Clinical Study Of Tibial Cortex Transverse Distraction In The Treatment Of Diabetic Foot Ulcer And Preliminary Exploration On The Molecular Mechanism Of Wound Healing

Part Ⅰ Tibial Cortex Transverse Distraction in Treating Diabetic Foot Ulcers: What Should We Be Concerned About?Objective: To evaluate the effectiveness and complications of the tibial cortex transverse distraction technique for diabetic foot ulcers,and to raise relevant issues that we need to concern about when performing this procedure.Methods: This case series study included 30 patients with diabetic foot ulcers from four medical centers.All included diabetic foot ulcers underwent routine conservative treatments and failed to heal completely for more than 6 months.After adequate preoperative preparation,these patients were admitted to the hospitals for tibial cortex transverse distraction,combined with other operations,including debridement,negative pressure aspiration,etc.All patients were followed up for more than 1 year.Results: Of the total enrolled patients,3 underwent amputation due to uncontrolled and widespread infection.There were 2 patients with tibial fracture after surgery,and after 3 months of external brace fixation,the tibial fracture healed smoothly.Nail hole infection occurred in 5 patients,and the infected nail hole sites were completely healed after dressing change for an average of 3.3 ± 2.1 weeks after traction needle removal.The average healing time of foot ulcers after surgery was 13.5 ± 8.2 weeks in 27 patients except for 3 amputations,and the VAS value of postoperative pain was significantly lower than that before surgery.Conclusions: Although transverse tibial bone transfer technique can be used as an effective method for the treatment of diabetic foot ulcers,we should not overstate the effectiveness of the surgery and should not ignore the complications associated with the surgery.In the future,experts will need to develop a standard procedure for this surgery so as to reduce the incidence of surgery-related complications such as tibial fractures.Part Ⅱ Impairment Characteristics of Static Balance and Plantar Load Distribution of Patients Undergoing Tibial Cortex Transverse Distraction for Diabetic Foot UlcersObjective: Tibial cortex transverse distraction has been reported to treat diabetic foot ulcers in recent years,and has achieved good clinical results.However,the function of lower limbs after ulcer healing has not received sufficient attention.In this study,we explored the impaired characteristics of lower limb static balance and plantar pressure distribution in patients with diabetic foot ulcer healing treated by tibial cortex transverse distraction,in order to provide theoretical basis for postoperative clinical rehabilitation of patients.Methods: We conducted a retrospective study on patients with diabetic foot ulcers.The study included 21 patients with diabetic foot ulcers who were treated with transverse tibial bone transfer technique.We routinely followed up All these patients postoperatively,and the follow-up time of all patients was greater than 1 year.In addition,we included 20 age-matched healthy individuals as a control group.The Zebris pressure platform was used to evaluate the static balance function and plantar pressure distribution in the lower limbs of patients and healthy controls while standing.Through background data analysis,quantified data of static balance and plantar pressure distribution of subjects were obtained,and statistical software was used to analyze and compare various parameters.Results: All 21 patients were regularly followed up postoperatively for over 12 months.One of the patients underwent amputation surgery due to the spread and severity of infection.In the patient group,the ellipse sway area of the center of pressure(COP),the path length of COP and the parameter values of the forward Angle θ were all greater than those of the control group.The differences were statistically significant(250.15 ± 98.36 mm vs.135.67 ± 53.21 mm,145.15 ± 67.43 mm vs.78.47 ± 34.15 mm,39.75 ± 17.61 ° vs.22.17 ± 14.15 °;P < 0.01).In the patient group,the plantar load of the healthy side foot and the plantar load of the hind foot were significantly greater than the corresponding parameter values of the healthy side foot,the difference was statistically significant(58.4 ± 5.5 % vs.41.6 ± 5.5 %,45.3 ± 6.4 % vs.36.5 ± 5.6 %;P < 0.01).In the control group,the values of these related parameters of bilateral feet were similar without significant difference.Conclusions: Although transverse tibial bone transfer technique may be a relatively effective method for the treatment of diabetic foot ulcers,postoperative damage to the static balance of the lower extremity and plantar pressure distribution is permanent,and these long-term problems need to be fully considered in the follow-up rehabilitation treatment plan.Part Ⅲ Analysis of mRNA Expression Profile in the Treatment of Diabetic Foot Ulcer Healing by Tibial Cortex Transverse Distraction:Analysis of Differentially Expressed Genes and Associated Signaling PathwaysObjective: Tibial cortex transverse distraction technique can treat diabetic foot ulcers,but the mechanism mainly focuses on biomechanical aspects,while the specific molecular mechanism is not known.In this study,we collected tissue samples from patients with diabetic foot ulcers.By comparing the gene expression in the marginal tissues before and after tibial cortex transverse distraction,we detected the differentially expressed genes in the tissues after tibial cortex transverse distraction surgery.Through bioinformatics analysis,the corresponding signaling pathway was explored,which provided the basis for the research on the molecular mechanism of tibial cortex transverse distraction technology in the treatment of diabetic foot ulcer.Methods: When the patient underwent tibial cortex transverse distraction surgery combined with