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Abstract

Background:

Diabetic forefoot ulcers often result from increased pressure on bony prominences, neuropathy, and poor limb perfusion. The management of these ulcers, particularly when infected, is challenging and can often lead to minor or even major amputation. This study aims to evaluate the efficacy and safety of minimally invasive surgical offloading of recurrent diabetic ulcers of the fifth metatarsal by minimally invasive fifth metatarsal osteotomy and bunionette removal.

Methods:

A retrospective case series study was conducted of patients who underwent surgical treatment for diabetic foot ulcers on the lateral or plantar side of the fifth metatarsal head between January 2020 and May 2025. Outcomes included time to healing of the primary ulcer and surgical wound, ulcer recurrence, postoperative complications, and reoperation rates. Clinical and radiologic parameters of the feet were assessed, and patient satisfaction Coughlin scores were collected.

Results:

Ten feet from 9 patients who did not respond successfully to conservative offloading were included. The mean age of the patients was 69.5 years. Five feet were classified as Wagner grade 3 wounds, and 4 as Wagner grade 2 wounds. The ulcers healed completely in a mean time of 9.8 weeks postoperatively. Two patients required 6 weeks of antibiotic treatment because of preexisting osteomyelitis. One postoperative infection occurred. There were no corrective failures, and all patients returned to wearing orthopaedic shoes postoperatively. The overall patient satisfaction using the Coughlin satisfaction score was “good” to “excellent.”

Conclusion:

Minimally invasive fifth metatarsal osteotomy with bunionette removal appears safe and effective for treating refractory diabetic ulcers of the fifth metatarsal head, including cases with active infection. However, larger studies with functional outcomes are needed to establish definitive treatment guidelines.

Level of Evidence:

Level IV, case series.

Keywords

diabetic foot ulcers minimally invasive wound infection bunionette

Introduction

Diabetic foot ulcers (DFUs) are a common and serious complication in patients with diabetes, often leading to significant morbidity and health care challenges. DFUs occur in approximately 18.1% of diabetic patients worldwide.² The management of these ulcers, particularly when infected, is challenging and often leads to toe or forefoot amputation. Patients with diabetic neuropathy may develop an ulcer because of an acute injury. More commonly, however, a neuropathic ulcer develops because of increased local pressure due to biomechanical deformities of the foot. Sometimes poor limb circulation is also associated with ulceration. Ulcers often develop on the metatarsal heads, where flexion deformity often leads to increased local pressure.⁸ One of the most common sites for ulceration is the plantar or lateral aspect of the fifth metatarsal head, which may be seen in tailor’s bunion or quintus varus.⁴ Ulcers at that location are particularly difficult to treat and recur frequently after healing. Conservative management, which includes offloading, wound care, and antibiotics, is usually the treatment of choice, but can be prolonged and does not always provide satisfactory results. If healing is achieved, orthotics or orthopaedic shoes are needed to prevent recurrence.¹¹ However, neuropathic ulcers due to tailor’s bunion are often refractory to treatment and/or recur frequently because of the anatomical deformity.⁶ In these cases, surgical off-loading may be a solution.^4,19 Several techniques have been described for surgical offloading of the metatarsal head. These include plantar condylectomy, Weil osteotomy (with or without additional fixation), closing-wedge metatarsal osteotomy, Helal osteotomy, and metatarsal head resection.^{1,10,13,18,22} However, these methods often involve extensive soft tissue dissection and pose risks, especially in diabetic patients with active ulcer, osteomyelitis, or osteoporotic bone. Minimally invasive surgery (MIS) has emerged as a promising alternative. MIS aims to correct deformities through tiny percutaneous incisions using high-speed burrs under control of fluoroscopic imaging.

This study aims to evaluate the efficacy and safety of minimally invasive fifth metatarsal osteotomy for recurrent ulcers on the lateral or plantar side of the fifth metatarsal that are unresponsive to conservative treatment.

Materials and Methods

All patients included in this study were identified from the diabetic foot database at the Multidisciplinary Diabetic Foot Clinic (MDFC) who underwent MIS for recurrent ulcers located on the plantar or lateral side of the fifth metatarsal between January 2020 and May 2025. The inclusion criteria consisted of patients aged 18 years or older, diagnosed with type 1 or 2 diabetes mellitus, and presenting with recurrent forefoot ulcers at the plantar or lateral side of the fifth metatarsal that were refractory to conservative treatment. Patients without diabetes mellitus were excluded from this study.

Ethical approval to report this case series was obtained from the hospital’s ethics committee (approval number: 2025/097). Patients provided verbal informed consent to conduct the study, publish the study, and have their photos or other images used.

