A feasibility study of the EMO scoring system to guide proximal tibial transverse transport in treatment of diabetic foot wounds_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LIU Wenhao ^1,2 , SHAN Jianyang ² ^{共同第一作者} , ZHU Mingming ³ ,  WEN Gen ² ,  CHENG Liang ²

1. College of Fisheries and Life Science, Shanghai Ocean University, Shanghai, 201306, P. R. China;
2. Department of Orthopedic Surgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, P. R. China;
3. Department of Rehabilitation Medicine, Shanghai Donghai Senior Nursing Hospital, Shanghai, 201303, P. R. China;

Corresponding author：

WEN Gen, Email: wengen2006@126.com; CHENG Liang, Email: cl_fly_214@163.com

Keywords：

Diabetic foot; wound; proximal tibial transverse transport; scoring system

DOI：

10.7507/1002-1892.202410054

Video：

Export PDF Favorites Scan Get Citation

Abstract Full text Figures/Tables Video References Cited by

Objective The self-defined multidisciplinary (endocrinology, vascular surgery, and orthopedics) scoring system (EMO scoring system for short) was designed. The feasibility of the EMO scoring system to guide the proximal tibial transverse transport (TTT) for diabetic foot wounds was preliminarily explored. Methods Based on the current commonly used clinical criteria for diabetic foot judgment, expert consensus, guidelines, and related research progress in the treatment of diabetic foot wounds, combined with clinical experience, a set of EMO scoring systems including endocrinology, vascular surgery, and orthopedics was formulated. The criteria for selecting conservative treatment, TTT after baseline improvement, and TTT based on scoring results was proposed. A total of 56 patients with diabetic foot wounds who were admitted between September 2017 and July 2022 and met the selection criteria was taken as the study subjects. Among them, 28 patients were treated with TTT and 28 patients were treated conservatively. The patients were graded according to the EMO scoring system, the corresponding treatment methods were selected, and the actual treatment methods and results of the patients were compared. Results The EMO scoring system was formed through literature retrieval and clinical experiences. The system included three criteria, namely endocrinology (E), macrovascular disease (M), and orthopedics (O), which were divided into multiple subtypes according to the relevant evaluation items, and finally the diabetic foot wound was divided into 8 types, which correspondingly selected TTT, TTT after baseline improvement, and conservative treatment. All 56 patients were followed up for 12 months after treatment. Among them, the wound healing rate of the TTT group was 85.71% (24/28), which was higher than that of the conservative treatment group [53.57% (15/28)]. At 12 week after treatment, CT angiography showed that there were more small blood vessels in the wound and ipsilateral limb in TTT group than in the conservative treatment group. Based on the EMO scoring system, 14 of the 56 patients needed conservative treatment, 29 patients needed TTT, and 13 patients needed TTT after baseline improvement. Compared with the clinical data of the patients, the wound healing rate of the patients judged to be TTT was 75.86% (22/29), of which 21 cases were actually treated with TTT, and the healing rate was 90.48%; 8 patients were treated conservatively, and the healing rate was 37.50%. The wound healing rate of the patients judged to be conservative treatment was 92.86% (13/14), of which 1 case was actually treated with TTT, and the healing rate was 100%; 13 cases were treated conservatively, and the healing rate was 92.31%; 1 case experienced minor amputation. The wound healing rate of the patients judged to TTT after baseline improvement was only 30.77% (4/13), of which 6 cases were actually treated with TTT, and the healing rate was 66.67%; 7 cases were treated conservatively, and the healing rate was 0. Conclusion EMO scoring system can comprehensively evaluate the diabetic foot wounds, and make personalized judgment on whether TTT treatment is feasible, so as to improve the level of diabetic foot wound treatment and the prognosis of patients.

