[in Japanese]

View full abstract

Since 2008, management fee for diabetic complications and foot care have been introduced in numerous hospitals. Foot care is also provided in other facilities in order to allow patients to continue on with their daily lives. In five fields such as hospital wards, hospital outpatient clinics, home-visit nursing care, nursing home, and clinics, nurses who provide foot care play an important role of the team approach in health care. Also, the current condition of foot care and the distinctive features in those fields are considered. Nurses work to share and secure patients’ information with other healthcare professionals, keep a close watch on patients and their families, and provide daily support during medical treatments. Therefore, it is evident that nurses play an important role in continuous foot care by ‘connecting’ in the team approach in health care.

View full abstract

Peripheral arterial disease (PAD) is common in patients on hemodialysis (HD). Our data provided that 25% of incident HD patients and 40% of maintenance HD patients had micro-circulation disorder. Arterial calcification is another characteristic feature of HD patients with PAD. Arterial calcification not only correlates with prevalence and severity of PAD but also associates with lower limbs’amputation and future cardiovascular mortality. Results of the treatment for HD patients with critical limb ischemia (CLI) in our hospital improved 2-year limb salvage rate up to 79% by various combination approaches including re-vascularization (endovascular interventional treatment or surgical bypass), wound treatment (VAC or maggot), LDL-apheresis, infection control, and nutritional intervention, but their 2-year survival rate was still very poor (44%). Most important issue is to diagnose PAD as early as possible. Concomitant evaluation and adequate treatment of other atherosclerotic complications including ischemic cardiovascular disease may be very important another point to improve survival in HD patients with PAD.

View full abstract

Peripheral arterial disease (PAD) is common in dialysis patients, and significantly associated with morbidity and mortality, while its prevalence appears to be elevated in those who are diabetic or elderly. When a patient develops critical limb ischemia (CLI), an endovascular procedure or open surgical intervention is generally chosen. However, because of existing comorbid conditions, management of CLI in dialysis patients can be difficult. These patients tend to heal slowly, have a high rate of infection, and are frequently at high operative risk, thus decision making related to CLI should be individualized to reflect patient preference and expected prognosis. Although an endovascular procedure can benefit some dialysis patients, many may be poor candidates due to the frequent presence of diffuse and distal lesions. On the other hand, a distal bypass procedure is not universally performed in Japan. It is important to train vascular specialists to treat such difficult patients with the options of endovascular and open surgical intervention strategies available to them.

View full abstract

Objective: The purpose of this study was to evaluate the efficacy of infrainguinal arterial reconstruction for critical limb ischemia in patients with end-stage renal disease (ESRD). Materials and Methods: From April, 2007 to March, 2011, 126 limbs in 103 patients with ESRD and 84 limbs in 75 patients with functioning kidneys underwent infrainguinal arterial reconstruction for limb salvage. The prevalence of coronary arterial disease was higher in the ESRD group (p<0.01). Results: Operative mortality and 2-year survival rate were significantly poorer in patients with ESRD (11 vs 2%; p<0.01, and 44 vs 70%, p<0.01, respectively). Most causes of death were related to atherosclerosis or infectious diseases. Although there was no significant difference in 2-year limb salvage rate between ESRD and non-ESRD groups (86 vs 91%), limb loss occurred as a result of uncontrolled infection in five cases in the ESRD group and one case in non-ESRF group. Conclusions: Operative mortality and patient survival rate were significantly poorer in the ESRD group. Preoperative full evaluation of cardiovascular system, appropriate treatment for wound infection, and careful follow-up for comorbid diseases may be needed in these patients.

View full abstract

Recent progress in endovascular treatment and multidisciplinary approach, the widely recognition of importance of preserving the knee joint when selecting the amputation level have lead to an increase in the numbers of trans-tibial amputation due to peripheral arterial disease (PAD). As a result, from the perspective of prosthetic rehabilitation, it should be possible to expect more amputees to attain better functionality. However, there has been no increase in the rate of successful prosthetic rehabilitation outcome among trans-tibial amputees in the past. What that means? It appears to have been due to the lack of effective post-amputation stump management and subsequent rehabilitation strategies for trans-tibial amputees due to PAD. As one of promising strategy, we propose a stump management program using silicone liners. It targets trans-tibial amputees due to PAD, and begins after the stump wound closes, regardless of the stump management method employed immediately after amputation.

View full abstract

There is a wide range of conditions calling for rehabilitation, from the severity of foot ulcer prevention to that of limb loss; but there are no guidelines. The content of rehabilitation differs depending on the severity of the disease, but all stages have in common the elements of physical therapy and the selection of orthotics. The thought process is, first of all, to check the general condition of the patient and evaluate the state of the foot (or local wound) and the leg function, and then, on the basis of those results, to choose a orthotics and plan a program of physical therapy. In choosing a prosthesis, the subject’s life expectancy and the prognosis for his/her leg must be taken into consideration, evaluating quantitatively whether or not the chosen orthotics is functioning as expected when it was prescribed and anticipating any adverse events that might be associated with its continuous use. Things to consider in planning a physical therapy program are any conditions that are a relative contraindication of exercise, also any systemic disease, so as to determine the appropriate amount of exercise.

