Going to provide safe and effective orthotics (foot, shoes and ankle foot orthotic devices) to the patients, it is important to know the examination information with prescription. The examination need not only neuropathic and broad flow condition. It should be include foot deformity, surgery history and functional evaluation (biomechanical information such as alignment, range of motion and quality of motion, etc.). When the patient wear these footwear with the good result, it is also important to provide with the wearing method and preventing type of education. Also, this treatment will get a better result when combined with a good, foot care, rehabilitation and management program. This is a second volume of “General Orthotic Care of the Diabetic Foot”.

View full abstract

Infectious disease is the second leading cause of death among dialysis patients, and the standardized mortality ratio for all infectious diseases was 7.5 (95% confidence interval, 7.3–7.6) in dialysis patients with respect to the general population in Japan. The incidence of sepsis is higher in dialysis patients than that in general population and chronic foot infections can induce sepsis. The control of infection is very important to treat foot ulcers. Bacterial cultures for wound and blood sample must be done before starting antibiotics and we must create the local database about the kinds of bacteria and the sensitivity for antibiotics. It is very important to start the empiric wide-spectrum antibiotics treatment as soon as possible before the detection of bacteria inducing foot infections. We must use an enough amount of antibiotics at beginning the treatment even in dialysis patients. Gram-positive bacteria, especially Methicilin-resistance Staphylococcus aureus and Coagulase-negative staphylococci, for example, Staphylococcus epidermidis are frequently detected. Furthermore, Gram-negative bacteria, such as Pseudomonas aerginosa is often detected in dialysis patients. Nutritional assessment must be done in dialysis patients with chronic foot infection.

View full abstract

The treatment of chronic infected wounds with medicinal fry larvae (maggot therapy) is often used when conventional medical and surgical treatments fail to heal the chronic wounds. Maggot therapy is effective for debriding for necrotic tissue and for antibiotic-resistant infected wounds. Maggot excretions and secretions contain molecules which not only kill bacteria directly, but also dissolve bacterial biofilm and inhibit formation of biofilm.

View full abstract

Diabetic foot osteomyelitis dramatically increases the risk of lower extremity amputation. The number of diabetic foot ulcer is increasing rapidly in Japan. For salvaging foot, early diagnosis and appropriate treatment of osteomyelitis is indispensable. This chapter shows current guidelines for diabetic foot osteomyelitis and our study as for efficacy of Magnetic Resonance Imaging (MRI) in diagnosing diabetic foot osteomyelitis.

View full abstract

Foot infection is a leading cause of amputations in diabetic patients. An infected foot would precede about 60% of lower extremity amputations. With an increasing infection severity, there is a significant trend toward an increased risk for amputation. Identification of critical colonization is essential in order to prevent infection. However, its diagnosis is challenging unless we bear in mind the possibility and the optimal method to diagnose critical colonization is not well established. Maintenance debridement and topical application of antibiotic dressings are effective treatment for critically colonized wound. It is recommended that all patients with a severe infection and patients with a moderate infection with critical limb ischemia be hospitalized initially. Clinicians should consider urgent surgical intervention for patients presenting with clinical evidence of life or limb threatening infection. A surgeon should also evaluate any patient who has evidence of a deep-space infection or abscess. Prompt surgical debridement and antibiotic therapy are indispensable to decrease the likelihood of major amputation.

View full abstract

In the management of chronic wound infection topical antimicrobial therapy is required to reduce wound bacterial load. Topical agents containing silver or iodine are useful because they have a broad spectrum of antibacterial activity and the development of bacterial resistance is unusual. The use of topical antibiotic ointment is not generally recommended to minimize the risk of the induction of resistance. It is also important to understand ointment bases to select appropriate topical agents matching the wound conditions.

View full abstract

For topical management to skin ulcers, dressings are useful materials. There are some types of dressings, hydro-fiber, polyurethane form and hydrocolloid dressings. We should choice the proper dressings aiming at exudate fluid quantity. Some dressings include silver for reducing local infection. On the other hand, foot ulcers are caused by various backgrounds. Ischemic ulcers are contraindication for dressings because these wounds never work healing process. Keeping the moist conditions, dressings facilitate the wound bed preparation to the “curable” ulcers. Conversely, the indication of dressings is limited for “incurable” wounds. We should consider the suitable indication of dressings to refractory foot ulcers.

View full abstract

Objectives: It is clear that abnormality of foot pressure of diabetes foot is related to limited ankle dorsiflexion (LA) and claw toe (CT). However it is not clear how the abnormality is influenced by these two factors. We investigated the effects of LA and CT on foot pressure during gait. Method: The subjects were 55 feet (F) of 55 type2 diabetic patients. We divided into 3 groups: group N (without LA/CT, 27 patients/F), group L (with LA without CT, 23 patients/F), group LC (with LA/CT, 5 patients/F). We made a comparison of these 3 groups about foot pressure during gait. Result: Compared with group N, maximal foot pressure of group LC and maximal forefoot pressure of group L were higher. Foot pressure during gait had a correlation with LA and limited 1st MTP joint extension. Conclusion: This study suggested the following two things. LA mainly lead to abnormality of foot pressure. The combination of CT and LA lead to foot pressure ascent.

View full abstract

We report herein 7 cases of intraosseous epidermoid cyst of the distal phalanx of the toe. All patients are over 70 years old and 6 of them undergo hemodialysis. Two patients have diabetes mellitus and no patient has apparent findings of critical limb ischemia. All patients were treated conservatively and healed except for 2 dead patients. However 2 patients had recurrence 1 to 2 years later. Clinical course suggests that compression by epidermoid cyst causes osteolysis and foreign body reaction to the contents of the cyst causes inflammation. Very few of similar cases arising in the toe are reported. It is speculated that some cases are diagnosed as osteomyelitis and undergo surgical procedures without close examination. Although differentiation from osteomyelitis is challenging, conservative therapy could be an option in cases that elimination of cyst wall is confirmed.

View full abstract

Early recognition of necrotizing fasciitis, a rare infection of the deeper layer of the subcutaneous tissues, is very crucial, and the most effective treatment for this infection is surgical debridement. On the other hand, cellulitis, a diffuse inflammation of the connective tissue, is usually treated with antibiotics. We analyzed nine patients with necrotizing fasciitis in the lower extremities who were treated between October 2011 and June 2013. The mean age of all patients was 69.2 years (range 37–86 years). Four patients were associated with diabetes mellitus. Only three patients had a diagnosis of necrotizing fasciitis at the time of admission. For eight patients, surgical debridement was performed. As a result, we had a mortality rate of 33.3%.

View full abstract