TRANSVERSE TIBIAL BONE TRANSFER (TTBT) IN DIABETIC FOOT ULCER (DFU): TECHNICAL ASPECTS, BIOCHEMICAL MECHANISMS, SAFETY AND OUTCOMES OF A NOVEL SURGICAL METHOD

Bartosz Zawadzki; Natalia Kornacka; Jakub  Zwardoń; Katarzyna Naja; Miłosz Rewekant; Zuzanna  Walczak; Anna Świerczek; Aleksander Gajkowski; Tomasz Adam Szczepanowski; Krzysztof Bednarski

doi:10.31435/ijitss.2(50).2026.6050

Authors

Bartosz Zawadzki Independent Public Health Care Institution of the Ministry of the Interior and Administration, Krakow, Lesser Poland, Poland https://orcid.org/0009-0004-9328-175X
Natalia Kornacka Beskid Oncology Center Municipal Hospital of John Paul II, Wyzwolenia 18, 43-300 Bielsko-Biała, Poland https://orcid.org/0009-0003-3657-2027
Jakub Zwardoń Dr Anna Gostynska Wolski Hospital, Marcina Kasprzaka 17, 01-211 Warsaw, Poland https://orcid.org/0009-0005-3944-2943
Katarzyna Naja National Medical Institute of the Ministry of the Interior and Administration, Warsaw, Poland https://orcid.org/0009-0008-6513-6984
Miłosz Rewekant Beskid Oncology Center Municipal Hospital of John Paul II, Wyzwolenia 18, 43-300 Bielsko-Biała, Poland https://orcid.org/0009-0004-3944-9363
Zuzanna Walczak 5th Military Clinical Hospital with Polyclinic SPZOZ, Kraków, Małopolska, Poland https://orcid.org/0009-0008-8417-5372
Anna Świerczek Beskid Oncology Center Municipal Hospital of John Paul II, Wyzwolenia 18, 43-300 Bielsko-Biała, Poland https://orcid.org/0009-0006-9612-237X
Aleksander Gajkowski Samodzielny Publiczny Zespół Zakładów Opieki Zdrowotnej w Wyszkowie, Wyszków, Poland https://orcid.org/0000-0001-9130-5931
Tomasz Adam Szczepanowski Samodzielny Publiczny Centralny Szpital Kliniczny, Warsaw, Mazovia, Poland https://orcid.org/0009-0006-2584-5554
Krzysztof Bednarski Beskid Oncology Center Municipal Hospital of John Paul II, Bielsko-Biała, Poland https://orcid.org/0009-0000-9801-2832

DOI:

https://doi.org/10.31435/ijitss.2(50).2026.6050

Keywords:

Transverse Tibial Bone Transfer; Diabetic Foot Ulcer Healing; Distraction Osteogenesis; External Fixator

Abstract

Background. Diabetic foot ulcers (DFUs) affect a substantial proportion of the 589 million adults currently living with diabetes worldwide and remain a leading cause of lower-limb amputation and excess mortality. Despite debridement, offloading, advanced dressings, negative-pressure wound therapy, hyperbaric oxygen, topical growth factors, and revascularisation, recalcitrant ulcers still progress to amputation in approximately 20% of cases, with five-year mortality near 70% among those amputated. Tibial cortex transverse transport (TTT), a derivative of Ilizarov’s distraction osteogenesis principle, has emerged as a regenerative surgical option for advanced DFUs.

Methods. We performed a narrative review of literature published between January 2001 and April 2026, identified through PubMed and Google Scholar, addressing surgical technique, biological mechanisms, clinical efficacy, and safety of TTT in DFU.

Results. TTT, a small antero-medial tibial corticotomy with slow transverse distraction, elicits a coordinated regenerative response. Mechanistic studies show distraction-induced elevation of proangiogenic mediators and satisfactory outcomes in patients. Clinical data, including a meta-analysis, a multicentre cohort and other small studies, indicate wound healing rates of approximately 95%, limb salvage rates exceeding 95%, and recurrence rates near 3% during two-year follow-up. Significant improvements in ankle-brachial index, dorsal foot temperature, pain scores, and quality of life are consistently reported. Complications are manageable: risks of approximately 2% for tibial fracture and 8% for pin-site infection.

