OBJECTIVE: To provide a comprehensive summary of the technological evolution, clinical protocols, mechanisms of action, and current research progress of tibial transverse transport (TTT), with the goal of facilitating its standardized application in clinical practice. METHODS: A systematic review of both domestic and international literature on TTT for the treatment of diabetic foot was conducted. The analysis encompassed technical developments, surgical protocols, combination therapies, regenerative mechanisms, and clinical outcomes. RESULTS: Diabetic foot is one of the most severe complications of diabetes mellitus. Conventional treatments show limited efficacy in patients with advanced stages, such as Wagner grade 3/4 or Texas grade C and above. TTT, an evolution of the Ilizarov technique, promotes tissue regeneration through the "tension-stress principle". The procedure for the treatment of diabetic foot has evolved from an open large cortical window (120 mm×20 mm) to a minimally invasive small window (50 mm×15 mm), with incision length reduced to 10 mm and simplified external fixators. A dual-incision technique (10 mm apart) is now applied at 5 cm distal to the tibial tuberosity. Bone transport typically begins 3-5 days postoperatively at a rate of 1 mm/day, incorporating the "accordion technique" (2 weeks distraction+3 days stabilization+reverse transport). Multicenter studies report a limb salvage rate of 96.1%, wound healing rate of 96.3%, and amputation rate of less than 5%. Combining TTT with vascular reconstruction and antibiotic-loaded bone cement further enhances outcomes. There are also a series of studies on the mechanism of TTT in treating diabetic foot. TTT has been shown to activate the hypoxia-inducible factor 1α-vascular endothelial growth factor/stromal cell-derived factor 1 (HIF-1α-VEGF/SDF-1) signaling pathway to facilitate microcirculatory reconstruction; mobilize immune cells and rebalance macrophage polarization, thereby improving the inflammatory microenvironment; recruit stem cells via chemotaxis to accelerate re-epithelialization; and promote the release of regenerative small extracellular vesicles. CONCLUSION TTT demonstrates promising clinical potential in the treatment of diabetic foot, particularly in improving limb perfusion and promoting tissue repair. However, the underlying mechanisms have not been fully elucidated. Further in-depth investigations are required. In addition, the current lack of high-quality randomized controlled trials highlights the urgent need for rigorously designed randomized controlled trial to validate the efficacy and safety of this technique.
Humans ; Bone Transplantation/methods* ; Diabetic Foot/surgery* ; Ilizarov Technique ; Limb Salvage/methods* ; Tibia/surgery* ; Treatment Outcome

