{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,11,27]],"date-time":"2025-11-27T06:44:16Z","timestamp":1764225856781,"version":"3.46.0"},"reference-count":37,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,11,27]],"date-time":"2025-11-27T00:00:00Z","timestamp":1764201600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Surg."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>It has been a great challenge to treat clinical stage 4 Diabetic foot ulcers (DFUs) due to high rates of major amputations and prolonged healing time. This study aimed to assess the effectiveness of a three-stage sequential surgical approach, which based on the Integrated Surgery Wound Treatment (ISWT) mode, to manage clinical stage 4 DFUs and compare the benefit of incorporating tibial cortex transverse transport (TTT) surgery at stage 3 treatment.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Twenty-three patients with clinical stage 4 DFUs aged 45\u201375 years treated between January 2022 and February 2023 were retrospectively analyzed. Eleven patients (Group A) received wound debridement, antibiotic-loaded bone cement (ALBC) at stage 1 treatment, percutaneous transluminal angioplasty (PTA), wound debridement, and ALBC at stage 2 treatment, and skin grafting with TTT at stage 3 treatment, while twelve patients (Group B) received the same treatment without TTT. Assessed clinical outcomes included length of hospital stay, ulcer healing duration, ulcer recurrence rate, reintervention (re)-PTA rate, amputation rate, mortality rate, visual analog scale (VAS) scores, ankle-brachial index (ABI), and two-point discrimination (2-PD) ability. The computed tomographic angiography (CTA) was used to evaluate vascular hyperplasia.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Group A showed no occurrences of re-PTA (\n                      <jats:italic>P<\/jats:italic>\n                      \u2009=\u20090.037) and similar ulcer healing times (\n                      <jats:italic>P<\/jats:italic>\n                      \u2009=\u20090.975) compared to Group B. Ulcer outcome, amputation, and mortality rate were also alike in the two groups (\n                      <jats:italic>P<\/jats:italic>\n                      \u2009&amp;gt;\u20090.05). One year after surgery, Group A demonstrated improvement in VAS scores, ABI, and 2-PD, while Group B showed no significant changes. Additionally, Group A exhibited enhanced lower limb artery characteristics compared to Group B.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The sequential three-stage approach based on the ISWT mode effectively manages clinical stage 4 DFUs. Incorporating TTT surgery at stage 3 extends the benefits of PTA surgery.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fsurg.2025.1696424","type":"journal-article","created":{"date-parts":[[2025,11,27]],"date-time":"2025-11-27T06:31:05Z","timestamp":1764225065000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["A three-stage sequential surgical approach to a more efficient management of clinical stage 4 diabetic foot ulcers"],"prefix":"10.3389","volume":"12","author":[{"given":"Fang","family":"Zhang","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yu","family":"Guo","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Wenduo","family":"Zhang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ilaria","family":"Dal 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