Mr Paul Nesbitt FRCS (Tr & Orth) · Manchester
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A Pioneering Limb Salvage Service · Manchester

Regenerating blood supply, saving limbs.

Transverse Cortical Tibial Transport (TTT) is a bone-transport technique that stimulates new blood vessel growth in the lower limb. Mr Nesbitt leads one of three main centres for TTT in the UK, and the only centre using the technique in patients with critical limb ischaemia and diabetes.

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Transverse Cortical Tibial Transport in clinical practice
QualificationsFRCS (Tr & Orth) · MBChB
GMC Number7074098
UK Centres1 of 3 main TTT centres
Unique in the UKTTT for CLI & diabetes
Indemnity£10m
Affiliated With Manchester Limb Reconstruction Unit
The Technique

What is Transverse Cortical Tibial Transport?

TTT applies the principles of distraction osteogenesis — the same biological process that underpins limb lengthening with a circular frame — to a different end: regenerating the blood supply to an ischaemic limb.

A circular frame is applied to the tibia and a small window of cortical bone is gradually transported across the bone using fine adjustments made daily by the patient or carer, in the same way bone is lengthened during limb reconstruction. Rather than lengthening the limb, this slow transport stimulates the formation of new microvasculature — small new blood vessels that improve perfusion to the surrounding soft tissues, skin and wound bed.

For patients with chronic limb-threatening ischaemia, non-healing diabetic foot ulcers, or severe claudication that has not responded to angioplasty, bypass or best medical therapy, this regenerative effect can mean the difference between progressive deterioration towards amputation and a limb that is salvaged, with a healed wound and improved walking distance.

“TTT sits at the intersection of limb reconstruction and vascular surgery. It is not a substitute for vascular intervention — it is what we offer when conventional options have been exhausted, and the limb is still salvageable.”

Manchester is one of three main centres for TTT in the UK, and the only centre using the technique in patients with critical limb ischaemia and diabetes, delivered through a dedicated multi-disciplinary pathway with vascular surgery — meaning patients are assessed jointly, optimised medically and surgically before frame application, and followed up by a team experienced in both reconstruction and vascular disease.

Circular frame applied for Transverse Cortical Tibial Transport
A circular frame applied for TTT, used to transport a window of cortical bone and stimulate neovascularisation.
Indications

When TTT may help.

TTT is considered for patients with chronic limb-threatening conditions where standard vascular treatment has reached its limit, but the limb remains potentially salvageable. Every referral is assessed jointly by the limb reconstruction and vascular teams.

i.

Diabetic Foot Ulceration

Non-healing diabetic foot ulcers where revascularisation has not restored sufficient perfusion for the wound bed to heal.

ii.

Critical Limb Ischaemia

Severe peripheral arterial disease with rest pain, tissue loss or ulceration in patients no longer suitable for angioplasty or bypass.

iii.

Chronic Claudication

Debilitating claudication pain that limits walking distance and quality of life despite optimal medical management.

iv.

Limb Salvage

An alternative to major amputation in carefully selected patients with a threatened but viable limb.

The TTT Pathway

From referral to recovery.

Every TTT pathway follows the same structured sequence, with the vascular and limb reconstruction teams involved at each stage.

i.

MDT Assessment

Joint review by the vascular and limb reconstruction teams, including imaging and vascular studies, to confirm TTT is appropriate.

ii.

Vascular Optimisation

Any reversible vascular issues — angioplasty, bypass or medical optimisation — are addressed first, where appropriate.

iii.

Frame Application

A circular frame is applied to the tibia and the corticotomy performed under the same anaesthetic.

iv.

Transport Phase

The bone window is transported gradually over several weeks, with regular clinic review to monitor progress and wound healing.

v.

Consolidation & Removal

Once transport is complete and the new blood supply established, the frame is removed and follow-up continues with the vascular team.

A Pathway Few Centres Can Offer

Why Manchester.

TTT requires both circular frame expertise and a vascular surgery partnership willing to work jointly through every stage of the pathway. Few units anywhere combine both.

1 of 3 Main centres for TTT in the UK
UK only Centre using TTT in critical limb ischaemia and diabetes
100+ Open fractures and complex frame cases managed each year by the unit
Questions

Frequently asked questions.

Answers to the questions most commonly raised by patients, GPs and referring teams about Transverse Cortical Tibial Transport.

What does TTT actually do to the leg?
A circular frame is used to gradually move a small window of the tibia’s cortical bone. This slow transport stimulates the body to grow new small blood vessels (neovascularisation) into the surrounding tissue, improving blood supply to the skin, soft tissue and any chronic wounds in the lower leg and foot.
Who decides if I’m suitable for TTT?
Suitability is decided jointly by the limb reconstruction and vascular surgery teams at a multi-disciplinary meeting, after reviewing your vascular imaging, wound history and previous treatments. TTT is generally considered once standard vascular options — angioplasty, bypass or medical therapy — have been explored.
Is the procedure painful?
The frame is applied under anaesthetic, and post-operative pain is managed in the same way as for any circular frame surgery. The daily transport adjustments are small and most patients find them tolerable, though some discomfort around the frame and pin sites is normal, particularly in the early weeks.
How long does the whole process take?
This varies between patients, but typically involves several weeks of bone transport followed by a period of consolidation before the frame is removed. Your team will give you an individual estimate based on your assessment, and progress is reviewed regularly throughout.
What happens if TTT doesn’t improve my circulation?
TTT is offered to patients where the limb is judged potentially salvageable, but outcomes cannot be guaranteed for any individual. If the expected improvement does not occur, the vascular and limb reconstruction teams will discuss the next steps with you, which may include further vascular review or, in some cases, a discussion about amputation if the limb remains unsalvageable.
How is TTT accessed privately?
Private assessment for TTT is available at The Alexandra Hospital, Cheadle. You may self-refer or be referred by your GP or consultant. Because TTT is a specialist, multi-disciplinary procedure, every enquiry is reviewed individually to confirm suitability before treatment is planned — please get in touch to discuss a specific case.
Will I be able to put weight on my leg during treatment?
Weight-bearing status during TTT depends on your individual frame construct, wound status and vascular findings, and will be set out clearly by your treating team. As with other circular frame treatment, most patients are supported to remain as mobile as safely possible throughout.
Get in Touch

Refer or enquire.

Early discussion is welcome for any patient with a chronic wound, critical limb ischaemia or claudication where TTT may be relevant.

Book or Enquire

Patients, GPs & Consultants

Private assessment for TTT can be arranged at The Alexandra Hospital, Cheadle. You may self-refer or be referred by your GP or consultant. Please include any relevant vascular imaging and a summary of treatment to date with your enquiry.

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Enquiries

Patients, GPs & Consultants

For general questions about TTT, suitability, or to discuss a specific case, please contact the practice secretary, who will direct your enquiry to Mr Nesbitt.

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