In the diabetic population, there is a lack of consensus on the indications for major leg amputations. Although studies cite a primary major leg amputation rate of 24%, there is a nine fold variation in this rate across the United States. We retrospectively reviewed the Georgetown Diabetic Limb Registry from 1990-1999 to identify a primary amputation rate in ambulatory diabetic patients, develop criteria for major leg amputations and assess the effectiveness of our multidisciplinary approach. We had a primary major leg amputation rate of 2.7% (25/937 pt.). All amputations were BKAs and there were no AKAs. We salvaged all patients who presented with forefoot disease and salvaged 86% of those who underwent mid-foot amputations (58 Trans Metatarsal Amputations, 17 Lis Franc, 13 Choparts). Overall, our secondary major leg amputation rate (primary amputations plus failed midfoot amputations) was 4%. Successful salvage was realized in the most threatened of limbs: 33% of those with non-bypassable peripheral vascular disease (PVD) and 66% of those with end stage renal failure. The presence of renal failure did not worsen the outcome of patients with PVD or non-bypassable PVD. A multidisciplinary approach to limb salvage is necessary to achieve high salvage rates in this population.