OBJECTIVE: To explore the effectiveness of limb shortening/re-lengthening technique combined with in situ tissue regeneration technique in limb salvage for patients with complex lower limb fractures and soft tissue defects. METHODS: Between January 2021 and December 2024, 12 patients with complex lower limb fractures and soft tissue defects caused by trauma were admitted. There were 10 males and 2 females; the age ranged from 18 to 46 years, with an average of 36 years. Among them, 1 case of open comminuted tibiofibular fracture caused bone necrosis and soft tissue infection; 4 cases of open tibiofibular fractures developed bone and soft tissue infections after being fixed with a combined external fixator, resulting in defects; 7 cases of closed tibial fractures that underwent internal fixation developed soft tissue infections, leading to bone and soft tissue necrosis. The time from injury to the formation of bone and soft tissue defects was 2-9 weeks, with an average of 6 weeks. The length of bone defects was 5.0-10.2 cm, with an average of 6.8 cm; the area of soft tissue defects was 32-54 cm ², with an average of 43.9 cm ². After admission, all patients underwent thorough debridement. The limb shortening treatment was performed after the wound had filled with fresh granulation tissue, and an Ilizarov ring-shaped external fixator was placed or replaced. The limb was shortened at a rate of 1 mm/day to reduce bone defects. At the same time, the soft tissue defects were repaired using the in situ tissue regeneration technique. After the wound healed, osteotomy was performed, and limb lengthening was carried out at a rate of 1 mm/day. The lower limb full-length X-ray films were taken, and the lengthening was stopped when the lower limb alignment was restored. The healing condition of the wound was observed and the healing time was recorded. RESULTS: One patient died due to a traffic accident during limb lengthening. The remaining 11 patients completed limb shortening and re-lengthening treatment and were followed up 18-36 months, with an average of 20 months. All 11 patients successfully preserved their limbs. The wound healing time was 4-12 weeks, with an average of 8 weeks; the limb shortening time was 4-8 weeks, with an average of 6 weeks; and the limb lengthening time was 4-12 weeks, with an average of 8 weeks. One patient experienced delayed bone mineralization during bone lengthening, and one had pin tract infection. Both were treated symptomatically. The lower limb mechanical axis of all 11 patients was restored, and they were able to walk independently. CONCLUSION The application of limb shortening/re-lengthening technique combined with in situ tissue regeneration technique in the treatment of large bone and soft tissue defects not only effectively avoids the occurrence of nonunion at the apposition ends and increases the stability of the lower limb, but also significantly shortens the wound healing time, avoids the risk of soft tissue infection and increases the limb salvage rate. It can be used as a treatment technique for patients with complex lower limb fractures combined with soft tissue defects.
Humans ; Adult ; Male ; Female ; Middle Aged ; Soft Tissue Injuries/surgery* ; Limb Salvage/methods* ; Adolescent ; Young Adult ; Bone Lengthening/methods* ; External Fixators ; Lower Extremity/surgery* ; Fracture Fixation, Internal/methods* ; Fractures, Bone/surgery* ; Tibial Fractures/surgery* ; Treatment Outcome ; Regeneration

PURPOSE: Outcomes of peripheral arterial injury (PAI) depend on various factors, such as warm ischemia time and concomitant injuries. Suboptimal prehospital care may lead to delayed presentation, and a lack of dedicated trauma system may lead to poorer outcome. Also, there are few reports of these outcomes. The study aims to review our experience of PAI management for more than a decade, and identify the predictors of limb loss in these patients. METHODS: This is a retrospective analysis of prospectively maintained database of trauma admissions at a level I trauma center from January 2008 to December 2019. Patients with acute upper limb arterial injuries or lower limb arterial injuries at or above the level of popliteal artery were included. Association of limb loss with ischemia time, mechanism of injury, and concomitant injuries was studied using multiple logistic regressions. Statistical analysis was performed using STATA version 15.0 (Stata Corp LLC, Texas). RESULTS: Out of 716 patients with PAI, the majority (91.9%) were young males. Blunt trauma was the most common mechanism of injury. Median ischemia time was 4 h (interquartile range 2-7 h). Brachial artery (28.5%) was the most common injured vessel followed by popliteal artery (17.5%) and femoral artery (17.3%). Limb salvage rate was 78%. Out of them, 158 (22.1%) patients needed amputation, and 53 (7.4%) had undergone primary amputation. The majority (88.6%) of patients who required primary or secondary amputations had blunt trauma. On multivariate analysis, blunt trauma, ischemia time more than 6 h and concomitant venous, skeletal, and soft tissue injuries were associated with higher odds of amputation. CONCLUSION Over all limb salvage rates was 77.9% in our series. Blunt mechanism of injury and associated skeletal and soft tissue injury, ischemia time more than 6 h portend a poor prognosis. Injury prevention, robust prehospital care, and rapid referral to specialized trauma center are few efficient measures, which can decrease the morbidity associated with vascular injury.
Humans ; Male ; Female ; Retrospective Studies ; Adult ; Middle Aged ; Vascular System Injuries/surgery* ; Limb Salvage/methods* ; Aged ; Amputation, Surgical ; Popliteal Artery/injuries*

Trauma is an important cause of death in young- and middle-aged people. Trauma is comprehensive and includes many surgical specialties, and the surgical techniques of these specialties have long been mature. To reduce the mortality and disability rate of trauma patients, it is necessary to improve trauma management. Trauma has attracted attention in China and trauma treatment and care developed rapidly in recent years. To decrease traumatic mortality and disability rates, our team is committed to building an efficient trauma system in Shaanxi province and has successfully developed a trauma limb salvage map to address the high rates of amputation and disability in patients with limb injuries. This article elaborates on the construction experience of a trauma limb salvage map and its application details in Shaanxi province of China.
Humans ; China ; Limb Salvage/methods* ; Wounds and Injuries/surgery* ; Male ; Extremities/injuries* ; Adult ; Amputation, Surgical ; Middle Aged ; Female

