Complete Fifth Ray Amputation with Peroneal Tendon Transfer to the Cuboid: A Retrospective Review of

Consecutive Cases Involving Lateral Column Diabetic Foot Ulceration and Osteomyelitis
Troy J. Boffeli, DPM, FACFAS; Steven R. Smith, DPM; Kyle W. Abben, DPM, AACFAS
Regions Hospital / HealthPartners Institute for Education and Research - Saint Paul, MN
STATEMENT OF PURPOSE Figure 2: Stage 1 procedure with complete fifth ray amputation and antibiotic bead placement Table 1: Patient demographics Figure 4: Preoperative 5th This study demonstrates that those at risk for higher level amputation are those with more
comorbidities and those with delayed healing of the fifth ray amputation site. The patients that
The traditional partial fifth ray amputation technique for treatment of wounds isolated to the fifth toe
a b c
Average Age 55.7 ray ulcer location (n=20) did not heal by 10 weeks were associated with more comorbidities including diabetes, peripheral
and metatarsal phalangeal joint (MPJ) area involves removal of the fifth toe and metatarsal head. The d Sex (M:F) 15 male, 5 female
neuropathy, history of drug-resistant bacterial infection, and peripheral arterial disease and were
goal with partial fifth ray amputation is to maintain at least 50% of the proximal fifth metatarsal with more likely to require further surgery.
the intent to maintain foot structure and preserve the peroneus brevis attachment. More proximal Diabetes 16/20 HEAD Included in those comorbidities, we assessed history of MRSA/VRE infection including 8/20 (40%)
wounds at the midshaft or base of the fifth metatarsal which may be associated with prior partial ray patients in this study. This has been shown to be a predictor of higher level amputations and
Peripheral Neuropathy 20/20 present in 15-30% of diabetic foot infections (8). In our sample of patients, 3/20 patients with
amputation, Charcot arthropathy or decubitus ulceration are not amenable to this preferred
BASE
amputation approach. Surgeons are reluctant to remove the entire fifth ray yet optimum treatment Chronic Kidney Disease 7/20 6 history of MRSA/VRE infection required higher level amputation including 2 patients with delayed
frequently involves combined medical and surgical treatment with the intent to resolve the infection, wound healing who ultimately required BKA and 1 patient with wound dehiscence and eventual
Charcot Marie Tooth 2/20 10
correct bone deformity, and close the wound deficit all while preserving foot function. Partial fifth ray HEAD AND BASE Symes amputation accounting for 3/5 (60%) of the patients without a functional foot at final
amputation is a safe and reliable procedure but lateral column reulceration can occur in patients with follow-up.
(a) A dorsal flap is preserved when amputating the 5th toe. (b) The incision is extended proximally allowing fifth metatarsal resection with care taken to not violate the fourth metatarsal or cuboid Peripheral Vascular Disease 6/20 3
cavovarus foot structure, severe tailors bunion with wide fourth-fifth intermetatarsal angle, and Patients at risk for delayed would healing are also those at risk for higher level amputation. 13/20
during stage 1 surgery. (c) A string of antibiotic impregnated methyl methacrylate beads are then placed within the void created by removal of the fifth metatarsal. (d) Primary or flap closure 1 STUMP ULCERATION (65%) patients had incisions that were healed at 6 weeks and 14/20 (70%) were healed at 10
metatarsus adductus foot deformity. Medical comorbidities such as diabetes mellitus (DM), peripheral
vascular disease (PVD), neuropathy, history of MRSA/VRE infection, chronic kidney disease (CKD) and over antibiotic beads. No drain is used as local hematoma aides in the elution of antibiotics to the surrounding tissue and bone. Note how the flap was advanced to cover the plantar MPJ wound. AFTER PARTIAL 5TH
weeks. Healing was determined by the removal of sutures, no further wound care being
History of MRSA/VRE infection 8/20 RAY AMPUTATION
performed and return to ambulation in shoes. A higher proportion of patients with delayed
Charcot-Marie-Tooth (CMT) also complicate the condition and can contribute to the failure of fifth ray
amputation requiring further surgery. wound healing required higher level amputation than those with healed incisions, as 5/6 (83.3%)
Complete fifth ray amputation is sometimes indicated for complicated lateral foot wounds with care
Figure 3: Stage 2 procedure with antibiotic bead removal and peroneus longus tendon transfer into the cuboid with delayed wound healing had further surgery versus 5/14 (35.7%) with healed incisions at 10
taken to resolve midfoot wounds and osteomyelitis while preserving the functional integrity of the foot. Figure 5: Intermediate to long- Figure 6: Preop and 6 week weeks required further surgery.
