The Journal of Foot & Ankle Surgery 52 (2013) 263270

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The Journal of Foot & Ankle Surgery

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Rotational Flap Closure of First and Fifth Metatarsal Head Plantar Ulcers:
Adjunctive Procedure When Performing First or Fifth Ray Amputation
Troy J. Boffeli, DPM, FACFAS 1, Matthew C. Peterson, DPM, AACFAS 2
1
2

Residency Director, Foot and Ankle Surgery, Regions Hospital/HealthPartners Institute for Education and Research, St. Paul, MN
Foot and Ankle Surgeon, Fairview Medical Group, Elk River, MN

a r t i c l e i n f o

a b s t r a c t

Keywords:
antibiotic bead
diabetes
infection
phalanx
surgery
toe

Partial ray amputation is a common treatment of diabetes-related neuropathic ulcers located beneath the
metatarsal heads. The standard incision for partial rst or fth ray amputation involves a tennis racket incision, with the proximal arm made mid-line along the respective medial or lateral side of the metatarsal head
and neck, creating equal dorsal and plantar aps. This incision works well when the ulcer is located within the
excised soft tissue distal to the incision or when the plantar ulcer is supercial and will heal secondarily once
the underlying bone has been removed. This standard rst or fth ray amputation incision does not, however,
allow excision and closure of plantar ulcers located beneath the rst or fth metatarsal head. Two cases are
presented to demonstrate our surgical protocol for partial rst or fth ray amputation using a local rotational
ap to cover plantar metatarsal head ulcers. These cases highlight our patient selection criteria, staging
protocol when cellulitis or abscess is present, rotational ap design, surgical technique pearls, and the typical
postoperative healing progress.
2013 by the American College of Foot and Ankle Surgeons. All rights reserved.

Diabetes-related neuropathic ulcers located beneath the metatarsal heads are frequently complicated by infection involving cellulitis, abscess, metatarsal phalangeal joint sepsis, and osteomyelitis.
These conditions are often treated with partial ray amputation. The
standard incision for rst or fth ray amputation involves a tennis
racket incision, with the proximal arm made midline along the
respective medial or lateral side of the metatarsal head and neck,
creating matching dorsal and plantar aps. This standard ray amputation incision works well when the ulcer is located within the excised
soft tissue distal to the incision or when the plantar ulcer is partial
thickness and will heal secondarily once the underlying bone is
removed. The standard incision approach does not, however, allow
excision and closure of plantar ulcers located beneath the rst or fth
metatarsal head. Large, deep, infected, full-thickness neuropathic
ulcers on the plantar surface of the foot can result in ongoing nonhealing wounds and persistent bone exposure if not excised and
closed as a part of the amputation procedure.
Representative cases are presented to demonstrate our surgical
protocol for partial rst or fth ray amputation using a local
Financial Disclosure: None reported.
Conict of Interest: None reported.
Address correspondence to: Matthew C. Peterson, DPM, 640 Jackson Street,
St. Paul, MN 55101.
E-mail address: mpeter11@fairview.org (M.C. Peterson).

rotational ap for coverage of plantar metatarsal head ulcers.

These cases highlight our patient selection criteria, staging protocol
when cellulitis or abscess is present, rotational ap design,
surgical technique pearls, and the typical postoperative healing
progress.
The ap technique described can be used in both acutely infected
and nonacutely infected scenarios. We typically perform a singlestage amputation with immediate ap closure when osteomyelitis is
present without active cellulitis or abscess. A 2-stage approach is used
for more acute soft tissue infection. The rst stage of a 2-stage
approach typically involves excision of the plantar ulcer, removal,
biopsy and culture of the underlying metatarsal and/or sesamoid
bones, incision and drainage of abscess, and open packing of the
wound. The ap incision is drawn before incision for drainage of
infection. This ensures that the incision and drainage procedure does
not compromise the options for subsequent ap coverage. The second
stage is typically a few days later when the soft tissue infection has
resolved and involves raising the ap, amputation of the toe, and ap
coverage of the wound.
As an alternative, the rst stage of a 2-stage approach may involve
raising the ap, removing the toe and metatarsal head, and closing the
ap over antibiotic impregnated beads. The second stage of the
antibiotic bead procedure is scheduled 2 weeks later. In the second
stage, the distal, non-weightbearing portion of the ap is opened, the
bead chain is removed, the hematoma is curetted, a biopsy specimen

