Comparative Efficacy and Safety of Tibial Cortex Transverse Transport Versus Antibiotic Bone Cement for Wagner Grade 3–4 Diabetic Foot Ulcers: A Retrospective Cohort Study

Background Diabetic foot ulcers (DFUs) represent a significant contributor to non-traumatic lower-extremity amputations. Wagner grade 3–4 ulcers, often complicated by deep infection and ischemia, pose substantial management challenges. Antibiotic-loaded bone cement (ALBC) establishes a localized high-concentration antimicrobial environment, while tibial cortex transverse transport (TTT) aims to enhance pedal perfusion via distraction-induced angiogenesis. Despite the prevalent use of both strategies in the management of DFUs, there is a notable lack of direct comparative evidence between them. Methods and analysis A retrospective analysis of clinical data was performed on patients with Wagner grade 3–4 DFUs who underwent TTT or ALBC at our center from January 2020 to December 2023. We collected and analyzed perioperative indicators along with postoperative follow-up outcomes, ensuring stratification by Wagner grade for a comprehensive evaluation. Results No significant differences were observed between the groups regarding the percentage area reduction (PAR) at 3 months or in the rates of major amputation. However, stratified analyses revealed notable findings for specific patient categories. Among those with Wagner grade 4 DFUs, the TTT group experienced a significantly higher PAR at 6 months compared to the ALBC group (P = 0.002) and also exhibited a lower rate of unplanned return to the operating room (URTOR) (P = 0.018). Similarly, patients with Wagner grade 3 DFUs in the TTT group demonstrated a significantly reduced URTOR rate (P = 0.012). Furthermore, the TTT group demonstrated a significantly greater improvement in the ankle–brachial index (ABI) (P < 0.05), while the ALBC group had a notably shorter time to infection clearance (P < 0.001). Conclusion ALBC and TTT play complementary roles in DFU management. ALBC provides a significant advantage in controlling early infections, while TTT improves perfusion and shows greater long-term healing potential, especially in patients with Wagner grade 4 DFUs, all while imposing a lower burden of reintervention. Therefore, clinical decision-making should be tailored to the individual, taking into account the ulcer grade, severity of infection, and perfusion status.