Clin Podiatr Med Surg

25 (2008) 609–622

Minimum-Incision Ray Resection

Ali Öznur, MDa,
Thomas S. Roukis, DPM, PhD, FACFASb,*
a
Department of Orthopaedics and Traumatology,
Hacettepe University, Sihhiye 06100, Ankara, Turkey
b
Limb Preservation Service, Vascular/Endovascular Surgery Service,
Department of Surgery, Madigan Army Medical Center,
9040-A Fitzsimmons Avenue, MCHJ-SV, Tacoma, WA 98431, USA

Diabetic forefoot ulcerations are a common pedal manifestation and

have a multitude of etiologies. The presence of dense peripheral neuropathy
[1], pedal deformity (ie, intrinsic minus foot type) [1–3], limited joint mobil-
ity [4–6], equinus contracture of the posterior calf musculature [7–10], distal
displacement or atrophy of the plantar forefoot padding [1–6], and periph-
eral arterial disease [1,11,12], however, usually coexist. These processes
make the goal of eradicating infection, providing stable wound closure,
and restoring a stable plantigrade, shoeable/braceable foot a significant
challenge [1]. Treatment of the infected plantar forefoot ulceration, espe-
cially about the central metatarsals, creates a particularly difficult challenge
because of the specialized nature of the soft tissues, relatively limited soft-
tissue coverage options, and significant shear and tangential forces sustained
during stance and the gait cycle [13–15].
Indications for a ray resection include localized gangrene of the toe and
web spaces, infection of the toe with extension into the metatarsophalangeal
joint or intermetatarsal spaces because of contiguous spread, or osteomye-
litis of a toe and/or metatarsal head [16–21]. Each of these scenarios creates
a situation where amputation of the toe alone will not allow for adequate
soft-tissue coverage of the resultant defect, thereby leaving the metatarsal
exposed and avascular. Performing a metatarsal resection in conjunction
with the toe amputation allows for sufficient soft-tissue coverage of the

The opinions or assertions contained herein are the private view of the author and are
not to be construed as official or reflecting the views of the Department of the Army or the
Department of Defense.
* Corresponding author.
E-mail address: thomas.s.roukis@us.army.mil (T.S. Roukis).

0891-8422/08/$ - see front matter. Published by Elsevier Inc.

doi:10.1016/j.cpm.2008.05.008 podiatric.theclinics.com
610 ÖZNUR & ROUKIS

toe amputation site and, when performed properly, leaves a balanced, func-
tional, albeit slightly narrower forefoot that can be fitted properly into pro-
tective shoe gear and accommodative insoles [16–21]. In practice, isolated
ray resection of one of the three central rays is technically more difficult
than performing border (ie, first and fifth metatarsal) ray resections. In cer-
tain instances, two adjacent metatarsal ray resections can be performed with
the same end result. This is especially true for the second and third and
fourth and fifth combined ray resections, which tend to be quite functional.
The natural history of great toe amputations, however, and first ray resec-
tions [22,23], as well as three or more toe amputations or three or more
ray resections [24–33] do not support the use of these procedures as defini-
tive procedures in high-risk patients, especially those who have concomitant
foot and lower extremity deformities, sensory–motor neuropathy, and
peripheral vascular disease. If these procedures are necessary in this patient
population, it is the authors’ opinion that strong consideration should be
given to performing a well-balanced transmetatarsal amputation [34–36]
or internal pedal amputation [37].
The traditional approaches to central metatarsal head ulcerations have
involved either limited osseous resection, with or without amputation of
the associated toe [11,12,16,17], or resection of the entire metatarsal [18–21].
In the traditional ray resection technique, a tennis-racquet incision is made cir-
cumferentially around the base of the toe, with a single limb extending prox-
imally over the dorsum of the involved metatarsal. Unfortunately, the
proximal extension of the incision may jeopardize future incisions necessary
to perform more proximal amputations if the ray resection procedure fails.
Additionally, it disrupts the fragile vasculature that courses within the inter-
metatarsal spaces and intrinsic musculature, thereby increasing the risk of
wound dehiscence and subsequent infection [11]. Finally, the traditional ap-
proach to ray resection creates a cleft-foot deformity that is prone to transfer
ulceration and recurrent wound breakdown because of the unstable nature of
the forefoot [38].
To expedite healing and create a stable, plantigrade forefoot following
central metatarsal ray resection, narrowing of the forefoot through manual
apposition of the medial and lateral forefoot segments has been advocated
using widely spaced, heavy- gauge sutures and splint immobilization to pro-
vide stability until soft-tissue healing has occurred [16–19]. Although this
concept inherently makes sense, the clinical application of this technique
has a large inherent flaw, that being relying on the tension across the adja-
cent soft tissues and external support to provide soft-tissue and skeletal sta-
bility in already compromised tissues.
With this concept in mind, Hansen [39] described resection of the entire
ray, including a segment of the adjacent cuneiform or cuboid, which allows
the adjacent metatarsals to become approximated and obliterates any dead
space formation. He described the use of compression internal fixation using
at least one screw across the cuneiforms and/or cuboid and another across
 MINIMUM-INCISION RAY RESECTION 611

