Automated Periosteal Distraction for Limb Salvage in Diabetic Foot Ulcers With Chronic Limb-Threatening Ischemia (Brief Communication)

Sep 30, 2026

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Chronic limb-threatening ischemia (CLTI) combined with diabetic foot ulceration is a major driver of lower-extremity amputation. Transverse tibial transport improves perfusion but typically requires corticotomy and bulky external fixation. This brief communication reports the first fully automated tibial periosteal distraction approach for limb preservation in a 65-year-old man with recurrent forefoot gangrene. Automated periosteal elevation was delivered via a miniaturized programmable motor over 13 days, followed by bedside device removal on day 21, with meaningful perfusion gains, uncomplicated progression to healing, and a need for prospective validation of safety, durability, parameters, and cost-effectiveness.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages4

Reading Time10 min

AccessFree to download

Introduction

Case Description

Procedure

Key Points/Highlights

International Wound Journal ORIGINAL ARTICLE OPEN ACCESS Automated Periosteal Distraction for Limb Salvage in Diabetic Foot Ulcers With Chronic Limb-Threatening Ischemia (Brief Communication) Lucian M. Feraru1 | Tze Woei Tan2 | David G. Armstrong2 1Department of Podiatric Surgery, Adventist Health White Memorial, Los Angeles, California, USA | 2Department of Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, California, USA Correspondence: Lucian M. Feraru ([lucian.m.feraru@gmail.com](lucian.m.feraru@gmail.com)) Received: 2 October 2025 | Revised: 25 December 2025 | Accepted: 29 December 2025 ABSTRACT Chronic limb-threatening ischemia (CLTI) compounded by diabetic foot ulceration remains a leading precursor to major lowerextremity amputation. Transverse tibial transport (TTT) can improve perfusion but requires corticotomy and bulky external fixation. We report what is, to our knowledge, the first application of fully automated tibial periosteal distraction (PD) for limb preservation. A 65-year-old man with recurrent forefoot gangrene underwent tibial PD using a miniaturised, programmable motor to gradually elevate the periosteum. Through a 1 cm incision, a low-profile subperiosteal plate was implanted and linked to the motor, which advanced 0.031 mm hourly (0.75mm/day) up to 10 mm. Distraction was completed uneventfully over 13 days, and the device was removed at the bedside on Day 21. Skin temperature increased by 2°C, and digital systolic (toe) pressure rose from 22 to 50 mmHg. The wound progressed to healing without complication. Automated PD may offer a minimally invasive, biologically driven alternative for high-risk CLTI patients, eliminating the need for patient-adjusted screws and standardising adherence. Prospective studies are required to validate its safety, durability, optimal distraction parameters and cost-effectiveness. 1 | Introduction Diabetic foot ulcers exact a high toll with five-year postamputation mortality exceeding 70% and recurrence rates exceeding all but the most high grade malignancies [1–3] . Risk stratification frameworks such as the Society for Vascular Surgery's WIfI classification highlight the combined threats of wound, ischemia and infection in determining prognosis [4] . Even after successful revascularisation, distal microischemia can perpetuate non-healing ulcers [4] . TTT harnesses the tension-stress principle to drive angiogenesis, yet it requires corticotomy and relatively bulky ring fixators [5, 6]. By contrast, periosteal distraction (PD) lifts the highly vascular periosteum without violating bone, potentially stimulating neovascularisation with fewer complications (Figure 1) . Limited series from Asia have reported ulcer healing and limb salvage rates equivalent to TTT, with significantly shorter operative times and fewer pin-site infections for PD [4–7] . Finally, all of these devices require a high degree of patient or caregiver adherence, as they have to advance a pin a fraction of a millimetre per day. Here we present what we believe is the first application of fully automated, mini-motorised tibial PD and discuss its place in contemporary limb-preservation strategies. 2 | Case Description Patient: A 65-year-old man with type 2 diabetes (HbA1c 8.4%) and moderate renal impairment (eGFR 55 mL/min) presented with recurrent dry gangrene of the fourth toe, 10 months after prior second-and third-ray amputations. Duplex imaging showed patent femoropopliteal inflow but severe distal arterial insufficiency. No osteomyelitis was seen on MRI. He adamantly refused any proximal amputation, including transmetatarsal amputation or This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. © 2026 The Author(s). International Wound

FAQs

What problem does automated tibial periosteal distraction aim to address in diabetic foot ulcers with CLTI?

It targets limb preservation in high-risk CLTI where ulcers may progress to major lower-extremity amputation. The approach is designed to improve perfusion while avoiding the burdens of conventional techniques such as corticotomy and bulky fixation.

How was the automated periosteal distraction delivered and monitored in the reported case?

A 1 cm incision was used to implant a low-profile subperiosteal plate connected to a programmable mini-motor. The device advanced 0.031 mm hourly (0.75 mm/day) up to 10 mm, with distraction completed uneventfully over 13 days and device removal at the bedside on day 21.

What perfusion and wound outcomes were reported after the procedure?

Skin temperature increased by 2°C and digital systolic toe pressure rose from 22 to 50 mmHg. The wound progressed toward healing without complication during follow-up, with near-healing at about 10 weeks as highlighted in the key points.

Sep 30, 2026

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