Josephine Kulman has had type 1 diabetes for 45 years, ever since she was five years old. For much of her life, her blood sugars were rarely in control.

Before she went on the pump a few years back, her A1c used to hover around 10%, and she'd often drag herself to work with blood glucose levels of up to 600 mg/dl.

In her forties, it all started to catch up with her. She got gastroparesis, lost vision in one eye, suffered a left-foot ulcer, and developed carpal tunnel syndrome and kidney problems.

On December 8, 2006, while walking in Manhattan, Josephine tripped. Three days later, she couldn't get her right shoe on. Looking down, she was appalled to find that her right foot was three times its normal size. In mid-December she entered the hospital for tests to discover why her foot was so inflamed.

Cellulitis was suspected, but eventually x-rays revealed that Josephine had Charcot foot. "My foot was shaped like an S," she says. "My ankle bone on the inside of my leg was underneath my arch. The one on the outside of my leg was in front of my foot. My foot was split from the big toe straight up, so half of my foot was going one way and half of it was going the other way."

Charcot foot is a softening of the bones of the foot that occurs in people with severe peripheral neuropathy. Their muscles lose the ability to support the foot, leading to a slackness of ligaments, dislocation of joints, damage to bone and cartilage, and deformity.

The bones slip out of position and then push on the soft tissue, breaking it down and leading to ulcers. The patient, unable to feel the pain that warns healthy people of injury, continues to walk on the broken foot, exacerbating the damage. That's exactly what happened to Josephine.

Amputation has always been a very real threat in cases of Charcot foot. But Josephine's story has a different ending, largely because she was fortunate enough to come under the care of Dr. Andrew Sands. Dr. Sands, the chief of foot and ankle surgery at St. Vincent's Catholic Medical Centers in Manhattan, is one of an innovative group of surgeons who is breaking new ground in the treatment of Charcot foot.

Dr. Sands was inspired to help people with diabetes by his cousin, who had type 1 diabetes and died at age 38 from a heart attack. "I went through everything with him," says Dr. Sands, "including partly amputating his foot." As a result of his cousin's influence, "I stay involved with diabetes and do new and exciting things for people with diabetes to save their feet."

In the past, says Dr. Sands, "people were very afraid to operate on diabetic feet, and a lot of people treated them in casts or in bulky boots or shoes. Wound care centers can treat the ulcers, but if the bone malposition isn't addressed, the foot is going to break down again the instant the patient starts walking on it again. More and more, people like me are operating on them and fixing the deformities. We're developing new and better implants, which are metal screws that fit inside the bones. Basically, it's like when a foundation collapses and then the walls start collapsing. You can shore it up with implants and allow the patients to keep their foot. Suddenly, a lot of people who before would have become wheelchair-bound or had an amputation are staying active on their own feet."

In Josephine's case, says Dr. Sands, "her forefoot was basically swept away from the rest of her foot. One row of bones 'bayoneted' over another row, shifting up, over, and on top of other bones. To get that back into alignment, you have to bring it all down and hold everything with screws. We took her forefoot and brought it around and lined it up again, and put big stainless steel screws through her bones to hold everything. The most important screw, which was about 4-1/2 inches long, went from the base of her big toe up into the big bone under her ankle. We recreated her entire arch."

These new operations are the product of a change in philosophy over the past ten to fifteen years, away from conservative treatments like casts and boots and toward more aggressive reconstruction. The trend has been fueled by advances in technology.

The older implants were too bulky to work well in a foot, but now the screws have been redesigned, says Dr. Sands, "to have a smaller head and a stronger shaft, so that they are strong enough to use in a foot, which bears the entire weight of the body."

"It used to be," says Dr. Sands, "that if someone had a terrible deformity in their hind foot or their ankle, the only option was to amputate. Now we have new implants that we can put through the heel and up through the sole of the foot, and we can lock the foot to the leg and save the foot. Sometimes the heel bone is still intact and the bones around it are destroyed, but now we can fix it."

Dr. Sands emphasizes that to benefit from foot reconstruction, patients must be "good partners" in the process. They must have good control of their blood sugar, and they must definitely not smoke.

"If you have a foot ulcer and you smoke," says Dr. Sands, "stop. If you're not a smoker and you have good circulation, if your foot is warm, then chances are strong that we can at least try to save your foot. Even if you have numbness up to your knee, as long as you have good circulation, we can get you to heal."

With regard to smoking with diabetes, Dr. Sands is adamant. "We guarantee very little in medicine," he says. "But to the degree that it is possible to guarantee anything in medicine, I can guarantee that if you have diabetes and you are a smoker, you will have an amputation. It's just that bad." Stop smoking, he advises, and then "keep your hopes up and keep your health up, because we're going to be able to do a lot more" when it comes to saving feet.

As for Josephine, she will be required to wear a special boot for about six months, but she expects to be fully healed once the boot comes off. Her best advice to people with a similar dilemma is to find the very best doctor they can.

"That was the key," she says. "It took time to get to Dr. Sands, but nobody else would have even considered doing a foot reconstruction. The foot would have eventually healed in an S shape, and I would have had problems for the rest of my life."