1067-2516/$ - see front matter 2013 by the American College of Foot and Ankle Surgeons. All rights reserved.
http://dx.doi.org/10.1053/j.jfas.2012.10.020

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Fig. 2. Preoperative radiographs from patient 1. Osteomyelitis was not seen on radiograph
but was assumed because of the preoperative ndings of bone exposure with deep wound
probing. Osteomyelitis was later conrmed with bone biopsy.

Fig. 1. Chronic, deep, worsening, plantar neuropathic ulcer beneath rst metatarsal head
and sesamoids in patient 1. Bone exposure on deep probing and dorsal cellulitis despite
a plantar wound raised the suspicion for deep infection involving the joint and/or bone.

of the involved metatarsal is taken to determine the clean margins,

and the wound is closed.
The nonhealing nature of diabetes-related plantar neuropathic
ulcers does not preclude successful incorporation of rotational aps.
Patients with neuropathic ulcers often have robust circulation, and
rotational aps have been shown to be effective in surgical treatment
of diabetic foot wounds (1). A carefully designed ap should not add
signicant risk or harm because partial ray amputation typically
involves the loss of otherwise viable soft tissue on the digit as the ray
is amputated. An optimal ap design should, therefore, use tissue that
would otherwise be discarded. Adequate blood ow is paramount,
and knowledge of the involved angiosomes is important when
designing rotational aps (2). Strict adherence to a given angiosome
might not always be possible with ap surgery of the diabetic foot;
however, taking care to follow established principles will certainly
improve the outcomes (3). In our experience, the described technique
has shown no evidence of creating consistent vascular compromise.

One goal of rst or fth ray amputation is to consider future

revision options when performing surgery for diabetes-related
neuropathic ulcers complicated by osteomyelitis. A patient undergoing partial ray amputation might later need transmetatarsal
amputation. The extent of bone resection and incision approach for
ray amputation often inuences future options for revision surgery.
Incorporation of rotational aps can allow the surgeon to preserve
the maximum length of the metatarsal. A traditional amputation
not involving ap closure can otherwise necessitate a shorter
metatarsal resection if soft tissue coverage of the plantar wound is
to be achieved. A loss of excessive metatarsal length can affect
future weightbearing function of the foot, increase the likelihood of
transfer ulcers, and negatively inuence the length of adjacent
metatarsal resection with subsequent ray or transmetatarsal
amputation.
Case 1
Patient 1 was a 64-year-old diabetic male with a recurrent,
chronic, nonhealing, neuropathic ulcer located beneath the rst
metatarsal head. He had received several years of nonoperative
treatment for this recurrent wound before the development of bone

Fig. 3. (AC) Flap design in patient 1 for coverage of plantar ulcer after rst ray amputation. Deep, nonhealing wounds in this location are frequently complicated by osteomyelitis of the
sesamoids, rst metatarsal head, and/or base of the proximal phalanx, which was the reason for this aggressive approach. Note how minimal tissue is discarded and much of the digital
tissue is preserved to create a rotational ap. This technique allows complete closure of the plantar wound once the rst toe and metatarsal head are removed. This incision approach is
easily converted to transmetatarsal amputation if future revision is necessary. Note how the proximal arm in Fig. 3B is promptly brought off the weightbearing surface along medial
midline of the rst metatarsal neck.

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265

Fig. 6. Antibiotic bead placement in patient 1 before ap closure. The bead chain is
inserted down the medullary canal and coiled into the void left by the metatarsal head
resection. This is a staged procedure with planned bead removal, repeat bone biopsy, and
nal ap closure 2 weeks later.

