First Ray Amputation

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A 72-year-old male patient with type 2 diabetes diagnosed at the age of 56 years and

Year Old Foot Ray

Figure 3.30 X-ray image of the foot illustrated in Figures 3.28 and 3.29. Disarticulation of the left second toe, dislocation of the metatarsophalangeal joint of the great toe, medial pronation of the first metatarsal head, and hallux valgus deformity with rotation, together with dislocation at the sesamoids and arthritis; necrosis of the head of the third metatarsal bone is also evident

Figure 3.31 Photograph of the foot shown in Figures 3.28-3.30 3 months after arthrodesis of the first metatarsophalangeal joint and second ray amputation. Note the absence of significant callus formation

Figure 3.31 Photograph of the foot shown in Figures 3.28-3.30 3 months after arthrodesis of the first metatarsophalangeal joint and second ray amputation. Note the absence of significant callus formation

Second Ray Amputation Diabetic Foot

treated with sulfonylurea and metformin, attended the outpatient diabetic foot clinic because of a deep, infected neuropathic ulcer under the first metatarsal head. His diabetes control was acceptable (HBAic: 7.6%). He had a history of hypertension and dyslipidemia and was being treated with a combination of angiotensin converting enzyme inhibitor with diuretic and simva-statin. He had neuropathic pain in his feet. He described the pain as a burning sensation which worsened at night. On examination, an ulcer 3 x 3 cm in size and 1.5 cm in depth surrounded by callus formation was seen on the left first metatarsal head. Its base was sloughy. Second left claw toe deformity was also observed. Pedal pulses were palpable, the ankle brachial index was 1.0; the patient had findings of severe peripheral neuropathy (loss of sensation of light touch, pain, temperature, vibration, and 5.07 monofilaments; the vibration perception threshold was 35 V on both feet).

A plain radiograph revealed osteomyelitis of the first metatarsal head extending to the base of the proximal phalanx of the great toe. Cultures of the base of the ulcer revealed the presence of Staphylococcus aureus and Escherichia coli. Based on the results of the swab culture he was given amoxicillin and clavu-lanic acid for 2 weeks. After this time a first ray amputation under local anesthesia was carried out. A culture of the bone was negative for pathogens but pathologic examination of the resected bone showed findings of chronic osteomyelitis (granulated fibrous tissue with a predominance of plasma cells and lymphocytes and involucrum formation at the periosteum). The postoperative period was free from complications and the wound healed well in 2 weeks (Figure 3.32). Antibiotics

1st Ray Amputation
Figure 3.32 First ray amputation due to osteomyelitis

were discontinued 7 days after the operation and he was put on imipramine for the neuropathic pain.

Removal of the great toe results in dysfunction of the foot during both stance and propulsion. This disability is related to the length of the removed metatarsal shaft. Most surgeons preserve the longest metatarsal shaft possible. The base of the proximal phalanx should be preserved, in order to keep the attachment of the short flexor of hallux intact, thus keeping sesamoids in place and maintaining the windlass mechanism. This mechanism protects the first metatarsal head from overloading during the propulsion phase of gait. In the case of an obligatory removal of hallux — due to osteomyelitis of the proximal phalanx — the surgeon should preserve all uninvolved portions of the metatarsal, except the avascular sesamoids and their fibrocartilaginous plate. A hal-lux disarticulation at the metatarsopha-langeal joint exposes the head of the third metatarsal to abnormally high pressure during stance, and may displace the second toe medially.

Keywords: First ray amputation; histology; chronic osteomyelitis


A 72-year-old male patient with type 2 diabetes attended the outpatient diabetes clinic for his usual follow-up. His diabetes control was fair with glibenclamide. He was free

Callus Before Feet

Figure 3.33 Callus over prominence of metatarsal head from retinopathy or nephropathy, but he had severe diabetic neuropathy. On examination a callus was present under the head of his right third metatarsal, which caused minor discomfort (Figure 3.33). Another bony prominence was evident on the outer aspect of his fifth metatarsal, without callus formation. Claw toes, onychomycosis and dry skin were also present. The callus was removed, and a tiny superficial ulcer revealed. The patient was prescribed extra depth shoes with orthotic insoles (preventive footwear). Hydrating cream was used to prevent skin cracking.

