Diabetic foot (DF) involves a neurogenic ulcer and wet necrosis. DF tends to be accompanied by infection. It is important to establish strict glycemic control and perform infection control by adequate administration of an appropriate antibiotic drug. We also evaluate the ischemic factor based on skin perfusion pressure (SPP) in all cases. When wound healing is delayed, and the pulse of the dorsalis pedis artery and posterior tibial artery can not be palpated, we perform an angiographic examination. In cases demonstrating deep infection, we open the wound and reduce the necrotic tissue in the wound as local treatment. When there are signs of vascular stenosis and obstruction, we perform thorough debridement after revascularization. As adjuvant therapy, we make full use of negative pressure wound therapy (NPWT) pre/postoperation for wound bed preparation. Furthermore, we promote hyperplasty of the granulation tissue using basic fibroblast growth factor (bFGF). In the case of suture, we reduce the number of dermostitches and subcutaneous sutures. A very thin split thickness skin graft technique is performed to cover the raw surface.
The treatment of DF is not merely confined to local treatment. We perform multidisciplinary treatment from a total viewpoint and careful treatment is necessary.

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Foot ulcer due to diabetes and/or peripheral arterial disease (PAD) frequently results in an intractable condition that is refractory to treatment. To manage such a condition, we developed a combination therapy consisting of conventional conservative therapy and surgery. This aggressive conservative treatment comprising aggressive debridement, trafermin (Fiblast Spray, Kaken, Japan) treatment and negative pressure wound therapy (NPWT) was adopted to treat 21 patients with diabetes and PAD-related refractory foot ulcer accompanied by bone exposure. Except for one patient who died during treatment, the remaining 18 patients obtained limb salvage. The mean time to cure was 5.7 months. This approach should be considered before proceeding amputation. Some patients may refuse amputation or cannot tolerate highly invasive surgical treatment including tissue transplantation. In such cases, this aggressive conservative therapy can be indicated as an excellent and repeatable technique requiring simple manipulation.

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Intra-Wound Continuous Negative Pressure and Irrigation Therapy (IW-CONPIT) is a technique we reported in 2007. This technique was applied to 18 cases of wound infection and diastases that occurred within one year after abdominal surgery. The therapy was performed after debridement of necrotic tissue and suture removal. Ten cases healed without any further surgical maneuver, while 8 cases required skin graft. In all cases, prompt healing was obtained, which confirmed the utility of this therapy.

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We report our experience between September 2006 and December 2007 using free fascia lata graft to treat three infectious cases after incisional hernia repair with artificial materials. Initially, we completely removed the artificial material and surrounding infectious scar. In selecting the surgical methods, we focused on the reliability of infection control and chose a simple technique. We performed split thickness skin graft in case that still had remaining peritoneum, and considered two-stage incisional hernia repair. Abdominal wall reconstruction was performed with free fascia lata graft in case of peritoneum defect. We achieved wound healing and complete infection control in all cases. All fascia lata grafts survived, but prolonged therapy was needed to control infection in one case in which there was not sufficient abdominal wall tissue to cover the fascia lata graft. This procedure is thought to be an effective treatment in the presence of covering tissue with good volume and sufficient blood flow. If such conditions are not present, we should consider the vascularized tissue transfer. In addition, we must further improve this surgical method in order to better maintain greater abdominal wall strength.

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To achieve greater convenience in supply, banking and utilization, a wound dressing containing lyophilized cultured keratinocytes and fibroblasts was designed. The present study evaluated the amounts of cytokines, bFGF and VEGF, released from the dressing materials.
Wound dressings containing the following were prepared: 1) keratinocytes alone; 2) fibroblasts alone; and 3) a combination of keratinocytes and fibroblasts. Each dressing was divided into the following two groups: the cryopreserved group and the lyophilized group. For one week, the materials were soaked in DMEM and the supernatant was collected for measurement of cytokines.
In the lyophilized fibroblast group, the amount of bFGF released was almost 100 times greater than that in the cryopreserved fibroblasts group. In the lyophilized co-culture group, the amount of bFGF released was significantly less than that in the cryopreserved co-culture group.
In the lyophilized fibroblast group, a significantly larger amount of VEGF was released than that in the cryopreserved group with fibroblasts alone. In contrast with bFGF release, significantly larger amounts of VEGF were released in the co-culture group than in the other group.
The present study demonstrated the ability of lyophilized cultured cells to release cytokines. In addition, an interaction between the keratinocytes and fibroblasts was suggested.

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