The skeletal shape of the human foot was specialized for bipedal walking. The principle character of its shape is termed“plantigrade”, which means that the sole of the foot always faces the ground when standing. The foot has three types of arch structures that work to absorb the load of the body on the sole during standing or walking. When the body weight is loaded, the foot arch compresses and sinks vertically. This truss mechanism is able to absorb the load on the sole. When humans stand on their tiptoes, the toes flex dorsally, pulling the plantar fascia. Following the arch lift once again by this function called“windlass mechanism”. However, the supportive properties of the foot during walking are controversial because the foot must be flexible enough to absorb the load on the sole, but rigidity is also important to push the body forward in the tiptoe phase. The subtalar joint allows for these two conflicting states. Knowledge on the functional anatomy of the foot during walking may be applied to limb salvage treatment.

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The diabetic foot clinic for prevention of diabetic foot ulcers（DFU）was established in 2006 in the University of Tokyo Hospital. Diabetes nurses, Wound, Ostomy and Continence Nurses and wound care researchers identify the risk to DFUs, care for non-ulcerative pathology and educate patients. Moreover, wound care specialists, engineers and bioengineers conducted collaborative research, and developed protocols which focus on identifying and caring for high risk patients with non-ulcerative pathology. The accumulation incidence of DFUs over a period of 60 months was kept at just 1.2% at the University of Tokyo Hospital. Recently the number of cases of diabetes is increasing and there is an urgent need to establish effective preventive methods for DFUs in Asia. We had the opportunity to conduct a diabetic foot clinic in China and recognized that the need for preventative care was high. We also gave a lecture about preventative care for DFUs, and introduced our protocol in Indonesia. Challenges encountered by our diabetic foot clinic are introduced in this paper, from establishment of the diabetic foot clinic to dissemination to the world.

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The aim of treatment for diabetic foot ulcers is to preserve the walking ability of patients by revascularization and wound management. In order to preserve walking, we must review the diagnostic and therapeutic studies, and clarify the mechanisms of walking and the ambulatory system. In Asian countries, there are no podiatrists or podiatric medicine. The Kobe classification should be implemented for diabetic foot. In the near future, a system for early intervention of rehabilitation for preserving the independent walking ability of diabetic patients should be established.

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Diabetic foot ulceration is a serious diabetic complication associated with neuropathy, peripheral vascular disease, infection, and other causes. In severe cases, it requires amputation, which negatively affects patients' QOL and survival. It develops as early-stage foot lesions and progresses with time. However, characteristically, its identification tends to be delayed due to diabetic neuropathy. In the absence of marked pain, some patients underestimate the severity of their lesions, resulting in delayed care. Therefore, medical professionals should periodically examine their feet to prevent and identify ulceration in the early stages, limiting the scope to high-risk patients, when necessary, as it is difficult to conduct such examination for all diabetic patients. The most important point is to periodically examine diabetic patients' feet according to their risk levels. Appropriate glycemic control is another approach needed to prevent neuropathy, arteriosclerosis, and vulnerability to infection progression. This section also provides an outline of pharmacotherapy for diabetes.

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In patients with chronic kidney disease（CKD）, particularly those on hemodialysis, the cardiovascular mortality rate is extremely high. Polyvascular diseases develop at an early stage of CKD. The pathophysiology includes insulin resistance and/or imbalance between nitric oxide（NO）and endothelin bioavailability, as well as oxidative stress. Pathophysiologies, such as hemorheological disarrangement, may be overlooked because of hyperfibrinogenemia and the higher rate of production of monocyte-platelet complexes in circulation, which plays an important role in atherosclerosis. Regarding clinical findings, most nephrologists understand the importance of coronary artery disease, but few are aware of the deleterious influence of peripheral arterial disease（PAD）on prognosis for CKD patients, which is known to be an independent risk factor for PAD. An understanding of the pathophysiology behind vascular calcification and strategic treatment are critical to achieve a favorable outcome for CKD patients. In this regard, FGF-23 and associated factors together with Klotho molecules play an important role. In this article, we review cardiovascular diseases in CKD patients with an emphasis on the clinical aspects of polyvascular disease. Finally, we will address how to detect microcirculatory impairment and eradicate vascular calcification as early as possible prior to renal replacement therapy. The FGF-23-Klotho gene axis, and vitamin D and phosphate control should be carefully investigated.

