Foot complications are one of the most serious and costly complications of diabetes. 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 curable. This perspective should motivate those fighting to make a difference for people living with diabetes around the world.

Death around the time of the amputation occurs in up to 10% of cases. Death rates increase over the 5 years following amputation: About 30% of patients die within 1 year, 50% die within 3 years, and 70% die within 5 years. In developing countries, these figures tend to be even higher because many people seek medical attention only when their foot problem is so far advanced that their limbs and their lives are threatened.

The lives of people after an amputation are profoundly affected. Many are unable to work become dependent upon others, and cannot pursue an active social life. Studies examining the quality of life of people with diabetic foot ulcers have also shown decreased physical, emotional, and social function. Recovery from foot ulcers may require several months of treatment and rehabilitation. Depression is common. Many live with the fear of recurrent ulcers, repeated bouts of infection, and potential life-long disability.

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.

The concept of CURE = REMISSION and 5-YEAR ULCER-FREE SURVIVAL needs to be brought in medical and nursing education and patient education.

Cadre of paramedics is needed for diabetic foot care at primary care level. India is woefully short of literature for primary physicians and nurses on diabetic foot education.

Dr Goyal has done admirable and stellar work to fill this void. Even a simple glance through this book “Case Studies in Diabetic Foot” reveals his deep understanding and passion for diabetic foot management. This book will serve as a landmark in diabetic foot education.

Many of these unfortunate consequences can be avoided or prevented by standard foot care and this is a challenging field of medicine where strong motivation and enthusiasm, relentless effort, sincere involvement with the patients, and concerted team approach are 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 a long period, he is working and developing diabetic foot clinic at ILS Hospitals, Salt Lake, Kolkata, and SVS Marwari Hospital, Kolkata, West Bengal, India.

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 this book on Diabetic Foot.

It is simple, useful, practical and will be extremely useful for the doctors and other caregivers of diabetes.

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

I am hopeful that by sharing the case studies with my fellow colleagues with a keen interest in the care of Diabetic Foot, will help us all in saving many more limbs.

In the first edition, I had described cases that I had come across in my clinical practice of diabetic foot of 15 years starting from Bansal Medical Services in Howrah, West Bengal, India in 2000, which was the first Diabetic Foot Clinic of Eastern India and then continued at SK Diabetes Research and Education Centre/SVS Diabetes Clinic at SVS Marwari Hospital and ILS Hospitals, Kolkata, West Bengal, India.

I still continue to practice Diabetic Foot, with the same passion, at ILS Hospitals, Salt Lake, Kolkata and SVS Marwari Hospital, Kolkata. In the intervening period, since the first edition of the book, many new developments have happened in both the diagnostic and treatment modalities for diabetic foot. I have incorporated only some of them in this edition, which are practical and available and can be put to practice in our Indian scenario. I have kept some of the cases from the first edition and added more new cases. In recent years I have also come across some Diabetic Hand cases and have added a section on this. In recent years I have also observed that Neuroischemic cases are increasing in clinical practice.

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 help them 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 constrains 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 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 (Professor) Debasish Maji, Past 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. I am also grateful to my footcare team who plays an important role in the management of patients and counseling family members.

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

I am also thankful to the surgical team at ILS Hospitals, Salt Lake, Kolkata, West Bengal.

I thank the executive committee of IDEA for giving me moral support and guidance.

I am grateful to Dr (Professor) Samar Banerjee, Past 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 Sabyasachi Hazra (Commissioning Editor) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for publishing this book.

Last but not the least to my mother, to my beloved wife Kusum, my son Nishant and daughter-in-law Priyanka, daughter Nandita and 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 >25 times greater than that in people without diabetes. In India >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 healthcare 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 remain 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. 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 our experience of thousands of patients we have observed that most of them (around 85%) are neuropathic in nature. In recent years, we 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 aspects. By giving proper offloading using the simplest offloading method based on Samadhan system/SK offloading successfully heal ulcers which we have used in a number of cases described in this book.

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 every healthcare professional. 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 prevents a small wound to progress. We have also seen some cases, described in this book, in which due to delayed referral and sometimes due to negligence/unawareness on part of patient and family members due to lack of education we were 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 six 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 (UT) classification system and PEDIS system. The limitation to Wagner's classification is that there is no mention of vascular status of feet.

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

We have added a section on ‘Diabetic Hand Wounds’. Since the publication of our previous edition of this book, we have seen a number of patients presenting with Diabetic Hand Wounds.

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.