Keywords: Callus; claw toes; dry skin


A 70-year-old female patient who had type 2 diabetes since the age of 50 years and was being treated with insulin, attended the foot clinic for chiropody treatment. She had a history of ischemic heart disease (myocardial infarction and stroke), peripheral vascular disease treated with low dose of aspirin; and proliferative retinopathy. She complained of numbness in both feet and a deep aching pain in her calves and painful heel cracks.

On examination, peripheral pulses were absent and her ankle brachial index was 0.8 on the left and 0.7 on the right. The vibration perception threshold was 30 V in both feet. Achilles tendon reflexes were absent, and pain, temperature, light touch and vibration sensation were severely diminished. Pes cavus and hallux valgus were present on both feet (most prominent on the left), together with an obvious prominence of her metatarsal heads and callus formation. The fat pads of her metatarsal heads were translocated towards the toes. The skin on her feet was dry (Figure 3.34). The calluses were debrided on a regular basis, and appropriate footwear was prescribed. Heel cracks (see Figure 4.6) persisted despite debridement.

Calluses develop in areas of high pressure in the feet as a physiological reaction of the skin in response to loading. A callus adds further pressure to the underlying tissues functioning as a foreign body under the foot. Prospective studies have shown that regular removal of calluses reduces the risk of foot ulceration.

Keywords: Prominent metatarsal heads; callus


A 64-year-old male patient with type 2 diabetes diagnosed at the age of 47 years attended the outpatient diabetic foot clinic because of an ulcer under his right foot.

On examination, a painless ulcer surrounded by a hemorrhagic callus was seen under the third metatarsal head (Figure 3.35). Claw toe deformity, a curly

Hemorrhagic Callus
Figure 3.35 A neuropathic ulcer under a hem-orrhagic callus
Heloma Molle

fourth toe, and a heloma molle in the fourth interdigital space were also observed. The patient had bounding peripheral pulses and severe peripheral neuropathy. After sharp debridement of his callus, an ulcer of dimensions 2.0 x 1.5 cm and depth 1 cm was revealed. Plantar fascia was exposed. A plain radiograph excluded osteomyelitis. The patient was instructed in foot care. Offloading of the ulcer area was achieved by the use of an 'almost half' shoe (Figure 3.36) and a total-contact orthotic insole, with a window under the ulcer area. These shoes cause instability, so the patient was instructed to use a crutch. The ulcer healed completely in 8 weeks.

The cause of the ulcer in this patient was high plantar pressure under his prominent metatarsal heads (Figure 3.37). After the ulcer had healed, protective footwear (extra depth shoes and custom-made insoles) was prescribed in order to reduce the peak pressure on the third metatarsal head. No relapse of the ulcer occurred in the subsequent months.

Keywords: Hemorrhagic callus; half shoes; protective footwear

First Ray Amputation

Figure 3.37 Peak plantar pressures recorded with a pedobarograph


Figure 3.37 Peak plantar pressures recorded with a pedobarograph

Half Shoes Diabetic Foot
Figure 3.36 Therapeutic half shoe for the treatment of forefoot ulcers


A 70-year-old male patient with longstanding type 2 diabetes attended the outpatient diabetic foot clinic for callus removal on his right foot. On examination, a neuropathic ulcer surrounded by callus was noticed under his fourth metatarsal head (Figure 3.38). He had normal peripheral pulses and severe peripheral neuropathy. Claw toes, varus deformity of the foot and prominent metatarsal heads on his right foot were observed. Discoloration of the skin on the lower tibia due to venous insufficiency was also evident. The callus was debrided. Shoes and insoles similar to those shown in Figure 3.36 were prescribed until the ulcer healed. The cause of the ulcer in this patient was the callus resulting from high plantar pressures. High peak pressures are present in almost all cases where there are prominent metatarsal heads due to claw toe deformity. Prevention of callus formation is necessary to avoid recurrence of the ulcer. Protective footwear was prescribed after the ulcer had healed.