the metatarsals to stabilize the narrowed forefoot similar in concept to

a technique described previously by Smith [20]. Although sound in theory,
this technique is difficult to perform in practice because of the relative osteo-
penia present in patients who have diabetes [1,40]. Additionally, it requires
prolonged nonweight-bearing immobilization and carries with it the inher-
ent risk of deep infection about the retained hardware, hardware failure
or prominence, and development of nonunion or malunion about the cune-
iform and/or cuboid osteotomy site(s).
Strauss and colleagues [41] employed the same concept proposed by Han-
sen [39] and Smith [20] but employed the use of manual apposition of the
forefoot, insertion of a series of half-pins in the first and fifth metatarsals,
which were connected to a triangular or cathedral-like external fixation sys-
tem. The authors discussed exploiting the viscoelastic properties of the fore-
foot soft tissues and articulations [42] through repeated manual compression
of the forefoot and locking-unlocking-locking the external fixation system
over a 5- to 10-minute period to completely obliterate the dead space cleft.
Subsequent dorsal and/or plantar soft-tissue defects were closed in primary
fashion, left to heal by means of secondary intent over time, or covered with
a split-thickness skin graft. The authors described the concomitant use of
hyperbaric oxygen in 14 of their 15 patients in addition to prolonged non-
weight-bearing immobilization. Careful analysis of the data presented
reveals a significant number of patient compliance issues as would be
expected with a bulky, heavy, external fixation device that mandates non-
weight-bearing immobilization and frequent office visits for local wound
care and hyperbaric oxygen treatments. Additionally, the need to use pro-
longed intraoperative manual compression and manipulation of the external
fixation device to achieve complete closure of the cleft foot deformity repre-
sents a disadvantage of this specific form of external fixation, especially
when taking into account the cost of operating room time required to assem-
ble the device and repeatedly manipulate it. The concept of employing an
external fixation device to stabilize cleft foot deformities, however, proved
sound in that of the 12 (87%) patients who resumed ambulation, a mechan-
ically sound forefoot remained that was cosmetically appealing to the pa-
tients and readily shoeable/braceable [41].
Öznur and Tokgözoğlu [43] employed the same inherent concept of
Strauss and colleagues [41] but employed the use of two external fixation
system half-rings and dueling medial and lateral olive wires that were ten-
sioned after creating an osteotomy at the level of the base of the remaining
lateral metatarsals. Through graduated tension across the opposing olive
wires, gradual and precise closure of the cleft deformity was performed.
The patients were allowed limited weight sharing during the time the exter-
nal fixation device was employed [44,45].
Bernstein and Guerin [46] presented the use of a mini-external fixator
originally intended for bone lengthening and transport to achieve gradual
closure of the resultant forefoot defect following central ray resection.
612 ÖZNUR & ROUKIS

