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Clinical and Mechanistic Study of Transverse Tibial Transport in Complex Foot Ulcers

Primary Purpose

Diabetic Foot Ulcer

Status
Not yet recruiting
Phase
Not Applicable
Locations
Study Type
Interventional
Intervention
Transverse Tibial Transport (TTT)
Conventional
Sponsored by
Chinese University of Hong Kong
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Diabetic Foot Ulcer

Eligibility Criteria

18 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria: Adults >18 years old Patients with a Wagner stage 4 Foot ulcer (partial foot gangrene) No active wound infection as confirmed by bacterial fluorescence imaging. (the Moleculight i:X, Smith and Nephew handheld device illuminates with 405nm violet light which causes bacteria to emit characteristic endogenous fluorescence signals that are visualised in real-time on the device's screen, allowing an objective measure of adequate surgical debridement) Biochemically confirmed diabetes with fasting plasma glucose ≥ 7.0 mmol/L, or a random plasma glucose ≥ 11.1 mmol/L or haemoglobin A1c (HbA1c) level ≥ 6.5% Triaged out for angioplasty/vascular bypass by the vascular surgeon Triaged out of reconstructive flap surgery by the microvascular surgeon Exclusion Criteria: Uncontrolled sepsis Contraindications for applying an external fixator device in the tibia (overlying skin conditions, surgical hardware such as tibial nails, total knee prosthesis etc.) Severe medical comorbidities precluding safe anaesthesia (recent myocardial infarct, limited pulmonary function etc.) Mental or physical disability which may impair the ability to adhere to the intervention plan, e.g. severe dementia, psychosis etc. Recent revascularisation procedure (<12 weeks) Recent medication/intervention affecting cell proliferation (e.g. chemotherapy, radiotherapy etc.), radiotherapy etc.)

Sites / Locations

    Arms of the Study

    Arm 1

    Arm 2

    Arm Type

    Other

    Experimental

    Arm Label

    Control Group

    TTT Group

    Arm Description

    Conventional Treatment: Dressing + Negative Pressure Wound Therapy

    Dressing + Negative Pressure Wound Therapy + Transverse Tibial Transport

    Outcomes

    Primary Outcome Measures

    Wound Size
    Wound size will be measured using digital photography with standardised marker dots.
    Wound Size
    Wound size will be measured using digital photography with standardised marker dots.
    Wound Size
    Wound size will be measured using digital photography with standardised marker dots.
    Wound Size
    Wound size will be measured using digital photography with standardised marker dots.
    Wound Size
    Wound size will be measured using digital photography with standardised marker dots.