Electronic patient records were reviewed to gather data on age, gender, comorbidities, American Society of Anesthesiologists (ASA) classification, diabetic foot–related variables, ulcer-related variables, treatment-related variables, and treatment outcomes.

Data from 10 feet of 9 patients were included in this study.

Collected information included age, sex, affected side, preoperative HbA_1c, body mass index (BMI), smoking status, the Wagner grade of the ulcer, the time from the first presentation with the ulcer to the surgery, the preoperative vascular status of the patient, the requirement for antibiotic therapy before and after surgery, type of shoe used before and after surgery, ASA score, time to bone healing, time to ulcer healing, pre- and postoperative intermetatarsal (IM) and metatarsophalangeal (MTP) angles, follow-up duration, the ability to walk before and after surgery, and whether additional foot surgery was performed on the same foot. ASA classification and HbA_1c levels were collected to assess the general health status and glycemic control of the included patients. Patient satisfaction was assessed using the Coughlin score (rated as excellent, good, fair, or poor).⁷

Digital radiographs were used for the evaluation of bone consolidation at the osteotomy site and to measure pre- and postoperative IM and MTP angles.

Surgical Technique

All surgeries were performed by a single foot and ankle surgeon (W.R.), who has completed advanced training in MIS of the foot and ankle. Two grams of cefazolin were administered 15 minutes before the start of the procedure. The surgery was performed under locoregional anaesthesia (popliteal sciatic nerve block) with the patient in a supine position and the foot placed at the edge of the operating table. A mini-C-arm fluoroscopy unit was positioned on the contralateral side of the operated limb to facilitate intraoperative imaging, using both anteroposterior (AP) and lateral views. No tourniquet was used during the procedure. The lower leg was prepped with chlorhexidine and draped in a sterile manner.

The surgery began with debridement of the forefoot ulcer located on the lateral or plantar side of the fifth metatarsal head until only healthy tissue remained. Figure 1 illustrates a case of an acute diabetic foot attack, triggered by a plantar ulcer over the fifth metatarsal. Initial management included surgical debridement of the wound and dorsal foot compartments, followed by placement of a drain.

Figure 1.

Patient with a diabetic foot attack, triggered by a plantar ulcer over the fifth metatarsal.

Figure 2 demonstrates the clinical resolution of the acute diabetic foot attack 1 week following surgical debridement.

Figure 2.

Same foot 1 week following surgical debridement with resolution of the foot attack.

The second stage involved surgical offloading of the fifth metatarsal head through a minimally invasive fifth metatarsal osteotomy combined with a bunionette removal, as detailed below.

The 3-mm incision was made approximately 1 cm proximal and dorsal to the bunionette, using a beaver blade, allowing access to both the lateral condylectomy and the oblique osteotomy through a single small portal. This dorsal-proximal orientation provides a safe angle for burr insertion while ensuring that the entry point remains outside the ulcer area and at a safe distance from the pressure zone. Percutaneous rasps were then introduced to separate the joint capsule from the condyle. One milliliter of saline was injected for joint capsule distention, creating an aqueous workspace and minimizing thermal damage. A 2.2 × 12-mm straight burr (Arthrex, Tampa, FL) was used to perform a limited resection of the lateral condyle (Figure 3). Continuous irrigation was employed to cool the burr and bone, and intracapsular bone debris was removed using rasps. The lateral condylectomy was verified through fluoroscopic control.

Figure 3.

Introduction of a 2.2 × 12-mm straight burr (Arthrex) to perform a limited resection of the lateral condyle.

Using the same lateral incision, the burr was introduced to perform the metatarsal osteotomy. The osteotomy site was located at the distal third of the diaphysis and confirmed under fluoroscopy (Figure 4). The osteotomy was made from dorsal-distal to plantar-proximal in the sagittal plane and from medial-proximal to lateral-distal in the axial plane. Figure 5 confirms this osteotomy orientation allowed for slight shortening of the fifth metatarsal, aiding offloading while preventing dorsal displacement of the metatarsal head.

Figure 4.

Osteotomy at the distal third of the diaphysis confirmed under fluoroscopy.

Figure 5.

Slight shortening of the metatarsal following the osteotomy.

A lateral condylectomy was performed in addition to the oblique osteotomy for 2 reasons: first, to enhance offloading in patients with limited joint mobility and stiffness, where osteotomy alone might be insufficient; and second, to remove compromised bone in cases where destructive changes of the lateral condyle or bunionette were present directly under the pressure ulcer, often because of postinfectious involvement.

