Limb salvage with transverse tibial bone transport in a high-risk patient with a Chronic Achilles Tendon Ulcer: a case report

<h2>Abstract</h2> Diabetic foot ulcers (DFUs), particularly in the Achilles region, pose significant challenges for limb salvage due to poor perfusion and high infection risk. Transverse tibial bone transport (TTBT), utilizing distraction osteogenesis, enhances local blood flow and promotes tissue regeneration(1, 2). This case report describes a high-risk 60- year-old female patient with a chronic Achilles tendon ulcer refractory to standard treatments who underwent TTBT. The procedure successfully resulted in complete wound healing and limb salvage, avoiding major amputation. This report discusses the clinical details and implications of TTBT as an effective intervention in managing recalcitrant diabetic foot ulcers. Background: Diabetic foot ulcers at the posterior heel/Achilles are difficult to heal due to limited soft tissue, high stress, and microvascular disease, often ending in major amputation. Purpose: To describe limb salvage using transverse tibial bone transport (TTBT) for a recalcitrant Achilles‑region ulcer in a high‑risk patient. Study Design: Single‑patient case report. Methods: A 60‑year‑old woman with type 2 diabetes, peripheral arterial disease, renal disease, and calcaneal osteomyelitis had a chronic 16 × 8 cm posterior heel/Achilles ulcer refractory to revascularization, antibiotics, and advanced wound care. After radical debridement, a circular external fixator was applied with a tibial corticotomy and TTBT module. Following a 7‑day latency, distraction was performed at 0.25 mm twice daily for 28 days, then compression 0.25 mm four times daily for 14 days until redocking. External fixation continued for consolidation. Results: Granulation developed during distraction; ulcer dimensions decreased ∼50% by frame removal. Complete epithelialization occurred by 20 weeks with infection control and limb preservation. Postoperative CT angiography showed a patent anterior tibial artery with collateral reconstitution of the peroneal and posterior tibial arteries, consistent with improved microcirculation. A superficial plantar heel ulcer related to calcaneal‑gait biomechanics after Achilles resection healed with offloading and local care. At 12‑month follow‑up the limb remained salvaged with functional recovery. Conclusion: TTBT may augment local perfusion and support healing of intractable Achilles‑region diabetic ulcers in selected patients. When macro‑revascularization is insufficient or contraindicated, TTBT offers a driven limb‑salvage option that targets distal microcirculatory failure while avoiding free‑tissue transfer in compromised hosts.