An additional risk factor for delayed wound healing is continued osteomyelitis in the cuboid. 3/20
Our typical approach involves a two stage operation with initial resection of the fifth toe and entire fifth
metatarsal followed by delayed cuboid remodeling and peroneal tendon transfer 2 weeks later.
a b c d term outcome (n=20) postoperative radiographs (15%) patients had either positive culture or pathology on proximal margin cuboid biopsy, 2 of
Insertion of antibiotic impregnated beads and flap coverage of the wound are commonly incorporated whom required additional surgery including one with BKA 9.4 months later and one with revision
during the stage 1 procedure. This technique allows for complete coverage of the wound deficit, proper bone resection after flap wound closure. 15/20 (75%) of the patients in this retrospective review
Healed without were able to maintain functional ambulation without limb loss at average follow up of 38.4
diagnosis of osteomyelitis by bone biopsy, confirmation of clean bone margin, correction of underlying
bone deformity, and tendon rebalancing. Our preferred surgical technique has been previously
1 further intervention months (2.9-105). A successful result is illustrated in Figure 7 by a patient who was followed 9
described by Boffeli and Abben (1) but no outcomes have been published regarding short term healing 4 BKA years post-operatively and continues to remain ulcer free and ambulates without the aid of a
rates or limb salvage rate. The purpose of this retrospective review was to evaluate the outcomes of brace.
consecutive patients who underwent complete fifth ray amputation from 2006 through 2015 and Symes Amputation Osteomyelitis of the fifth metatarsal can be a limb and life threatening infection and this was
present the short term wound healing rates and intermediate outcomes of the procedure. (a) The distal sutures are left in place with the stage 2 procedure. The proximal portion of the incision is opened to allow removal of the antibiotic beads and hematoma washout. (b) The 10 evident in 5/20 (25%) patients in this study who required late stage BKA or Symes amputation.
1
prominent distal aspect of the cuboid is then smoothed to remove any plantar and lateral bony prominences with a portion of bone sent for clean margin biopsy (arrow). (c) The incision is then TMA BKA occurred an average of 25.9 months (range = 6 – 55.2 months) and Symes at 8 months after
MATERIALS AND METHODS lengthened proximally if needed allowing exposure to the peroneus longus tendon for transfer into a drill hole in the cuboid using an absorbable soft tissue anchor. (d) The wound is closed fifth ray amputation and was generally needed to treat recurrent wounds and infection. A
primarily and sutures are commonly left in place for another 2-4 weeks. 4 Revision bone
functional limb was present at final follow-up in 15/20 (75%) of patients who had a bad enough
An IRB approved retrospective review was performed of consecutive patients that underwent lateral column wound condition to warrant complete fifth ray amputation, which would suggest
complete fifth ray resection during a nine year span (2006-2015) by one surgeon. Data collected remodeling
reasonable success of the procedure considering the high risk nature of recurrent wounds and
included patient demographics, comorbidities, history of partial fifth ray resection, ulcer location, use LITERATURE REVIEW RESULTS osteomyelitis in this fragile population.
of antibiotic beads, incorporation of peroneal tendon transfer, bone culture results, pathology results, Osteomyelitis of the fifth metatarsal is a difficult condition to treat and complete fifth ray amputation The medical records of 20 consecutive patients who had undergone complete fifth ray resection in a Limitations to this study are related to the retrospective and descriptive nature of the study
success with initial surgical wound healing, final outcome, and follow-up time (in months). has been shown to be beneficial for both eradication of the infection and treatment of lateral column nine year period, from 2006 to 2015. Of the 20 patients, 15 were male and 5 were female, with a mean design. The study followed a small cohort of patients and therefore was not able to draw
overload (2). We typically perform complete fifth ray amputation when greater than 50 percent of the age of 55.68 (range 42 to 77) years. Average follow-up was 38.4 (range 2.9 to 105) months. Patient Figure 7: Nine year follow-up after complete fifth ray statistically significant conclusions. This study was retrospective and although consecutive, some
PROCEDURE metatarsal needs to be removed due to extent of infection or wound location. It is prudent to avoid demographics are presented in Table 1. selection bias may be involved regarding procedure selection.
