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Chronic limb-threatening ischemia (CLTI) compounded by diabetic foot ulceration remains a leading precursor to major lower-extremity 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 (0.75 mm/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.