Fig. 4. Intraoperative photographs of stage 1 procedure in patient 1. (A) Full-thickness

excision of ulcer and surrounding tissue. This allows inspection of the deep tissue and
aids decision making regarding the extent of the initial incision and drainage. Note how
the proposed ap is drawn before initial incision for drainage of infection. This approach
minimizes the likelihood that ap options will be compromised by the stage 1 procedure.
(B) After ulcer excision with exposed sesamoids that can easily be removed for biopsy and
culture.

exposure on deep probing of the wound, poor quality of tissue at the

base of the wound, and dorsal metatarsal phalangeal joint cellulitis
(Fig. 1). The foot pulses were palpable. The infection marker laboratory workup revealed a white blood cell count of 16.6  103/mL,
erythrocyte sedimentation rate of 48 mm/h, and C-reactive protein of
4.3 mg/L. Radiographs did not show denitive evidence of osteomyelitis (Fig. 2). Additional imaging was considered but not performed.
The initial incision and drainage (I&D) procedure was performed
emergently because of the clinical presentation of worsening wound
appearance, obvious cellulitis, and clinical suspicion of osteomyelitis
from a positive probe to bone test (4).
The traditional rst ray amputation incision with a medially
based tennis racquet incision would not have allowed excision of the
plantar ulcer or complete coverage of the exposed metatarsal.
Surgical treatment involved a staged rotational ap rst ray

Fig. 5. Intraoperative photograph demonstrating viable nature of the ap and deep

tissues during the stage 2 procedure in patient 1. A full-thickness ap was developed
followed by rst metatarsal phalangeal joint disarticulation. The ap was raised full
thickness with subperiosteal dissection to preserve vascularity and tissue thickness. The
rst toe and metatarsal head have been removed in this photograph. Note how the
medullary canal of the rst metatarsal has been reamed to remove abnormal bone.

amputation with care taken to plan the ap before the initial I&D
incision (Fig. 3). The stage 1 procedure involved excision of the
plantar ulcer, removal of the sesamoids, and partial resection of the
rst metatarsal head (Fig. 4). Biopsy specimens were taken from the
chronic wound and bone to conrm osteomyelitis of the sesamoids
and rst metatarsal head. The wound was packed open for subsequent surgical treatment.
The cellulitis on the dorsum on the foot worsened in the 2 days
after the stage 1 procedure. A 3-stage approach was therefore used.
The second stage involved rst ray amputation with creation of
a rotational ap, insertion of antibiotic-impregnated beads within the
rst metatarsal shaft and preliminary ap closure of the wound
(Figs. 5 to 7).
The third stage was intentionally delayed for 2 weeks to allow
resolution of soft tissue infection and to assess the viability of the ap
(Fig. 8). The stage 3 procedure involved limited opening of the distal,

Fig. 7. Postoperative radiograph of patient 1 showing antibiotic bead placement down

metatarsal shaft. Metatarsal length is preserved just proximal to the distal metaphyseal
air when possible to avoid excessive shortening of the medial column. Care should be
taken to avoid medial or plantar prominence.

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Fig. 8. Photographs of patient 1 at 2 weeks after ap closure over antibiotic beads.

Cellulitis has resolved, yet edema remains. Note how the ap margin has nonviable tissue
at the skin surface. This nding does not indicate ap failure and can be monitored over
the next 1 month of wound healing. The distal sutures have been removed in preparation
for stage 3 procedure involving limited opening of the non-weightbearing portion of the
incision for antibiotic bead removal and nal bone biopsy.

non-weightbearing portion of the ap incision (Fig. 9), removal of the

antibiotic bead chain, repeat biopsy of the rst metatarsal medullary
canal, debridement and washout of hematoma, and nal wound
closure.
Intravenous antibiotics were continued for a total of 6 weeks,
because repeat biopsy was positive for acute osteomyelitis. The
patient remained non-weightbearing for a total of 6 weeks, at which
point the plantar ap and wound were completely healed. At 9 weeks
postoperatively, radiographs demonstrated stump overgrowth or
periosteal reaction (Fig. 10), despite apparently successful treatment
of osteomyelitis, indicated by a normalized white blood cell count,
erythrocyte sedimentation rate, and C-reactive protein. The surgical

Fig. 9. Stage 3 incision in patient 1 involved antibiotic bead removal, repeat bone biopsy,
and nal closure 2 weeks later. The ap is opened distal to the weightbearing surface to
minimize disruption of the fragile plantar incision. Note how the plantar and proximal
sutures are not disturbed. The hematoma has cleared.

