A new research field, nursing science and engineering, is emerging. Nursing science and engineering is a field of basic science and engineering that aims to produce new technologies and research based on the experiences of nurses, who are in direct and close daily contact with patients for long periods of time. In particular, it aims to contribute to care provision and support recuperation and rehabilitation. Nursing, which emphasizes a holistic whole-person way of thinking that focuses on clinical support, plays a central role in the paradigm shift from cure to care. We consider that the advance of nursing engineering through the cooperation will become key to improving the results of research in this field; i.e., it will facilitate the development of products and services and their penetration into society. Taking some examples from research into preventive care for diabetic foot ulcers, such as the objective measurement and visualization of plantar surface load during walking and the classification of blood flow patterns based on the plantar surface temperature distribution using artificial intelligence and automation, we provide an overview of how nursing engineering can contribute to limb salvage and podiatric medicine.

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Lymphedema is caused by the accumulation of fluid and other substances（e.g., proteins）in tissue spaces due to an imbalance between interstitial fluid production and transport（Best Practice for the Management of Lymphedema）. In Japan, cancer-induced secondary lymphedema is the most common form of the condition. Regarding lower limb lymphedema（LLL）, it predominantly affects females and is caused by various diseases including uterine and ovarian cancer. Cellulitis, which involves the acute spreading of inflammation of the skin and soft tissues, can worsen LLL. Some patients with cellulitis have to be hospitalized due the systemic symptoms of the condition, and cellulitis recurs in some cases. Many previous studies have described the risk factors for cellulitis, but identifying risk factors for cellulitis in individual patients with LLL is difficult. Systematic reviews have shown that antibiotic treatment and surgical interventions reduce the frequency of cellulitis. In contrast, few studies have examined the effects of skin care on the frequency of cellulitis. In future, evidence-based skin care regimens should be established.

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It is important to determine the circulatory condition of the lower limbs when treating foot necrosis or ulcers caused by diabetes or peripheral arterial disease. Among the various methods used to estimate lower limb blood flow, vascular ultrasonography is capable of evaluating stenosis and obstruction in a minimally invasive manner. Although there are some problems with this technique, e.g., the results of such evaluations can vary depending on the experience and skill of the examiner, and screening of the bilateral lower limbs takes time, it has been introduced in many institutions because it is less stressful for patients compared with the other invasive procedures used to visualize the microcirculation and is very useful for evaluating blood flow in patients with lower limb ulcers. Furthermore, ultrasonography provides both morphological and functional hemodynamic information about the vasculature in real time. This article describes the efficacy of ultrasonography for estimating lower limb circulation and the techniques used to perform such examinations.

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Early assessment of nonulcerative pathology and proper care are important for the prevention of diabetic foot ulcer. This article focused on tinea, a nonulcerative pathology. Infection and deterioration prevention by early detection are essential for the care of tinea. First, we examined effective foot washing methods for removing dermatophytes attached to the feet and then the usefulness of sheets for foot care. The results showed that daily foot washing, washing between each toe 4 or 5 times with soap, appropriate advice on posture when patients have difficulty reaching their feet with their hands, and using sheets for foot care when patients have difficulty physically washing their feet can be effective for tinea prevention. For early detection, the possibility of tinea should be considered when scales appear on the foot, nail has discoloration, or the skin temperature of the toe whose nail has subungual hyperkeratosis is <33.0℃. Therefore, assessment of patients’ self-care ability or tinea and providing the appropriate care described herein are important for the prevention of diabetic foot ulcer.

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Healthcare providers that treat limb and foot diseases require substantial knowledge about the differential diagnosis of skin ulcers on the limbs and feet. Skin ulcers can be caused by several cutaneous disorders, which are broadly classified into 7 groups, vascular diseases, autoimmune diseases, infectious diseases, skin tumors, skin disorders induced by physical stress, drug-induced skin reactions, and others. At present, these conditions are mainly treated by dermatologists. The purpose of this chapter is to promote understanding about skin diseases and to describe how such knowledge should be utilized to aid differential diagnosis in clinical practice. Representative diseases of each group are described in detail, and their cutaneous manifestations and how they can be discriminated from other conditions are outlined.

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We have been developing new systems for measuring the forces generated on the plantar surface of the foot in order to help prevent diabetic foot ulcers. The systems include 1）a measurement system consisting of a plantar pressure distribution sensor and a motion sensor, which can measure leg and foot motion; 2）a shear force measurement system involving a sheet-type shear force sensor; and 3）a measurement system that can evaluate both pressure and shear stress at small sites on the plantar surface of the foot during walking using a 3-axis force sensor. These systems enable shear force measurements to be acquired during walking, which is currently considered to be difficult due to sensor limitations. Using our system, we obtained some information about callus formation in people with diabetes. We are currently expanding the system to produce a new education system, which is able to present the obtained measurements to patients in a visual form.