View full abstract

Foot orthosis (footwear) plays a big part in foot treatment and effects preventively. Prevention of recurrence is expected with orthotic therapy, which is developed for protection of affected area such as symptomatic improvement. How-to select an optimum orhosis is considered not only the therapeutic strategy but also ADL of the patient such as activity, age, gender, and rehabilitation. It is required to prescribe a foot orthosis ideally for usage environment; the point of view, materials and form of the foot orthosis in consideration of depressurization etc. should be selected individual carefully. The effect of orthosis should be objectively checked, and it is desirable to provide a foot orthosis which has certificated evidences to the user. Contrary to this optimum theory, orthosis is prescribed under the present conditions of the user and the materials are usually selected by CPOs based on their individual experiences; the effect is actually judged in many cases subjectively by user only. In the concept of limb salvage, there is the necessity to renew current approach at orthotic therapy. In accordance with mentioned theory, a foot orthosis should be prescribed individually and tested objectively before it will be provided to each user. Regarding to renewal approach, optimal conformity such as evaluation method how they actually go is reported.

View full abstract

In recent years, various treatments for limb salvage have been performed on patients with critical limb ischemia. Unfortunately, some patients may not be without lower limb amputation surgery. We studied on dialysis patients of our hospital, about daily life return after having adopted prosthetic limbs and rehabilitation of lower limb amputation surgery. Patients using energy-storing prosthetic feet made of carbon obtained immediately stable walking ability. The patients were able to walk stairs relatively quickly. Suitable early rehabilitation was useful for returning, for the daily life. Even if patients with the disability hands who were operated by the bilateral lower limb amputation, were possible to get on and off wheelchairs by the little assistance with appropriate early rehabilitation. Therefore we should try to make the patient with lower limb amputation using the suitable early rehabilitation and prosthesis return to daily life.

View full abstract

In 2010, Negative pressure wound therapy began to be covered under the Japanese National Health Insurance, resulting in significant progress for limb salvage. Negative pressure exerts mechanical stress on the wound for its therapeutic effect and differs from conventional wound therapy. Macrodeformation and microdeformation occur due to mechanical stimulation. Macrodeformation draws together the edges of the wound and removes exudate and infectious materials. Removal of exudate changes the interstitial-fluid pressure gradient, reduces edema, and increases blood flow. Microdeformation causes the cell shape to change, resulting in signal transmission to the nucleus and gene transcription. Consequently, cell proliferation and differentiation occur. Furthermore, metabolism increases, growth factor and cytokine expression changes, granulation tissue formation is promoted, blood flow increases, and wound healing is promoted. It is important to use this procedure with a thorough understanding of its indications and contraindications in order to optimize its features.

View full abstract

Objects: We performed a retrospective study to evaluate the validity of a free flap procedure for limb-salvage. Patients and Methods: Seventy-two patients with a foot ulcer were admitted to the Department of Plastic and Reconstructive Surgery of Fujisawa Citizens’ Hospital between 2007 and 2010. A free flap was applied to 6 patients. We compared the preoperative background and postoperative course between the 6 patients treated with a free flap and the 66 patients not treated with a free flap. Results: Mean age of patients treated with a free flap was 14 years old younger than that of patients without the free flap. All 6 cases had uncontrolled diabetes. Although vessel anastomosis was successful in all cases, total flap loss occurred in one case due to infection. One patient was unable to bear weight on her salvaged foot and eventually died, and another patient did not maintain contact with us after discharge. Conclusions: A free flap can be safely performed in younger patients with diabetic foot ulcer, but patient adherence should be considered. A multidisciplinary team approach for diabetic foot ulcers might be necessary to improve the results of limb-salvage procedure using a free flap.

View full abstract

Wound bed preparation after debridement can be accomplished in several ways. Artificial dermal scaffolding is one method of reconstructing skin-like tissue in an early stage. Negative pressure wound therapy using the V.A.C.^®ATS system is another method that results in good granulation. At present, few reports have addressed the issues surrounding chronic wound therapy and the potential of artificial dermal scaffolding and negative pressure wound therapy. In this study, dermal tissues were examined and treated with a combination of artificial dermal scaffolding and postoperative negative pressure wound therapy. Between March and September 2012, six patients with chronic wounds in the lower extremities were treated with a combination of artificial dermal scaffolding and postoperative negative pressure wound therapy. Granulation tissue was examined and artificial dermal scaffolding combined with postoperative negative pressure wound therapy was compared to postoperative negative pressure wound therapy alone. The combination of artificial dermal scaffolding and negative pressure wound therapy resulted in significantly better dermal regeneration through infiltration of cells and neovascularization than negative pressure wound therapy alone (P<0.01). The dermal substitutes were completely successful in all cases, and no graft failures were observed. Thus, combination therapy with dermal scaffolding and negative wound pressure therapy potentially results in good wound bed preparation.

View full abstract

Purpose: To examine the experience of a nurse who provides foot care to inpatients with diabetic foot. Methods: We interviewed a nurse who provided foot care to inpatients with diabetic foot and analyzed the obtained data using a phenomenological approach. Results: By providing patients with foot care involving physical contact, the nurse came to understand the patients’ background and implement nursing care in the place where she was with the patients. Through this, she came to realize that she had preconceptions about the patients and to use foot care as a means to connect with the patients. Although she became aware of the differences between herself and other staff members in their feelings toward the patients, she was willing to advocate foot care that enabled her to better assess the prognosis of the patients. Discussion: Foot care helped a nurse to connect with patients, which enabled her to better understand the patients and to assess their prognosis more accurately, modifying the whole nursing care.

View full abstract