However, through a care strategy that combines prevention, the multidisciplinary treatment of foot ulcers, appropriate organization, close monitoring, and the education of people with diabetes and healthcare professionals, it is possible to reduce amputation rates by 49–85%. Most of the foot ulcers in Asia are of neuropathic origin. Such neuropathic ulcers are usually possible to heal. This perspective should motivate those fighting to make a difference for people living with diabetes around the world.

Diabetic foot complications result in huge costs for both society and people living with diabetes. Foot problems use 12–15% of the healthcare resources for diabetes. In developing countries, the latter figure may be as high as 40%. In some developing countries, foot problems may account for up to 40% of available resources. In India every hospitalization for foot ulcer infection costs 50,000/-. However, reliable and population-based studies are not available in India especially for operated patients.

India is likely to face enormous public health and economic problems if the strategies to educate lay people about foot care and train the paramedics and primary level physicians in essentials of diabetic foot care and primary prevention techniques are not installed speedily. At present there have been sporadic attempts at some NGOs and state level to achieve this objective. However, no national comprehensive plan exists. Medical, nursing and paramedical curriculum have very scanty input about management of diabetic foot ulcers. There is great paucity of books which can educate, train and equip family and primary physicians to prevent and treat effectively diabetic foot ulcers. Such practical help is important when we are faced with millions of patients. In fact we are facing tsunami of diabetic foot patients in our country. It is necessary that urgent action-oriented plans with time bound objectives are put in place to avoid possible health-related and economic disaster.

Dr Goyal's book Case Studies in Diabetic Foot is a step in direction to bridge this gap. Practical aspects enumerated in this book will help physicians treating diabetes patients to effectively prevent the ulcers as well as treat the ulcers optimally. This book will definitely help in preventing higher level amputation in many patients.

Diabetic foot is one of those complications where patients lead a life with morbidities, unless proper foot care and treatment is given. Some of them will need amputation of parts of foot or leg which is the unfortunate thing a physician likes for his patients. Many of these unfortunate consequences can be avoided or prevented and this is a challenging field of medicine where strong motivation and enthusiasm, relentless effort, sincere involvement with the patients and concerted team approach is essential. Many physicians dealing with diabetics know this, but cannot afford to organize a good foot-care service. Dr Ghanshyam Goyal has done it. For more than a decade, he is working and developing diabetic foot clinic in these twin cities of Howrah and Kolkata. He has developed unique skill and organized a team approach in Eastern India to deal with this menace of diabetic foot. Hundreds and thousands of patients with diabetic foot problems have benefitted from his center.

From his practical experience he has written the book Case Studies in Diabetic Foot. So, it is simple, practical and will be extremely useful for the doctors and other caregivers of diabetes.

I hope readers will get lot of help and encouragement after reading this book.

I believe that going through these case studies will help the healthcare providers in better understanding of the complex nature of diabetic foot and help them in their day-to-day practice. They will also understand that how difficult it is to manage a diabetic foot in a practical way with many barriers in the way and particularly financial barriers which constraints us from not only using the best treatment options available but sometimes even the basic treatment is unaffordable.

The case studies described in this book will make it clear in the mind of the treating clinician that treating a diabetic foot is at times simple and at times difficult task with each patient having comorbidities to be taken care of managing diabetic foot is a teamwork which involves a diabetologist, general surgeon, plastic surgeon, a vascular surgeon, interventional radiologist, orthopedic surgeon, physician, podiatrist, orthotist, nursing staff and diabetic educators all play a crucial role in the successful management of diabetic foot.

This book is aimed at all healthcare professionals who are interested in diabetic foot care.

I am grateful to Dr Arun Bal, Founder President, Diabetic Foot Society of India (DFSI), and Dr (Prof) Debasish Maji, President, Integrated Diabetes and Endocrine Academy (IDEA), who have kindly agreed to go through the book and write the forewords.

I am also grateful to my colleagues Dr SP Banka and Dr KS Chhajer for helping me in the surgical aspects. Dr (Prof) PS Chattopadhyay, Dr Koushik Chaki, Dr Binod Moore and to support team members of diabetic foot clinic Miss Suvra Basak, Mr Dilip Ram, Mrs Saheli Mitra.

I am grateful to Mr Surendra Bansal and Dr ML Bhansali with whom I started the 1st Diabetic Foot Clinic of Eastern India.

I am also thankful to Dr Sunil Lhila, Dr J Naik, Dr Amitava Chakraborty for vascular interventions in my cases.

