStatistical analysis was performed using SPSS 27.0 software. Measurement data were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. Comparisons between groups were conducted using the independent sample t-test, and multiple group comparisons were analyzed using one-way ANOVA. Count data were presented as percentages. A difference was considered statistically significant when P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Outcomes","content":"\u003cp\u003e\u003cstrong\u003eGeneral Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 62 patients (63 affected feet) were included. Among them, 51 patients (52 affected feet) achieved the follow-up outcome in the final centralized follow-up. The patient selection process is shown in Figure 1, and the general information of the patients is presented in Table 1.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"631\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1 General information form\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eItems\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNumber/Mean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRate(%)/standard deviation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e63.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e64.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eProfession\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n 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\u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eOffice clerk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eworker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003eDegree of education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIlliterate and semi-literate individuals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePrimary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eJunior high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSenior high school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTechnical secondary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eJunior college\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eregular college course\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMarital status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ediscoverture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003emarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e82.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003edivorce\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ewidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eelse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eResidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ecity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ecountry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e57.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePayment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003emedical insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e86.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eself-paying\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLength of stay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eposition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eleft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e61.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"left\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eLong-term clinical effect analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e52 affected feet were included in the analysis. Among them, 23 cases had surgery lasting for up to 4 years, of which 17 cases recovered, 3 cases relapsed. The relapse occurred at the 2nd and 3rd years after surgery respectively. With active improvement of lifestyle and dressing changes, these cases recovered. 1 case underwent amputation due to persistent non-healing of the ulcer, and 2 cases died due to sudden accidents and pulmonary infection leading to multiple organ failure. Another 19 cases had surgery lasting for up to 5 years, among which 14 cases recovered, 2 cases relapsed. The relapse occurred at the 3rd and 4th years after surgery respectively. With active dressing changes and surgical debridement, these cases recovered. 1 case underwent amputation due to acute lower extremity vascular embolism and acute gangrene, and 2 cases died due to complications. The patients\u0026apos; basic conditions were all poor. Another 10 cases had surgery lasting for up to 6 years, among which 4 cases recovered, 1 case relapsed. The relapse occurred at the 3rd year after surgery. After active dressing changes, this case recovered. 2 cases underwent amputation due to persistent non-healing of ulcers after poor postoperative blood sugar control, and 3 cases died due to complications. The death ages were all over 75 years old. See Table 2. For 1 special patient, left foot ulcer treatment was performed in 2020, and there was no recurrence of the left foot ulcer. However, a right foot ulcer occurred in 2021, which was treated and recovered without recurrence. The records for all cases were that they recovered.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2 curative effect Number\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003cstrong\u003e）\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eFollow-up outcome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003eFollow-up time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e4 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRecovery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17（73.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14（73.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4（40.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35（67.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRecurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;3（13.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;2（10.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1（10.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;6（11.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAmputation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1（4.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1（5.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2（20.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4（7.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2（8.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;2（10.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3（30.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;7（13.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;23（100.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;19（100.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10（100.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;52（100.