Complete Fifth Ray Amputation with Peroneal Tendon Transfer—A Staged Surgical Protocol

Nonhealing neuropathic ulcers overlying the fifth metatarsal are frequently associated with cavus foot structure and are often complicated by osteomyelitis. Partial fifth ray amputation for metatarsal phalangeal joint ulceration and osteomyelitis is a time-proven procedure. Recurrent wounds and persistent osteomyelitis at the amputation stump or fifth metatarsal base create significant challenges in a cavus foot with neuropathy. Long-term success with removal of the entire fifth ray is largely dependent on preventing infection of the cuboid and maintaining peroneal tendon function. The described technique demonstrates our surgical principles and technical pearls in performing a staged complete fifth ray amputation with initial antibiotic bead placement and delayed peroneal tendon transfer. The peroneus longus tendon transfer has the advantage of preserving the eversion force to counterbalance the posterior tibial tendon and allowing the first ray to elevate, thereby alleviating some of the sagittal plane deformity associated with a cavus foot structure. The surgical tips and pearls are accompanied by procedure indications and incision planning options. To our knowledge, this is the first report of a staged protocol involving complete fifth ray resection, initial antibiotic bead placement, and delayed peroneus longus tendon transfer.