    Secondary Outcome Measures

    Foot Function
    Foot function will be objectively measured using our validated Chinese Foot and Ankle Outcome Score or the original English version.
    Foot Function
    Foot function will be objectively measured using our validated Chinese Foot and Ankle Outcome Score or the original English version.
    Foot Function
    Foot function will be objectively measured using our validated Chinese Foot and Ankle Outcome Score or the original English version.
    Foot Function
    Foot function will be objectively measured using our validated Chinese Foot and Ankle Outcome Score or the original English version.
    Foot Function
    Foot function will be objectively measured using our validated Chinese Foot and Ankle Outcome Score or the original English version.
    Incidence of Amputation
    Incidence of Amputation
    Ankle Brachial Pressure Index
    The ankle brachial pressure index (API) is a clinical measurement of peripheral vascular perfusion.
    Ankle Brachial Pressure Index
    The ankle brachial pressure index (API) is a clinical measurement of peripheral vascular perfusion.
    Ankle Brachial Pressure Index
    The ankle brachial pressure index (API) is a clinical measurement of peripheral vascular perfusion.
    Ankle Brachial Pressure Index
    The ankle brachial pressure index (API) is a clinical measurement of peripheral vascular perfusion.
    Ankle Brachial Pressure Index
    The ankle brachial pressure index (API) is a clinical measurement of peripheral vascular perfusion.
    ELISA of angiogenic factors
    10ml peripheral blood samples will be collected at multiple time points and human serum vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), and platelet-derived growth factor (PDGF) will be analysed with an ELISA kit was processed according to its protocol.
    ELISA of angiogenic factors
    10ml peripheral blood samples will be collected at multiple time points and human serum vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), and platelet-derived growth factor (PDGF) will be analysed with an ELISA kit was processed according to its protocol.
    ELISA of angiogenic factors
    10ml peripheral blood samples will be collected at multiple time points and human serum vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), and platelet-derived growth factor (PDGF) will be analysed with an ELISA kit was processed according to its protocol.
    ELISA of angiogenic factors
    10ml peripheral blood samples will be collected at multiple time points and human serum vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), and platelet-derived growth factor (PDGF) will be analysed with an ELISA kit was processed according to its protocol.
    ELISA of angiogenic factors
    10ml peripheral blood samples will be collected at multiple time points and human serum vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), and platelet-derived growth factor (PDGF) will be analysed with an ELISA kit was processed according to its protocol.
    Immunostaining of angiogenic markers
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. Markers for angiogenesis (CD31, alpha-SMA) and cell proliferation (Ki-67) antibodies will be used for immunostaining on the paraffin section according to the previously published protocol. The positively stained cell numbers in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of MSCs proportion, angiogenesis, and cell proliferation in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Immunostaining of angiogenic markers
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. Markers for angiogenesis (CD31, alpha-SMA) and cell proliferation (Ki-67) antibodies will be used for immunostaining on the paraffin section according to the previously published protocol. The positively stained cell numbers in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of MSCs proportion, angiogenesis, and cell proliferation in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Immunostaining of angiogenic markers
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. Markers for angiogenesis (CD31, alpha-SMA) and cell proliferation (Ki-67) antibodies will be used for immunostaining on the paraffin section according to the previously published protocol. The positively stained cell numbers in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of MSCs proportion, angiogenesis, and cell proliferation in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Immunostaining of angiogenic markers
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. Markers for angiogenesis (CD31, alpha-SMA) and cell proliferation (Ki-67) antibodies will be used for immunostaining on the paraffin section according to the previously published protocol. The positively stained cell numbers in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of MSCs proportion, angiogenesis, and cell proliferation in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Immunostaining of angiogenic markers
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. Markers for angiogenesis (CD31, alpha-SMA) and cell proliferation (Ki-67) antibodies will be used for immunostaining on the paraffin section according to the previously published protocol. The positively stained cell numbers in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of MSCs proportion, angiogenesis, and cell proliferation in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Semmes Weinstein monofilament test
    a monofilament sized 0.57, with a buckling force of 10gm, is the clinically accepted cutoff for the presence or absence of protective sensation. Measurements will be standardised to 3 sites; the 1st metatarsal, 3rd metatarsal and 5th metatarsal.
    Semmes Weinstein monofilament test
    a monofilament sized 0.57, with a buckling force of 10gm, is the clinically accepted cutoff for the presence or absence of protective sensation. Measurements will be standardised to 3 sites; the 1st metatarsal, 3rd metatarsal and 5th metatarsal.
    Semmes Weinstein monofilament test
    a monofilament sized 0.57, with a buckling force of 10gm, is the clinically accepted cutoff for the presence or absence of protective sensation. Measurements will be standardised to 3 sites; the 1st metatarsal, 3rd metatarsal and 5th metatarsal.
    Semmes Weinstein monofilament test
    a monofilament sized 0.57, with a buckling force of 10gm, is the clinically accepted cutoff for the presence or absence of protective sensation. Measurements will be standardised to 3 sites; the 1st metatarsal, 3rd metatarsal and 5th metatarsal.
    Semmes Weinstein monofilament test
    a monofilament sized 0.57, with a buckling force of 10gm, is the clinically accepted cutoff for the presence or absence of protective sensation. Measurements will be standardised to 3 sites; the 1st metatarsal, 3rd metatarsal and 5th metatarsal.
    Section of neurogenic markers
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. The samples will be dewaxed and rehydrated. After antigen recovery (by Citrate Antigen Retrieval solution, ~30min, 65℃) and Permeabilization (by Triton™ X-100), markers for axon (beta-tubulin 3) (38) will be incubated overnight and corresponding secondary antibody will be incubated for 1 hours. The positively stained area in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of axon area in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Section of neurogenic markers
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. The samples will be dewaxed and rehydrated. After antigen recovery (by Citrate Antigen Retrieval solution, ~30min, 65℃) and Permeabilization (by Triton™ X-100), markers for axon (beta-tubulin 3) (38) will be incubated overnight and corresponding secondary antibody will be incubated for 1 hours. The positively stained area in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of axon area in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Section of neurogenic markers
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. The samples will be dewaxed and rehydrated. After antigen recovery (by Citrate Antigen Retrieval solution, ~30min, 65℃) and Permeabilization (by Triton™ X-100), markers for axon (beta-tubulin 3) (38) will be incubated overnight and corresponding secondary antibody will be incubated for 1 hours. The positively stained area in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of axon area in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Section of neurogenic markers