Fig. 10. Postoperative radiograph of patient 1 at 9 weeks postoperatively. Note the

periosteal reaction at metatarsal resection site, which likely represented stump overgrowth and not persistent osteomyelitis. The patient had a 6-week course of intravenous
antibiotics and infection marker laboratories had returned to normal at cessation of
medical treatment.

site demonstrated healthy plantar soft tissues without a residual open

wound or infection at 9 weeks postoperatively (Fig. 11). This patient
remained ulcer free and did not require subsequent surgery or
amputation at the 1-year follow-up visit, despite a full return to
normal activities in diabetic footwear.
Case 2
Patient 2 was an 82-year-old female with the recent development
of a complicated plantar fth metatarsal head ulcer. The plantar
wound tissue was nonviable, and associated cellulitis was noted in the
plantar arch (Fig. 12). Bone was not exposed through the wound on
deep probing. Preoperative radiographs (Fig. 13) demonstrated
questionable changes in the fth metatarsal head. The subsequent
bone scan was read as highly suggestive of osteomyelitis in the fth
metatarsal head. Preoperative blood workup revealed a white blood
cell count of 5.6  103/mL, erythrocyte sedimentation rate of 52 mm/h,
and C-reactive protein of 16.2 mg/L.
A 2-stage rotational ap fth ray amputation was performed
because of suspicion of osteomyelitis complicated by acute soft tissue
infection. The rotational ap was drawn before I&D. The ap technique mirrored ap design used in patient 1 to accomplish partial fth
ray amputation and coverage of the plantar wound defect with viable
tissue from the lateral side of the foot (Fig. 14). Most of the soft tissue
from the fth toe was used to create the ap. Care was taken to avoid
raising the ap until it was determined whether incision through the
plantar arch would be necessary to drain a deep space abscess in the
arch, because this could change the surgical approach. Stage 1 surgery
involved excision of the plantar ulcer with removal and biopsy of the
fth metatarsal head (Fig. 15).
The stage 2 procedure was performed 3 days later with partial fth
ray amputation and rotational ap closure of the plantar wound after
resolution of cellulitis (Figs. 16 and 17). The extent of fth metatarsal
bone resection was determined by the bone quality, location of the

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267

Fig. 11. Postoperative photographs of patient 1 showing nal healed ap at 9 weeks after
surgery. All sutures were removed at 6 weeks postoperatively followed by debridement of
sloughing eschar. Edema persists, a common nding when radiographs demonstrate
stump overgrowth.

Fig. 12. Preoperative appearance of sub-fth metatarsal head ulcer in patient 2. Note how
tissue at the base of the ulcer is nonviable and cellulitis extends into the arch.

wound, mobility of the ap, and our desire to preserve most of the
fth metatarsal (Fig. 18).
The ap was completely healed at 7 weeks postoperatively
(Fig. 19). Patient 2 remained ulcer free and did not require subsequent
surgery or amputation at 14 months of follow-up despite a full return
to normal activities in diabetic footwear (Fig. 20).

The ap incision is designed to create a ap from the medial side of

the rst proximal phalanx and metatarsal head for rst ray procedures. The ap design for the rst ray amputation ap is shown in
Fig. 3. The proximal arm of the incision curves medially away from the
weightbearing surface to extend along the medial midline of the rst
metatarsal. This technique minimizes postoperative weightbearing on
the incision and is more easily converted to transmetatarsal amputation should that become necessary in the future.
The dorsal incision on the rst toe is approximately midpoint
along the proximal phalanx and appears transverse when viewed on
the dorsal surface of the foot. This dorsal, transverse hallux incision
continues along the lateral side of the toe, preserving the fullthickness digital soft tissue. This lateral and dorsal digital portion of
the ap is approximated with the medial portion of the ap during
closure. This allows complete coverage at the most distal aspect of the
surgical wound. The ap design is a mirror image for the fth ray as
demonstrated in Fig. 14.

