First Ray Osteomyelitis

Abstract

Osteomyelitis of the first ray is most frequently encountered in the diabetic population. However, infection may also occur due to other conditions including puncture wounds, open trauma, and infected tophaceous gout. Diabetes-related first ray osteomyelitis is generally associated with contiguous spread of infection from neuropathic ulcers or infected gangrene. Osteomyelitis along the medial column may be localized or extensive, involving the distal phalanx, the proximal phalanx, the first metatarsal, or the sesamoids. A combined medical and surgical treatment protocol is generally preferred for first ray osteomyelitis in an effort to address not only bone infection but also the soft tissue wound defect and mechanical or structural issues. The ideal surgical plan should also attempt to preserve the important weight bearing function of the first ray when possible. Partial first ray amputation is commonly performed for osteomyelitis and ranges from partial hallux amputation to complete first ray amputation. Reconstructive procedures are possible that involve limited bone resection, allow early bone biopsy, and create laxity in the tissue allowing use of rotational flaps to close the wound. The ideal procedure for a given patient should address abnormal mechanics and structural deformities yet minimize the potential for future wound breakdown. A treatment algorithm is provided to assist the surgeon with ideal procedure selection based on the extent and location of the wound and osteomyelitis as well as underlying structural deformities.