The closure occurred over a 30-day period, which was followed by removal
of the device and application of a total contact cast for 2 weeks. Bibbo [47]
employed a similar technique but achieved complete wound closure in the
operating room along with primary closure of the dorsal incision used to
perform central ray resection, which replaced his prior technique of serial
tightening of transosseous metatarsal wires with local wound care and even-
tual coverage with a split-thickness skin graft.
Most recently, Zgonis and colleagues [38] discussed the use of a split-
thickness skin graft within the cleft space followed by use of a circular exter-
nal ring fixator that allowed:
Precise narrowing of the forefoot without the need for osteotomy of the
metatarsals or their tarsal components
Weight sharing during the postoperative recovery period
Limited duration of external fixation use
Rapid healing by means of application of a split-thickness skin graft
about the remaining cleft foot deformity, which has the added benefit
of producing additional scarring and contracture over time during the
skin graft maturation process
Although the use of external fixation to close the problematic cleft foot
deformity represents a major advancement over previous techniques, the
prolonged time required to afford complete wound closure represents a sig-
nificant disadvantage, because it is accepted that the longer a wound
remains open, the greater the likelihood of developing an infection
[1,48,49]. Additionally, the fairly short time frame that a patient will tolerate
the presence of an external fixation device attached to his or her foot and
lower limb is an important consideration [50]. With these concepts in
mind, the authors have used a minimum-incision technique [51] to decrease
the dorsal soft-tissue dissection necessary to expose the metatarsal without
compromising the resection, which maintains an intact soft-tissue envelope
and preserves vascularity within the intermetatarsal spaces. This approach
has the added benefit of allowing direct primary closure of the incisions in
most patients. If necessary, a mini-external fixator device or half-ring system
can be applied to rapidly approximate the skin edges in patients who have
decreased compliance of their skin, as seen in long-standing uncontrolled
diabetes [4–7] or nonreconstructable peripheral vascular disease where ten-
sion about the incision sites will lead to necrosis [12,18,25].

Minimum-incision ray resection

The surgical procedure begins with the patient positioned in the supine
position on the operating room table with a well-padded bolster placed
beneath the ipsilateral buttock to control physiologic external rotation of
the lower limb. The procedure most commonly is performed under local
regional anesthesia (ie, ankle or popliteal block) and monitored sedation.
 MINIMUM-INCISION RAY RESECTION 613

A contraindication to use of local regional anesthesia is the presence of

active infection or gangrene in the field intended to be infiltrated. The use
of a tourniquet is not necessary because of the limited soft-tissue dissection
afforded by this procedure, and it is contraindicated in the high-risk patient.
The initial debridement must be radical and include all obvious nonviable
soft tissue to establish a viable, healthy, and well-perfused wound bed
[52–55]. If this cannot be achieved with the proposed minimal incision ray
resection, then either the traditional approach should be chosen or definitive
treatment delayed until delayed primary closure with or without additional
soft-tissue coverage techniques is deemed appropriate [52–55].
The involved toe should be grasped with a towel clamp through the distal
interphalangeal joint (Fig. 1A) to facilitate dissection by employing the
clamp as a toggle to move the toe and limit handling of the infected, necrotic
tissue by the surgical team, which maintains an aseptic surgical field. Con-
verging semielliptic incisions are placed about the base of the toe at the level
of the midshaft of the proximal phalanx and carried directly to bone. A
small periosteal elevator is used to elevate the soft tissues off of the shaft
and base of the proximal phalanx to expose the metatarsophalangeal joint,
which then is incised circumferentially to amputate the toe. The capsule to
the metatarsophalangeal joint is freed from the dorsal, medial, and lateral
aspects of the metatarsal with a No. 10 blade to the metaphyseal–diaphyseal
junction. Next, a small periosteal elevator is inserted in subperiosteal fash-
ion and advanced proximally along the shaft of the metatarsal to the prox-
imal metaphyseal–diaphyseal junction (Fig. 1B) that is verified under
intraoperative image intensification. The periosteal elevator is withdrawn
from the surgical site and then advanced along the medial and lateral aspects
of the metatarsal in subperiosteal fashion as described for the dorsal aspect.
Finally, a small, curved metatarsal scoop-type elevator is placed plantarly
between the metatarsal head and plantar plate and advanced proximally
in subperiosteal fashion as described. This effectively shells-out the metatar-
sal while preserving the vasculature to the intrinsic musculature. Once the
metatarsal has been freed, the proximal extent of subperiosteal dissection
on the involved metatarsal is identified under image intensification
(Fig. 1C), and a 1 cm transverse incision is marked at this location. The
incision is carried through the skin only and is followed by blunt dissection
with a hemostat in line with the incision to the underlying metatarsal, with
care taken to mobilize any regional soft-tissue structures out of the surgical
field. The jaws of the hemostat then are opened, and the hemostat is
advanced to define the medial and lateral borders of the metatarsal
(Fig. 1D). This also serves to elevate the intrinsic musculature off of the
respective aspects of the involved metatarsal, thereby protecting the regional
vascular anatomy. Care is taken not to inadvertently create an osteotomy in
an uninvolved metatarsal. Under direct image intensification, a narrow-
width (ie, 5 mm), long-length saw blade is passed from dorsal-to-plantar
at the level of the proximal metaphyseal–diaphyseal junction (Fig. 1E).
614 ÖZNUR & ROUKIS