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eSelf-management Ability\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eThe self-management behavior scale for diabetic patients was completed in 23 cases. The scores at 4 years, 5 years, and 6 years after surgery were (42.40 \u0026plusmn; 3.34) points, (40.29 \u0026plusmn; 2.69) points, and (36.00 \u0026plusmn; 4.42) points, respectively. The comparison between groups showed significant differences in scores between 4 years and 6 years after surgery, and between 5 years and 6 years after surgery (P \u0026lt; 0.05), as shown in Table 3. 29 cases did not complete the assessment of the scale due to time constraints or their own conditions.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3 Self-management Ability Outcome\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003e`\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003ex\u0026plusmn;s\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e）\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eItems\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFour years after the operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFive years after the operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSix years after the operation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSDSCA score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42.40\u0026plusmn;3.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40.29\u0026plusmn;2.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36.00\u0026plusmn;4.42\u003csup\u003e*#\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDiet\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.50\u0026plusmn;2.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17.43\u0026plusmn;0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16.67\u0026plusmn;1.75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMovement\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.10\u0026plusmn;2.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.86\u0026plusmn;1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.83\u0026plusmn;0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBlood glucose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.50\u0026plusmn;1.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.57\u0026plusmn;0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.33\u0026plusmn;1.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFoot care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.80\u0026plusmn;1.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.14\u0026plusmn;1.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.17\u0026plusmn;1.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePharmacy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.50\u0026plusmn;0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.29\u0026plusmn;0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.67\u0026plusmn;0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCompared with the operation time of 4 years，\u003csup\u003e*\u003c/sup\u003eP＜0.05；Compared with the operation time of 5 years，\u003csup\u003e#\u003c/sup\u003eP＜0.05\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFollow-up outcomes and self-management ability\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eAmong the 23 patients who completed the self-management behavior scale for diabetic patients, 17 were cured, 3 relapsed, and 3 underwent amputation. The outcomes of relapse and amputation were both defined as non-recovery. The results showed that there was a significant difference in scores between recovery and non-recovery (P \u0026lt; 0.05), as shown in Table 4.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4 \u0026nbsp;Follow-up outcomes and self-management ability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eItems\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRecovery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUnhealed\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSDSCA score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e41.65\u0026plusmn;3.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35.67\u0026plusmn;4.27\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDiet\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.35\u0026plusmn;1.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.83\u0026plusmn;1.60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMovement\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.82\u0026plusmn;1.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.17\u0026plusmn;0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBlood glucose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.47\u0026plusmn;1.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.50\u0026plusmn;2.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFoot care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.94\u0026plusmn;1.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.17\u0026plusmn;2.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePharmacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.29\u0026plusmn;0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.00\u0026plusmn;0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCompared with the outcome of recovery，\u003csup\u003e*\u003c/sup\u003eP＜0.05\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis of satisfaction degree\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 51 patients who had follow-up outcomes, 31 patients received the satisfaction survey, with a score of (3.23 \u0026plusmn; 0.42) points. Among them, 7 cases were very satisfied and 24 cases were satisfied, resulting in a satisfaction rate of 100%. 20 cases did not receive the satisfaction survey results due to time constraints or their own conditions.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eLong-term clinical effect\u003c/h2\u003e\n\u003cp\u003eThe recovery rate within 3 years or more after the surgery is a key indicator for evaluating long-term efficacy\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e, representing whether the treatment plan is effective and whether it can reduce the risk of disability. It is of great significance for delaying disease progression and reducing the consumption of medical resources. The current research follow-up periods are mostly around 2 years (24 months), and the clinical effects are generally good. However, there are relatively few studies on the long-term clinical effects, especially those lasting for 4 years (48 months) or more. Professor Qu and Hua and others applied the transverse tibial bone repositioning surgery to patients with diabetic foot and achieved good therapeutic effects. All 40 patients were followed up, with the longest follow-up period reaching 34 months. The ulcer healing rate reached 100%\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Others, such as Ou, used a percutaneous minimally invasive surgical method to further improve the transverse tibial bone repositioning surgery, and the results were also satisfactory. Among the 