Surgical Technique
Proper incision planning is critical to success with rotational ap
surgery. The proposed ap should be drawn before the initial I&D
incision if surgery is performed in a staged manner, which was the
situation for the 2 cases presented. Standard incision placement for
I&D procedures is typically longitudinal, which could negatively
affect ap donor site options because the ap incisions are typically
curved.

Fig. 13. Preoperative radiographs in patient 2 showing possible radiographic evidence of osteomyelitis of fth metatarsal head. Osteomyelitis was later conrmed by bone biopsy.

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Fig. 14. Flap design for plantar wound closure in partial fth ray resection is a mirror image of the rst ray option. Note how much ap tissue would normally be discarded with traditional
fth ray amputation technique. Hash lines indicate tissue that will be discarded as the ap is raised.

The initial incision allows removal of the full-thickness neuropathic plantar ulcer. A no-touch technique is used to avoid contamination of the deeper structures. The plantar wound tissue is removed
full thickness down to the metatarsal and sesamoid bones (Fig. 4).
Surgical gloves can be changed and the wound prepared again if
concern exists for possible contamination. A sharp towel clamp is
placed through the distal aspect of the toe for ease of manipulation.
The incision is continued around the digit with 90 incisions made
straight to bone. No attempt is made to undermine the ap or incision
areas to search for bleeding vessels. The procedure is typically performed without a tourniquet. A wide double skin hook is then used to
assist in raising the ap off the metatarsal and proximal phalanx.

The ap is raised beneath the periosteum, creating a full-thickness

ap of soft tissue, including neurovascular structures, periosteum,
extensor tendons, subcutaneous fat, and skin. The bone segment in
this region is essentially skeletonized (Fig. 21). The only skin
remaining on the toe is around the tip of the toe, including the toenail.
The toe is disarticulated at the metatarsal phalangeal joint. A bone
saw is then used to resect the respective metatarsal head just proximal to the metaphyseal are. Care is taken to bevel the metatarsal to
avoid prominence at the plantar aspect of the weightbearing surface
or along the margin where shoes could rub. The phalangeal bones, tip
of the toe, sesamoids, and metatarsal head are set on the back table for
subsequent culture and pathologic biopsy. Bone culture is typically

Fig. 15. Patient 2 was treated with a 2-stage approach to allow resolution of plantar
cellulitis before ap closure of wound. Photograph taken at conclusion of stage 1 procedure after ulcer was excised and fth metatarsal head was removed.

Fig. 16. (A) Intraoperative photograph from stage 2 procedure in patient 2 demonstrating
the full-thickness ap created at fth ray amputation. The ap is everted to show tissue
viability. The fth toe and metatarsal head have been removed. (B) The ap was easily
rotated and advanced to cover plantar wound defect.

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269

Fig. 17. Intraoperative photographs illustrating ap closure of the plantar wound in the
stage 2 procedure of patient 2.

Fig. 19. Postoperative photographs of patient 2 showing the healed ap at 7 weeks

postoperatively.

taken from the plantar aspect of the metatarsal head and/or sesamoid
bones.
Thorough irrigation is provided after bone resection. The medullary canal of the metatarsal is inspected to determine the quality of
the cancellous bone. Soft or purulent-looking medullary bone is
curetted to healthy bleeding bone. It is not unusual for the entire
medullary canal to be abnormal. A signicant attempt is made to
preserve the metatarsal cortex just proximal to the distal metaphyseal
are. This desired metatarsal length is benecial for weightbearing
function and will help to establish the location of the adjacent
metatarsal head resection if subsequent ray or transmetatarsal
amputation is needed in the future. Intraoperative ndings regarding
the quality of the residual metatarsal shaft will help to determine the
extent of postoperative antibiotic therapy. Reaming the metatarsal
medullary canal with a large curette also creates a canal for insertion

of antibiotic beads if that is desired in staged surgery. Intraoperative

imaging is used to conrm the desired location and angulation of the
osteotomy.
The ap easily rotates into the wound defect and provides
complete coverage (Fig. 16). There is typically little or no tension on
the ap. Simple sutures are placed with a no-touch technique to
close the ap. The postoperative course involves strict nonweightbearing for 6 weeks or until the wound has healed. It is not
unusual for sutures to be left in place for a total of 6 weeks with
plantar wound surgery involving aps, because premature suture
removal and eschar debridement might disrupt the healing
progress.

