Ray Amputation Procedure: Complete Surgical Steps
Ray amputation is a limb-sparing surgical procedure that involves removal of a toe along with part or all of its corresponding metatarsal bone to treat localized necrosis, infection, or osteomyelitis while preserving foot function.
Preoperative Assessment and Planning
- Evaluate the extent of infection, necrosis, or osteomyelitis using imaging studies (X-ray, MRI) and clinical examination
- Assess vascular status to ensure adequate blood supply for healing
- Consider antibiotic prophylaxis according to guidelines (48-72 hours maximum for open fractures) 1
- Mark surgical landmarks and plan incisions with patient in supine position
Surgical Steps for Ray Amputation
1. Anesthesia and Preparation
- Position patient supine on operating table
- Apply appropriate anesthesia (regional or general)
- Prepare and drape the foot in sterile fashion
- Apply tourniquet if appropriate for vascular status
2. Incision Design
- Create a racquet-shaped incision with the handle portion along the dorsal aspect of the metatarsal and the oval portion encircling the toe 2
- For plantar ulcers beneath metatarsal heads, consider rotational flap design to ensure adequate coverage 3
- Ensure surgical clips are placed to identify high-risk areas if margins are positive 1
3. Soft Tissue Dissection
- Incise skin and subcutaneous tissues down to bone
- Identify and ligate digital vessels and nerves
- Carefully dissect soft tissues from the metatarsal, preserving adjacent structures
- Identify and protect tendons that cross the surgical field
4. Bone Resection
- Determine appropriate level of metatarsal resection based on extent of disease
- Use oscillating saw or bone cutter to transect the metatarsal at predetermined level
- For first ray amputation, consider resection at the base of the metatarsal or through the tarsometatarsal joint if necessary
- For lesser rays, resect the metatarsal at appropriate level to allow tension-free closure
- Consider biopsy of remaining bone to ensure complete removal of infected/necrotic tissue 1
5. Soft Tissue Management
- Irrigate the wound thoroughly with sterile saline
- Consider antibiotic bead placement in cases of osteomyelitis (to be removed in staged procedure) 4
- For fifth ray amputation with lateral column instability, consider peroneal tendon transfer to the cuboid for stabilization 4
6. Closure
- Achieve tension-free closure of soft tissues
- Close deep tissues with absorbable sutures
- Close skin with non-absorbable sutures or staples
- Consider primary closure, split-thickness skin graft, or delayed primary closure with mini-external fixation device based on wound characteristics 2
7. Dressing and Immobilization
- Apply sterile dressing
- Apply well-padded splint or cast as appropriate
- Elevate extremity to reduce postoperative edema
Postoperative Management
- Maintain elevation of extremity to control edema
- Monitor wound healing and assess for signs of infection
- Begin appropriate rehabilitation once wound healing is adequate
- Evaluate for appropriate footwear or orthotic devices
- For diabetic patients, implement comprehensive wound care to achieve complete wound healing 1
Special Considerations
- First ray amputations significantly alter foot biomechanics and may lead to abnormal gait patterns requiring specialized orthotics and rehabilitation 5
- Partial first ray resections have a high rate of progression to more proximal amputations (24% progressing to transmetatarsal amputation in one study) 6
- For diabetic patients with osteomyelitis, consider staged procedures with initial debridement and antibiotic bead placement followed by definitive closure 4
Ray amputation preserves foot function while removing diseased tissue, but careful surgical technique and postoperative management are essential to prevent complications and maintain ambulatory status.