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. The samples will be dewaxed and rehydrated. After antigen recovery (by Citrate Antigen Retrieval solution, ~30min, 65℃) and Permeabilization (by Triton™ X-100), markers for axon (beta-tubulin 3) (38) will be incubated overnight and corresponding secondary antibody will be incubated for 1 hours. The positively stained area in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of axon area in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Section of neurogenic markers
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. The samples will be dewaxed and rehydrated. After antigen recovery (by Citrate Antigen Retrieval solution, ~30min, 65℃) and Permeabilization (by Triton™ X-100), markers for axon (beta-tubulin 3) (38) will be incubated overnight and corresponding secondary antibody will be incubated for 1 hours. The positively stained area in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of axon area in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Inflammatory cell flow cytometry
    10ml of peripheral blood will be obtained. Mononuclear cells will be collected by isolation of Ficoll-Paque density gradient centrifugation. The populations of classical and non-classical monocytes will be analyzed by flow cytometry and identified from proportions of CD172a+ and CD43+ cells.
    Inflammatory cell flow cytometry
    10ml of peripheral blood will be obtained. Mononuclear cells will be collected by isolation of Ficoll-Paque density gradient centrifugation. The populations of classical and non-classical monocytes will be analyzed by flow cytometry and identified from proportions of CD172a+ and CD43+ cells.
    Inflammatory cell flow cytometry
    10ml of peripheral blood will be obtained. Mononuclear cells will be collected by isolation of Ficoll-Paque density gradient centrifugation. The populations of classical and non-classical monocytes will be analyzed by flow cytometry and identified from proportions of CD172a+ and CD43+ cells.
    Inflammatory cell flow cytometry
    10ml of peripheral blood will be obtained. Mononuclear cells will be collected by isolation of Ficoll-Paque density gradient centrifugation. The populations of classical and non-classical monocytes will be analyzed by flow cytometry and identified from proportions of CD172a+ and CD43+ cells.
    Inflammatory cell flow cytometry
    10ml of peripheral blood will be obtained. Mononuclear cells will be collected by isolation of Ficoll-Paque density gradient centrifugation. The populations of classical and non-classical monocytes will be analyzed by flow cytometry and identified from proportions of CD172a+ and CD43+ cells.
    Macrophage Immunofluorescence staining
    A 3mm punch biopsy (RazorMed) will be obtained and prepared for paraffin sections. The populations and localisations of both monocytes (classical and non-classical phenotypes) and macrophages (M1 and M2 phenotype) in the skin wound site will be determined by immunofluorescence staining with specific antibodies to CD68 (general marker for macrophage), anti-iNOS (M1 macrophage), CD206 (M2 macrophage) [32] CD172a (general marker for monocyte) and CD43 (non-classical monocyte specific marker).
    Macrophage Immunofluorescence staining
    A 3mm punch biopsy (RazorMed) will be obtained and prepared for paraffin sections. The populations and localisations of both monocytes (classical and non-classical phenotypes) and macrophages (M1 and M2 phenotype) in the skin wound site will be determined by immunofluorescence staining with specific antibodies to CD68 (general marker for macrophage), anti-iNOS (M1 macrophage), CD206 (M2 macrophage) [32] CD172a (general marker for monocyte) and CD43 (non-classical monocyte specific marker).
    Macrophage Immunofluorescence staining
    A 3mm punch biopsy (RazorMed) will be obtained and prepared for paraffin sections. The populations and localisations of both monocytes (classical and non-classical phenotypes) and macrophages (M1 and M2 phenotype) in the skin wound site will be determined by immunofluorescence staining with specific antibodies to CD68 (general marker for macrophage), anti-iNOS (M1 macrophage), CD206 (M2 macrophage) [32] CD172a (general marker for monocyte) and CD43 (non-classical monocyte specific marker).
    Macrophage Immunofluorescence staining
    A 3mm punch biopsy (RazorMed) will be obtained and prepared for paraffin sections. The populations and localisations of both monocytes (classical and non-classical phenotypes) and macrophages (M1 and M2 phenotype) in the skin wound site will be determined by immunofluorescence staining with specific antibodies to CD68 (general marker for macrophage), anti-iNOS (M1 macrophage), CD206 (M2 macrophage) [32] CD172a (general marker for monocyte) and CD43 (non-classical monocyte specific marker).
    Macrophage Immunofluorescence staining
    A 3mm punch biopsy (RazorMed) will be obtained and prepared for paraffin sections. The populations and localisations of both monocytes (classical and non-classical phenotypes) and macrophages (M1 and M2 phenotype) in the skin wound site will be determined by immunofluorescence staining with specific antibodies to CD68 (general marker for macrophage), anti-iNOS (M1 macrophage), CD206 (M2 macrophage) [32] CD172a (general marker for monocyte) and CD43 (non-classical monocyte specific marker).
    Identification of regulatory cytokines for peripheral blood mesenchymal stem cells (PB-MSCs) mobilization
    10ml of peripheral blood will be collected at multiple timepoints. Each peripheral blood samples will be collected using tubes containing K2-EDTA. Blood samples will be centrifuged at 1800g for 6 min at 4 °C to get plasma and apportioned into 1 mL aliquots and stored at -80 °C. Differential protein expression will be determined by 8-plex isobaric tags for relative and absolute quantitation (iTRAQ)-based quantitative proteomics analysis.
    Identification of regulatory cytokines for peripheral blood mesenchymal stem cells (PB-MSCs) mobilization
    10ml of peripheral blood will be collected at multiple timepoints. Each peripheral blood samples will be collected using tubes containing K2-EDTA. Blood samples will be centrifuged at 1800g for 6 min at 4 °C to get plasma and apportioned into 1 mL aliquots and stored at -80 °C. Differential protein expression will be determined by 8-plex isobaric tags for relative and absolute quantitation (iTRAQ)-based quantitative proteomics analysis.
    Identification of regulatory cytokines for peripheral blood mesenchymal stem cells (PB-MSCs) mobilization
    10ml of peripheral blood will be collected at multiple timepoints. Each peripheral blood samples will be collected using tubes containing K2-EDTA. Blood samples will be centrifuged at 1800g for 6 min at 4 °C to get plasma and apportioned into 1 mL aliquots and stored at -80 °C. Differential protein expression will be determined by 8-plex isobaric tags for relative and absolute quantitation (iTRAQ)-based quantitative proteomics analysis.
    Identification of regulatory cytokines for peripheral blood mesenchymal stem cells (PB-MSCs) mobilization
    10ml of peripheral blood will be collected at multiple timepoints. Each peripheral blood samples will be collected using tubes containing K2-EDTA. Blood samples will be centrifuged at 1800g for 6 min at 4 °C to get plasma and apportioned into 1 mL aliquots and stored at -80 °C. Differential protein expression will be determined by 8-plex isobaric tags for relative and absolute quantitation (iTRAQ)-based quantitative proteomics analysis.
    Identification of regulatory cytokines for peripheral blood mesenchymal stem cells (PB-MSCs) mobilization
    10ml of peripheral blood will be collected at multiple timepoints. Each peripheral blood samples will be collected using tubes containing K2-EDTA. Blood samples will be centrifuged at 1800g for 6 min at 4 °C to get plasma and apportioned into 1 mL aliquots and stored at -80 °C. Differential protein expression will be determined by 8-plex isobaric tags for relative and absolute quantitation (iTRAQ)-based quantitative proteomics analysis.