I am thankful to Dr Om Tantia for giving me inspiration and insights.

I am grateful to the executive committee of Diabetic Foot Society of India.

I want to thank my colleagues Dr Debjit Ghosh, Dr Pinaki De, Dr AK Ojha, and Dr AK Jain for their support.

I thank the executive committee of IDEA under the leadership of Dr (Prof) Debasish Maji for giving me moral support and guidance.

I am grateful to Dr (Prof) Samar Banerjee, President of Research Society for the Study of Diabetes in India (RSSDI) for his inspirations and guidance.

I am also grateful to SVS Marwari Hospital for giving me the opportunity to admit and treat some of these cases at very low cost and also to ILS Hospitals.

I am grateful to the industry for giving me the opportunity to the use of advance modalities.

I am grateful to the whole medical fraternity of Eastern India for having faith in me and referring their foot patients to Diabetic Foot Clinic.

I am grateful to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President) and Mr Tarun Duneja (Director–Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for publishing this book.

Last but not the least to my parents, to my beloved wife Kusum, my son Nishant, daughter Nandita, son-in-law Ankush and all my friends for their patience and tolerance.

The diabetic foot is a major medical, social and economic problem not only in developing countries like India but also in developed countries. Even in most developed countries, the annual incidence of foot ulceration amongst people with diabetes is about 2%.

People with diabetes may develop a number of foot problems as a result of damage to nerves and blood vessels. These problems can easily lead to infection and ulceration, which increases a person's risk of amputation. People with diabetes face a risk of amputation that may be more than 25 times greater than that in people without diabetes. In India more than 1,00,000 amputations occur every year (a grossly underestimated figure because in India there is no amputation registry) and most of them are neuropathic and infective of which around 75–80% are preventable with early intervention. Even when a person undergoes amputation, the remaining leg and the person's life can be saved by good follow-up care from a multidisciplinary foot care team. People with diabetes must examine their feet regularly.

This disabling complication of the disease is draining the health care resources of both developed and developing countries. In diabetic patients, diabetic foot problems are the most common cause of hospital admissions.

In our country, poverty, lack of sanitation, hygiene and barefoot walking are the major causes leading to diabetic foot.

Every patient of diabetic foot is unique and complex, and hence, there are lessons to be learnt from each patient.

Basic foot care and education play the most important role in avoiding the development of foot complications but in patients who develop diabetic foot complications sometimes the use of advanced modalities becomes essential in successful management which will be evident from some of the cases presented in this book.

In my experience of thousands of patients I have observed that most of them (around 85%) are neuropathic in nature. In recent years, I have seen a paradigm shift with increasing number of ischemic/neuroischemic cases.

The three basic principles in the management of diabetic foot are adequate debridement with infection management, adequate vascularity and adequate offloading. Of these offloading is one of the most important and unfortunately overlooked aspect. By giving proper offloading using the simplest offloading method based on Samadhan system/SK offloading successfully heal ulcers which I have used in a number of cases described in this book. Two methods of offloading are described below.

Availability of diabetic footwear is a problem in our country. I have observed that only 5–10% of diabetic foot patients require customized footwear and the rest can be managed with standard diabetic footwear.

Basic foot care education needs to be imparted to even healthcare professionals who often delay in referring a diabetic foot patient. It is very important to educate all diabetic patients and family members or caregivers on the need for daily foot inspection. In some of the cases described in this book it was this education which prompted the patient/family members or caregivers to report early and prevent a small wound to progress and I have also seen some cases described in this book in which due to delayed referral and sometimes due to negligence on part of patient and family members due to lack of education I was unable to salvage a digit and sometimes even a limb.

Basically, diabetic foot is classified on the basis of etiology into neuropathic and neuroischemic foot (a) with infection, (b) without infection and then, according to natural history, the foot is staged in 6 stages according to ME Edmonds and AV Foster.

Various systems have been proposed to classify the diabetic foot ulcers of which the most popular are Meggitt-Wagner system (which has been used by me in the entire book). The other popular systems are University of Texas or UT classification system and PEDIS system. The limitation to Wagner's classification is that there is no mention of vascular status of feet.

In my case series I have selected cases where simple, cost-effective and easy to apply modalities have been used and simultaneously in cases where aggressive multidisciplinary approach and advanced modalities were used to prevent amputations.

Involvement of patient, patient's family members and multidisciplinary team is mandatory for prevention of amputation and successful outcomes.

The diagnostic and treatment modalities have been described in brief in separate pages in this book at the beginning of the case studies for better understanding of the same.