Keywords: High plantar pressure; callus, prominent metatarsal heads; varus deformity

Diabetic Foot Ulcer
Figure 3.38 A neuropathic ulcer under a callus


A 70-year-old male patient with longstanding type 2 diabetes treated with insulin and sulfonylurea, attended the outpatient diabetic foot clinic because of a hemor-rhagic callus under the phalangophalangeal joint of the right hallux (Figure 3.39). He had ischemic heart disease, hypertension, peripheral vascular disease, background retinopathy and microalbuminuria. The patient had severe diabetic neuropathy; the ankle brachial index was 0.7. After his callus was debrided a clean neuro-ischemic ulcer was revealed. A plain radiograph excluded osteomyelitis. Therapeutic footwear was prescribed and the ulcer healed in 6 weeks.

The forefoot is the usual site for ulceration. In one series, ulcers of the forefoot accounted for 93% of all foot ulcers. Almost 20% of the ulcers developed under the hallux, 22% over the metatarsal heads, 26% on the tips of the toes and 16% on the dorsum of the toes. Ulcer under the hal-lux is associated with rigid hallux and high peak pressures on this area.

Keywords: Hemorrhagic callus; prevalence of foot ulceration


Painful heel cracks due to dry skin were noted in the patient whose feet are shown in Figure 3.34 (Figure 3.40).

Dry skin in diabetic patients is caused by sympathetic cholinergic denervation of the sweat glands in their feet. Patients with dry foot skin often develop reactive hyper-hydrosis of the upper body. Heel cracks

Ulceration Hallux
Figure 3.39 Hemorrhagic callus under the hallux
Hemorrhagic Callus Pictures
Figure 3.40 Heel cracks

may become infected and may lead to deep ulcers with calcaneous involvement if left untreated. The crack resists healing, despite the correct foot care. Heel cracks are aggravated by microvascular disease and neuropathy, and resist healing, despite adequate foot care. Local application of hydrating creams—avoiding the areas between the toes — is the treatment which is usually recommended.

Keywords: Dry skin; heel cracks


A 73-year-old male patient with type 2 diabetes diagnosed at the age of 61 years attended the outpatient diabetes foot clinic for a chronic ulcer under his left partially amputated foot. He had had bilateral mid-tarsal (Chopart) disarticulations (on the right foot at the age of 66 years and on the left foot at the age of 68 years) because of infected foot ulcers under the metatarsal heads complicated by osteomyelitis.

On examination, his feet pulses were palpable, but the patient had severe peripheral neuropathy. A full thickness neuropathic ulcer, which developed 2 months after the amputation, was evident on the plantar area of the left foot (Figure 3.41). The patient had never used any ankle prosthesis or orthosis, but instead used crutches and shoes with a firm outsole and a soft molded insert. The ulcer healed for a period of only 2 months, when the patient was hospitalized because of a hip fracture.

Chopart disarticulation is performed through the talonavicular and calcaneocu-boid joints, preserving the hindfoot only (talus and calcaneus). As no muscles attach to the talus, all active dorsiflexion of the remaining short foot is lost. However, dorsiflexion can be restored, by reattaching the anterior tibial tendon to the neck of the talus. Chopart disarticulation preserves the normal length of the leg and the patient can undertake limited walking without a prosthesis. Reasonable walking is possible by the use of an intimately fitting fixed-ankle prosthesis or orthosis placed into a shoe with a rigid rocker bottom.

In the present case, walking without crutches was not possible even if an appropriate prosthesis was used because of the bilateral Chopart disarticulation. However, the use of a prosthesis and offloading the pressure on the ulcerated area with suitable insoles helped to heal the ulcer. In addition, the patient's severe instability, which was the cause of the hip fracture, was reduced.

