Rotational Flap Closure of First and Fifth Metatarsal Head Plantar Ulcers: Adjunctive Procedure When Performing First or Fifth Ray Amputation

Partial ray amputation is a common treatment of diabetes-related neuropathic ulcers located beneath the metatarsal heads. The standard incision for partial first or fifth 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 flaps. This incision works well when the ulcer is located within the excised soft tissue distal to the incision or when the plantar ulcer is superficial and will heal secondarily once the underlying bone has been removed. This standard first or fifth ray amputation incision does not, however, allow excision and closure of plantar ulcers located beneath the first or fifth metatarsal head. Two cases are presented to demonstrate our surgical protocol for partial first or fifth ray amputation using a local rotational flap to cover plantar metatarsal head ulcers. These cases highlight our patient selection criteria, staging protocol when cellulitis or abscess is present, rotational flap design, surgical technique pearls, and the typical postoperative healing progress.