INTRODUCTION: Percutaneous transluminal angioplasty (PTA) is commonly used to treat patients with chronic limb-threatening ischaemia (CLTI). This study aimed to examine the mortality and functional outcomes of patients with CLTI who predominantly had diabetes mellitus in a multi-ethnic Asian population in Singapore. METHODS: Patients with CLTI who underwent PTA between January 2015 and March 2017 at the Vascular Unit at Singapore General Hospital, Singapore, were studied. Primary outcome measures were 30-day unplanned readmission, two-year major lower extremity amputation (LEA), mortality rates, and ambulation status at one, six and 12 months. RESULTS: A total of 221 procedures were performed on 207 patients, of whom 184 (88.9%) were diabetics. The one-, six- and 12-month mortality rate was 7.7%, 16.4% and 21.7%, respectively. The two-year LEA rate was 30.0%. At six and 12 months, only 96 (46.4%) and 93 (44.9%) patients were ambulant, respectively. Multivariate analysis revealed that preoperative ambulatory status, haemoglobin, Wound Ischaemia and foot Infection (WIfI) score, and end-stage renal failure (ESRF) were independent predictors of one-year ambulatory status. Predictors of mortality at one, six and 12 months were ESRF, preoperative albumin level, impaired functional status and employment status. CONCLUSION PTA for CLTI was associated with low one-year mortality and two-year LEA rates but did not significantly improve ambulation status. ESRF and hypoalbuminaemia were independent predictors of mortality. ESRF/CKD and WIfI score were independent predictors of loss of ambulation at six months and one year. We need better risk stratification for patients with CLTI to decide between initial revascularisation and an immediate LEA policy.
Amputation ; Chronic Disease ; Chronic Limb-Threatening Ischemia ; Humans ; Ischemia/surgery* ; Limb Salvage/methods* ; Lower Extremity/surgery* ; Peripheral Arterial Disease/surgery* ; Retrospective Studies ; Risk Factors ; Singapore ; Treatment Outcome

Shark attacks are rare unique pathological processes. Some of them represent devastating injuries with a high morbidity and significant mortality. Related published articles are limited. The increased human interaction within the environment of sharks is the cause of rising incidence of such attacks. This study reported a case of level 4 shark injuries (shark-induced trauma scale) in a 33-year-old male patient, who presented with an extensive injury of the right lower limb with the characteristic features of shark bite. At admission the patient was in a state of shock with profuse bleeding that was controlled by tourniquet. The patient was resuscitated according to the advanced trauma life support. Clinical examination showed hard signs of vascular injury with absent pedal pulse, associated neurological deficits and severance at the knee joint. Prompt vascular intervention after resuscitation was performed to manage the major vascular injuries, together with proper washout and debridement of all the necrotic tissues under strong antibiotic coverage to prevent infection. After that, the patient underwent sequenced plastic, orthopedic, and neurological interventions. Strict follow-up was conducted, which showed that the patient was saved and achieved a functioning limb. This study aims to highlight the management of level 4 shark injuries, which are considered serious and challenging with a high fatality rate and a great risk of amputation due to the associated major vascular injuries. Immediate well organized management plan is crucial. Prompt resuscitation and surgical intervention by a highly-skilled medical team are required to improve the chance of patient survival and limb salvage.
Adult ; Animals ; Bites and Stings/complications* ; Humans ; Limb Salvage ; Male ; Retrospective Studies ; Sharks ; Vascular System Injuries/surgery*

Amputation ; Chronic Limb-Threatening Ischemia ; Fibrinolytic Agents/therapeutic use* ; Humans ; Limb Salvage ; Peripheral Arterial Disease ; Risk Factors ; Singapore ; Treatment Outcome

