The discovery and commercial production of insulin in the early 1920s were seminal developments in the treatment of diabetes that allowed people affected by this disease to live an almost normal life. Although insulin commuted the death sentence attributed to diabetes, it was soon recognized that it was not a cure. As people affected by this disease lived longer, they began to experience serious complications including blindness, kidney failure, heart disease, stroke and amputations. In 1934, the American diabetes specialist Elliott P. Joslin remarked that following the introduction of insulin, mortality from diabetic coma had fallen significantly from 60% to 5%. Yet, deaths from diabetic gangrene had risen significantly. Joslin alleged that the reason for this complication was that physicians were not aggressive enough in their treatment of diabetes. He firmly believed that gangrene and amputations were preventable. He noted that there was almost always a history of injury to the foot that preceded the development of gangrene and led to amputation. He observed that burns and shoes were responsible for the most common injuries. Joslin's remedy was a team approach to diabetes care that emphasized patient education in foot care, dietary therapy, exercise, prompt treatment of foot infections and specialized surgical care.

Joslin stressed the importance of cleanliness, daily foot inspection for early signs of trouble and preventive foot care. These recommendations are just as relevant today and are the foundation of diabetes foot care and self-management education.

Surgical management of the diabetic foot plays an integral role in the prevention and management of limb-threatening complications for people with diabetes. The objective of this chapter is to provide clinicians with a comprehensive and practical discussion of surgical management, as part of a team approach to care for patients with diabetes. It should be understood at the outset that early intervention provides the best chance of surgical cure and limb salvage. The goal is to preserve a functional plantigrade foot, and to prevent major amputation. In the words of the Roman poet Ovid, 'Stop it at the start: it's late for medicine to be prepared when disease has grown strong through long delays' (Ovid, 43BCE-18CE, Remedia Amoris, line 91).

For the purpose of this discussion, surgery of the diabetic foot will be stratified into three broad categories including:

• Elective surgical procedures

• Prophylactic surgical procedures

• Emergent (emergency) surgical procedures.

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