Fig. 1. Intraoperative photograph demonstrating the use of a sharp towel clamp placed dorsal-
to-plantar through the distal interphalangeal joint of the third toe for control of the toe during
dissection and to employ no-touch technique (A). A periosteal elevator is shown being advanced
across the dorsal aspect of the third metatarsal in subperiosteal fashion (B) until it reaches the
proximal metaphyseal–diaphyseal junction as verified under intraoperative image intensification
with the use of a metallic instrument (C). A hemostat is used to free the intrinsic musculature off
of the metatarsal and verify the proper location and metatarsal before osteotomy (D). A nar-
row-width, long-length saw blade is used to complete the osteotomy (E) followed by insertion
of a small osteotome or periosteal elevator to pry the transected metatarsal distally, verifying
complete transection and release of the surrounding soft tissues (F). The metatarsal head
then is grasped through the distal incision, and the metatarsal is retrieved in toto (G). Adherence
to the technique described allows for atraumatic amputation of the toe (left) and a skeletonized
metatarsal free of soft-tissue (right) (H). Intraoperative image intensification view of the fore-
foot following minimum incision ray resection before (I) and following manual compression
of the forefoot (J), revealing easy closure of the soft-tissue defect without tension (K). Note
the presence of a suction drain that has been sutured distally and stapled proximally at the
exit site from the incision used to perform the metatarsal osteotomy.
 MINIMUM-INCISION RAY RESECTION 615

Fig. 1 (continued )

Alternatively, a 1.5 mm drill can be employed to make several drill holes

over the osteotomy level, which then are connected with an osteotome
and mallet. Once the osteotomy has been completed, a small osteotome is
introduced into the osteotomy, and the metatarsal is levered distally to ver-
ify complete release from any soft tissue restraints (Fig. 1F). The metatarsal
head then is grasped through the toe amputation incision with a clamp and
retrieved from the foot (Fig. 1G). By performing the technique as described
previously, amputation of the toe and resection of the metatarsal can be per-
formed in en block fashion rather than piecemeal (Fig. 1H). The fifth meta-
tarsal should be osteotomized obliquely from dorsal-distal-lateral to
plantar-proximal-medial. The proximal part of the shaft is left to enhance
the weight-bearing area and retain the insertion of peroneus brevis tendon.
616 ÖZNUR & ROUKIS

