Tibial periosteal distraction as an adjunct to percutaneous transluminal angioplasty for diabetic foot ulcers complicated by peripheral arterial disease/chronic limb-threatening ischemia: a retrospective cohort study

BACKGROUND: Diabetic foot ulcer (DFU) complicated by peripheral arterial disease/chronic limb-threatening ischemia (PAD/CLTI) is a major cause of impaired wound healing and limb loss. In some patients, local tissue perfusion remains insufficient and wound healing is delayed even after technically successful percutaneous transluminal angioplasty (PTA). Tibial periosteal distraction (TPD) may offer incremental benefit after PTA, but direct comparative evidence supporting its role as an adjunctive strategy remains limited. METHODS: This single-center retrospective cohort study included patients with DFU and PAD/CLTI who underwent index PTA. In the adjunctive group, TPD was performed as a prespecified staged procedure within 7 days after PTA during the same hospitalization. The primary outcome was time to complete wound healing, and the key secondary outcome was 12-month amputation-free survival (AFS). Secondary outcomes included complete wound healing at 3 and 6 months, wound recurrence within 12 months, and longitudinal changes in wound area, transcutaneous oxygen pressure (TcPO₂), and ankle-brachial index (ABI). RESULTS: A total of 64 patients were included, with 24 in the PTA + TPD group and 40 in the PTA-alone group. PTA + TPD was associated with a shorter time to complete wound healing than PTA alone, and this association remained significant after adjustment for prespecified baseline covariates (adjusted HR, 3.90; 95% CI 2.23-6.83; P < 0.001). The 3-month complete wound healing rate was also higher in the PTA + TPD group (P = 0.016), whereas the 6-month healing rate did not differ significantly between groups (P = 0.642). Although 12-month AFS was numerically higher in the PTA + TPD group (95.8% vs 82.5%), the between-group difference was not statistically significant (P = 0.240). Linear mixed-effects models showed more favorable trajectories of wound area, TcPO₂, and ABI in the PTA + TPD group, with significant group-by-time interactions for all three outcomes (all P < 0.001). Complication rates were comparable between groups (all P > 0.05). CONCLUSION: In patients with DFU and PAD/CLTI, the addition of TPD after PTA was associated with faster wound healing and more favorable perfusion-related changes during follow-up. TPD may have potential value as a post-revascularization adjunct, although this requires confirmation in prospective studies.