The vacuum-assisted closure therapy system (VAC) is a therapeutic device that enables safe and efficient clinical application of negative pressure wound therapy (NPWT) . Although the material characteristics of specialized VAC polyurethane foam (black foam) are extremely useful for facilitating the effects of NPWT, these characteristics also have disadvantages.
We present herein 15 cases of VAC application between April 2010 and March 2011. Black foam was shaped in a three-dimensional mold of the tissue deficit and placed in extensive contact with the wound surface. In patients with subcutaneous pockets, black foam application methods were classified into three types based on skin and soft tissue thickness and pocket length. In all 15 patients, proliferation of healthy granulation, reduction or disappearance of subcutaneous pockets, and wound shrinkage were observed at an early stage and complete recovery was achieved in all cases through minimally-invasive surgery and conservative therapy.
Molding that utilizes the material characteristics of the black foam and treatment of subcutaneous pockets are important for effective VAC-mediated NPWT, particularly for the elicitation of maximum mechanical wound deformation.

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The V.A.C. ATS system was listed in the National Health Insurance in Japan in 2010. In this system, direct application of foam to the periwound skin causes skin damage such as erosion, blisters and subcutaneous hemorrhage. The cost of wound-dressing materials used for the prevention of such damage is not covered by insurance. Here, we examine the efficacy of skin protection and compare the cost of wound-dressing materials (hydrocolloid dressing and silicone foam) , protective ointment and specific low-irritative surgical tape. In the V.A.C. ATS system, periwound skin was well protected with hydrocolloid dressing and surgical tape, whereas other materials showed poor efficacy. A comparison of hydrocolloid dressing and surgical tape revealed that the latter was less than 1/30 the cost of the former. In conclusion, low-irritative surgical tape is conducive for periwound skin protection with V.A.C. ATS therapy.

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Transmetatarsal amputation (TMA) is an effective procedure for treating forefoot infection, gangrene in the diabetic foot and / or peripheral arterial disease (PAD) , and for maximizing limb function. Nonetheless, complications after TMA are not uncommon. We propose a modified TMA, preserving the soft tissue around metatarsal bones in which arterial-arterial connections are located between the dorsal pedis artery and the lateral planter artery. This modified TMA would preserve blood flow of stumps after amputation, because the circulation of arterial-arterial connections is not damaged. The healing rate after modified TMA (95%) was higher than after conventional TMA (44 - 68.6%) , and the ratio of ambulatory patients was 86% , with walking ability maintained. We conclude that modified TMA is a useful procedure for CLI (critical limb ischemia) involving ulcer or gangrene in the forefoot.

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Toe amputation for chronic ulcers associated with osteomyelitis or malignant tumor requires additional metatarsal bone resection for covering the stump ; alternatively, the stump is kept raw and skin is grafted after the formation of granulation. The fillet toe flap is one of the options for primary coverage of the stump when the lesion is restricted to half the side of the toe and the digital artery is preserved after the lesion is resected. Minimization of the level of amputation is related to improvements in ADL after surgery. Moreover, because long rest causes disuse atrophy, early healing is desirable. Although the fillet toe flap is used only in special cases, it could be used as a sensory flap. We believe the use of the fillet toe flap deserves more widespread consideration in toe amputation.

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Patients with critical lower limb ischemia require major amputation, that is, amputation above the ankle, for several reasons such as life endangerment, major tissue necrosis, and excruciating pain. However, depending on the condition of the disease, even major amputation is not always safe. We examined five cases in which revascularization was performed for the purpose of major amputation. As a result, all the patients healed without re-amputation. There was one case of death during the four-year follow-up period. The prognosis of our patients was better than the prognosis of CLI amputee patients without revascularization.
Even in cases where it is determined that major amputation is required at the time of the first medical examination, circulation in the lower limb should still be evaluated. Our findings suggested that the potential benefits of revascularization as an alternative to major amputation should be considered.

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Infrared thermography is easily conducted, disclosing the skin surface temperature in color. In this study, we evaluated whether measuring the surface temperature of replanted fingers with a portable thermal imaging camera was useful for evaluating their blood circulation. We measured the surface temperatures of 16 replanted fingers after replantation surgery due to crush injury with a portable infrared camera, and compared the fingers with the surface temperatures of the adjacent intact fingers. Our findings showed that the mean temperature of the surviving fingers (32.7°C) was significantly higher than that of necrotic fingers (29.8°C) . Also, the mean temperature difference between the surviving replanted fingers and intact adjacent fingers (-1.7°C) was significantly smaller than that between necrotic fingers and intact adjacent fingers (-5.9°C) . Evaluation is complicated by the ambient environmental temperature and dressing type, which may influence the surface temperature of fingers. Therefore, it may be difficult to determine exact parametric values based only on the surface temperature of replanted fingers. However, the temperature difference between replanted fingers and intact adjacent fingers may provide for more meaningful evaluation than surface temperature measurement alone. In conclusion, our findings show that portable infrared thermography facilitates evaluation of the fate of replanted fingers.

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