Conclusions. TTT is a mechanistically rich, clinically effective, and reasonably safe option for advanced DFUs. Adequately powered multicentre randomised trials comparing TTT with contemporary best practice are needed to define its definitive role.

References

American Diabetes Association Professional Practice Committee. (2025). 12. Retinopathy, neuropathy, and foot care: Standards of care in diabetes—2025. Diabetes Care, 48(Suppl. 1), S252–S265. https://doi.org/10.2337/dc25-S012

Armstrong, D. G., Boulton, A. J., & Bus, S. A. (2017). Diabetic foot ulcers and their recurrence. New England Journal of Medicine, 376(24), 2367–2375. https://doi.org/10.1056/NEJMra1615439

Chen, L., Sun, S., Gao, Y., & Ran, X. (2023). Global mortality of diabetic foot ulcer: A systematic review and meta-analysis of observational studies. Diabetes, Obesity and Metabolism, 25(1), 36–45. https://doi.org/10.1111/dom.14840

Chen, Y., Ding, X., Zhu, Y., Jia, Z., Qi, Y., Chen, M., Lu, J., Kuang, X., Zhou, J., Su, Y., Zhao, Y., Lu, W., Zhao, J., & Hua, Q. (2022). Effect of tibial cortex transverse transport in patients with recalcitrant diabetic foot ulcers: A prospective multicenter cohort study. Journal of Orthopaedic Translation, 36, 194–204. https://doi.org/10.1016/j.jot.2022.09.002

Chen, Y., Kuang, X., Zhou, J., Zhen, P., Zeng, Z., Lin, Z., Gao, W., He, L., Ding, Y., Liu, G., Qiu, S., Qin, A., Lu, W., Lao, S., Zhao, J., & Hua, Q. (2020). Proximal tibial cortex transverse distraction facilitating healing and limb salvage in severe and recalcitrant diabetic foot ulcers. Clinical Orthopaedics and Related Research, 478(4), 836–851. https://doi.org/10.1097/CORR.0000000000001075

Das, S., Goldstone, A. B., Wang, H., Farry, J., D’Amato, G., Paulsen, M. J., Eskandari, A., Hironaka, C. E., Phansalkar, R., Sharma, B., Rhee, S., Shamskhou, E. A., Agalliu, D., de Jesus Perez, V., Woo, Y. J., & Red-Horse, K. (2019). A unique collateral artery development program promotes neonatal heart regeneration. Cell, 176(5), 1128–1142.e18. https://doi.org/10.1016/j.cell.2018.12.023

Dawi, J., Tumanyan, K., Tomas, K., Misakyan, Y., Gargaloyan, A., Gonzalez, E., Hammi, M., Tomas, S., & Venketaraman, V. (2025). Diabetic foot ulcers: Pathophysiology, immune dysregulation, and emerging therapeutic strategies. Biomedicines, 13(5), Article 1076. https://doi.org/10.3390/biomedicines13051076

Fan, Z. Q., Yu, Z. H., Zheng, J. Z., Yu, B. F., & Liu, D. W. (2020). Tibial cortex transverse distraction in treating diabetic foot ulcers: What are we concerned about? Journal of International Medical Research, 48(9), Article 300060520954697. https://doi.org/10.1177/0300060520954697

Feldman, E. L., Callaghan, B. C., Pop-Busui, R., Zochodne, D. W., Wright, D. E., Bennett, D. L., Bril, V., Russell, J. W., & Viswanathan, V. (2019). Diabetic neuropathy. Nature Reviews Disease Primers, 5(1), Article 41. https://doi.org/10.1038/s41572-019-0092-1

Forsythe, R. O., Apelqvist, J., Boyko, E. J., Fitridge, R., Hong, J. P., Katsanos, K., Mills, J. L., Nikol, S., Reekers, J., Venermo, M., Zierler, R. E., Hinchliffe, R. J., & Schaper, N. C. (2020). Effectiveness of revascularisation of the ulcerated foot in patients with diabetes and peripheral artery disease: A systematic review. Diabetes/Metabolism Research and Reviews, 36(S1), Article e3279. https://doi.org/10.1002/dmrr.3279

