With the increase in the incidence of diabetes, total patient numbers and the number of those patients requiring lower limb amputation are increasing. When treating patients to prevent diabetic foot ulcerations, it is important to use both suitable footwear in conjunction with orthoses in order to prevent recurrence of ulcerations and the amputations that can result. The value of using appropriate diabetic footwear and orthoses is not yet well understood in Japan. In order to make the correct footwear to assist the diabetic patient, it is important to do gait analysis and to understand the fundamental foot type of the patient. Another key to limb salvage is to not rely on just the footwear and orthotic. This treatment will get a better result when combined with a good, foot care, rehabilitation and management program.

View full abstract

The total contact cast (TCC) has long been considered the gold standard of care for diabetic foot lesions in the U.S. The TCC is constructed to fit the exact contour of the whole foot below the knee in such a way that the weight is distributed across the lower leg as well as the entire bottom surface of the foot; this helps protect the foot that lacks sensation due to diabetic paresthesia from the repeated and focused pressure or rubbing on the foot surface during walking, thereby allowing the lesion to heal. In the present study, we examined the effects, procedure, and complications of the TCC. While TCC construction requires proficiency in the technique and utmost caution to avoid complications, evidence to support the treatment efficacy for treating plantar ulcers has been documented by multiple randomized controlled trials. We plan to examine the effects and complications and publish detailed results from our multicenter research study.

View full abstract

It has been said that there is no effective medicine for critical limb ischemia (CLI). But recently, it is reported that Cilostazol, Beraprost, and Sarpogrelate improve the skin perfusion pressure in patients of peripheral arterial disease. These drugs are expected as an adjunctive medical therapy for CLI. And patients with CLI always have other critical atherosclerosis. We recommend the risk reduction medical therapy for critical atherosclerosis in this report.

View full abstract

With increase in compromised hosts with diabetes and elderly patients, the incidence of lower extremity wounds and ischemia, as well as major leg amputations have been increasing rapidly in the United States. Limb loss leads to dramatic decline in quality of life as well as high mortality and morbidity, which is associated with high cost of medical care. Hyperbaric oxygen therapy (HBOT) is a medical treatment based on breathing 100% oxygen under high pressure environment. HBOT has been proven to be effective in treating infectious and ischemic conditions in soft tissues and bones in lower extremity, and it is considered as a valuable adjunctive therapy for limb preservation in the US. In contrast, HBOT is not widely used in Japan due to extremely low reimbursement for this particular therapy.

View full abstract

Re-vascularization therapy is essential as limb salvage strategy in patients with critical limb iscmeia (CLI). Although endovascular therapy (EVT) or surgical bypass is performed, restenosis rate after EVT for below knee arteries (BKA) in hemodialysis (HD) patients is surprisingly high. Preliminary study comparing EVT alone or hybrid therapy of EVT plus LDL apheresis for BKA-EVT in HD patients in our hospital showed favorable results for preventing restenosis of target vessels. Synergistic beneficial effect might be expected for limb salvage in patients with severe CLI by not only performing local re-vascularization therapies, but also by combining them with LDL apheresis, i.e., systemic therapy which improve whole blood rheology and have anti-inflammatory effect.

View full abstract

Negative pressure wound therapy (NPWT) has achieved a certain level of success in the treatment of diabetic foot ulcers. However, critical limb ischemia (CLI) has a complicated pathology, and it is difficult to predict the therapeutic outcome. In 2011, two recommendations were published on the application of NPWT for the treatment of CLI. Recommendation 1: The cautious use of NPWT in chronic limb ischemia when all other modalities have failed may be considered in specialist hands and never as an alternative for revascularization. Recommendation 2: NPWT may be considered as an advanced wound care therapy for lower limb ulceration after successful revascularization. The grades of recommendation were C and D for recommendations 1 and 2, respectively. These grades were lower than the grade of recommendation for NPWT for diabetic ulcers which was published at the same time as the aforementioned. The literature, on which the grades were based, cannot be said to be high-quality studies that examined CLI patients with difficult revascularization, the type of patients encountered by the members of Japanese Society of Limb Salvage and Podiatric Medicine. Treatment strategies for CLI are sought which do not adhere to one treatment method but are flexible and multifaceted.

View full abstract

We performed the maggot therapy using by medical aseptic larvae for refractory wounds in clinical fields of Japan, and furthermore we established the bioventure business to develop and spread the maggot therapy in Japan. The maggot therapy has great debridement effect, and is very effect to infectious wounds for antimicrobial peptides etc. And so the maggot therapy will get the great effect of reducing the wound healing periods to growing up the healthy granulation for very short time. We also developed the maggot bag of high molecular compound which first maggots never escape from bag, second can’t see the maggots from outside, third less feel pain, fourth easy to attach and remove the bag. In our department the results of maggot therapy in 159 cases are 91.8% of the limb salvage rate, and 91.2% of survival rate in 7.1±0.2 years of mean follow-up periods. Especially the diabetic foot gangrene without peripheral arterial disease (PAD) is very effect and safe with any events and troubles. The maggot therapy is a novel wound treatment which everybody can perform easily, except out of national health insurance.