    Full Information

    First Posted
    October 13, 2022
    Last Updated
    January 20, 2023
    Sponsor
    Chinese University of Hong Kong
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    1. Study Identification

    Unique Protocol Identification Number
    NCT05704075
    Brief Title
    Clinical and Mechanistic Study of Transverse Tibial Transport in Complex Foot Ulcers
    Official Title
    Clinical and Mechanistic Study of Transverse Tibial Transport in Complex Foot Ulcers
    Study Type
    Interventional

    2. Study Status

    Record Verification Date
    January 2023
    Overall Recruitment Status
    Not yet recruiting
    Study Start Date
    December 1, 2023 (Anticipated)
    Primary Completion Date
    January 31, 2026 (Anticipated)
    Study Completion Date
    January 31, 2026 (Anticipated)

    3. Sponsor/Collaborators

    Responsible Party, by Official Title
    Principal Investigator
    Name of the Sponsor
    Chinese University of Hong Kong

    4. Oversight

    Studies a U.S. FDA-regulated Drug Product
    No
    Studies a U.S. FDA-regulated Device Product
    No

    5. Study Description

    Brief Summary
    TTT is a novel surgical technique that may potentially solve the long-standing deficit of seeking effective treatment for diabetic foot ulcers, decreasing the need for amputations and softening the socio-economic impact it brings. This trial will be the world's first prospective RCT to verify the promising clinical studies on the clinical benefit of TTT in treating diabetic foot ulcers. In addition, blood samples from this study will allow us to study the various systemic circulating soluble factors in relation to neovascularisation, immunomodulation, and stem cell mobilisation. By taking the blood and various time points, we will better understand the complex interplay between various biomarkers. This GRF will allow us to obtain tissue samples to analyse the histological cellular changes after TTT surgery. It will provide us with more insight on how TTT works, as well as potentially helping us pinpoint the important changes and timeframes related to this intervention. The PI, Co-Is and collaborators create a strong team of clinicians and scientists with a solid clinical and basic science track record. The team has published guidelines and surgical techniques in TTT and run several training cadaveric workshops teaching the TTT surgical technique to local orthopaedic surgeons. The team has also established a rat TTT model and published on TTT immunomodulation and neovascularisation in addition to other ongoing mechanistic experiments in animals. This prospective multi-centre randomised controlled trial may act as the foundation for launching this cost-effective TTT surgery to regulate neovascularisation, neurogenesis, immunomodulation and mobilisation of MSCs for the treatment of various chronic conditions. Regenerative medicine is a multi-million dollar industry, and the potential use of TTT can result in a range of clinical applications not limited to DFUs.

    6. Conditions and Keywords

    Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
    Diabetic Foot Ulcer

    7. Study Design

    Primary Purpose
    Treatment
    Study Phase
    Not Applicable
    Interventional Study Model
    Parallel Assignment
    Masking
    None (Open Label)
    Allocation
    Randomized
    Enrollment
    54 (Anticipated)

