Staged antibiotic-loaded cement-based reconstruction versus flap-based reconstruction for complex diabetic foot defects in patients with osteoporosis: a retrospective cohort study

Objective This retrospective cohort study aimed to compare the clinical efficacy and safety of a staged antibiotic-loaded bone cement combined with negative pressure wound therapy (AB-NPWT) pathway vs. flap transplantation in the treatment of chronic foot ulcers with soft tissue defects in patients with type 2 diabetes mellitus (T2DM) and osteoporosis. Methods We retrospectively analyzed 56 patients with T2DM and osteoporosis who underwent surgical treatment between January 2020 and December 2024. Treatment allocation was non-randomized and determined by the attending surgeon; no formal sample size calculation was performed. In the AB-NPWT group, 5 patients (17.2%) crossed over to receive local flap coverage as part of the staged pathway. The analysis was not adjusted for multiple comparisons. The AB-NPWT group ( n = 29) and flap transplantation group ( n = 27) were compared for perioperative parameters, wound healing, limb salvage, complications, and AOFAS scores. Adjusted analyses (multivariable regression and propensity score matching) were performed to account for potential confounding. Results Operative time and blood loss were significantly lower in the AB-NPWT group (both p < 0.001). At 12 months, complete wound healing (86.2% vs. 88.9%, p = 0.754), limb salvage (93.1% vs. 92.6%, p = 1.000), and median healing time (126 vs. 112 days, p = 0.221) did not differ significantly between groups. Complication rates were similar (24.1% vs. 33.3%, p = 0.446), but profiles differed. AOFAS scores at final follow-up were comparable (72.5 ± 10.3 vs. 75.8 ± 11.6, p = 0.270). Conclusions In this retrospective exploratory cohort, no statistically significant between-group differences were detected in the main clinical outcomes. AB-NPWT was associated with reduced surgical trauma, whereas flap transplantation provided definitive coverage in a single operative session after debridement. Treatment selection should be individualized based on wound characteristics, patient systemic status, and healthcare resources. These findings are hypothesis-generating and require confirmation in larger prospective trials.