Abstract
Neuropathic plantar forefoot ulceration remains a difficult limb-salvage problem when recurrent or persistent ulceration continues despite wound care, accommodative offloading, and surveillance. Repetitive mechanical stress beneath the metatarsal heads is a major driver of ulcer formation and recurrence, particularly in the setting of peripheral neuropathy and structural forefoot deformity. Operative offloading procedures may facilitate healing when nonoperative treatment fails, but focal procedures may incompletely address broader forefoot overload or shift pressure to adjacent rays.
We present a bilateral case of chronic recalcitrant plantar forefoot ulceration treated with staged multiray minimally invasive distal metatarsal osteotomies designed to redistribute plantar load across the forefoot while preserving the digits and plantar soft-tissue envelope. An elderly male with long-standing type 2 diabetes mellitus complicated by peripheral neuropathy and poor glycemic control initially presented with sepsis and an exposed first metatarsal on the right foot. The right foot subsequently developed chronic overload ulceration after infection, osteomyelitis, and multiple resections/amputations that left the forefoot mechanically unbalanced. The left foot developed chronic plantar callusing and recurrent ulcer breakdown after Charcot midfoot fusion procedures despite exhaustive conservative treatment and prior surgical soft tissue balancing.
He underwent staged multiray minimally invasive distal metatarsal osteotomies, first on the right and later on the left. Postoperatively, each foot was managed with protected weightbearing in a postoperative shoe for 4 weeks, followed by diabetic shoegear. Complete epithelialization was achieved within approximately 4 weeks after each procedure. At 41 months, he remained ambulatory in diabetic shoes without assistive devices, with maintained bilateral ulcer resolution and no further operative intervention.
Introduction
Diabetes-related foot ulceration is strongly linked to repetitive mechanical stress applied to an insensate foot, especially when peripheral neuropathy coexists with structural deformity and focal plantar overload. The lifetime risk of diabetic foot ulceration has been estimated at 19% to 34%, and recurrence after healing approaches 40% at 1 year and 65% at 5 years, which has led to the concept that many healed ulcers are more accurately described as being in remission rather than cured. , Plantar forefoot ulcers are particularly challenging because the metatarsal heads are exposed to concentrated pressure and shear during gait, making durable healing difficult if the underlying biomechanical pathology is not corrected. ,
Current management emphasizes local wound care, infection control when indicated, vascular assessment, and effective offloading. International guidance continues to support nonremovable knee-high offloading as first-line treatment for uncomplicated plantar forefoot ulcers, with surgical offloading considered in selected cases when conservative care fails or when deformity prevents durable healing. Operative strategies described for neuropathic forefoot ulceration include metatarsal head resection, flexor tenotomy in appropriate digital deformity patterns, and minimally invasive surgery (MIS) floating or distal metatarsal osteotomy. ,,, These interventions can be effective, but focal procedures may incompletely address diffuse forefoot overload and may create transfer pressure to adjacent rays. ,, In carefully selected patients with chronic forefoot ulceration, preserved plantar soft tissues, and a goal of maintaining forefoot length, a tissue-preserving offloading procedure may offer an alternative to formal transmetatarsal amputation.
Our case was conceived around that limitation. Rather than treating a single symptomatic ray, the objective was broader redistribution of plantar forefoot load through multiray minimally invasive distal metatarsal osteotomies acting as an internal transmetatarsal amputation-like effect (“The Internal TMA”) while preserving the digits, plantar soft tissues, and overall forefoot length. To our knowledge, after review of the accessible literature, we did not identify a prior published report describing staged bilateral application of this specific multiray MIS construct as an internal TMA-like offloading strategy for chronic recalcitrant plantar forefoot ulceration. ,,,, We present the clinical course, surgical technique, and postoperative outcome of this limb-salvage approach in a single patient whose right and left feet reached the same mechanical endpoint through different underlying pathologies.
Case report
A now 79-year-old male with a past medical history significant for long-standing type 2 diabetes mellitus with peripheral neuropathy and insulin use, chronically poor glycemic control, coronary artery disease, chronic kidney disease stage III, and former tobacco use presented with chronic bilateral plantar forefoot ulceration that had persisted or recurred for years despite prolonged conservative treatment.
Right foot
The right foot represented a residual overload problem following infection-related damage control. The patient had a history of osteomyelitis, multiple infections, and multiple resections/amputations, including first ray amputation, resulting in a mechanically unbalanced residual forefoot. Treatment had included accommodative offloading, total contact casting, grafting, and local wound care without durable resolution. At the time of operative planning for the definitive MIS offloading procedure, the chronic right-sided ulcer was centered beneath the second metatarsal head (See Fig. 1 ). The greatest documented wound dimensions during the treatment course were 3 × 3 × 1 cm, although interval offloading had reduced the wound size by the time of surgery. There was no probe-to-bone at the time of surgery, no clinical evidence of active infection, and no evidence of active osteomyelitis at the time of the index procedure.
Preoperative clinical photograph of the right foot demonstrating chronic plantar ulceration centered beneath the second metatarsal head.
Clinical and radiographic evaluation demonstrated sequelae of resectional surgery and first ray loss with residual forefoot imbalance contributing to sub-second metatarsal overload (see Fig. 2 ). In this foot, the driving pathology was chronic plantar pressure concentration beneath the second metatarsal head produced by a structurally unbalanced forefoot after infection-related resection.
Preoperative radiograph of the right foot demonstrating prior resectional changes and first ray deficiency contributing to residual forefoot imbalance.
Left foot
The left foot represented a different pathomechanical route to the same endpoint of chronic forefoot overload. The patient had previously undergone multiple Charcot midfoot fusion procedures. Thereafter, he developed years of plantar callusing and recurrent ulcer breakdown. Because of concern regarding existing hardware and reconstructive history, conservative and intermediate surgical measures were exhausted before attempting this limb-salvage technique. Treatment included offloading, sharp debridement, total contact casting, and soft tissue balancing and tendon rebalancing to address the equinus deformity, but these measures did not provide durable ulcer resolution.
At the time of operative intervention, the left foot demonstrated two chronic plantar ulcers: one beneath the first metatarsal head measuring 2 × 1 × 0.5 cm and a second beneath the third metatarsal head measuring 1 × 1 × 0.7 cm (See Fig. 3 ). Clinical and radiographic findings demonstrated chronic structural forefoot overload in the setting of Charcot reconstruction (see Fig. 4 ). At the time of definitive MIS offloading, the left foot was being treated as a chronic salvage problem after exhaustion of standard treatments rather than as an active infectious process.