23 cases, 21 cases of affected feet were cured, and the cure rate within 19 months reached 91%. The remaining 2 cases had poor basic conditions and ended up with amputation and death\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e.Wang and others treated diabetic foot patients using the combined bone cement method. Within 21 months, the recovery rate of affected feet reached 92%. One patient died due to pulmonary infection and multiple organ failure, and another was amputated due to acute lower extremity vascular embolism\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Liu conducted a retrospective study at two centers, including 43 affected feet. The recovery rate one year after surgery was 95%\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Chen carried out a multicenter study, including 1175 affected feet. This study broke through the limitations of previous single-center studies with a smaller sample size and followed up for 2 years. A total of 1157 affected feet were included, with a recovery rate of 85%, a mortality rate of 7.2%, an amputation rate of 4.5%, and a recurrence rate of 2.8%. These results strongly demonstrated the value of TTT in the treatment of diabetic foot\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. The shortest follow-up period in this study was 4 years, and the longest was 6 years. The recovery rate of the 52 included affected feet was 67.3%. The recovery rates in the 4th, 5th, and 6th years after surgery were 73.9%, 73.6%, and 40.0% respectively. The recovery rate was significantly different from the results of other scholars' studies. The reasons may be as follows: Firstly, diabetic foot is a chronic disease. During the long-term treatment process, patients not only bear economic burdens but also suffer from psychological problems such as anxiety, depression, and physical symptoms such as pain and insomnia\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. As the disease progresses, the long-term and slow pain will gradually lead patients to develop stubborn and incorrect cognition, even questioning the professional guidance of medical staff, and then adopting some inappropriate treatment methods, ultimately resulting in improper disease management.The series of problems caused by the chronic course of diabetic foot disease may be an important reason for the decline in the recovery rate. Secondly, for patients whose surgery was performed 6 years ago, the surgery was conducted in 2019, and the surgical techniques and nursing plans at that time had certain differences from the current ones\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Moreover, the patients included in this study were all relatively old, especially those whose follow-up outcomes were death, whose ages were basically above 75 years old, and the oldest was 90 years old. The causes of death were mainly the underlying diseases and complications, and only one patient was 31 years old and died due to an accident rather than the disease itself. The causes of death were mainly the underlying diseases and complications. Therefore, the mortality rate of this study may lack certain representativeness, and the recovery rate discussed in this study is the recovery rate of all patients who could be followed up to the outcome, that is, the death patients will also be included, which means the number of death patients will directly affect the recovery rate, leading to a decrease in the recovery rate. Finally, the Wagner classification of the patients included in this study at admission was all at level 3 or above, the patients' conditions were severe, and the duration of diabetic foot disease was long. Even without other diabetes-related complications, there were many risk factors\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. And the other studies compared and discussed in this study included more patients with Wagner classification of level 1. This difference in the severity of the included study subjects' conditions may also be one of the reasons for the significant gap in the healing rates between the two. In conclusion, it is not appropriate to simply equate the lower recovery rate in this study with poor surgical efficacy. The results more reflect the diversity of influencing factors, which suggests that we should focus on the factors affecting surgical efficacy in the future and provide targeted improvement measures to maintain the long-term efficacy of the surgery. It is worth noting that the recurrence rate, amputation rate, and mortality rate of the patients in this study were 11.5%, 7.7%, and 13.4% respectively, which were significantly lower than the results of previous related studies. This indicates the long-term effectiveness of TTT in treating DFU, and its safety and operability are good, and it has the value of being widely promoted in clinical practice\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e][\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e][\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eSelf-management skills\u003c/h2\u003e\u003cp\u003eTTT can treat diabetic foot but not diabetes itself. Therefore, the long-term maintenance of surgical effects depends on the continuous maintenance and active cooperation of the patients. Currently, in the research on diabetes self-management, the self-management ability of patients is mainly evaluated through aspects such as diet, exercise, blood sugar monitoring, medication, and foot care. Based on previous related studies, there are many tools for assessing the self-management ability of diabetic patients. Among them, the SDSCA and the Morisky Medication Adherence Scale are widely used and verified in multiple countries, and the SDSCA scale, as a comprehensive measurement tool, has fewer items and meets the requirements of this study\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e.In the research conducted by Wang\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e, the SDSCA scale was used to assess the self-management practice ability of rural patients with type 2 diabetes. The results showed that rural patients lacked the ability in blood glucose monitoring and foot care, which was consistent with the results of this study. This might be related to the poorer economic conditions of rural patients, as well as their insufficient attention to foot care and lack of nursing skills. The study also proved that knowledge has a positive impact on improving patients' self-management. This suggests the importance of health education for patients by medical staff. However, it should be noted that the effectiveness of health education decreases gradually over time after discharge\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. This highlights the importance of follow-up. During the follow-up process, strengthening patients' mastery of health education knowledge can further improve their self-management ability\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. This study also revealed that while patients' self-management ability tends to decline over time in general, a closer look at individual cases shows that even those who underwent surgery 6 years ago may have a higher level of self-management ability than those with only 4 years post-surgery. The reasons for this might be as follows: Firstly, it is related to the patient's living environment. Patients with higher self-management ability often have higher economic and knowledge levels, enabling them to obtain health knowledge and implement healthy behaviors. Secondly, some patients have had hospitalizations in other departments during the follow-up period, and each hospitalization may provide health education for the patients, thereby increasing their awareness of the disease. This also reminds us of the importance of postoperative follow-up. During each follow-up, timely detection of patients' unhealthy behaviors and correction are necessary to maintain the surgical efficacy.