Genitsaridi, I., Salpea, P., Salim, A., Sajjadi, S. F., Tomic, D., James, S., Thirunavukkarasu, S., Issaka, A., Chen, L., Basit, A., Luk, A. O. Y., Ma, R. C. W., Mbanya, J.-C., Ramachandran, A., Wild, S. H., Duncan, B. B., Boyko, E. J., & Magliano, D. J. (2026). 11th edition of the IDF Diabetes Atlas: Global, regional, and national diabetes prevalence estimates for 2024 and projections for 2050. The Lancet Diabetes & Endocrinology, 14(2), 149–156. https://doi.org/10.1016/S2213-8587(25)00299-2

Hu, X. X., Xiu, Z. Z., Li, G. C., Zhang, J. Y., Shu, L. J., Chen, Z., Li, H., Zou, Q. F., & Zhou, Q. (2023). Effectiveness of transverse tibial bone transport in treatment of diabetic foot ulcer: A systematic review and meta-analysis. Frontiers in Endocrinology, 13, Article 1095361. https://doi.org/10.3389/fendo.2022.1095361

Khalid, M., Petroianu, G., & Adem, A. (2022). Advanced glycation end products and diabetes mellitus: Mechanisms and perspectives. Biomolecules, 12(4), Article 542. https://doi.org/10.3390/biom12040542

Lavery, L. A., Armstrong, D. G., & Harkless, L. B. (1996). Classification of diabetic foot wounds. The Journal of Foot and Ankle Surgery, 35(6), 528–531. https://doi.org/10.1016/S1067-2516(96)80125-6

Liao, M. M., Zhang, F., Wang, Y. K., Wang, M. W., Cao, J. R., Jin, Z. H., Ren, Y. J., & Chen, S. (2026). Transverse tibial bone transport promotes distraction osteogenesis and improves blood flow in the management of diabetic foot. World Journal of Diabetes, 17(1), Article 111847. https://doi.org/10.4239/wjd.v17.i1.111847

Liu, J., Huang, X., Su, H., Yu, J., Nie, X., Liu, K., Qin, W., Zhao, Y., Su, Y., Kuang, X., Chen, D., Lu, W. W., Chen, Y., & Hua, Q. (2024). Tibial cortex transverse transport facilitates severe diabetic foot wound healing via HIF-1α-induced angiogenesis. Journal of Inflammation Research, 17, 2681–2696. https://doi.org/10.2147/JIR.S456590

Liu, J., Yao, X., Xu, Z., Wu, Y., Pei, F., Zhang, L., Li, M., Shi, M., Du, X., & Zhao, H. (2024). Modified tibial cortex transverse transport for diabetic foot ulcers with Wagner grade ≥ II: A study of 98 patients. Frontiers in Endocrinology, 15, Article 1334414. https://doi.org/10.3389/fendo.2024.1334414

Malkova, T. A., & Borzunov, D. Y. (2021). International recognition of the Ilizarov bone reconstruction techniques: Current practice and research (dedicated to 100th birthday of G. A. Ilizarov). World Journal of Orthopedics, 12(8), 515–533. https://doi.org/10.5312/wjo.v12.i8.515

Murphy-Lavoie, H. M., Ramsey, A., Nguyen, M., & Vadakekut, E. S. (2025). Diabetic foot infections. In StatPearls. StatPearls Publishing.

Nieves, B. J., D’Amore, P. A., & Bryan, B. A. (2009). The function of vascular endothelial growth factor. BioFactors, 35(4), 332–337. https://doi.org/10.1002/biof.46

Ou, S., Wu, X., Yang, Y., Xia, C., Zhang, W., Qu, Y., Li, J., Chen, B., Zhu, L., Xu, C., & Qi, Y. (2023). Tibial cortex transverse transport potentiates diabetic wound healing via activation of SDF-1/CXCR4 signaling. PeerJ, 11, Article e15894. https://doi.org/10.7717/peerj.15894