    8. Arms, Groups, and Interventions

    Arm Title
    Control Group
    Arm Type
    Other
    Arm Description
    Conventional Treatment: Dressing + Negative Pressure Wound Therapy
    Arm Title
    TTT Group
    Arm Type
    Experimental
    Arm Description
    Dressing + Negative Pressure Wound Therapy + Transverse Tibial Transport
    Intervention Type
    Procedure
    Intervention Name(s)
    Transverse Tibial Transport (TTT)
    Intervention Description
    Transverse tibial transport is a novel adaptation of concepts used in distraction histogenesis. The most common use of this surgical principle is in bone lengthening surgery, which is a well-established surgical procedure by applying an external fixator to the bone, creating a corticotomy, and gradually lengthening the bone at the optimal rate of 0.5mm/12hrs. The biological mechanisms of distraction histogenesis involve activating signalling pathways such as cytokines Interleukin 1 and Interleukin 6, pro-inflammatory markers TNF alpha, pro-osteogenic TGF-beta, BMPs and pro-angiogenic factors VEGF and angiopoietin . TTT utilises the concept of distraction histiogenesis, but distraction is performed in the transverse plane instead of a longitudinal distraction. In addition, the period of distraction is coupled with a corresponding compression period and ultimately results in no net change in limb length.
    Intervention Type
    Procedure
    Intervention Name(s)
    Conventional
    Intervention Description
    Dressing + Negative Pressure Wound Therapy
    Primary Outcome Measure Information:
    Title
    Wound Size
    Description
    Wound size will be measured using digital photography with standardised marker dots.
    Time Frame
    0 month
    Title
    Wound Size
    Description
    Wound size will be measured using digital photography with standardised marker dots.
    Time Frame
    1 month
    Title
    Wound Size
    Description
    Wound size will be measured using digital photography with standardised marker dots.
    Time Frame
    3 month
    Title
    Wound Size
    Description
    Wound size will be measured using digital photography with standardised marker dots.
    Time Frame
    6 month
    Title
    Wound Size
    Description
    Wound size will be measured using digital photography with standardised marker dots.
    Time Frame
    12 month
    Secondary Outcome Measure Information:
    Title
    Foot Function
    Description
    Foot function will be objectively measured using our validated Chinese Foot and Ankle Outcome Score or the original English version.
    Time Frame
    0 month
    Title
    Foot Function
    Description
    Foot function will be objectively measured using our validated Chinese Foot and Ankle Outcome Score or the original English version.
    Time Frame
    1 month
    Title
    Foot Function
    Description
    Foot function will be objectively measured using our validated Chinese Foot and Ankle Outcome Score or the original English version.
    Time Frame
    3 month
    Title
    Foot Function
    Description
    Foot function will be objectively measured using our validated Chinese Foot and Ankle Outcome Score or the original English version.
    Time Frame
    6 month
    Title
    Foot Function
    Description
    Foot function will be objectively measured using our validated Chinese Foot and Ankle Outcome Score or the original English version.
    Time Frame
    12 month
    Title
    Incidence of Amputation
    Description
    Incidence of Amputation
    Time Frame
    Up to 52 weeks
    Title
    Ankle Brachial Pressure Index
    Description
    The ankle brachial pressure index (API) is a clinical measurement of peripheral vascular perfusion.
    Time Frame
    0 month
    Title
    Ankle Brachial Pressure Index
    Description
    The ankle brachial pressure index (API) is a clinical measurement of peripheral vascular perfusion.
    Time Frame
    1 month
    Title
    Ankle Brachial Pressure Index
    Description
    The ankle brachial pressure index (API) is a clinical measurement of peripheral vascular perfusion.
    Time Frame
    3 month
    Title
    Ankle Brachial Pressure Index
    Description
    The ankle brachial pressure index (API) is a clinical measurement of peripheral vascular perfusion.
    Time Frame
    6 month
    Title
    Ankle Brachial Pressure Index
    Description
    The ankle brachial pressure index (API) is a clinical measurement of peripheral vascular perfusion.
    Time Frame
    12 month
    Title
    ELISA of angiogenic factors
    Description
    10ml peripheral blood samples will be collected at multiple time points and human serum vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), and platelet-derived growth factor (PDGF) will be analysed with an ELISA kit was processed according to its protocol.
    Time Frame
    0 month
    Title
    ELISA of angiogenic factors
    Description
    10ml peripheral blood samples will be collected at multiple time points and human serum vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), and platelet-derived growth factor (PDGF) will be analysed with an ELISA kit was processed according to its protocol.
    Time Frame
    1 month
    Title
    ELISA of angiogenic factors
    Description
    10ml peripheral blood samples will be collected at multiple time points and human serum vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), and platelet-derived growth factor (PDGF) will be analysed with an ELISA kit was processed according to its protocol.
    Time Frame
    3 month
    Title
    ELISA of angiogenic factors
    Description
    10ml peripheral blood samples will be collected at multiple time points and human serum vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), and platelet-derived growth factor (PDGF) will be analysed with an ELISA kit was processed according to its protocol.
    Time Frame
    6 month
    Title
    ELISA of angiogenic factors
    Description
    10ml peripheral blood samples will be collected at multiple time points and human serum vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), and platelet-derived growth factor (PDGF) will be analysed with an ELISA kit was processed according to its protocol.
    Time Frame
    12 month
    Title
    Immunostaining of angiogenic markers
    Description
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. Markers for angiogenesis (CD31, alpha-SMA) and cell proliferation (Ki-67) antibodies will be used for immunostaining on the paraffin section according to the previously published protocol. The positively stained cell numbers in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of MSCs proportion, angiogenesis, and cell proliferation in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Time Frame
    0 month
    Title
    Immunostaining of angiogenic markers
    Description
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. Markers for angiogenesis (CD31, alpha-SMA) and cell proliferation (Ki-67) antibodies will be used for immunostaining on the paraffin section according to the previously published protocol. The positively stained cell numbers in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of MSCs proportion, angiogenesis, and cell proliferation in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Time Frame