View full abstract

In Japan, aging of the population and Westernization of lifestyle lead to increased morbidity of atherosclerotic diseases. Especially, the prognosis for patients with critical limb ischemia complicated with diabetes mellitus is poor and lower limb amputation is needed in some of those patients. We have previously reported that low-energy extracorporeal shock wave (SW) therapy induces neovascularization, and improves myocardial ischemia in a pig model of chronic myocardial ischemia and in patients with severe angina pectoris, without any adverse effects. We also reported that the SW therapy improves walking ability in patients with peripheral arterial disease and intermittent claudication (Fontaine stage II) and that the SW therapy facilitate wound healing in a mouse model of skin ulcer. Thus, the low-energy extracorporeal SW therapy appears to be an effective, safe, and non-invasive angiogenic approach in cardiovascular medicine and its indication could be extended to refractory critical limb ischemia (Fontaine stage III and IV).

View full abstract

Waon therapy is ‘soothing warm’ therapy, that is, gentle and holistic medical therapy. Patients are placed in a far-infrared ray dry sauna for 15 min at 60°C, and then subsequently kept in a supine position on a bed with sufficient warmth provided by blankets for an additional 30 min outside the sauna room. Oral hydration with water is used to compensate for weight loss at the end. We have experienced a dramatic effect of Waon therapy for 10–15 weeks (once a day, 5 times a week) on patients with severe peripheral artery disease (ASO) (Fontaine classification III–IV). Waon therapy improves symptoms, status, and blood flow in patients with ASO. Waon therapy regulates nitric oxide (NO) and endothelial NO synthase (eNOS) and augments ischemia-induced angiogenesis in mice and improve limb ischemia. Heat shock protein 90 (Hsp90) and phosphorylated-eNOS were detected in arterial endothelial cells of ischemic hind limbs in mice after five weeks Waon therapy. It is suggested that Waon therapy up-regulates Hsp90, and induces angiogenesis. In conclusion, Waon therapy is a safe, gentle, innovative, holistic and highly promising strategy for treating ASO.

View full abstract

This paper aims to discuss how to establish and practice Interprofessional Work (IPW) for foot care. Although the importance of IPW has been acknowledged, we are still in the process of trial and error, searching how best we can create teams to realize effective and efficient care. At our hospital, we clarified challenges facing our foot care team by interviews with other types of professionals, refined them into goals of individual sections and at different stages, and then substantiated and implemented tasks to cope with. In the process, it was important for workers of different professions and sections to work under mutual trust through communication—an element of collaboration among team members implementing IPW. I believe this will enable the performance of new teams and care by each section and at each stage to result in limb salvage, a major goal of IPW for foot care.

View full abstract

The artificial dermis is established therapy for more than 20 years. It’s suitable for use in full thickness skin defect wounds and formation of new dermis-like tissue. Operation at chronic wounds of the lower extremities is usually two-stage operation. Wounds exposed muscle, tendon and bone after first operation suit for using artificial dermis. Using negative pressure wound therapy and basic fibroblast growth factor with artificial dermis shape better dermis-like tissue. Artificial dermis will function as release and delivery system of factor in future.

View full abstract

We conducted a preliminary survey to establish nutritional therapy that contributes to the treatment/prevention of chronic limb wounds. The subjects were 14 males with lower limb ulcers (excluding venous ulcers) who underwent oral nutrition and two-stage closing procedure. In a retrospective study, we investigated factors influencing the treatment period. In the diabetes group, the mean treatment period was 90±30 (average ± SD) days, being significantly longer than in the diabetes-free group (43±17 days) (p<0.01). Regarding the patient group whose treatment period was longer than the median of the treatment days, the rate of serum albumin change/day from hospitalization until surgical closure was lower than that of the group with shorter treatment period (p<0.05). The results of this survey suggest that the rate of serum albumin change/day might be useful for predicting the risk of delayed wound healing. Furthermore, it is important to consider the influence of concomitant diseases when performing nutritional therapy or evaluating the treatment response.

View full abstract

The purpose of this study was to observe the gait characteristics of patients who have undergone minor amputations, and establish how safe it is for them to continue walking. In this study, we analyzed foot contact information that we collected from research conducted on 23 patients who had undergone minor amputations in the Wound Care Center of Oita-Oka Hospital. The patients were barefoot and walked with their natural gaits. In our results, we observed significant differences in gait distance and time factor between the non-amputated and amputated limbs. We also found, in our results on plantar pressure distribution, that the highest level of plantar pressure was on the forefoot of the non-amputated limb. Therefore, patients who have undergone minor amputations may be at risk from plantar pressure problems in the non-amputated limb, because the damage to their foot may cause their gait configuration to change, resulting in left-right asymmetry. Therefore, we conclude that it is important to pay careful attention to the non-amputated limb, in addition to the amputated limb, when providing rehabilitation and orthotic treatment, to protect the feet and the walking ability of patients who have undergone minor amputations.

View full abstract

Background: When the patient was forced to amputate their leg, the level of amputation is decided mainly by the surgeon’s leadership. However, the decision should be includes various considerable backgrounds of each patient. We created the decision supportive tool of the level of amputation for these patients who have several options of amputation level. Method: First, We conducted the selection of patients to apply the tool. We have shown the time-course to return to daily life after surgery in each amputation level, and picked up the factors influenced by the amputation level. The factors were “wound healing,” “rehabilitation,” and “Medical insurance system.” Then, we have created a supportive tool based on the Prior knowledge to offers information regarding these three factors for a better understanding of their postoperative life which is different from each amputation level. Future Issue: We have to evaluate the effectiveness of our tool.

View full abstract