Ou, S., Xu, C., Yang, Y., Chen, Y., Li, W., Lu, H., Li, G., Sun, H., & Qi, Y. (2022). Transverse tibial bone transport enhances distraction osteogenesis and vascularization in the treatment of diabetic foot. Orthopaedic Surgery, 14(9), 2170–2179. https://doi.org/10.1111/os.13416

Pang, R., & Poon, R. T. P. (2006). Angiogenesis and antiangiogenic therapy in hepatocellular carcinoma. Cancer Letters, 242(2), 151–167. https://doi.org/10.1016/j.canlet.2006.01.008

Prompers, L., Huijberts, M., Apelqvist, J., Jude, E., Piaggesi, A., Bakker, K., Edmonds, M., Holstein, P., Jirkovska, A., Mauricio, D., Ragnarson Tennvall, G., Reike, H., Spraul, M., Uccioli, L., Urbancic, V., Van Acker, K., van Baal, J., van Merode, F., & Schaper, N. (2007). High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe: Baseline results from the Eurodiale study. Diabetologia, 50(1), 18–25. https://doi.org/10.1007/s00125-006-0491-1

Qin, W., Liu, K., Su, H., Hou, J., Yang, S., Pan, K., Yang, S., Liu, J., Zhou, P., Lin, Z., Zhen, P., Mo, Y., Fan, B., Li, Z., Kuang, X., Nie, X., & Hua, Q. (2024). Tibial cortex transverse transport promotes ischemic diabetic foot ulcer healing via enhanced angiogenesis and inflammation modulation in a novel rat model. European Journal of Medical Research, 29(1), Article 152. https://doi.org/10.1186/s40001-024-01752-4

Su, H., Zhen, P., Hou, J., Qin, W., Liu, J., Pan, K., Jack, G., Nie, X., Hua, Q., & Zhao, J. (2025). Finite element analysis safety of tibial cortex transverse transport. Bone & Joint Research, 14(4), 281–291. https://doi.org/10.1302/2046-3758.144.bjr-2024-0157.r1

Wagner, F. W., Jr. (1981). The dysvascular foot: A system for diagnosis and treatment. Foot & Ankle, 2(2), 64–122. https://doi.org/10.1177/107110078100200202

Walsh, J. W., Hoffstad, O. J., Sullivan, M. O., & Margolis, D. J. (2016). Association of diabetic foot ulcer and death in a population-based cohort from the United Kingdom. Diabetic Medicine, 33(11), 1493–1498. https://doi.org/10.1111/dme.13054

Wen, R., Cheng, X., Cao, H., Zhang, L., Luo, F., & Shang, W. (2023). Transverse tibial bone transfer in the treatment of diabetes foot ulcer: A pilot study. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 16, 2005–2012. https://doi.org/10.2147/DMSO.S413884

Wen, Y., Chen, L., Lan, J., & Li, L. (2024). Efficacy of tibial cortex transverse transport in treating diabetic foot ulcer and its effect on serum omentin-1 and irisin levels. Diabetology & Metabolic Syndrome, 16(1), Article 138. https://doi.org/10.1186/s13098-024-01400-1

Xie, J., Liu, X., Wu, B., Chen, B., Song, Q., Guan, Y., Gong, Y., Yang, C., Lin, J., Huang, M., Tan, X., Lai, R., Lin, X., Zhang, S., Xie, X., Chen, X., Zhang, C., Yang, M., Nong, H., … Bai, X. (2024). Bone transport induces the release of factors with multi-tissue regenerative potential for diabetic wound healing in rats and patients. Cell Reports Medicine, 5(6), Article 101588. https://doi.org/10.1016/j.xcrm.2024.101588

Yuan, Y., Ding, X., Jing, Z., Lu, H., Yang, K., Wang, Y., & Xu, H. (2021). Modified tibial transverse transport technique for the treatment of ischemic diabetic foot ulcer in patients with type 2 diabetes. Journal of Orthopaedic Translation, 29, 100–105. https://doi.org/10.1016/j.jot.2021.04.006

Zhang, D., Huang, J., Shi, B., & Chen, B. (2020). Analysis of complications in diabetic foot treated with tibial transverse transport. Chinese Journal of Reparative and Reconstructive Surgery, 34(8), 985–989. https://doi.org/10.7507/1002-1892.202003114