The 5th ray is amputated through a dorsolateral approach, with a racquet incision encircling the 5th toe. The toe is disarticulated at the metatarsophalangeal joint, and all necrotic tissues are excised. The incision is then extended

proximally, in a curvilinear fashion over the 5th metatarsal shaft, to the level of the base. Dissection is kept close to the bone. The soft tissues are retracted using blunt Senn retractors. The exact amount of bone to be removed is determined, at the time of surgery, by how well the skin edges can be approximated without tension. Removing more bone may facilitate closure of the wound. The 5th metatarsal shaft is cut in an oblique manner, using a sagittal saw, from distal-medial to proximal-lateral. The reason for this angled cut is to avoid a bony prominence that could cause pressure on the skin. The wound is then thoroughly irrigated with normal sterile saline solution using a pulsed irrigation system. The decision to close the wound, or to pack it open is based upon the appearance of the wound and the results of reliable wound cultures.

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