Appropriate Strategy of Surgical Treatment in Ischemic Diabetic Foot

Study Overview
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Brief Summary
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This cohort study aims to evaluate the outcomes of appropriate surgical treatment strategies in diabetic foot ulcers with different rate of popliteal artery stenosis(<50% or ≥50%). In this study, patients with Texas university grade 2-4(stage C-D) ischemic diabetic foot ulcers will be included. Data of patients who underwent surgical treatment in the past will be retrospectively collected. The patients with follow-up time less than 12 months will continue to follow up. Also the postoperative patients will be prospectively collected. Effects of different surgical strategies, including wound healing therapy, interventional therapy and tibial transverse bone transport therapy will be measured by several indexes.

Official Title
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Appropriate Strategy of Surgical Treatment in Ischemic Diabetic Foot

Conditions
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Diabetic Foot, Ischemic Diabetic Foot Ulcer, Popliteal Artery Stenosis

Intervention / Treatment
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* Procedure: Wound treatment
* Procedure: Vascular intervention surgery
* Procedure: Tibial transverse transport surgery


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients with diabetic foot, according to Chinese Guidelines for Diagnosis and Treatment of Diabetic Foot (2017). Texas university grade 2-4(stage C-D) ischemic diabetic foot ulcers. Have clear consciousness, not suffer from mental illness, can cooperate in research and treatment. Patients who are informed, participate in the research voluntarily, and have signed the informed consent. Have complete clinical data. Exclusion Criteria: Patients with severe systemic infection, who need to be amputated immediately to save lives. Patients with mental illness, who cannot cooperate to complete the adjustment and nursing of the external fixator. Patients with severe cardiovascular and cerebrovascular diseases (such as severe cardiac insufficiency, severe sequelae of cerebrovascular disease), or with acute infectious diseases. Have used or using glucocorticoids systemically within 3 months before admission. Have participated in other medical clinical trials within 3 months before admission. Patients with severe liver or kidney function abnormalities Pregnant or lactating women. Patients who lost follow-up.
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: Rate of popliteal artery stenosis < 50%, W.<br>If the rate of popliteal artery stenosis of patients < 50%, the patients only receive the wound treatment. | Procedure: Wound treatment<br>* According to the guidelines and recommendations of the International Diabetic Foot Working Group, ulcer surface debridement, negative pressure suction drainage, and routine dressing were performed until the wound healed or the end of the trial.<br>|
| Other: Rate of popliteal artery stenosis < 50%, WT.<br>If the rate of popliteal artery stenosis of patients < 50%, the patients receive the wound treatment and tibial transverse transport surgery. | Procedure: Wound treatment<br>* According to the guidelines and recommendations of the International Diabetic Foot Working Group, ulcer surface debridement, negative pressure suction drainage, and routine dressing were performed until the wound healed or the end of the trial.<br>Procedure: Tibial transverse transport surgery<br>* In the anteromedial area of the proximal tibia of the affected limb, the external fixation frame was compared with the area along the midline of the medial longitudinal axis of the proximal tibia. Subsequently, two 3.0 Steinmann pins were inserted through the single layer of cortical bone. The skin was cut along the long axis with the 3.0 Steinmann pin as the centre, and the subcutaneous tissue was separate bluntly to expose the periosteum. The Steinmann pins were used as the centre point for the drilling on four sides with a 2.0 drill bit and use of a rapid osteotomy device; the length of each side was 2.5 cm. Subperiosteal osteotomy was performed with a 5-mm narrow bone knife at an angle of 15°-30° to the bone surface. The surgeons should pay attention to protect the blood supply of the periosteum during this procedure. The external fixators were fixed with 4.0 Steinmann pins at the distal and proximal ends. The subcutaneous tissue and skin were sutured.<br>|
| Other: Rate of popliteal artery stenosis ≥ 50%, WV.<br>If the rate of popliteal artery stenosis of patients ≥ 50%, the patients receive the wound treatment and vascular intervention surgery. | Procedure: Wound treatment<br>* According to the guidelines and recommendations of the International Diabetic Foot Working Group, ulcer surface debridement, negative pressure suction drainage, and routine dressing were performed until the wound healed or the end of the trial.<br>Procedure: Vascular intervention surgery<br>* Segmented distal angiography under the guidance of digital subtraction angiography (DSA) were perform after local anesthesia. The superficial artery is expanded by a 3-4 mm balloon.<br>|
| Other: Rate of popliteal artery stenosis ≥ 50%, WT.<br>If the rate of popliteal artery stenosis of patients ≥ 50%, the patients receive the wound treatment and tibial transverse transport surgery. | Procedure: Wound treatment<br>* According to the guidelines and recommendations of the International Diabetic Foot Working Group, ulcer surface debridement, negative pressure suction drainage, and routine dressing were performed until the wound healed or the end of the trial.<br>Procedure: Tibial transverse transport surgery<br>* In the anteromedial area of the proximal tibia of the affected limb, the external fixation frame was compared with the area along the midline of the medial longitudinal axis of the proximal tibia. Subsequently, two 3.0 Steinmann pins were inserted through the single layer of cortical bone. The skin was cut along the long axis with the 3.0 Steinmann pin as the centre, and the subcutaneous tissue was separate bluntly to expose the periosteum. The Steinmann pins were used as the centre point for the drilling on four sides with a 2.0 drill bit and use of a rapid osteotomy device; the length of each side was 2.5 cm. Subperiosteal osteotomy was performed with a 5-mm narrow bone knife at an angle of 15°-30° to the bone surface. The surgeons should pay attention to protect the blood supply of the periosteum during this procedure. The external fixators were fixed with 4.0 Steinmann pins at the distal and proximal ends. The subcutaneous tissue and skin were sutured.<br>|
| Other: Rate of popliteal artery stenosis ≥ 50%, WVT.<br>If the rate of popliteal artery stenosis of patients ≥ 50%, the patients receive the wound treatment, vascular intervention and tibial transverse transport surgery. | Procedure: Wound treatment<br>* According to the guidelines and recommendations of the International Diabetic Foot Working Group, ulcer surface debridement, negative pressure suction drainage, and routine dressing were performed until the wound healed or the end of the trial.<br>Procedure: Vascular intervention surgery<br>* Segmented distal angiography under the guidance of digital subtraction angiography (DSA) were perform after local anesthesia. The superficial artery is expanded by a 3-4 mm balloon.<br>Procedure: Tibial transverse transport surgery<br>* In the anteromedial area of the proximal tibia of the affected limb, the external fixation frame was compared with the area along the midline of the medial longitudinal axis of the proximal tibia. Subsequently, two 3.0 Steinmann pins were inserted through the single layer of cortical bone. The skin was cut along the long axis with the 3.0 Steinmann pin as the centre, and the subcutaneous tissue was separate bluntly to expose the periosteum. The Steinmann pins were used as the centre point for the drilling on four sides with a 2.0 drill bit and use of a rapid osteotomy device; the length of each side was 2.5 cm. Subperiosteal osteotomy was performed with a 5-mm narrow bone knife at an angle of 15°-30° to the bone surface. The surgeons should pay attention to protect the blood supply of the periosteum during this procedure. The external fixators were fixed with 4.0 Steinmann pins at the distal and proximal ends. The subcutaneous tissue and skin were sutured.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Healing rate of wound surface |  | 12 months after surgical operation | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Ankle-brachial index |  | 3 months after surgical operation | 
| Ankle-brachial index |  | 12 months after surgical operation | 
| Recurrence rate of foot ulcer |  | 12 months after surgical operation | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Cohort study, Ischemic Diabetic Foot Ulcer, Surgical Strategy