1.	Toscano CM, Sugita TH, Rosa MQM, et al. Annual direct medical costs of diabetic foot disease in brazil: a cost of illness study. Int J Environ Res Public Health, 2018, 15(1): 89. doi: 10.3390/ijerph15010089.
2.	Kerr M, Barron E, Chadwick P, et al. The cost of diabetic foot ulcers and amputations to the National Health Service in England. Diabet Med, 2019, 36(8): 995-1002.
3.	Telfer S, Erdemir A, Woodburn J, et al. What has finite element analysis taught us about diabetic foot disease and its management? A systematic review. PLoS One, 2014, 9(10): e109994. doi: 10.1371/journal.pone.0109994.
4.	Monteiro-Soares M, Russell D, Boyko EJ, et al. Guidelines on the classification of diabetic foot ulcers (IWGDF 2019). Diabetes Metab Res Rev, 2020, 36 Suppl 1: e3273. doi: 10.1002/dmrr.3273.
5.	Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. Part Ⅰ. The influence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res, 1989(238): 249-281.
6.	Yuan Y, Ding X, Jing Z, et al. Modified tibial transverse transport technique for the treatment of ischemic diabetic foot ulcer in patients with type 2 diabetes. J Orthop Translat, 2021, 29: 100-105.
7.	Nie X, Kuang X, Liu G, et al. Tibial cortex transverse transport facilitating healing in patients with recalcitrant non-diabetic leg ulcers. J Orthop Translat, 2020, 27: 1-7.
8.	Wang A, Lv G, Cheng X, et al. Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition). Burns Trauma, 2020, 8: tkaa017. doi: 10.1093/burnst/tkaa017.
9.	Yang Y, Li Y, Pan Q, et al. Tibial cortex transverse transport accelerates wound healing via enhanced angiogenesis and immunomodulation. Bone Joint Res, 2022, 11(4): 189-199.
10.	Noor S, Zubair M, Ahmad J. Diabetic foot ulcer—A review on pathophysiology, classification and microbial etiology. Diabetes Metab Syndr, 2015, 9(3): 192-199.
11.	Paraskevas KI, Baker DM, Pompella A, et al. Does diabetes mellitus play a role in restenosis and patency rates following lower extremity peripheral arterial revascularization? A critical overview. Ann Vasc Surg, 2008, 22(3): 481-491.
12.	Hu XX, Xiu ZZ, Li GC, et al. Effectiveness of transverse tibial bone transport in treatment of diabetic foot ulcer: A systematic review and meta-analysis. Front Endocrinol (Lausanne), 2023, 13: 1095361. doi: 10.3389/fendo.2022.1095361.
13.	Wang F, Kong L, Wang W, et al. Adrenomedullin 2 improves bone regeneration in type 1 diabetic rats by restoring imbalanced macrophage polarization and impaired osteogenesis. Stem Cell Res Ther, 2021, 12(1): 288. doi: 10.1186/s13287-021-02368-9.
14.	Matsuyama J, Ohnishi I, Kageyama T, et al. Osteogenesis and angiogenesis in regenerating bone during transverse distraction: quantitative evaluation using a canine model. Clin Orthop Relat Res, 2005(433): 243-250.
15.	Jianda X, Maosheng B, Chenjian P, et al. An novel and alternative treatment method for large heel ulceration in diabetic patients: Proximal tibial cortex transverse distraction. Int Wound J, 2023, 20(3): 732-739.
16.	Xie J, Liu X, Wu B, et al. Bone transport induces the release of factors with multi-tissue regenerative potential for diabetic wound healing in rats and patients. Cell Rep Med, 2024, 5(6): 101588. doi: 10.1016/j.xcrm.2024.101588.
17.	Chen Y, Ding X, Zhu Y, et al. Effect of tibial cortex transverse transport in patients with recalcitrant diabetic foot ulcers: A prospective multicenter cohort study. J Orthop Translat, 2022, 36: 194-204.
18.	Houlind K. Surgical revascularization and reconstruction procedures in diabetic foot ulceration. Diabetes Metab Res Rev, 2020, 36 Suppl 1: e3256. doi: 10.1002/dmrr.3256.
19.	Ou CY, Wu MS, Lin MC, et al. Short-term and long-term outcomes of free flap reconstruction versus amputation for diabetic foot reconstruction in patients with end-stage renal disease. J Plast Reconstr Aesthet Surg, 2022, 75(8): 2511-2519.
20.	Chen P, Vilorio NC, Dhatariya K, et al. Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev, 2024, 40(3): e3644. doi: 10.1002/dmrr.3644.
21.	Chen Y, Kuang X, Zhou J, et al. Proximal tibial cortex transverse distraction facilitating healing and limb salvage in severe and recalcitrant diabetic foot ulcers. Clin Orthop Relat Res, 2020, 478(4): 836-851.
22.	Guo J, Bao H, Hu H, et al. Effect of tibial transverse transport on chronic lower extremity angiopathy: a protocol for a systematic review and meta-analysis. BMJ Open, 2022, 12(9): e060249. doi: 10.1136/bmjopen-2021-060249.
23.	Lechleitner M, Abrahamian H, Francesconi C, et al. Diabetic neuropathy and diabetic foot syndrome (Update 2019). Wien Klin Wochenschr, 2019, 131(Suppl 1): 141-150.
24.	Volmer-Thole M, Lobmann R. Neuropathy and diabetic foot syndrome. Int J Mol Sci, 2016, 17(6): 917. doi: 10.3390/ijms17060917.