    1 month
    Title
    Immunostaining of angiogenic markers
    Description
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. Markers for angiogenesis (CD31, alpha-SMA) and cell proliferation (Ki-67) antibodies will be used for immunostaining on the paraffin section according to the previously published protocol. The positively stained cell numbers in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of MSCs proportion, angiogenesis, and cell proliferation in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Time Frame
    3 month
    Title
    Immunostaining of angiogenic markers
    Description
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. Markers for angiogenesis (CD31, alpha-SMA) and cell proliferation (Ki-67) antibodies will be used for immunostaining on the paraffin section according to the previously published protocol. The positively stained cell numbers in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of MSCs proportion, angiogenesis, and cell proliferation in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Time Frame
    6 month
    Title
    Immunostaining of angiogenic markers
    Description
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. Markers for angiogenesis (CD31, alpha-SMA) and cell proliferation (Ki-67) antibodies will be used for immunostaining on the paraffin section according to the previously published protocol. The positively stained cell numbers in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of MSCs proportion, angiogenesis, and cell proliferation in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Time Frame
    12 month
    Title
    Semmes Weinstein monofilament test
    Description
    a monofilament sized 0.57, with a buckling force of 10gm, is the clinically accepted cutoff for the presence or absence of protective sensation. Measurements will be standardised to 3 sites; the 1st metatarsal, 3rd metatarsal and 5th metatarsal.
    Time Frame
    0 month
    Title
    Semmes Weinstein monofilament test
    Description
    a monofilament sized 0.57, with a buckling force of 10gm, is the clinically accepted cutoff for the presence or absence of protective sensation. Measurements will be standardised to 3 sites; the 1st metatarsal, 3rd metatarsal and 5th metatarsal.
    Time Frame
    1 month
    Title
    Semmes Weinstein monofilament test
    Description
    a monofilament sized 0.57, with a buckling force of 10gm, is the clinically accepted cutoff for the presence or absence of protective sensation. Measurements will be standardised to 3 sites; the 1st metatarsal, 3rd metatarsal and 5th metatarsal.
    Time Frame
    3 month
    Title
    Semmes Weinstein monofilament test
    Description
    a monofilament sized 0.57, with a buckling force of 10gm, is the clinically accepted cutoff for the presence or absence of protective sensation. Measurements will be standardised to 3 sites; the 1st metatarsal, 3rd metatarsal and 5th metatarsal.
    Time Frame
    6 month
    Title
    Semmes Weinstein monofilament test
    Description
    a monofilament sized 0.57, with a buckling force of 10gm, is the clinically accepted cutoff for the presence or absence of protective sensation. Measurements will be standardised to 3 sites; the 1st metatarsal, 3rd metatarsal and 5th metatarsal.
    Time Frame
    12 month
    Title
    Section of neurogenic markers
    Description
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. The samples will be dewaxed and rehydrated. After antigen recovery (by Citrate Antigen Retrieval solution, ~30min, 65℃) and Permeabilization (by Triton™ X-100), markers for axon (beta-tubulin 3) (38) will be incubated overnight and corresponding secondary antibody will be incubated for 1 hours. The positively stained area in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of axon area in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Time Frame
    0 month
    Title
    Section of neurogenic markers
    Description
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. The samples will be dewaxed and rehydrated. After antigen recovery (by Citrate Antigen Retrieval solution, ~30min, 65℃) and Permeabilization (by Triton™ X-100), markers for axon (beta-tubulin 3) (38) will be incubated overnight and corresponding secondary antibody will be incubated for 1 hours. The positively stained area in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of axon area in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Time Frame
    1 month
    Title
    Section of neurogenic markers
    Description
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. The samples will be dewaxed and rehydrated. After antigen recovery (by Citrate Antigen Retrieval solution, ~30min, 65℃) and Permeabilization (by Triton™ X-100), markers for axon (beta-tubulin 3) (38) will be incubated overnight and corresponding secondary antibody will be incubated for 1 hours. The positively stained area in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of axon area in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Time Frame
    3 month
    Title
    Section of neurogenic markers
    Description
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. The samples will be dewaxed and rehydrated. After antigen recovery (by Citrate Antigen Retrieval solution, ~30min, 65℃) and Permeabilization (by Triton™ X-100), markers for axon (beta-tubulin 3) (38) will be incubated overnight and corresponding secondary antibody will be incubated for 1 hours. The positively stained area in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of axon area in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Time Frame
    6 month
    Title
    Section of neurogenic markers
    Description
    3mm punch biopsy (RazorMed) will be obtained from the wound edge at multiple timepoints. The samples will be processed for paraffin embedding and 7μm serial thin sections will be cut. The samples will be dewaxed and rehydrated. After antigen recovery (by Citrate Antigen Retrieval solution, ~30min, 65℃) and Permeabilization (by Triton™ X-100), markers for axon (beta-tubulin 3) (38) will be incubated overnight and corresponding secondary antibody will be incubated for 1 hours. The positively stained area in the DFU zone in each patient will be quantified using imaging software according to published protocol. The paired T test will be adopted to compare the difference of axon area in each patient by SPSS 18.0 software for windows (SPSS, Chicago, IL, USA). Nonparametric test will be used for comparison of mean values with p<0.05 considered as statistically significant.
    Time Frame
    12 month
    Title
    Inflammatory cell flow cytometry
    Description
    10ml of peripheral blood will be obtained. Mononuclear cells will be collected by isolation of Ficoll-Paque density gradient centrifugation. The populations of classical and non-classical monocytes will be analyzed by flow cytometry and identified from proportions of CD172a+ and CD43+ cells.
    Time Frame
    0 month
    Title
    Inflammatory cell flow cytometry
    Description
    10ml of peripheral blood will be obtained. Mononuclear cells will be collected by isolation of Ficoll-Paque density gradient centrifugation. The populations of classical and non-classical monocytes will be analyzed by flow cytometry and identified from proportions of CD172a+ and CD43+ cells.
