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. 2025 Dec 28.
doi: 10.1186/s12916-025-04586-x. Online ahead of print.

Tibial periosteal distraction for ischemic leg ulcers: animal and clinical cohort study

Peilin Zhou #  1   2 , Wenqiang Wang #  1 , Yi You #  3 , Nian Zhou #  4 , Taifeng Zhang  5 , Jiangtao Yang  1 , Xiang Chen  1 , Linghui Tang  6 , Meng Gan  7 , Wei Xu  7 , Wengao Wu  3 , Boyang Liu  3 , Huiyan Liu  3 , Xiaochong Zou  1 , Yongzhen Liu  1 , Xiao Peng  1 , Lu Wei  1 , Xingyu Chen  1 , Feng Yang  1 , Yueyue Zhu  1 , Ruibin Feng  1 , Xiaoping Yu  4 , Junliang Ye  4 , Ronghan Wu  4 , Yu Chen  4 , Lan Lan  4 , Jiajun Chen  8 , Yi Ding  1 , Xinyu Nie  9 , Bingfeng Lu  10 , Naxin Zeng  11   12 , Qikai Hua  13   14
Affiliations
Free article

Tibial periosteal distraction for ischemic leg ulcers: animal and clinical cohort study

Peilin Zhou et al. BMC Med. .
Free article

Abstract

Background: Ischemic leg ulcers (ILU) represent a severe manifestation of chronic limb-threatening ischemia (CLTI), characterized by high recurrence and amputation rates. This study evaluated the efficacy and safety of tibial periosteal distraction (TPD) for treating ILU through a combination of animal experiments and clinical trials.

Methods: Nine Beagle dogs were randomly allocated into TPD group, tibial soft tissue distraction (TSD) group, and control group. Standardized 15-mm circular wounds were created on the foot, followed by periosteal distraction at a rate of 0.5 mm/day for 11 days. Parameters assessed included wound healing rates, serum VEGF levels, histopathological changes, and CT angiography/perfusion parameters. A multicenter retrospective cohort study was conducted from June 2019 to January 2024, enrolling 103 ILU patients treated with TPD compared with 127 patients receiving conventional treatment. Primary endpoints included ulcer healing rates at 3 and 6 months, amputation rates, and recurrence within 1 year. Secondary endpoints comprised complications and safety assessments.

Results: In animal study, the TPD group demonstrated accelerated wound healing compared to both control and TSD groups, with residual wound area of 2.08 ± 1.68% on day 16, versus 5.46 ± 1.98% in the control group and 12.49 ± 2.97% in the TSD group. Serum VEGF levels were markedly elevated in the TPD group from days 8 to 16 (peak: 27.25 ± 2.16 pg/ml vs. 17.90 ± 1.72 pg/ml in controls, P < 0.01). CT angiography revealed enhanced collateral circulation in the distraction region with increased tissue perfusion parameters (equivalent blood volume and arterial flow). In clinical study, the TPD group achieved superior healing rates compared to controls: 90.3% vs. 77.2% at 3 months (P = 0.008) and 94.2% vs. 85.8% at 6 months (P = 0.039). Major amputation rate was reduced in the TPD group (2.9% vs. 9.5%, P = 0.046), while minor amputation rates showed no significant difference (38.8% vs. 44.1%, P = 0.421). Recurrence within 1 year was markedly decreased (8.7% vs. 19.7%, P = 0.020). Complications included pin tract infection in 7 cases (6.8%) and pain intolerance requiring distraction rate adjustment in 9 cases (8.7%), all successfully managed with conservative treatment.

Conclusions: TPD offers a promising therapeutic option for CLTI patients, particularly those unsuitable for vascular reconstruction. Further prospective randomized trials are warranted to establish standardized protocols and optimize treatment parameters.

Keywords: Chronic limb threatening ischemia; Diabetic foot ulcer; Ischemic leg ulcer; Tibial periosteal distraction; Tibial transverse transport.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: All animal experiments were conducted in strict accordance with the Guide for the Care and Use of Laboratory Animals (8th edition, National Research Council, 2011) and the ARRIVE guidelines for reporting animal research. Rretrospective clinical study was conducted in accordance with the Declaration of Helsinki (2013 revision) and Good Clinical Practice guidelines. The study protocol was reviewed and approved by the Ethics Review Boards of all participating institutions: The First Affiliated Hospital of Guangxi Medical University (approval number: 2024-E626-01), Yueyang Central Hospital (approval number: 2024–030), Qinzhou Second People's Hospital (approval number: 2025527). Consent for publication: Given the retrospective nature of this study, the requirement for written informed consent was waived by the Institutional Ethics Review Boards. This waiver was granted as the study involved the analysis of existing medical records with no direct patient contact, and all data were de-identified to protect patient privacy. The study was conducted in accordance with the Declaration of Helsinki. Competing interests: There are no financial conflicts of interest to declare. The authors disclose that a portion of clinical data from Yueyang Central Hospital was previously published as a pilot study (Gan M, et al. J Orthop Surg 2024). This study represents a significant expansion with new data and different research objectives.

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