Acute and chronic wounds are not determined by time alone. Acute wounds normally proceed through an ordered and timely reparative process, resulting in the sustained restoration of anatomic and functional integrity, while chronic wounds do not follow such a process. Orderliness is a sequence of biological events including the control of infection, resolution of inflammation, angiogenesis, regeneration of a functional connective tissue matrix, contraction, resurfacing differentiation, and remodeling. Chronic wounds comprise venous, diabetic, arterial, and pressure ulcers, and guidelines for the treatment and prevention of such chronic ulcers as well as the eleven impeding factors for the systemic and local treatment of acute wounds have been proposed. Thus, a clarified definition of either acute or chronic wounds has not yet been elucidated. The transition between acute and chronic wounds should also be investigated further.

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The multidisciplinary team approach to diabetic foot disorders and critical limb ischemia (CLI) has been demonstrated as the optimal method to achieve favorable rates of limb salvage. A team approach has played an integral role in preventing major limb amputation in our wound care center, which consists of a vascular surgeon, cardiologist, plastic surgeon, and orthopedic surgeon. Revascularization and debridement are key procedures for wound bed preparation that should be performed in a timely and ordered manner. Moist wound treatment is then useful for early healing. We used additive therapies, such as maggot debridement therapy (MDT), negative pressure wound treatment (NPWT), and platelet rich plasma (PRP). We treated 213 limbs in 195 cases of chronic wounds over a period of 4 and a half years. The rate of limb salvage in 52 limbs with diabetic foot ulcers or gangrene was 88.5%. Fifty-three revascularizations (23 intravascular interventions, 27 bypass surgeries, and 3 hybrid therapies) were performed in 113 limbs with CLI. The rate of limb salvage with CLI was 68.1%.

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The prevalence of diabetes mellitus and peripheral arterial disease (PDA) is likely to continue to rise rapidly and to a particularly serious level in Japan which is already a super-aged society. Severe diabetic foot ulcers and critical limb ischemia frequently do not respond well to appropriate intensive care, resulting in amputation of the lower extremities. Maggot therapy is suitable for therapeutic use in the debridement of chronic wounds using sterile larvae of flies. It is expected to be useful as an alternative to conventional therapy for wound healing. Outpatient clinics can play an important role in promoting recognition of the benefits and use of this treatment for non-healing ulcers in Japan.

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Infected peripheral ulcers represent the major reason for leg amputation. We formed a multidisciplinary team for patients who needed to undergo amputation that combined the use of conventional interventions and maggot debridement therapy (MDT). Various factors were reviewed to clarify the problem and ideal application as well as determine the importance of multidisciplinary / MDT treatment for limb salvage.
A questionnaire was provided to the nurse and patients. Seventy-eight patients underwent maggot debridement therapy (between Jan 2008 and November 2011). Prognoses including adverse events and conflicting clinical factors were analyzed by multiple regression analysis.
Answers provided on the questionnaire indicated the importance of a multidisciplinary team approach. Multiple regression analysis revealed that patients on hemodialysis and those complicated with antibiotic-resistant bacterial infections had worse outcomes. Thus, intractable ulcers with MDT are best treated by a multidisciplinary team of physicians and co-medical experts, resulting in a 93% clinical successful rate (against death and limb amputation).

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Although topical negative pressure wound therapy (V.A.C.^® therapy) is a very effective method for wound healing, it cannot be used for infected wounds and only a 4-week treatment period is covered by Japanese health insurance. We developed the so-called IW-CONPIT (Intra-Wound Continuous Negative Pressure and Irrigation Treatment; IW-CONPIT) method for wounds in 2004, which simultaneously implements topical negative pressure wound therapy and sustained irrigation. Regional perfusion treatment including IW-CONPIT is covered by national health insurance (J040-2) as an effective treatment for periostitis or osteomyelitis.
Four cases of infected chronic ulcers have been treated by the two sequential treatments, IW-CONPIT followed by V.A.C.^® therapy. This combination resolved the problems associated with V.A.C.^® therapy. This combined treatment method also represents a solution to profit-related problems in hospitals, such as health insurance claims or long-term hospitalization.

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Post-operative hypertrophic and atrophic scars are commonly seen as the side effects of continuous mode CO₂ laser therapy. Prolonged wound healing is known to cause hypertrophic scars and early reepithelialization with poor collagen synthesis in granulation tissue may result in atrophic operative scars. In this study, these scars were treated with a long-pulsed dye laser under consistent laser settings (Vbeam^®, Vbeam Perfecta^® : wavelength 595 nm, pulse duration 20-30 msec, fluence 6J / cm², cryogen spray duration 30-40 msec, and delay 20-30 msec). Treatments were repeated every 2-4 weeks until patient satisfaction was obtained. The results suggest that a long-pulsed dye laser is effective for flattening hypertrophic scars and reducing atrophic scars and can improve skin texture.

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Negative pressure wound therapy (NPWT) is effective for granulation tissue formation and accelerating wound healing. NPWT using the V.A.C. ATS system is covered by national health insurance for a period of four weeks. Thirty-seven patients with refractory ulceration including post-surgical wound dehiscence, diabetic ulcers, PAD, and venous leg ulceration were treated with the V.A.C. ATS system between December 2010 and April 2012. Thirty-two patients were included in the analysis. Complete wound healing was achieved in 25 patients (78 percent) within four weeks of VAC therapy. On the other hand, 7 patients (22 percent) needed to continue with NPWT after 4 weeks of VAC therapy because of insufficient wound healing, incomplete coverage of bone exposure, and pocket formation. Complete wound healing was observed at the end of VAC therapy in 5 patients after additional NPWT and surgical intervention. The average duration of additional NPWT was 43 days. No significant differences were observed in patient characteristics or laboratory data between these two groups. Although VAC therapy is widely used and an effective method for wound treatment, some patients need prolonged NPWT for more than four weeks. A suitable duration of NPWT may need to be elucidated to obtain effective wound healing course.

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