Tibial Transverse Transport (TTT) For Treatment Of Severe Diabetic Foot And The Mechanism Research Of The Bone Marrow Stem Cell Mobilization

Background: The diabetic foot is one of the most severe complications of the diabetics.The higher level of the Wagner classification,the risk of amputation will increase significantly,and general condition of patients became worse.Many surgical methods have been applied to treat diabetic foot including free flap,radiofrequency ablation,transcutaneous angioplasty,vascular stents implanting,vascular interventional thrombolytic therapy,and stem cells transplanting,but limb salvage is a good choice to treat the diabetic foot Wagner3 or higher levels.Efficacy is correlated to Wagner classification,and the recovery rate was between 60%-90% depending on severity of the disease.There is still controversial on the best strategy of treating diabetic foot for better wound healing and salvage rate,sometimes the cases of Wagner 3 or above were required amputation.TTT using external fixation like Ilizarov technique has been proved effectiveness in clinical practice for treating long bone defects,chronic osteomyelitis and limb lengthening and reconstruction.Based on principle of tension-stress,new theory of distraction histogenesis(DH)is used to explain the bone remodeling progress how the variety of tissue defects repaired under a long-term traction through stimulating cell proliferation to form newvessels in recent years.We designed this study to illustrate the mechanism of the clinical phenomenon that TTT can provide 99% of ulceration healing rate and limb salvage rate in treatment of severe diabetic foot.Objectives: Discuss using tibial transverse transport to treat the diabetic foot and establish the relative treatment method,and deeply understand the function of bone marrow stem cells mobilization in the removal method to generate many kinds of the mobilization to regeneration and repair.Methods: Chose 93 patients who have the severe diabetic foot from the administrative office in the period of 2013-2016 years.Regard the tibial transverse transport method as the core therapy,combine with the anesthesia,internal medicine and debridement to check the index of the limb salvage rate,wound healing rate,peripheral nerve injury(10 g nylon thread test),pain measurement(visual analogue score),vascular blood supply index(ankle l index,foot skin temperature),lower extremity vascular CT check and the changing observation of wound healing visual observation in the microscopic.Clear the function of tibial transverse transport method to lead to the micro vascular regeneration and wound skin repair regeneration,and use the clinical observation and summary of unilateral tibial transverse transport to treat the patients whom have bilateral severe diabetic foot typical cases.Results: The tibial transverse transport treatment has cured 93 cases of severe diabetic foot,limb salvage rate of 99%(92/93),wound healing rate of99%(92/93).(1)Relieve the pain: after cleaning the injury patients will feel the pain relieved,with the removal started,the patients will become feel no pain and the patient visual analogy score improved significantly.(2)The feeling of skin:after accepting the lateral tibial treatment about 2 to 3 months,numbness was significantly reduced,the skin feel better and better,began to have somedifferent feelings,but still can not reach the use of 10 g nylon line test level,after 6 months can start the test of perception.(3)Limb recovery: 1 case amputation due to acute vascular thrombosis,92 patients muscle strength were back to normal after the treatment,without using such as crutches and other tools can walk independently,walking distance can be longer than 2000 m.CT of the lower limb showed that the origin of the bone migration began to extend a large number of 0.5 ~ 1.0 mm diameter arteries,extending horizontally and obliquely into the muscle and subcutaneous tissue.Collect the structure of epithelial tissue structure(epidermis)and connective tissue(dermis)can found that the cuticle,granule layer,acanthoma layer,basal layer cells,the dermis of the main,visible collagen fibers and vascular structure,can not find the significant amount of fibrous tissue.Further investigation shows the characteristics of bone transport therapy:(1)There’s a distance between the site of bone transport and that of the diabetic foot.(2)Bone transport can take a long period of time and have slow mechanical action.At the same time,the 1month and 3 month points can also be measured after the tibial bone graft surgery,peripheral blood stem cell clones were significantly higher than during the preoperative period,moreover Serum SDF-1 at corresponding time points with peripheral blood monocytes CD34+ and CXCR4+ cells levels were also significantly higher than the levels at the preoperative period(P<0.05),CD34+/CXCR4+ increased,but there was no significant difference in statistics.Conclusions: Treatment approach towards severe diabetic foot was based on tibial transverse transport surgery as the core comprehensive treatment model that showed high curative efficacy and high rate of limb salvage.Furthermore,tibial transverse transport also activates the regeneration of blood capillaries,nerves and the skin.This mechanism SDF-1-CXCR4 axis mediated CD34+ and other bone marrow stem cell mobilization are closely related.