In general, we aimed to avoid the use of a Kirschner (K)-wire in patients with active infection. However, in cases where sufficient offloading could not be achieved intraoperatively with condylectomy and osteotomy alone, because of joint stiffness or limited mobility, a temporary K-wire was placed to maintain alignment (Figure 6). A single 1.5-mm K-wire was used to stabilize the osteotomy. The K-wire was passed distally through the incision along the soft tissue of the lateral fifth toe, exiting at the medioplantar aspect of the toe tip. It was then inserted retrograde into the medullary canal of the fifth metatarsal. After confirmation of clinical and radiologic correction, the wound was closed using 3/0 nonabsorbable sutures (Figure 7). A protective bandage was applied to cover the surgical wounds and K-wire.

Figure 6.

Maintenance of the correction using a K-wire due to rigid resistance of the lesser toe after osteotomy.

Figure 7.

Wound closure using 3/0 nonabsorbable sutures.

Full weightbearing was permitted 1 day postoperatively, using a postoperative shoe with a flat, rigid sole. Bandages were changed after 1 and 3 weeks. The K-wire and sutures were removed 3 weeks after surgery. Patients were advised to rest and elevate the foot during the first 2 weeks to minimize swelling, pain, and inflammation. Patients with active infection were treated as having osteomyelitis, receiving 6 weeks of antibiotic therapy, with the first 2 weeks administered intravenously.

Postoperative weightbearing protocols remained the same for both patients with and without K-wire fixation. However, wound care was adapted and closely monitored in cases with K-wire fixation and infection to account for the presence of infection and hardware.

The postoperative shoe was used for 6 weeks before transitioning to custom orthopaedic shoes. Figure 8 shows complete ulcer healing 10 weeks after surgical offloading in the same case as above.

Figure 8.

Complete ulcer healing at 10 weeks following surgical offloading.

Postoperative radiographs were taken at 6 weeks and 3 months postoperatively, and at the final follow-up. Standardized weightbearing anteroposterior and lateral foot radiographs were used for radiologic evaluation. Figure 9 demonstrates radiographic evidence of bone consolidation at the osteotomy site 3 months postoperatively.

Figure 9.

Radiographic consolidation of the osteotomy site at 3 months.

Results

This study included 10 feet from 9 patients with recurrent active diabetic ulcers of the fifth metatarsal head, who did not respond successfully to conservative therapy. The mean age of the patients was 69.5 (range 49-84) years (median age 65 years; range 49-84). There were 8 male and 2 female patients. The mean HbA_1c was 6.82 (range 5.5-8.4) mg/dL (median HbA_1c 7 mg/dL; range 5.5-8.4). The mean BMI was 31.11 (range 26-37) (median BMI 31.4, range 26-37). Of all patients, 5 had never smoked, 3 stopped smoking more than 10 years ago, and 1 patient was still actively smoking. Five patients had previously undergone vascular surgery. Seven patients were previously treated with a felt and thick cotton bandage in a hard-soled shoe for several weeks, 6 of which received antibiotic treatment for several weeks. Of all patients, 7 patients received antibiotic treatment preoperatively orally or intravenously for treatment of a preoperative infection. Two patients were previously treated with custom-made orthopaedic shoes with custom-made insoles preoperatively (Table 1).

Table 1.

Baseline Characteristics of the population.