    Time Frame
    1 month
    Title
    Inflammatory cell flow cytometry
    Description
    10ml of peripheral blood will be obtained. Mononuclear cells will be collected by isolation of Ficoll-Paque density gradient centrifugation. The populations of classical and non-classical monocytes will be analyzed by flow cytometry and identified from proportions of CD172a+ and CD43+ cells.
    Time Frame
    3 month
    Title
    Inflammatory cell flow cytometry
    Description
    10ml of peripheral blood will be obtained. Mononuclear cells will be collected by isolation of Ficoll-Paque density gradient centrifugation. The populations of classical and non-classical monocytes will be analyzed by flow cytometry and identified from proportions of CD172a+ and CD43+ cells.
    Time Frame
    6 month
    Title
    Inflammatory cell flow cytometry
    Description
    10ml of peripheral blood will be obtained. Mononuclear cells will be collected by isolation of Ficoll-Paque density gradient centrifugation. The populations of classical and non-classical monocytes will be analyzed by flow cytometry and identified from proportions of CD172a+ and CD43+ cells.
    Time Frame
    12 month
    Title
    Macrophage Immunofluorescence staining
    Description
    A 3mm punch biopsy (RazorMed) will be obtained and prepared for paraffin sections. The populations and localisations of both monocytes (classical and non-classical phenotypes) and macrophages (M1 and M2 phenotype) in the skin wound site will be determined by immunofluorescence staining with specific antibodies to CD68 (general marker for macrophage), anti-iNOS (M1 macrophage), CD206 (M2 macrophage) [32] CD172a (general marker for monocyte) and CD43 (non-classical monocyte specific marker).
    Time Frame
    0 month
    Title
    Macrophage Immunofluorescence staining
    Description
    A 3mm punch biopsy (RazorMed) will be obtained and prepared for paraffin sections. The populations and localisations of both monocytes (classical and non-classical phenotypes) and macrophages (M1 and M2 phenotype) in the skin wound site will be determined by immunofluorescence staining with specific antibodies to CD68 (general marker for macrophage), anti-iNOS (M1 macrophage), CD206 (M2 macrophage) [32] CD172a (general marker for monocyte) and CD43 (non-classical monocyte specific marker).
    Time Frame
    1 month
    Title
    Macrophage Immunofluorescence staining
    Description
    A 3mm punch biopsy (RazorMed) will be obtained and prepared for paraffin sections. The populations and localisations of both monocytes (classical and non-classical phenotypes) and macrophages (M1 and M2 phenotype) in the skin wound site will be determined by immunofluorescence staining with specific antibodies to CD68 (general marker for macrophage), anti-iNOS (M1 macrophage), CD206 (M2 macrophage) [32] CD172a (general marker for monocyte) and CD43 (non-classical monocyte specific marker).
    Time Frame
    3 month
    Title
    Macrophage Immunofluorescence staining
    Description
    A 3mm punch biopsy (RazorMed) will be obtained and prepared for paraffin sections. The populations and localisations of both monocytes (classical and non-classical phenotypes) and macrophages (M1 and M2 phenotype) in the skin wound site will be determined by immunofluorescence staining with specific antibodies to CD68 (general marker for macrophage), anti-iNOS (M1 macrophage), CD206 (M2 macrophage) [32] CD172a (general marker for monocyte) and CD43 (non-classical monocyte specific marker).
    Time Frame
    6 month
    Title
    Macrophage Immunofluorescence staining
    Description
    A 3mm punch biopsy (RazorMed) will be obtained and prepared for paraffin sections. The populations and localisations of both monocytes (classical and non-classical phenotypes) and macrophages (M1 and M2 phenotype) in the skin wound site will be determined by immunofluorescence staining with specific antibodies to CD68 (general marker for macrophage), anti-iNOS (M1 macrophage), CD206 (M2 macrophage) [32] CD172a (general marker for monocyte) and CD43 (non-classical monocyte specific marker).
    Time Frame
    12 month
    Title
    Identification of regulatory cytokines for peripheral blood mesenchymal stem cells (PB-MSCs) mobilization
    Description
    10ml of peripheral blood will be collected at multiple timepoints. Each peripheral blood samples will be collected using tubes containing K2-EDTA. Blood samples will be centrifuged at 1800g for 6 min at 4 °C to get plasma and apportioned into 1 mL aliquots and stored at -80 °C. Differential protein expression will be determined by 8-plex isobaric tags for relative and absolute quantitation (iTRAQ)-based quantitative proteomics analysis.
    Time Frame
    0 month
    Title
    Identification of regulatory cytokines for peripheral blood mesenchymal stem cells (PB-MSCs) mobilization
    Description
    10ml of peripheral blood will be collected at multiple timepoints. Each peripheral blood samples will be collected using tubes containing K2-EDTA. Blood samples will be centrifuged at 1800g for 6 min at 4 °C to get plasma and apportioned into 1 mL aliquots and stored at -80 °C. Differential protein expression will be determined by 8-plex isobaric tags for relative and absolute quantitation (iTRAQ)-based quantitative proteomics analysis.
    Time Frame
    1 month
    Title
    Identification of regulatory cytokines for peripheral blood mesenchymal stem cells (PB-MSCs) mobilization
    Description
    10ml of peripheral blood will be collected at multiple timepoints. Each peripheral blood samples will be collected using tubes containing K2-EDTA. Blood samples will be centrifuged at 1800g for 6 min at 4 °C to get plasma and apportioned into 1 mL aliquots and stored at -80 °C. Differential protein expression will be determined by 8-plex isobaric tags for relative and absolute quantitation (iTRAQ)-based quantitative proteomics analysis.
    Time Frame
    3 month
    Title
    Identification of regulatory cytokines for peripheral blood mesenchymal stem cells (PB-MSCs) mobilization
    Description
    10ml of peripheral blood will be collected at multiple timepoints. Each peripheral blood samples will be collected using tubes containing K2-EDTA. Blood samples will be centrifuged at 1800g for 6 min at 4 °C to get plasma and apportioned into 1 mL aliquots and stored at -80 °C. Differential protein expression will be determined by 8-plex isobaric tags for relative and absolute quantitation (iTRAQ)-based quantitative proteomics analysis.
    Time Frame
    6 month
    Title
    Identification of regulatory cytokines for peripheral blood mesenchymal stem cells (PB-MSCs) mobilization
    Description
    10ml of peripheral blood will be collected at multiple timepoints. Each peripheral blood samples will be collected using tubes containing K2-EDTA. Blood samples will be centrifuged at 1800g for 6 min at 4 °C to get plasma and apportioned into 1 mL aliquots and stored at -80 °C. Differential protein expression will be determined by 8-plex isobaric tags for relative and absolute quantitation (iTRAQ)-based quantitative proteomics analysis.
    Time Frame
    12 month