debridement and vacuum closed drainage(VSD),tissue samples were collected from the wound edge and stored according to the standard procedure of tissue storage.In the later stage of tibial cortex transverse distraction surgery,some patients’ wounds needed debridement and suture surgery,and we also collected tissue samples trimmed from patients’ wound edges for storage.After reference genome transcriptome sequencing and subsequent bioinformatics analysis,the differentially expressed genes and related signaling pathways were explored,and functional analysis of important genes and signaling pathways was conducted.qRT-PCR assay was used to verify the significantly up-regulated expression of HLA-DRB1,HLA-DRB5,CXCL5 and significantly down-regulated expression of IGFL1.Results: Differential gene analysis showed that there were 2441 significantly up-regulated differential genes and 3904 significantly down-regulated differential genes in the postoperative group compared with the preoperative group.qRT-PCR verification results showed that the expression of HLA-DRB1,HLA-DRB5 and CXCL5 was significantly up-regulated in the postoperative treatment group compared with the preoperative control group,while the expression of IGFL1 was significantly down-regulated in the postoperative treatment group compared with the preoperative control group.These results were consistent with the transcriptional sequencing results.Among them,CXCL5 and CXCL6 differentially up-regulated genes are involved in the process of neovascularization,and HLA-DRB1 is involved in the improvement of the degree of diabetic peripheral nerve degeneration.Signal pathway analysis showed that differential genes were most significantly enriched in Adherens junction,Inflammatory mediator regulation of TRP channels and Wnt signaling pathway.Inflammatory mediator regulation of TRP channels is involved in the improvement of peripheral neurodegeneration,VEGF signaling pathway is involved in the process of neovascularization,and Wnt signaling pathway is involved in the process of bone healing.Conclusions: Significantly up-regulated differential genes CXCL5 and CXCL6 and significantly enriched VEGF signaling pathway analyzed in this study may be involved in postoperative lower limb neovascularization.The significantly up-regulated differential gene HLA-DRB1 and the significantly enriched Inflammatory mediator regulation of TRP channels may be related to the improvement of postoperative peripheral neurodegeneration.Significantly enriched Wnt signaling pathway may regulate the fracture healing process after bone removal.The differentially expressed genes and related signaling pathways explored in this study can provide objective basis for further target exploration for precise intervention and further mechanism in-depth study.Part Ⅳ Analysis of LncRNA Expression Profile in the Treatment of Diabetic Foot Ulcer Healing by Tibial Cortex Transverse Distraction:Analysis of Differentially Expressed LncRNAs and Associated Signaling PathwaysObjective: Tibial cortex transverse distraction technique can be used to treat diabetic foot ulcers,and LncRNA may be involved in regulating the healing process.In this study,we collected tissue samples of patients with diabetic foot ulcer.By comparing the expression of LncRNA in marginal tissues before and after transverse tibial bone removal,differential expression of LncRNA in tissues after transverse tibial bone removal was detected and analyzed by bioinformatics means.The analysis of the corresponding signaling pathway provides the basis for the molecular mechanism of the treatment of diabetic foot ulcer by transverse tibial bone transfer technique.Methods: When the patient underwent tibial bone removal surgery,tissue specimens were collected from the wound edge and stored according to the standard procedure of tissue storage.At the later stage of tibial bone removal surgery,the patient’s wound needed debridement and suture surgery,and we also collected the tissue samples clipped from the patient’s wound edge for storage.The collected specimens were detected by LncRNA chips and bioinformatics analysis to identify differentially expressed LncRNA and related signaling pathways,and functional analysis of important LncRNA and signaling pathways was conducted.Results: In patients with diabetic foot ulcer,7996 differential LncRNAs were significantly up-regulated and 4516 significantly down-regulated after transverse tibial bone removal.After analyzing the top 10 differentially expressed LncRNAs and their adjacent mRNA,AF086184-PANX1,AC093915.1-IQCA1,KB-226F1.1-GSTT1,AF086184-panx1,AC093915.1-iqca1,KB-226F1.1-gst T1 were found in the top 10 LncRNAs with the most significant differences.AC114689.3-DSEL,MKNK1-AS1-MKNK1,a total of 5 pairs of differentially expressed lncRNA-mRNA combinations.Among the top 10 LncRNAs with the most significant down-regulated differences,four pairs of lncRNA-mRNA combinations were found: AC244502.1-TRAV9-2,AC103740.1-TLN2,ADIRF-AS1-ADIRF and AC012594.1-MYO3 B.KEGG analysis showed that LncRNAs with the most significant differences were mainly in VEGF signaling pathway,maturity onset diabetes of the young,insulin secretion and m TOR signaling pathway are enriched.VEGF signaling Pathway-related differences include AC092819.1,AC020601.1,AC109462.3,and AL355306.2.Conclusion: The lncRNA-mRNA combination analyzed in this study including AF086184-PANX1,AC093915.1-IQCA1,KB-226F1.1-GSTT1 et al.may play an important role in the healing process of diabetic foot ulcer.However,VEGF signaling pathway and the corresponding differentially expressed lncRNA(AC092819.1,AC020601.1,AC109462.3,AL355306.2)may be involved in the postoperative neovascularization process.The differentially expressed lncRNA and related signaling pathways explored in this study can provide an objective basis for further target exploration for precise intervention and further in-depth mechanistic research.