Vasculogenic therapy has developed into a useful approach to limb salvage in patients with critical limb ischemia. The transplantation of endothelial progenitor cells (EPC) is a promising method for promoting vascular regeneration. In this review, we focus on recent developments in EPC transplantation.

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Lower limb-conserving treatment has developed, and it is now possible to preserve not only large sections of the leg, but also gait functions. On the other hand, as favorable gait functions can help to prevent ulcers developing, footwear plays an indispensable role in the prevention of recurrent ulceration and high-level amputation. However, the majority of currently available medical footwear is not fit for Japanese lifestyles or treatment policies as it is influenced by Western orthoses. Under these circumstances, advances in such footwear are necessary. To promote its development by learning from the past, this paper examines the history of medical footwear.

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Diabetic foot ulcers are a common precursor of limb loss in patients with diabetes. The conventional treatment often involves prolonged periods of non-weight bearing, frequent ulcer debridement, advanced wound dressing, and repeated hospitalization. When ulcers are complicated by wound infection, peripheral vascular disease, osteomyelitis, gangrene, or septicemia, they can become life-threatening. Prophylactic diabetic foot surgery is the primary treatment of choice when conservative therapy has failed to prevent or heal an ulcer. Thus, prophylactic diabetic foot surgery should be performed once ulceration has stabilized and the patient has no significant arterial vascular disease. Careful patient selection together with a thorough evaluation of the pathology of the affected foot and the management of any comorbidities are the key to a successful outcome. Timely and aggressive surgical interventions aimed at healing the affected foot can prevent many months of unsuccessful conservative care. In this brief review, I discuss some of the indications for diabetic prophylactic foot surgery and the pathomechanical foot problems that can lead to ulcer formation.

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After arterial reconstruction and infection control, ulcer treatment and recurrence prevention are achieved via wound management and off-loading. While preventive footwear and foot care are important components of diabetic foot ulcer (DFU) treatment, these methods might not achieve sufficient recurrence control when DFU are complicated with foot deformities and/or diabetic neuropathy.Including the surgical correction of foot deformities in the treatments for diabetic foot lesions could help us understand the mechanisms responsible for foot ulcer development, and thereby, lead to more effective recurrence prevention. Prophylactic surgery can correct the alignment of the lower limbs and adjust foot deformities so that off-loading footwear can be worn in order to prevent DFU recurrence. Prophylactic surgery includes, for example, tendon transfer and lengthening, tendon rebalancing, removing prominent bone, osteotomy, and functional amputation. We consider that it is necessary to carefully consider the indications, efficacy, and disadvantages of such procedures, since they are performed not to treat ulcers, but rather to prevent them. To spread this concept of prophylactic surgery, a new multidisciplinary approach that involves a combination of orthopedic surgeons, plastic surgeons, physical therapists, and pedorthists should be considered.

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Although remarkable progress has recently been made in the field of limb salvage, recurrent cases are becoming a problem. In such cases, blood circulation and the function of the limb worsen. We treat such cases using a combination of rehabilitation, specialized equipment, and artificial limbs. In some cases, we are unable to prevent recurrence. Therefore, wound care doctors have begun performing surgical off-loading. Surgical off-loading is a technique that aims to maintain and improve the function of corrected foot deformities. There are no definitive guidelines in this field; therefore, we discuss planned surgical off-loading procedures with rehabilitation staff, prosthetists, and orthotists. This study focuses on cooperation with prosthetists and orthotists in cases in which patients undergo surgical off-loading.

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Diabetic foot wounds often recur in the short term. Abnormal foot sole pressure is one cause of such recurrence. Prophylactic surgery can be considered in cases in which foot wear has an adverse effect on diabetic foot wounds. As prophylactic surgery is a biomechanical approach, it requires a medical team that includes plastic surgeons, orthopedists, and physical therapists. In this article, I report who should perform evaluations and make decisions in such teams and discuss Achilles' tendon lengthening.

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Critical limb ischemia(CLI) represents the most serious type of peripheral arterial disease and is associated with a high risk of limb amputation and a poor prognosis. Recently, its prevalence has been rising rapidly because of aging populations and increases in the numbers of patients with diabetes and dialysis patients. CLI treatment requires a multidisciplinary approach involving revascularization and wound care. However, few institutes can provide multidisciplinary treatment at a single center because ordinary hospitals cannot assemble the required CLI experts. In 2008, we developed a regional cooperative CLI treatment team, which was named “J.WALK” and included institutions specializing in cardiology, vascular surgery, plastic surgery, and dialysis, etc. In 2013, we also created a regional foot care team for preventing CLI, which was named “JOYFUL” and included foot care nurses, home care nurses, and medical staff that worked at elderly care facilities or dialysis clinics. In this article, we report the current status of and problems associated with J.WALK and JOYFUL.

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Many diabetic patients with foot ulcers tend to exhibit restricted dorsiflexion in the ankle joint, which can arise for a variety of reasons. Diabetic patients with nerve disorders are at particular risk of recurrent ulceration of the forefoot, even if appropriate insoles or molded shoes are created, and the patient is non-weight-bearing. We performed transcutaneous Achilles tendon lengthening in 4 limbs belonging to 4 individuals. By improving the movement restrictions seen during dorsiflexion of the ankle joint, we were able to control recurrent ulceration in the forefoot. The present report documents our experiences with these cases. Aimlessly continuing conservative treatment for recurrent ulceration can ultimately lead to the exacerbation of the ulceration or infection, and thus, represents a major risk factor, as it can lead to long-term hospitalization or even amputation in some cases. In order to enable diabetic patients to live actively without ulceration for as long as possible, further aggressive preventative therapy must also be considered. Transcutaneous Achilles tendon lengthening is a typical “surgical off-loading” procedure that ameliorates range of motion restrictions in the ankle joint, and thus, represents a highly effective procedure that can help to prevent the onset and recurrence of forefoot ulceration. However, special consideration is required regarding the potential complications of and patient eligibility for this procedure.

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We have experienced 3 cases of blood disorder-related acute limb ischemia. In cases 1 and 2, the patients were diagnosed with idiopathic thrombocytopenic purpura. After a thrombopoietin receptor agonist was administered, acute limb ischemia occurred. In both cases, the patients’ platelet counts were within normal limits. Thus, it is suggested that multiple factors including the administration of thrombopoietin receptor agonists can induce thrombosis. In case 3, acute limb ischemia occurred in a patient with myeloproliferative disease. Although revascularization alone was not effective, combination treatment with phlebotomy and hydroxyurea decreased the patient’s blood viscosity and improved their condition.

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