The forefoot is compressed manually from medial-to-lateral (Fig. 1I) un-

der intraoperative image intensification and, if the distal incision can be
apposed easily without tension (Fig. 1J), direct primary closure can be per-
formed. All incisions are reapproximated with a No. 2-0 nylon in vertical
mattress fashion and metallic skin staples with a suction drain placed in
the resultant dead space to limit the potential for hematoma formation
(Fig. 1K). The drain should be sutured at its distal end [56] and stapled at
the exit point from the skin to prevent it from being inadvertently removed
prematurely.
If the defect created following appropriate debridement precludes pri-
mary closure, filling the dead space with polymethylmethacrylate antibi-
otic-loaded bone cement beads is a useful technique and has been
described in depth in the literature [57–59]. The antibiotic beads usually
are removed and replaced during subsequent debridements in the operative
theater but can be left in place for 2 to 3 weeks if necessary. Intravenous -
antibiotics and any necessary local wound care are continued until the inci-
sions are granular, at which point they can be covered with a split-thickness
skin graft that usually is harvested from the medial arch of the foot [60–63],
posterior calf [61–63], or thigh region of the ipsilateral limb [61,63]. The har-
vested split-thickness skin graft then is prepared for soft-tissue wound cov-
erage by either fenestration of the graft manually with repeated passes of
a surgical scalpel (ie, pie crusting’) or meshing it at a ratio of 1:1.5 or greater
using a commercially available mesher [63,64].
If it is not possible to primarily close the toe amputation incision, and the
ability to perform extended local wound care is inappropriate, the use of
mini-external fixation to assist in wound closure can be performed. This is
especially useful in patients who have noncompliant skin [4–7] or nonrecon-
structable peripheral vascular disease, where tension across the wound
would lead to necrosis [12,18,25].
Several techniques are possible, but the ones most commonly employed
involve mini-external fixation [46,47] or ring-type external fixation devices
[38,43,44]. With either technique, it is important to place a suction or gravity
drain in the dead space (Fig. 2A), and place all sutures for delayed closure of
the distal incision site (Fig. 2B). If the sutures are not placed at this time, it
will be exceedingly difficult if not impossible to reapproximate the skin edges
once the forefoot is narrowed sufficiently. For the mini-external fixation
device [46,47], one or two half-pins are inserted in the metatarsals adjacent
to the resected ray. It is important to insert these pins at the level of the sur-
gical neck of the metatarsal (ie, metaphyseal–diaphyseal junction) to take
advantage of the distal lever arm, which allows more rapid approximation
of the metatarsals and therefore the intended soft tissues. The mini-external
fixation device then is compressed using the wrench as much as possible on
the operating room table but not so much as to fracture the metatarsals or
disrupt vascular flow. The mini-external fixation device then is compressed,
with advancement of the wrench every 24 to 48 hours until the skin edges are
 MINIMUM-INCISION RAY RESECTION 617

Fig. 2. Intraoperative anterior–posterior (A) and en fass (B) photographs demonstrating the
use of a mini-external fixation device to facilitate close the distal incision through narrowing
of the forefoot following minimum-incision ray resection. Note the use of a suction drain
that has been stapled in place exiting through the dorsal incision to perform the metatarsal
osteotomy and the placement of sutures through the distal incision, which will be used to for-
mally reapproximate the skin edges after narrowing of the forefoot has been completed. Post-
operative anterior–posterior (C) and en fass (D) photographs demonstrating closure of the
distal incision and narrowing of the forefoot following-minimum incision ray resection. Postop-
erative anterior–posterior (E) and en fass (F) photographs following removal of the mini-
external fixation device demonstrating complete healing of the distal incision and some
sustained narrowing of the forefoot following minimum-incision ray resection.

fully reapproximated with no tension (Fig. 2C). At this time, the preplaced
sutures are tied, with or without supplementation of metallic skin staples
(Fig. 2D). The mini-external fixation device is left in place until the skin
edges have healed fully, and the device is loosened gradually every 24 to
618 ÖZNUR & ROUKIS