Fig. 18. Postoperative radiographs of patient 2 with partial fth metatarsal resection. We
attempt to preserve at least 50% of the metatarsal when possible to minimize the chance
of recurrent ulceration at prominence of fth metatarsal base.

Discussion
Current data support ap surgery for diabetic foot wounds.
Evidence indicates that full-thickness grafts or aps are the most
successful approach for plantar foot wounds due to durability that can
withstand weightbearing stress (1). For example, the use of fullthickness lleted toe aps has been described by Lin et al (5) in
a series of 9 patients, 8 of whom healed successfully. A recent case
series of 4 patients reported by Aerden et al (6) described a hallux toe
ap for closure of a plantar medial forefoot wound with complete
healing at a mean of 44 days. Reulceration did, however, occur in 3 of
the 4 patients.
Complete coverage of soft tissue defects limits the potential for
repeat ulceration and infection (7). Relatively small or partial depth
plantar ulcers are commonly left open at surgery and allowed to heal
secondarily. We prefer rotational ap closure of full depth wounds
when possible, especially when treating osteomyelitis. Our goal is to
leave the patient with a surgical site that is capable of healing during
the postoperative course of antibiotic treatment. Persistent postoperative bone exposure is not likely to be a denitive treatment for
plantar neuropathic wounds complicated by osteomyelitis. Both
patients remained ulcer free and had not required subsequent surgery
or amputation at 1 year postoperatively. Prompt healing of both aps
brought closure to delicate clinical situations for which deep infection
would require ray amputation.

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Fig. 20. Postoperative photographs of patient 2 showing the healed ap at 14 months postoperatively.

The rst or fth ray amputation ap technique described allows for

complete coverage of plantar metatarsal head wounds without the
need for excessive shortening of the metatarsal. The standard tennis
racket approach does not typically allow planter metatarsal head
ulcer excision and immediate closure unless the metatarsal is cut
shorter than otherwise desired. Ray amputation is frequently followed by transfer ulceration and subsequent amputation (8). It is our
desire to preserve most of the rst or fth metatarsal by removing
only the metatarsal head when possible. This approach maintains
a more functional foot structure and sets the stage for more distal
resection if there is future need for resection of adjacent metatarsal
heads or transmetatarsal amputation.
The rst or fth ray amputation ap described uses soft tissue that
would largely be removed and discarded with traditional ray amputation. This amputation ap technique is easily converted to

transmetatarsal amputation if required for poor healing after surgery,

recurrent wounds, or ongoing infection. A staged approach is possible
when ulceration and osteomyelitis is complicated by acute cellulitis or
abscess. In this scenario, initial wound and bone excision is performed, and the wound is left open to allow the soft tissue infection to
clear before delayed ray amputation and ap closure of the wound.
Concomitant or delayed Achilles tendon lengthening might be needed
to dissipate any undue force on the forefoot if ankle equinus is
present. After healing, appropriate diabetic shoe gear is essential for
preventing reulceration (8).
Patient compliance with postoperative non-weightbearing is of
paramount importance with plantar ap surgery if primary healing is
to be achieved. Premature weightbearing will likely cause delayed
healing along the sutured incision rather than frank necrosis of the
actual ap.
Our goal with ap surgery in rst or fth ray amputation is to
provide immediate wound coverage with durable, vascular, fullthickness tissue, which should provide prompt healing of plantar
weightbearing ulcers and successful treatment of osteomyelitis with
long-term avoidance of recurrent ulcers or the need for repeat
amputation.
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Fig. 21. Skeletonized hallux shown, illustrating resection technique for the rst ray
amputation ap. Dissection directly to bone maximizes thickness of the remaining tissue
ap, helping to maintain viability by avoiding vascular compromise.

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