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eFollow-up outcomes and self-management ability\u003c/h2\u003e\u003cp\u003eThe results of this study show that there is a difference in the self-management scale scores between patients with a follow-up outcome of recovery and those without recovery. The former has higher scores than the latter. From the perspective of disease management, the higher scores of the recovered patients in the self-management scale indicate that they exhibit more standardized and systematic behavioral patterns in aspects such as blood glucose monitoring, foot care, diet control, and exercise management. Good self-management can, to a certain extent, prevent ulcer recurrence and sustain the efficacy of TTT surgery. In contrast, the lower scale scores of the non-recovered patients suggest that there may be knowledge gaps and behavioral deficiencies during the disease management process, such as lacking regular foot examinations and blood glucose monitoring behaviors, neglecting the importance of exercise, and these factors collectively contribute to the occurrence of non-healing outcomes, thereby weakening the efficacy of TTT surgery. This difference further corroborates the importance of establishing a sound follow-up supervision mechanism to enhance patients' self-management efficacy, improve clinical outcomes, especially for patients with longer surgical durations.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eSatisfaction\u003c/h2\u003e\u003cp\u003eSatisfaction is the overall perception of the quality of life of patients with diabetic foot disease, including their acceptance and adaptation to the impacts brought by diabetic foot. Patients with higher satisfaction tend to have a more positive attitude towards life, which helps them better manage the disease and maintain the therapeutic effect\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Although the transverse tibial bone repositioning surgery has achieved good results in the healing of diabetic foot ulcers, consistent with the research results of Zhou\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e, some studies have found that there is still room for improvement in the satisfaction of patients with diabetic foot. The research by Yin\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e shows that the satisfaction of 120 patients was 90.8%, and after effective intervention, the satisfaction of the patients improved. Therefore, clinical practice should attach importance to the management of satisfaction of patients with diabetic foot, by establishing a multi-dimensional intervention system, continuously improving the quality of life and disease self-management ability of patients, and promoting the coordinated improvement of the therapeutic effect and patient satisfaction of diabetic foot treatment.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, this study aimed to explore the long-term efficacy of the transverse tibial bone repositioning surgery in the treatment of diabetic foot ulcers. We collected the medical records of patients who underwent TTT surgery for DFU in our department from 2019, sorted them out, and conducted centralized follow-up. The main analysis focused on the healing rate, recurrence rate, amputation rate, mortality rate, and their related factors of DFU over the long term. The results showed that the healing rate in patients with a surgery duration of up to 4 years was lower than that at around 2 years after surgery, and the healing rate tended to decrease as the surgery duration increased. This study also found that the follow-up outcomes were related to the patients' self-management ability to some extent. Therefore, it is necessary to strengthen postoperative care for patients and attach importance to the follow-up work. During the follow-up, problems existing in patients should be promptly identified to maximize the quality of the surgery and reduce the burden on patients and society. In the future, the sample size can be further increased, and the potential relationship between the surgery duration and the patients' self-management ability can be explored.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eH.L. , Y.Z., J.G.,J.X.：Conception and design of the research.B.W. ,X.Y. , P.Z. ,C.H.,J.X. :Acquisition of dataB.W. ,X.Y. , P.Z. ,D.W. ,C.H. ,Q.W. ,B.W. :Statistical analysisD.W. ,Y.Z. :guided the surgeryY.R. , H.L. :Writing of the manuscriptY.R. ,J.G. :Critical revision of the manuscript for intellectual content\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eI acknowledge anyone who contributed towards the article that does not meet the criteria for authorship, including anyone who gave professional writing services or materials.This study received ethical approval and informed consent.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWang D, Zhang Y, He G, et al. Tibial transverse bone repositioning technique combined with antibiotic bone cement for the treatment of chronic ischemic diseases of the lower extremities accompanied by chronic infections of the foot and ankle [J]. Chin J Reconstr Aesthetic Surg. 2020;34(08):979\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGlobal regional. and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021[J]. Lancet (London, England), 2023, 402(10397): 203\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhu YL, Guo BF, Zang JC, et al. Ilizarov technology in China: a historic review of thirty-one years [J]. Int Orthop. 2022;46(3):661\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang L, Wang M, Duan C, et al. Analysis of the clinical effect of Ilizarov transverse tibial bone transport in the treatment of Wagner Grade III and IV Diabetic foot Ulcers [J]. Chin J Bone Joint Injury. 2024;39(08):891\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJiang W, Zhang Y, Yan F, et al. Effectiveness of a nurse-led multidisciplinary self-management program for patients with coronary heart disease in communities: A randomized controlled trial. Patient Educ Couns. 