Ray amputations

A ray resection consists of excision of a toe and its corres

Metatarsal Transection Amputation
Fig. 8.23 A full-thickness neuropathic plantar ulcer developed beneath the 1st metatarsal, as a complication of amputation of the hallux with resectionofthelst metatarsal head.

ponding metatarsal. The most frequent complication of a ray resection is transfer ulceration. The highest success appears to be with resection of a central ray (2nd or 3rd), or 5th ray. Amputation of the hallux and 1st metatarsal frequently results in imbalance of the medial column of the foot with a poor functional outcome. Therefore, it is very important to preserve 1st metatarsal shaft length whenever possible.

Amputation of the 5th ray alone is indicated when infection and necrosis involve the 5th toe and/or the skin over the metatarsophalangeal joint. This can develop in neuroischaemic patients from unremitting pressure, caused by a tight shoe or bandage, over the lateral aspect of the 5th metatarsal head. In neuropathic individuals, repetitive moderate stress on the skin beneath a prominent 5th metatarsal head will eventually result in callus formation, ulceration and infection. The primary objective of this procedure is to achieve adequate resection of the infected or necrotic tissues, in order to create a wound that can be closed without tension. The configuration of the skin incision is determined by the extent of the infected necrotic tissues to be excised. Whenever possible, the 5th metatarsal base should be preserved together with its muscle attachments for the peroneus brevis and tertius.

This is important for the prevention of varus deformity of the foot. Varus deformity occurs when inversion of the foot is left unopposed. Following ray resection, part or all of the incision may be left open, with the patient returning to the operating theatre for delayed primary closure. Ray resections are sometimes performed as an initial incision and drainage procedure to control infection prior to a more definitive amputation.

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