48 hours to make certain the reapproximated skin edges are able to mature
and sustain tension. Once this occurs, the mini-external fixation device is
removed in the clinic under aseptic technique (Fig. 2E, F) with the sutures
and staples being removed sequentially over the next 2 to 3 weeks.
For ring-type external fixation, the foot is placed inside of a half-ring ori-
ented 90 to the plantar aspect of the foot when viewed from a lateral direc-
tion and parallel with the intended direction of compression across the
metatarsals when viewed from an anterior–posterior direction (Fig. 3A)
[43,44]. Alternatively, a foot plate ring can be used, with the plantar aspect
of the foot parallel to the long axis of the foot plate when viewed from a lat-
eral view and the transosseous wires oriented parallel with the intended
direction of compression across the metatarsals when viewed from an ante-
rior–posterior direction [38]. If the foot plate ring is employed, the hindfoot
must be incorporated and is stabilized with several crossed olive wires
through standard pedal safe corridors about the calcaneus and talus. For
either external fixation technique, one olive wire is placed from medial-to-
lateral at the level of the distal metaphyseal–diaphyseal junction of the meta-
tarsals, and another is placed from lateral-to-medial in this same region.
Simultaneous tensioning of the forefoot wires allows for precise and gradual
closure of the cleft foot deformity (Fig. 3B). However, on occasion, percuta-
neous osteotomy of the adjacent metatarsals is necessary to allow complete
soft-tissue reapproximation, especially with large defects that have a higher
incidence of wire pull-out and metatarsal fracture if the wires are

Fig. 3. Intraoperative photograph following application of a half ring oriented 90 to the plan-
tar aspect of the foot and parallel with the intended direction of compression across the meta-
tarsals (A). Note the complete apposition of the skin about the distal incision under no tension.
Intraoperative image intensification view of the forefoot following minimum-incision ray resec-
tion demonstrating polymethylmethacrylate antibiotic-loaded bone cement beads within the
second intermetatarsal space (B). Note the use of olive wires that have been cut flush with
the olive bulb to allow placement under the skin edges and the location and orientation of
the wires to facilitate forefoot narrowing.
 MINIMUM-INCISION RAY RESECTION 619

overtensioned, especially in osteopenic bone. Because all interosseous com-

partments are passed through with either form of wire-based external fixa-
tion, compartment syndrome, nerve and vessel injury, and metatarsal
fractures can be possible complications. The same sequence of events as
described for postoperative treatment with use of the mini-external fixation
device occurs with the ring-type external fixation devices described previ-
ously, although there is usually less of a need to slowly adjust the device.
With either external fixation technique, the patient is seen weekly for
dressing changes and wire site care [64,65], which consists simply of
cleansing the foot, ankle, and lower limb and external fixation device with
antibacterial soap, followed by application of povidone–iodine solution to
the pin–skin interface and a petroleum- impregnated gauze wrapped around
each pin site followed by generous application of gauze pads fluffed and
placed about the space created between the foot and external fixation device
[66]. A bulky padded dressing [58] then is applied from toes to knee to limit
edema, maintain hygiene, and limit the patient’s direct view of the external
fixation device, which improves tolerance during the fairly short recovery
process while still permitting weigh sharing through a modified postopera-
tive shoe application [45] if applicable. Once completely healed, appropriate
postoperative shoe and orthoses or brace therapy is initiated and used by the
patient along with proper pedal self-care and close follow-up on an indefi-
nite basis [58].

Summary
Ulceration with infection and necrosis about the forefoot in high-risk
patients represent significant challenges to the foot and ankle surgeon.
The authors have presented a minimum-incision approach to metatarsal
ray resection that allows minimum soft-tissue dissection, which preserves
vascularity without compromising the intended goal of the procedure.
This technique allows for precise narrowing of the forefoot without the
need for osteotomy of adjacent metatarsals or their tarsal components
and affords rapid healing by means of direct primary closure, application
of a split-thickness skin graft, or use of mini- or ring-type external fixation
to facilitate delayed primary closure. Minimum-incision ray resection is
a safe, simple, reliable, and reproducible technique useful for treating local-
ized toe and forefoot ulceration, infection, and necrosis that results in a sta-
ble, plantigrade, and functional foot.

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