Any type of amputation alters the biome-chanics of the foot and is considered to be a risk factor both for a recurrence of foot ulceration and for a new amputation. Several studies have shown that previous amputations account for 30-50% of new amputations on the same or the contralateral foot within the following 5 years.

Keywords: Neuropathic ulcer; mid-tarsal disarticulation; Chopart disarticulation


An ostensibly small neuropathic ulcer surrounded by callus formation was present under the fourth metatarsal head

Hindfoot Amputation
Figure 3.41 Full thickness neuropathic ulcer in a patient with Chopart disarticulation
Chopart Joints
Figure 3.42 A neuropathic ulcer under callus formation in a patient with fourth toe disarticulation

(Figure 3.42) of a patient with severe diabetic neuropathy. A history of fourth toe disarticulation at the metatarsophalangeal joint was reported to have occurred 2 years previously because of osteomyelitis in the proximal phalanx. Claw second and third toe, quintus varus (due to fourth toe disarticulation), dry skin and heel cracks were also present. The real size of the ulcer was 1.5 x 1.5 x 1.0 cm post-debridement. The little toe diverged medially and the third toe laterally. Therapeutic footwear was prescribed and the ulcer healed in 2 months.

A fourth ray amputation may lead to better functional and cosmetic results. Sole incisions pose a risk for ulceration; therefore incisions are carried out on the dorsum or the side of the foot. Scar tissue which has healed over an ulcer may predispose to new ulceration in a similar manner to callus formation.

Brown Nail Discoloration
Figure 3.43 Onychocryptosis (ingrown nail) of both halluxes. Note brown nail discoloration probably caused by chronic infection with Candida albicans. Second, third, and fourth left claw toe deformity

Keywords: Fourth toe disarticulation; neuropathic ulcer


An ingrown toenail is a common condition usually affecting the hallux. A section of a nail curves into the adjacent flesh and becomes embedded in the soft tissue (Figure 3.43). Peeling the nail at the edge or trimming it down at the corners is the most common cause. In addition to congenital or traumatic reasons, ingrown nails may be caused by tight shoes or socks which press on the sides of the nail making it curve into the skin.

An ingrown nail predisposes to local infection (paronychia) as it provides an entry point for pathogens; therefore it should be treated as soon as it is recognized. Nails should be trimmed in a straight line.

Infection with Candida albicans is another cause of chronic paronychia, especially when patients' feet are exposed to moisture for long periods. The nail is usually affected and becomes ridged, deformed and brown.

Keywords: Onychocryptosis; ingrown nail

Atlas of the Diabetic Foot. N. Katsilambros, E. Dounis, P. Tsapogas and N. Tentolouris Copyright © 2003 John Wiley & Sons, Ltd.

ISBN: 0-471-48673-6

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  • fethawi
    Is it good to put amoxicillin to a foot wound of a diabetic person?
    8 years ago
  • Hyiab Idris
    How to perform a 4th ray amputation foot?
    8 years ago
  • Ausonia
    What causes Brown Skin Discoloration on the Leg?
    8 years ago
  • klaudia
    Which toe is the 1st ray?
    7 years ago
  • deodato piazza
    What is a first ray ampututatiaon?
    2 years ago
  • leah schaefer
    Where does the big toe get amputated from ra?
    2 years ago
  • Kerri Lesko
    Is a first ray amputation related to diabetes?
    1 year ago
    What is a partial ray amputation?
    1 year ago
  • cora
    How to perform a first ray resection?
    11 months ago
  • brogan
    Does third toe amputation with partial ray resection go to high,low, mid?
    8 months ago
  • ilaria
    What does first ray amputation include?
    7 months ago
  • ALAN
    What is a first ray amputation definition?
    7 months ago
    What is a 1st complete ray amputation?
    4 months ago
  • niklas zimmermann
    What does amp first ray left foot look like?
    1 month ago
  • orgulas
    Why is it called ray amputation?
    30 days ago

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