2020;103(4):854\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHu L. Analysis of the Therapeutic Effect of Mid-Segment Un-tension Suspension of the Urethra Through the Pubic Fossa [D]. Zhengzhou University; 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhao Y, Chen Z, Zhang W. The Effects of Closed Negative Pressure Drainage Combined with Ilizarov Tibial Transverse Bone Shifting on Oxidative Stress and Inflammatory Response in Patients with Severe Diabetic Foot [J/OL]. Practical Med J, 1\u0026ndash;6 [2025-07-10].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHua Q, Qin S, Zhao L, et al. Ilizarov Technique for Transverse Tibial Bone Translocation in the Treatment of Diabetic Foot [J]. Chin J Orthop Surg. 2017;25(04):303\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOu S, Qi Y, Sun H, et al. Percutaneous minimally invasive tibial osteotomy with transverse bone repositioning for the treatment of diabetic foot [J]. Chin J Orthop Surg. 2018;26(15):1385\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu J, Du X, Yao X, et al. Micro-bone window bone transplantation combined with negative pressure closed drainage for the treatment of diabetic foot: A retrospective cohort study from two centers [J]. J Practical Med. 2024;40(18):2590\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen Y, Ding X, Zhu Y, 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\u0026ndash;204.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang S, Wang Y, Zhu S, et al. Analysis of the current situation and influencing factors of depression in middle-aged and elderly diabetic patients based on CHARLS [J]. J Nurs. 2025;40(11):86\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWei M, Weng Y, Liu J et al. Coronary heart disease combined with diabetes increases the risk of cognitive impairment: A cross-sectional study of rural population in Xi'an [J/OL]. J Xi'an Jiaotong Univ (Medical Sciences), 1\u0026ndash;15 [2025-07-10].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang Y, Liu H, Yang Y, et al. Incidence and risk factors for amputation in Chinese patients with diabetic foot ulcers: a systematic review and meta-analysis. Front Endocrinol (Lausanne). 2024;15:1405301.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eArmstrong DG, Boulton AJM, Bus SA. Diabetic Foot Ulcers and Their Recurrence. N Engl J Med. 2017;376(24):2367\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYang L, Rong GC, Wu QN. Diabetic foot ulcer: Challenges and future. World J Diabetes. 2022;13(12):1014\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePeng X. Research on the Influencing Factors of Self-Management Behaviors of Type 2 Diabetic Patients Based on the Three-Dimensional Theory of Attitudes [D]. Chengdu Medical College; 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang L, Li S, Wang X et al. Research on the Impact Path of Diabetes Knowledge and Self-Efficacy on Self-Management and Quality of Life of Rural Type 2 Diabetes Patients Based on ITHBC Model [J/OL] Chinese General Practice,1\u0026ndash;8[2025-06-17].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChatterjee S, Davies MJ, Heller S, et al. Diabetes structured self-management education programmes: a narrative review and current innovations. Lancet Diabetes Endocrinol. 2018;6(2):130\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePolsook R, Aungsuroch Y, Thontham A. The effect of self-management intervention among type 2 diabetes: A systematic review and meta-analysis. Worldviews Evid Based Nurs. 2024;21(1):59\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhou Tao D, Xiaorong L. Jiuqun, The influence of the collaborative nursing model on the psychological state, self-care ability and nursing satisfaction of diabetic foot patients after Ilizarov transverse tibial bone transfer [J]. Evidence-based Nurs 2022,8(01):87\u0026ndash;90.Yin Jianhong, Liu Ming, Li Mina.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThe application effect. of the joint management of medical staff based on the multidisciplinary team diagnosis and treatment model in patients with diabetic foot [J]. Nurs Res 2023,37(23):4307\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\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, Transverse tibial bone transport, Follow-up","lastPublishedDoi":"10.21203/rs.3.rs-7661681/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7661681/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: To conduct long-term follow-up on patients who underwent transverse tibial bone transfer for the treatment of diabetic foot ulcers and evaluate the long-term efficacy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: The clinical data of patients with diabetic foot ulcers who underwent transverse tibial bone transfer in our hospital from 2019 to 2021 were retrospectively collected. The last centralized follow-up was conducted on April 30, 2025. The recovery status of diabetic foot in the patients was collected, and the self-management ability and satisfaction of the patients were evaluated.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: A total of 51 patients (52 with affected feet) were followed up, and the recovery rate was 67.3%. Among them, the recovery rates at 4, 5, and 6 years after the operation were 73.9%, 73.6%, and 40%, respectively. A total of 23 self-management scoring scales were collected. The scores at 4, 5, and 6 years after the operation were (42.40±3.34) points,(40.29±2.69)points,and(36.00±4.42) points, respectively. The self-management ability level of the recovered patients was higher than that of the non-recovered patients, P \u0026lt; 0.05; A total of 31 satisfaction survey forms were collected, with a score of (3.23±0.42) points. Among them, 7 cases were very satisfied and 24 cases were satisfied, with a satisfaction rate of 100%.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: The long-term efficacy of tibial transverse bone transfer in the treatment of diabetic foot ulcers is good. Patients have a relatively good level of self-management ability and high patient satisfaction.\u003c/p\u003e","manuscriptTitle":"The long-term clinical efficacy of transverse tibial bone transfer in the treatment of diabetic foot ulcers: more than 4 years of follow-up in a single center","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-12 14:04:29","doi":"10.21203/rs.3.rs-7661681/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":"028587d8-f634-4023-8502-01fcf336c0f9","owner":[],"postedDate":"October 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-18T11:23:29+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-12 14:04:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7661681","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7661681","identity":"rs-7661681","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}