Clinical outcomes of tibial cortex transverse transport versus antibiotic-loaded bone cement for Wagner grade 3-4 diabetic foot ulcers: a real-world retrospective cohort study.

Background: Diabetic foot ulcers (DFUs) are a primary cause of non-traumatic lower-extremity amputations. Wagner grade 3-4 ulcers, which are often complicated by deep infection and impaired perfusion, present significant management challenges. Antibiotic-loaded bone cement (ALBC) establishes a localized high-concentration antimicrobial environment and facilitates dead-space management, while tibial cortex transverse transport (TTT) is designed to enhance pedal perfusion via distraction-induced angiogenesis, thereby promoting wound healing. Rather than being interchangeable procedures, ALBC and TTT are two distinct, clinically selected surgical limb-salvage approaches. ALBC primarily addresses infection control and dead-space management, while TTT targets perfusion improvement. However, there is a notable lack of direct comparative evidence between these two approaches. Methods and analysis: A retrospective analysis of clinical data was conducted on patients with Wagner grade 3-4 DFUs who received TTT or ALBC at our center from January 2020 to December 2023. Following standardized initial management and multidisciplinary reassessment, patients were assigned to either the TTT or ALBC pathway, based on their dominant clinical problem, infection burden, perfusion status, and vascular anatomical feasibility. We collected and analyzed perioperative indicators and postoperative outcomes, with further stratification by Wagner grade for a comprehensive evaluation. Kaplan-Meier analysis was used to evaluate major amputation-free survival. Factors associated with the postoperative 3-month ankle-brachial index (ABI) were assessed using multivariable linear regression, while multivariable binary logistic regression identified independent factors associated with unplanned return to the operating room (URTOR). Results: There were no significant differences between the groups regarding the percentage area reduction (PAR) at 3 months or in the rates of major amputation. Kaplan-Meier analysis revealed no statistically significant difference in major amputation-free survival between the TTT and ALBC groups. However, stratified analyses revealed marked findings for specific patient categories. Among patients with Wagner grade 4 DFUs, the TTT group demonstrated a significantly higher PAR at 6 months compared to the ALBC group (P = 0.002) and a lower rate of unplanned return to the operating room (URTOR) (P = 0.018). Similarly, for patients with Wagner grade 3 DFUs, the TTT group showed a significantly lower URTOR rate (P = 0.012). Furthermore, the TTT group demonstrated a significantly greater improvement in the ankle-brachial index (ABI) (P < 0.05), while the ALBC group had a notably shorter time to infection clearance (P < 0.001). In multivariable analyses, treatment group and preoperative ABI were significantly associated with postoperative 3-month ABI. Treatment with TTT was independently associated with lower odds of URTOR compared with ALBC, and higher preoperative ABI was associated with reduced URTOR risk. Conclusion: ALBC and TTT represent two clinically selected surgical limb-salvage strategies with different therapeutic priorities for Wagner grade 3-4 DFUs complicated by coexisting infection and perfusion impairment. ALBC may be more appropriate when infection control, osteomyelitis, abscess formation, or dead-space management is the principal clinical concern, whereas TTT may be more suitable when impaired distal perfusion is the dominant factor limiting wound healing. In this real-world cohort, TTT was associated with greater improvement in perfusion and a lower rate of unplanned reintervention, particularly in patients with Wagner grade 4 ulcers; meanwhile, ALBC was associated with faster infection clearance. Collectively, these findings suggest an individualized treatment approach following standardized initial management, where treatment selection is determined by ulcer severity, infection burden, perfusion status, and vascular anatomy.