1. Toscano CM, Sugita TH, Rosa MQM, et al. Annual direct medical costs of diabetic foot disease in brazil: a cost of illness study. Int J Environ Res Public Health, 2018, 15(1): 89. doi: 10.3390/ijerph15010089.
2. Kerr M, Barron E, Chadwick P, et al. The cost of diabetic foot ulcers and amputations to the National Health Service in England. Diabet Med, 2019, 36(8): 995-1002.
3. Telfer S, Erdemir A, Woodburn J, et al. What has finite element analysis taught us about diabetic foot disease and its management? A systematic review. PLoS One, 2014, 9(10): e109994. doi: 10.1371/journal.pone.0109994.
4. Monteiro-Soares M, Russell D, Boyko EJ, et al. Guidelines on the classification of diabetic foot ulcers (IWGDF 2019). Diabetes Metab Res Rev, 2020, 36 Suppl 1: e3273. doi: 10.1002/dmrr.3273.
5. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. Part Ⅰ. The influence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res, 1989(238): 249-281.
6. Yuan Y, Ding X, Jing Z, et al. Modified tibial transverse transport technique for the treatment of ischemic diabetic foot ulcer in patients with type 2 diabetes. J Orthop Translat, 2021, 29: 100-105.
7. Nie X, Kuang X, Liu G, et al. Tibial cortex transverse transport facilitating healing in patients with recalcitrant non-diabetic leg ulcers. J Orthop Translat, 2020, 27: 1-7.
8. Wang A, Lv G, Cheng X, et al. Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition). Burns Trauma, 2020, 8: tkaa017. doi: 10.1093/burnst/tkaa017.
9. Yang Y, Li Y, Pan Q, et al. Tibial cortex transverse transport accelerates wound healing via enhanced angiogenesis and immunomodulation. Bone Joint Res, 2022, 11(4): 189-199.
10. Noor S, Zubair M, Ahmad J. Diabetic foot ulcer—A review on pathophysiology, classification and microbial etiology. Diabetes Metab Syndr, 2015, 9(3): 192-199.
11. Paraskevas KI, Baker DM, Pompella A, et al. Does diabetes mellitus play a role in restenosis and patency rates following lower extremity peripheral arterial revascularization? A critical overview. Ann Vasc Surg, 2008, 22(3): 481-491.
12. Hu XX, Xiu ZZ, Li GC, et al. Effectiveness of transverse tibial bone transport in treatment of diabetic foot ulcer: A systematic review and meta-analysis. Front Endocrinol (Lausanne), 2023, 13: 1095361. doi: 10.3389/fendo.2022.1095361.
13. Wang F, Kong L, Wang W, et al. Adrenomedullin 2 improves bone regeneration in type 1 diabetic rats by restoring imbalanced macrophage polarization and impaired osteogenesis. Stem Cell Res Ther, 2021, 12(1): 288. doi: 10.1186/s13287-021-02368-9.
14. Matsuyama J, Ohnishi I, Kageyama T, et al. Osteogenesis and angiogenesis in regenerating bone during transverse distraction: quantitative evaluation using a canine model. Clin Orthop Relat Res, 2005(433): 243-250.
15. Jianda X, Maosheng B, Chenjian P, et al. An novel and alternative treatment method for large heel ulceration in diabetic patients: Proximal tibial cortex transverse distraction. Int Wound J, 2023, 20(3): 732-739.
16. Xie J, Liu X, Wu B, et al. Bone transport induces the release of factors with multi-tissue regenerative potential for diabetic wound healing in rats and patients. Cell Rep Med, 2024, 5(6): 101588. doi: 10.1016/j.xcrm.2024.101588.
17. Chen Y, Ding X, Zhu Y, et al. Effect of tibial cortex transverse transport in patients with recalcitrant diabetic foot ulcers: A prospective multicenter cohort study. J Orthop Translat, 2022, 36: 194-204.
18. Houlind K. Surgical revascularization and reconstruction procedures in diabetic foot ulceration. Diabetes Metab Res Rev, 2020, 36 Suppl 1: e3256. doi: 10.1002/dmrr.3256.
19. Ou CY, Wu MS, Lin MC, et al. Short-term and long-term outcomes of free flap reconstruction versus amputation for diabetic foot reconstruction in patients with end-stage renal disease. J Plast Reconstr Aesthet Surg, 2022, 75(8): 2511-2519.
20. Chen P, Vilorio NC, Dhatariya K, et al. Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev, 2024, 40(3): e3644. doi: 10.1002/dmrr.3644.
21. Chen Y, Kuang X, Zhou J, et al. Proximal tibial cortex transverse distraction facilitating healing and limb salvage in severe and recalcitrant diabetic foot ulcers. Clin Orthop Relat Res, 2020, 478(4): 836-851.
22. Guo J, Bao H, Hu H, et al. Effect of tibial transverse transport on chronic lower extremity angiopathy: a protocol for a systematic review and meta-analysis. BMJ Open, 2022, 12(9): e060249. doi: 10.1136/bmjopen-2021-060249.
23. Lechleitner M, Abrahamian H, Francesconi C, et al. Diabetic neuropathy and diabetic foot syndrome (Update 2019). Wien Klin Wochenschr, 2019, 131(Suppl 1): 141-150.
24. Volmer-Thole M, Lobmann R. Neuropathy and diabetic foot syndrome. Int J Mol Sci, 2016, 17(6): 917. doi: 10.3390/ijms17060917.

Chinese Journal of Reparative and Reconstructive Surgery

Latest ArticlesA feasibility study of the EMO scoring system to guide proximal tibial transverse transport in treatment of diabetic foot wounds

Abstract Full text Figures/Tables Video References Cited by

Format

Content