Plantar ulcers beneath the metatarsal heads are among the most common neuropathic wounds of the diabetic foot. Most heal with sharp debridement, wound care, and sustained offloading, yet some persist for months or return soon after closure. For this subgroup, surgeons have long considered resecting the underlying metatarsal head to remove the bony prominence that concentrates pressure. This article reviews what published studies report about that approach.
Why Surgical Offloading Is Considered
Neuropathy, foot deformity, and limited joint mobility raise peak plantar pressure under the forefoot. When nonsurgical offloading fails, whether because of non-adherence, a fixed deformity, or a recalcitrant ulcer, the mechanical cause remains in place. The International Working Group on the Diabetic Foot (IWGDF) 2023 offloading guideline (Bus et al.) emphasizes non-removable knee-high devices as first-line treatment for plantar forefoot ulcers. It also discusses surgical offloading procedures, including metatarsal head resection, Achilles tendon lengthening, and arthroplasty, as options to consider when nonsurgical treatment has not succeeded. Surgery is therefore positioned as a second-line strategy, not a substitute for appropriate conservative care.
Healing and Recurrence
Yammine, Kheir and Assi (Advances in Wound Care, 2021) pooled 11 studies covering 477 patients and 593 neuropathic forefoot ulcers. In the three comparative studies, which involved recent, non-infected ulcers, metatarsal head resection was associated with significantly better healing, shorter time to healing, and lower recurrence than standard care. Failure to heal, recurrence, and infection were roughly four times more likely with standard care, and amputation about twice as likely. The case series, which included chronic, recalcitrant ulcers, reported broadly similar results.
These findings need careful interpretation. The comparative studies were retrospective, and the remaining evidence came from uncontrolled case series. Selection bias is likely, because patients offered surgery may differ from those managed conservatively in perfusion, infection status, and adherence.
Complications and Longer-Term Outcomes
A systematic review by Sanz-Corbalán and colleagues (Journal of Clinical Medicine, 2020) analyzed 21 studies with 483 patients. Mean healing time was about 16 weeks (15.9 ± 6.6 weeks) across the 11 studies reporting it. Pooled recurrence was 7.2% (95% CI 4.0–10.4), but reulceration reached 20.7% (95% CI 11.6–29.8), which the authors identified as the most common medium- to long-term complication. Pooled amputation was 7.6% (95% CI 3.4–11.8). Heterogeneity between studies was high (I² between 73% and 94% for these outcomes), and the review identified no randomized controlled trials.
Resection changes forefoot load distribution, so pressure may transfer to adjacent metatarsal heads. Transfer lesions are a recognized mechanism of reulceration, and this is one reason that postoperative footwear and offloading remain important.
Minimally Invasive Osteotomy as an Alternative
Less extensive bony procedures have also been studied. Tamir and colleagues (Journal of Orthopaedic Surgery and Research, 2016) described a mini-invasive floating metatarsal osteotomy in 17 patients with diabetic neuropathy and 20 resistant or recurrent plantar ulcers. Seventeen of 20 ulcers (85%) resolved within six weeks, and none of the healed ulcers recurred over a mean follow-up of 11.5 months. Complications included one postoperative osteomyelitis, two transfer lesions, and six asymptomatic non-unions (30%). As an uncontrolled case series, it cannot establish superiority over resection, but it illustrates that surgeons are exploring procedures that preserve more of the metatarsal.
Clinical Takeaways
Current evidence suggests that metatarsal head resection can shorten healing time and reduce recurrence in carefully selected patients with neuropathic plantar forefoot ulcers that have not responded to adequate nonsurgical offloading. The strongest signals come from observational data, and no randomized trials are available. Reulceration, transfer lesions, infection, and in some series amputation remain meaningful risks. Adequate perfusion, control of infection or osteomyelitis, and a plan for postoperative offloading and footwear are generally considered prerequisites. Surgical offloading is best understood as one tool within a multidisciplinary strategy, and higher-quality comparative trials are still needed.
References
- Bus SA, Armstrong DG, Crews RT, et al. Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2023/2024.
- Yammine K, Kheir N, Assi C. A meta-analysis of the outcomes of metatarsal head resection for the treatment of neuropathic diabetic foot ulcers. Advances in Wound Care. 2021;10(2):81–90.
- Sanz-Corbalán I, Tardáguila-García A, García-Alamino JM, et al. Metatarsal head resections in diabetic foot patients: a systematic review. Journal of Clinical Medicine. 2020;9(6):1845.
- Tamir E, Finestone AS, Avisar E, Agar G. Mini-invasive floating metatarsal osteotomy for resistant or recurrent neuropathic plantar metatarsal head ulcers. Journal of Orthopaedic Surgery and Research. 2016.
Comments