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In treatment for lower limbs with diabetic deformity, disorders, or severe ischemia, it is necessary not only to protect the feet, but also to preserve the ability to walk. However, an increased level of activity after restoring walking ability occasionally leads to injury again. In addition to the progression of diabetic neuropathy, changes in gait dynamics due to alterations in foot morphology after wound care, resulting in excessive variations in plantar loading on the feet, may also be associated with such injury. In short, poor load control may be problematic. Thus, the use of appropriate footwear may be effective. It is desirable to select, prescribe, and use the most appropriate type of footwear, which meets the purposes, after clarifying the morphological conditions of each foot with deformity, its remaining ability, and alignment when walking in consideration of the mechanisms of the foot. As the foot condition time-dependently changes, footwear should be reselected based on the results of various assessments to clarify the situation.

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This study aimed to assess the changes in blood pressure（BP）pulse waves（PW）associated with the wearing of compression stockings（CS）and the factors that influence such changes. The study subjects consisted of 40 legs from 20 healthy adults with baseline ankle-brachial pressure indices（ABI）of 1.0≤ABI≤1.4. The subjects took bed rest for at least five minutes before and after wearing open-toed, knee-high stockings（induced pressure increase: 15-20 mmHg）so that their BPPW could be measured appropriately. It has been found that physique-related factors influence the changes in the BP indices of the lower extremities. Furthermore, the factors that influence changes in PW include age and sex. As for the changes in the examined parameters detected after the subjects put on the stockings, the mean observed differences were as follows: the ankle systolic blood pressure（SBP）fell by 8 mmHg（95％ confidence interval［CI］: 6-10 mmHg; p<0.001）, the ABI decreased by 0.07（95％CI: 0.05-0.08; p<0.01）, and the upstroke time increased by 16 ms（95％CI: 14-19; p<0.001）. No significant changes were observed in the first toe SBP, ％mean arterial pressure, or brachial SBP. Thus, the compressive pressure exerted on the ankles by the CS only caused a marginal reduction in the subjects’ ankle SBP. This study suggests that ankle SBP is likely to be lower in smaller and thinner individuals with smaller ankle circumferences.

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Calluses and corns occur in daily life due to weakened toe flexor, abductor, and interosseous muscles of the foot. Unhealthy lifestyles may lead to their ulceration and delays in their healing. This paper reports a patient with refractory ulcer in a region of the left ankle, displaced from the site of normal foot loading. Lifestyle intervention focusing on the patient’s daily activities during hospitalization successfully promoted the healing process.

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A 60-year-old male patient presented with occlusion of his right superficial artery and stenosis of his right common femoral artery combined with severe calcification. In March 2013, he underwent common femoral endarterectomy and a femoropopliteal bypass（F-P bypass）with a prosthetic graft. In May, he was hospitalized to undergo treatment for critical limb ischemia of his bilateral lower limbs. Numerous revascularization procedures were performed, but his symptoms did not improve. He underwent bilateral below-the-knee amputation for limb salvage in July. His wound healed, and his ability to perform daily activities steadily improved with rehabilitation. However, in January 2014, he felt pain and a cold sensation below his right knee. Ultrasonography demonstrated that his F-P bypass graft was occluded. He was diagnosed with acute limb ischemia. We performed endovascular therapy（EVT）and thrombolytic therapy, but it was not effective. The next day, we carried out profundoplasty and Fogarty embolectomy. Although the patient’s symptoms improved temporarily, re-occlusion of the bypass graft occurred on the day after the operation. Finally, we revascularized the deep femoral artery via EVT to avoid hip disarticulation. After the EVT, the patient underwent an above-the-knee amputation. The necrosis did not progress. The patient was discharged to his home with the help of a walker.

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Introduction: Functional salvage is the most important aspect of limb salvage. Deformities caused by forefoot amputations can result in foot inversion for several years and promote wound formation. Therefore, they are usually treated with surgical off-loading. Here, we report the use of triple arthrodesis to correct an inverted foot deformity after a Lisfranc amputation. Methods: Surgical off-loading is an established method for correcting foot deformities and treating and preventing wounds. Our patient was a 48-year-old female who developed a lateral malleolar injury due to an inversion deformity after a Lisfranc amputation. The injury was unresponsive to conservative therapy; therefore, we performed triple arthrodesis to treat the wound. Results: The patient was fitted with a new orthosis and was able to walk and had not developed any wounds at one postoperative year. Conclusion: Triple arthrodesis is a useful option for surgical off-loading aimed at correcting foot deformities or treating/preventing wounds.

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