Periosteal distraction-related treatments for diabetic foot/diabetic foot ulcer: a systematic review and meta-analysis

BACKGROUND: Periosteal distraction (PD) has been used as a salvage strategy for diabetic foot (DF) and diabetic foot ulcer (DFU), yet its relative effectiveness compared with other approaches is still unclear. METHODS: Up to March 17, 2026, seven databases were searched for comparative studies assessing PD-related treatments in DF/DFU. Twenty-six studies were included for qualitative synthesis, and 14 contributed to the primary comparative evidence set. The studies were organized into three categories: PD-based interventions versus conventional treatment, pure PD versus transverse tibial transport (TTT), and PD-inclusive multimodal regimens versus non-equivalent regimens. RESULTS: A formal pooled meta-analysis could not be performed for Group A, so this group was synthesized descriptively. For Group B, pure PD showed no statistically significant differences from TTT with respect to ABI, pain, or adverse events. For Group C, PD-containing multimodal regimens were linked with beneficial short-term changes in surrogate perfusion-related measures (ABI, skin temperature, toe oxygen) and pain. However, when wound/ulcer healing time was pooled, the results suggested only a non-significant tendency favoring PD-containing multimodal regimens. CONCLUSIONS: Current findings do not support a clear superiority of pure PD over TTT. Apparent advantages were mainly seen in PD-containing multimodal regimens and were largely restricted to short-term surrogate outcomes. These findings should not be interpreted as evidence that PD alone has an independent effect, and robust limb-salvage endpoints remain insufficiently reported.