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Today, catheter-based endovascular therapy is widely accepted as a method to treat critical limb ischemia patients due to its rapid improvement over the last 10 years. New techniques for guidewire maneuvering and distal puncture have been introduced. In addition to these, domestic medical device companies release many new guidewires and micro-catheters that are specialized for peripheral use. These technical and device improvements synergistically strengthen the potential of endovascular therapy. In this article, I will review the current status of endovascular treatment for below-the-knee lesions.

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Diabetes as well as lifestyle-related diseases from smoking and aging leading to peripheral artery disease and obstructive arteriosclerosis cause severe foot lesions. In nursing foot care, the target is not only the foot but also the patient, and we place emphasis on the patient’s self-foot care. It is important to understand the patient’s life while caring for them and their foot. For foot care in diabetes nursing, methods to prevent foot lesions, such as cleanliness and prevention of dryness, necessary care techniques, such as nail care and bathing, and wounds, such as corns and ingrown nails, should be explained to patients. Appropriate care methods for foot lesions will support self-care. We will continue to evaluate foot care practice and connect it with further care.

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Critical limb ischemia is a richly diverse, complex pathology in which peripheral tissues cause necrosis and ischemia due to arterial occlusion and stenosis. Therefore, multidisciplinary treatment is necessary. In 2016, with the aim of promoting multidisciplinary care between clinical departments in Japan, a new medical system, the Podiatric Cooperation System, was established by the government. Early intervention for dialysis patients improves their status. As dialysis patients undergo dialysis at the clinic three times a week, early detection and intervention are possible. In dialysis clinics, a system for early CLI detection by blood flow assessment has been initiated. In the future, early cooperation between orthopedic surgery and rehabilitation departments is desired to preserve gait function and prevent sarcopenia.

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The diversity in the CLI population in terms of preoperative patient risk and foot condition is one of the significant factors that make treatment strategies very complex. Diversity is important for not only preoperative status but also for prognosis of limbs and survival. Therefore, the treatment goal for each individual should be set by predicting each individual’s outcome before selecting the revascularization procedure. The minimum goal of CLI treatment should be limb salvage, but higher goals, such as complete ulcer healing, recovering walking ability, or improving QOL, can be achieved by durable revascularization with high-quality multidisciplinary approaches. After revascularization, the preoperative treatment goal should be modified to reflect the residual infection, re-stenosis of the revascularized artery, and foot deformity after minor amputation. Based on the above, four important factors: foot condition（WIfI classification）, vascular condition, general condition, and functional status of limbs and brain, are key for the initial decision-making process to select bypass surgery, endovascular treatment, or primary amputation.

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In order to improve the prognosis of both legs and life of the patients with critical limb ischemia, multidisciplinary treatment by special teams is mandatory. Our foot care team consists of doctors, nurses, nutritionists, laboratory technicians, and physical therapists, who have been collaborating with each other to fight against the most advanced form of lower extremity vascular disease. Here, we introduce a representative case with a favorable clinical course treated with intensive support by our team.

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This study aimed to evaluate the preventive effects of compression therapy on cellulitis in patients with lymphedema. The study included 82 patients（110 limbs）who received compression therapy for lymphedema and were followed-up as outpatients for 6 months or longer. Exclusion criteria were patients who had malignant lymphedema, who had undergone surgical treatment for lymphedema, who were on prophylactic antibacterial therapy, or who had an ankle brachial pressure index of less than 0.5. On comparison of the incidence of cellulitis before and after the first visit to our hospital, the mean number of cellulitis episodes per limb over a 6-month period decreased from 0.71 to 0.07（p<0.001）. The mean number of recurrent episodes of cellulitis per limb over a 6-month period decreased from 2.8 to 1.0（p<0.01）. The preventive effects of compression therapy on cellulitis for lymphedema were found to be related with the level of compression, frequency of wearing of compression garments, and stage of lymphedema. Compression therapy that is appropriate for the stage of lymphedema is considered to be effective for preventing cellulitis

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