The singular event in ?1 human evolution that first separated us from our simian ancestors was long held to be brain enlargement, but the tipping point was a more pedestrian development. Relatives of Lucy (Australopithecus afarensis) walked in the volcanic ash of Laetoli, Tanzania, 3.6 million years ago. Analysis of their fossil footprints strongly suggests these still partly-arboreal ancestors walked likemodern humans, fully erect with extended limbs, rather than with the less efficient apelike, bent-knee, bent-hip gait. By 2 million years ago, genus Homo had abandoned arboreal life altogether; freeing of the hands associated with permanent adoption of bipedalism thus preceded, and likely drove, brain enlargement. As Darwin suggested, bipedal walking is the defining feature of our human lineage. The 21st century is witnessing a worldwide epidemic of diabetes, which is accompanied by one of its most feared sequela: limb amputation. Limb loss often reduces quality of life, functional status, and independence. Amputation may thus steal a defining characteristic of one’s humanity— bipedalism. Lower-extremity complications remain among the most common reasons for hospitalization in diabetic patients. During their lifetime, approximately one in four people with diabetes will develop a foot ulcer, the precursor of amputation. It is sobering to consider that one diabetes-related amputation is performed every 30 seconds around the world, a figure that exceeds all other causes of limb loss, including those from landmines. Diabetic wounds are caused largely by neuropathy and repetitive trauma from everyday activity. These wounds, when infected, all too frequently result in amputation. Concomitant vascular disease further complicates matters. A graphic plot of noninvasive vascular studies used to predict wound healing generally assumes a sigmoid-curve. This curve follows a rather steep incline centrally, with flat plains of nonhealing at the bottom left (low flow/pressure) and likely healing at the top right (normal flow/pressure). Revascularization may ‘‘push’’ ischemic wounds up this incline, expediting healing. Conversely, with protection (by surgical and nonsurgical off-loading) and debridement, neuropathic wounds in the absence of ischemia predictably heal. Unmonitored, these wounds are prone to recur. Diabetic foot care is highly variable, often fragmented, and lacks standardization. A wide variety of clinicians, frequently working in isolation, manage diabetic foot problems. Contemplation of this steep, slippery slope to healing and the resulting frustration it causes clinicians evokes the pre-Homeric tale of Sisyphus in Hades. This solitary tragic figure was condemned to roll a boulder up an incline only to have it roll back down in a neverending pointless cycle. Despite major advances in wound-healing and revascularization procedures, amputation rates in diabetic patients remain unchanged or even increased in many regions, creating a burden worthy of an epic tragedy. But what if Sisyphus no longer had to toil endlessly alone, but instead had a partner to assist him? Over the past decade, many modern-day clinical protagonists have learned that teamwork matters. Recent studies suggest that interdisciplinary teams employing an integrated ‘‘toe and flow’’ care philosophy can reduce the incidence of major amputations. Podiatry and vascular surgery are natural allies in the struggle against amputation. Last year, leaders of the Society for Vascular Surgery (SVS) and the *Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona Health Sciences Center, Tucson, AZ. †Amputation Prevention Center, Valley Presbyterian Medical Center, Van Nuys, CA. Corresponding author: Joseph L. Mills, Sr, MD, and David G. Armstrong, DPM, PhD, Professors of Surgery, Division of Vascular and Endovascular Surgery, SALSA (Southern Arizona Limb Salvage Alliance), University of Arizona College of Medicine, Tucson, AZ 85724. (E-mail: jmills@u. arizona.edu or armstrong@usa.net)
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