A three-stage sequential surgical approach to a more efficient management of clinical stage 4 diabetic foot ulcers

Fang Zhang^1,2Yu Guo^1,2Wenduo Zhang^1,2Ilaria Dal Pra³Wei Chen^1,2Xiaojin Mo^1,2Hehua Song⁴Anna Chiarini³Jinpiao Yang^1,2Kaiyu Nie^1,2Zairong Wei^1,2*Shusen Chang^1,2,5*

• ¹Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China
• ²The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine, Zunyi Medical University, Zunyi, China
• ³Department of Surgery, Dentistry, Pediatrics & Gynecology, University of Verona Medical School, Verona, Italy
• ⁴Organ Transplantation Center, Affiliated Hospital of Zunyi Medical University, Zunyi, China
• ⁵Affiliated Hospital of Zunyi Medical University, Zunyi, China

Background: It has been a great challenge to treat clinical stage 4 Diabetic foot ulcers (DFUs) due to high rates of major amputations and prolonged healing time. This study aimed to assess the effectiveness of a three-stage sequential surgical approach, which based on the Integrated Surgery Wound Treatment (ISWT) mode, to manage clinical stage 4 DFUs and compare the benefit of incorporating tibial cortex transverse transport (TTT) surgery at stage 3 treatment. Methods: Twenty-three patients with clinical stage 4 DFUs aged 45-75 years treated between January 2022 and February 2023 were retrospectively analyzed. Eleven patients (Group A) received wound debridement, antibiotic-loaded bone cement (ALBC) at stage 1 treatment, percutaneous transluminal angioplasty (PTA), wound debridement, and ALBC at stage 2 treatment, and skin grafting with TTT at stage 3 treatment, while twelve patients (Group B) received the same treatment without TTT. Assessed clinical outcomes included length of hospital stay, ulcer healing duration, ulcer recurrence rate, reintervention (re)-PTA rate, amputation rate, mortality rate, visual analog scale (VAS) scores, ankle-brachial index (ABI), and two-point discrimination (2-PD) ability. The computed tomographic angiography (CTA) was used to evaluate vascular hyperplasia. Results: Group A showed no occurrences of re-PTA (P=0.037) and similar ulcer healing times (P=0.975) compared to Group B. Ulcer outcome, amputation, and mortality rate were also alike in the two groups (P>0.05). One year after surgery, Group A demonstrated improvement in VAS scores, ABI, and 2-PD, while Group B showed no significant changes. Additionally, Group A exhibited enhanced lower limb artery characteristics compared to Group B. Conclusion: The sequential three-stage approach based on the ISWT mode effectively manages clinical stage 4 DFUs. Incorporating TTT surgery at stage 3 extends the benefits of PTA surgery.