leaving a prominent metatarsal base for fear of recurrent ulceration in this fragile population (1). For patients requiring complete fifth ray amputation, 6/20 (30%) patients had preoperative ulcerations resection with peroneal tendon transfer to the cuboid
The 2 stage approach to complete fifth ray amputation including antibiotic bead placement, peroneus The literature supports resection of infected or necrotic bone, as well as removal of bony prominences located at the fifth metatarsal head, 3/20 (15%) had ulcers at the base of the fifth metatarsal, 1/20 (5%) CONCLUSION
longus tendon transfer to the cuboid and flap closure was previously published by Boffeli and Abben that prevent wound healing, although careful tendon balancing of the foot must be taken into patient had ulcerations located at the metatarsal base and head, and 10/20 (50%) patients had previous
in 2012 (1).The surgical technique is presented in Figures 1-3. Previous literature has discussed fifth metatarsal resection in conjunction with peroneal tendon
consideration if altering tendon insertions (3-7). This is certainly the case when removing the base of partial fifth ray resection with midshaft stump ulceration. This data is presented in Figure 4. transfer as a way to treat cavovarus foot deformity and osteomyelitis to the fifth metatarsal. This
the fifth metatarsal with subsequent loss of the peroneus brevis tendon insertion. The concern with Regarding adjunctive procedures, 15/20 (75%) had a 2 staged approach. The decision for staged surgery retrospective review of consecutive patients treated with fifth ray amputation with peroneal
removing the entire fifth metatarsal is that if the pronatory power of the peroneus brevis tendon is was based on severity of infection and desire for implantable beads or tendon transfer. 10/20 (50%) tendon transfer and antibiotic bead placement when necessary has shown to be a reproducible
Figure 1: Incision design based on ulcer location not maintained. The supinatory strength of the posterior tibial tendon may then force the foot into an
adductovarus deformity (3). If the peroneal tendon is viable, tendon transfer should be attempted (4).
patients had antibiotic beads placed during stage 1 surgery while 16/20 (80%) patients had peroneus
longus tendon transfer to the cuboid. Of those requiring a stage 2 procedure, antibiotic beads were
procedure with fair outcomes in a difficult patient population.
Various locations for transfer of the peroneus brevis tendon have been described, including transfer
into the cuboid, base of the fourth metatarsal, and side-to-side anastomosis with the peroneus longus
implanted in 10/15 (66%) cases, and peroneal tendon transfer was performed in 13/15 (86.6%) cases.
15/20 (75%) patients had positive bone cultures during the stage 1 procedure and 2/12 (16.6%) patients
REFERENCES
a b tendon (6). Altman and Rick described transfer of the peroneus brevis tendon to the cuboid after who had stage 2 biopsy had positive bone cultures at the proximal margin (cuboid). Pathology was 1. Boffeli T and Abben K. "Complete Fifth Ray Amputation with Peroneal Tendon Transfer—A
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the soft tissue and bone are amenable. The typical patient who requires this end stage intervention surgeries included four below-the-knee (BKA) amputations at an average of 25.9 months (range 6.0 - diagnosis and direct antibiotic therapy and correction of the biomechanical issues that contributed to the 94.6 (2004): 594-60.
Fig. 1a-d. A variety of incision options are available for complete 5th ray amputation has failed more conservative treatment and is at high risk for higher level amputation due to 55.2 months), one Symes amputation at 8 months, four transmetatarsal amputations at an average of recurrent or non-healing wound. Research has previously shown that transfer of the peroneal tendons can be 7. Carlson R, Smith N, Stuck R, Sage R. Dislocation of the fifth metatarsal base following partial
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amputation of the fifth toe. Removal of the entire fifth metatarsal creates laxity in the reported for this approach. This retrospective review was performed to assess the outcomes complete fifth ray amputation (Figure 5). The remaining 9/20 patients required no further surgical study demonstrate that complete fifth ray amputation with adjunctive procedures as indicated achieves the Association 102(1): 71-74, 2012.
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