Comparison of Tibial Cortex Transverse Transport and Free Anterolateral Thigh Perforator Flap in the Treatment of Severe Diabetic Foot Ulcers: A Retrospective Study
Summary: Published March 9, 2026 in Frontiers in Surgery (Orthopedic Surgery section), this retrospective study from the First Affiliated Hospital of Guangxi Medical University directly compares two surgical strategies for severe diabetic foot ulcers (DFUs) classified as Wagner grade 3 or 4 in 174 patients treated between January 2016 and December 2022. The two approaches are tibial cortex transverse transport (TTT), a minimally invasive technique that uses distraction angiogenesis — whereby a cortical bone window is incrementally transported in a transverse vector, creating a biological stimulus for neovascularization, nerve regeneration, and microcirculatory reconstruction — and free anterolateral thigh perforator flap (ALTPF) reconstruction, a conventional microsurgical approach in which a skin and subcutaneous tissue flap is harvested from the lateral thigh and transferred to the wound. A total of 88 patients underwent TTT and 86 received ALTPF; baseline characteristics including Wagner grade, ulcer area, ABI, peripheral neuropathy prevalence, and osteomyelitis rates were comparable between groups. TTT was dramatically less invasive: mean operative time 59 vs. 274 minutes and blood loss 12 vs. 356 mL, with a transfusion rate of 3.4% vs. 43.0%. At one year or more of follow-up, the TTT group achieved a 97.7% ulcer healing rate versus 88.4% in the ALTPF group (p<0.05), with significantly lower ulcer recurrence (2.3% vs. 10.5%) and major amputation rates (1.1% vs. 7.0%). Three months postoperatively, TTT patients showed superior ankle-brachial index recovery (0.96 vs. 0.84), nerve conduction velocity (51.3 vs. 28.6 m/s), Semmes-Weinstein monofilament test restoration (93.2% vs. 77.9% negative), and Maryland Foot Score (85.2 vs. 80.0). Complications were minimal in the TTT group (two pin-tract infections); ALTPF saw four complete and six partial flap necrosis events, contributing to six major amputations. Authors caution that the retrospective design limits causal inference and that prospective RCTs are needed.
Key Highlights:
- 174 patients with Wagner grade 3–4 DFU; TTT n=88, ALTPF n=86; single-centre retrospective design; minimum 1-year follow-up; First Affiliated Hospital of Guangxi Medical University
- TTT operative time 59 min vs. 274 min (ALTPF); blood loss 12 mL vs. 356 mL; transfusion rate 3.4% vs. 43.0% — all highly significant (p<0.05)
- Healing rate: 97.7% (TTT) vs. 88.4% (ALTPF); recurrence: 2.3% vs. 10.5%; major amputation: 1.1% vs. 7.0% — all p<0.05
- TTT mechanism: transverse tibial cortex distraction stimulates HIF-1α-induced angiogenesis, activates SDF-1/CXCR4 signalling, promotes M2 macrophage polarization, and enhances collagen remodelling in the wound microenvironment
- Superior neurological recovery with TTT: NCV 51.3 vs. 28.6 m/s; SWMT negative rate 93.2% vs. 77.9%; Maryland Foot Score 85.2 vs. 80.0 (all p<0.05) — authors attribute this to TTT’s systemic improvement of limb microcirculation rather than ALTPF’s primarily local tissue coverage
- Limitations: retrospective, single-centre, n=174; prospective multicentre RCTs needed to validate generalizability; TTT complication rate low but includes rare risk of tibial fracture not observed in this cohort
Keywords: tibial cortex transverse transport, diabetic foot ulcer surgery, anterolateral thigh flap DFU, limb salvage diabetic foot, distraction angiogenesis wound, Wagner grade diabetic foot ulcer
Shunan Dong Jiyong Jiang Sijie Yang Qikai Hua