After diagnosis of peripheral artery disease in diabetic patients, revascularization can be considered in those who are not improved after guideline-directed medical therapy. Recently, more aggressive approaches with interventional treatment have been recommended. Before revascularization therapy, it is important to differentiate patients with claudication or critical limb ischemia, and the final goal and treatment modality of interventional treatments should be based on clinical diagnosis. For patients with claudication, the goal of revascularization is improvement of functional capacity or quality of life; however, in more severe forms of critical limb ischemia, the purpose of revascularization is limb salvage and ultimately saving patient's life. With improvement of vascular interventions, interventional treatment for peripheral artery disease is preferred, although surgical treatment might show better results than intervention in some cases.
Diabetes Mellitus ; Diagnosis ; Extremities ; Humans ; Ischemia ; Limb Salvage ; Peripheral Arterial Disease ; Quality of Life

PURPOSE: The clinical characteristics and results of femoropopliteal artery injury (FPAI) remain unclear. In this study, we evaluated the outcomes and risk factors of limb loss in patients treated for FPAI. MATERIALS AND METHODS: We retrospectively reviewed data from a database of patients who underwent revascularization for an FPAI at a single institution between January 2013 and December 2017. We reviewed and analyzed the characteristics, postoperative results, and factors that influence amputation rates. RESULTS: Twenty-four femoropopliteal arterial reconstructions in 24 patients were included in this study. Among the patients were 20 (83.3%) male with a first-quartile age of 28 years and a third-quartile age of 45 years (range, 15–68 years). The mean injury severity score (ISS) was 16 (range, 4–55), and 5 patients (20.8%) had ISSs of >20 points. The mean mangled extremity severity score (MESS) was 3.8 (range, 1–11), and 8 patients (33.3%) had MESSs of >5 points. In terms of arterial reconstruction methods, autogenous saphenous vein grafting, vein patching, and primary closure were performed in 9 patients (37.5%), 4 patients (16.7%), and 11 patients (45.8%), respectively. Despite arterial reconstruction, 5 patients (20.8%) underwent above-knee amputation. ISSs of >20, MESSs of >7, and orthopedic fixation were statistically significant factors associated with amputation. CONCLUSION: In cases of FPAI with ISSs of >20, MESSs of >7, and orthopedic fixation, amputations should be considered. We were also careful to attempt limb salvage in such cases.
Amputation ; Amputation, Traumatic ; Arteries ; Extremities ; Femoral Artery ; Humans ; Injury Severity Score ; Limb Salvage ; Lower Extremity ; Male ; Orthopedics ; Popliteal Artery ; Retrospective Studies ; Risk Factors ; Saphenous Vein ; Transplants ; Vascular System Injuries ; Veins

Ameloblastoma in the tibia is rare. Limb reconstruction after tumor resection is challenging in terms of selection of the operative method. Here, we report a case of radical resection of an ameloblastoma in the mid-distal tibia combined with limb salvage using a three-dimensional (3D)-printed prosthesis replacement, with 1-year follow-up results. After receiving local institutional review board approval, a titanium alloy prosthesis was designed using a computer and manufactured with 3D-printing technology. During the operation, the stem of the prosthesis was inserted closely into the proximal tibial medullary cavity. Then, the metal ankle mortise and the talus were compacted closely. Radiographic results at 1-year follow up showed that the prosthesis was well placed, and no loosening was observed. The Musculoskeletal Tumor Society (MSTS) 93 functional score was 26 points, and the functional recovery percentage was 86.7%. Computer-assisted 3D-printing technology allowed for more volume and structural compatibility of the prosthesis, thereby ensuring a smooth operation and initial prosthetic stabilization. During the follow up, the presence of bone ingrowths on the porous surface of some segments of the prosthesis suggested good outcomes for long-term biological integration between the prosthesis and host bone.
Alloys ; Ameloblastoma ; Ankle ; Ethics Committees, Research ; Extremities ; Follow-Up Studies ; Limb Salvage ; Methods ; Prostheses and Implants ; Talus ; Tibia ; Titanium