    10. Eligibility

    Sex
    All
    Minimum Age & Unit of Time
    18 Years
    Accepts Healthy Volunteers
    No
    Eligibility Criteria
    Inclusion Criteria: Adults >18 years old Patients with a Wagner stage 4 Foot ulcer (partial foot gangrene) No active wound infection as confirmed by bacterial fluorescence imaging. (the Moleculight i:X, Smith and Nephew handheld device illuminates with 405nm violet light which causes bacteria to emit characteristic endogenous fluorescence signals that are visualised in real-time on the device's screen, allowing an objective measure of adequate surgical debridement) Biochemically confirmed diabetes with fasting plasma glucose ≥ 7.0 mmol/L, or a random plasma glucose ≥ 11.1 mmol/L or haemoglobin A1c (HbA1c) level ≥ 6.5% Triaged out for angioplasty/vascular bypass by the vascular surgeon Triaged out of reconstructive flap surgery by the microvascular surgeon Exclusion Criteria: Uncontrolled sepsis Contraindications for applying an external fixator device in the tibia (overlying skin conditions, surgical hardware such as tibial nails, total knee prosthesis etc.) Severe medical comorbidities precluding safe anaesthesia (recent myocardial infarct, limited pulmonary function etc.) Mental or physical disability which may impair the ability to adhere to the intervention plan, e.g. severe dementia, psychosis etc. Recent revascularisation procedure (<12 weeks) Recent medication/intervention affecting cell proliferation (e.g. chemotherapy, radiotherapy etc.), radiotherapy etc.)

    12. IPD Sharing Statement

    Learn more about this trial

    Clinical and Mechanistic Study of Transverse Tibial Transport in Complex Foot Ulcers

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