**3.3 Metatarsal head removal**

Foot surgeons have recommended metatarsal head resection to heal ulcers plantar to metatarsal heads. Even though this procedure frequently resulted in ulcer healing, transfer metatarsal ulcer frequently occurred later. Transfer ulcers occurred in 52% (53/101) of patients in the 35 months of follow-up after metatarsal head resection [3]. Repeated transfer ulcer and metatarsal head removal can result in gradual resection of the forefoot, then amputation stump ulcer and possible major amputation [42].

Tendon lengthening can be used instead of metatarsal head resection to decrease the potential for transfer ulcers resulting from the increased pressure on the forefoot. The metatarsal head should be removed if bone infection is severe enough to cause bone fragmentation or necrotic tissue. The metatarsal head can be removed if osteomyelitis persists after the ulcer healing and antibiotics completion [26].

#### **3.4 Osteotomy of metatarsal**

A high rate, 95% (21/22), of successful healing of neuropathic forefoot ulcers occurred after dorsiflexion metatarsal osteotomy [4]. However, a 68% complication rate occurred with seven patients developing acute Charcot disease, three developing midfoot ulcers, three deep wound infections, two transfer ulcers under adjacent metatarsal heads, and one transtibial amputation. Fewer complications occurred after tendon lengthening for forefoot ulcers resulted with no new or worsening Charcot arthritis or foot arthritis, new mid-foot ulcers, transfer metatarsal ulcers or wound infections [26]. After tendon lengthening complication rate is less than after metatarsal osteotomy and similar to non-operative treatment [4, 16, 26].

#### **3.5 Amputation**

Amputation becomes necessary when infection and gangrene progress. In one study of amputations in diabetic patients, 84% (67/80) were attributed to foot ulcers [16]. In diabetics with forefoot ulcers, ray amputation resulted in transfer ulcers occurred in 12% (11/89) and additional amputation in 18% (16/89) [46]. Transmetatarsal amputation has used to treat chronic diabetic forefoot ulcers [47]. This resulted in wound breakdown in 9% (8/85), transtibial amputation in 26% (17/65) and 30% (17/57) death. Tendon lengthening complication rates lower than above have been reported with for forefoot ulcers [26, 41]. To increase healing rate to 81%, Pinzur et al. recommended Achilles lengthening be done at same time as transmetatarsal amputation (52/64) [48]. Achilles tenotomy was recommended by Lieberman et al. with midfoot (Chopart) amputation for gangrene and/or infection [49]. For forefoot ulcers, tendon lengthening seems to be better than amputation. Also combining Achilles lengthening with ray or transmetatarsal amputation for forefoot gangrene and/or severe infection appears preferable. By putting glove over infected foot, doing tendon lengthening first, applying dressing to leg, removing glove and then preforming partial foot amputation, tendon lengthening can be done at time of amputation without infection of proximal incisions.

The reported amputation rate was 16% (80/514) and 17% (78/468) during three years after healing of foot ulcers, [23, 42]. No patients (0/16) required amputation for progressive infection at average follow-up of 45 months in one study of tendon lengthening for forefoot ulcers [26]. More proximal major amputation may become necessary when all other treatments fail.