Patient	Age (y)	Time to surgery (wk)	Sex	BMI	Typeof DM	Wagner Stage	Comorbidities	Preoperative Treatment	Smoking Status	Ulcer Side	Preoperative Vascular Surgery	Timing of Vascular Surgery Before Orthopaedic Surgery(Number of Months Ago)
1	63	72	Male	37	2	3	Obesity, COPD, psoriasis, hyperlipidemia, colitis ulcerosa	- Orthopaedic shoes - Hard-soled shoe (with felt and thick cotton bandage) for 6 mo - ATB: oral for 3 mo	Stopped 2013	Left	PTA bilateral superficial femoral arteries + stenting left superficial femoral artery Pulses: DP+, TP+	10
2	84	44	Male	31.3	2	2	Obesity, COPD, arterial hypertension	- Hard-soled shoe (with felt and thick cotton bandage) for 1 mo - ATB: oral 3 periods of 10 d	Stopped 2008	Left	PTA superficial femoral artery left + tibiofemoral truncus left Pulses: DP-, TP+	6
3	81	2	Male	31.5	2	1	Obesity, arterial hypertension, hyperlipidemia, hypercholesterolemia, NSTEMI 2005, polymyalgia rheumatica with corticoid therapy, Multiple CABG surgery, spondylarthrosis, Stroke	- Hard-soled shoe for 3 mo - Orthopaedic shoes - ATB: IV 5 for d + oral for 3 wk	No	Right	PTA and stenting superficial femoral artery right + PTA deep femoral artery right + PTA anterior tibial artery right Pulses: DP+, TP+	5
4	75	16	Female	29.4	2	3	Obesity, rheumatoid arthritis, hypercholesterolemia, arterial hypertension	- Hard-soled shoe (with felt and thick cotton bandage) for 6 wk - ATB: oral for 6 wk	No	Right	No vascular intervention performed Pulses: DP+, TP+	/
5^a	65	21	Male	32	2	2	Obesity, arterial hypertension, hypercholesterolemia	- Hard-soled shoe (with felt and thick cotton bandage) - ATB: IV for 4 wk	No	Right	No vascular intervention performed Pulses: DP+, TP+	/
	65	24	Male	32	2	3	Obesity, arterial hypertension, hypercholesterolemia	- Orthopaedic shoes- ATB: IV for 4 wk	No	Left	No vascular intervention performedPulses: DP+, TP+	/
6	80	3	Male	26.4	2	3	Arterial hypertension, dyslipidemia	- No weightbearing for 3 wk- ATB: oral for 4 wk	Stopped 1991	Right	No vascular intervention performedPulses: DP+, TP+	/
7	49	29	Male	29.1	1	3	Obesity, nephropathy, renal-pancreas tumor	- Hard-soled shoe (with felt and thick cotton bandage) for 6 mo- ATB: oral for 2 mo	No	Right	PTA dorsalis pedis artery rightPulses: DP+ (not strong), TP+	6
8	62	28.5	Male	26	2	2	Obesity, arterial hypertension	- Hard-soled shoe (with felt and thick cotton bandage) for 7 mo	Yes	Left	PTA superficial and deep femoral artery leftPulses: DP+, PT+	3
9	71	37	Female	36.4	2	2	Obesity, arterial hypertension, chronic kidney insufficiency stage 3, hepatic steatosis	- Orthopaedic shoes for 9 mo	No	Right	No vascular intervention performedPulses: DP+, TP+	/
Mean/Median	69.5	27.6		31.11		2.4

Abbreviations: ATB, antibiotic therapy; BMI, body mass index; CABG, coronary artery bypass grafting; COPD, chronic obstructive pulmonary disease; DP, dorsalis pedis artery; DM, diabetes mellitus; IV, intravenous; NSTEMI, Non-ST-Elevation Myocardial Infarction; PTA, Percutaneous transluminal angioplasty; TP, posterior tibial artery.

Note that patient 5 has had surgery to both feet.

All but 1 patient had an active forefoot ulcer at the time of surgery. The mean duration from the initial appearance of the ulcer to surgery was 25 (range 1.43-72) weeks (median duration 22.5 weeks; range 1.43-72). Five patients presented with a Wagner grade 3 forefoot ulcer, whereas 4 had a Wagner grade 2 ulcer, and 1 had a Wagner grade 1 ulcer. Preoperatively, 5 patients were ambulating with orthopaedic shoes, and the remaining 4 required offloading devices, such as hard-soled postoperative shoes or walkers, because of active forefoot ulcers. Four patients had a hard-soled shoe. Two combined with thick cotton padding, whereas 2 other patients had a felt padding. Six patients received antibiotic therapy for ulcer superinfection prior to surgery. The median ASA score was 3. One patient underwent bilateral foot surgeries in 2 stages.

The mean preoperative IM angle was 9.25 (range 3.2-13.5) degrees (median 10 degrees; range 3.2-13.5), and the mean preoperative MTP angle was 10.44 (range 1.4-16.7) degrees (median 11.5 degrees; range 1.4-16.7). Postoperatively, the mean IM angle was 4.89 (range 1.7-8.2) degrees (median 5.2 degrees; range 1.7-8.2), and the mean MTP angle was 3.02 (range −8.6 degrees to 12.2) (median 4.3 degrees; range −8.6 degrees to 12.2).

Three patients underwent additional forefoot surgery at the time of the procedure: one patient had a hallux valgus correction, another had a second toe amputation because of a recurrent ulcer following a previous amputation, and a third patient had a distal soft tissue release and hammertoe correction of the fifth toe. All but 2 patients were treated in 1 stage with debridement of the ulcer and unloading osteotomy. Two patients had a diabetic foot attack episode needing debridement and antibiotic therapy following International Working Group on the Diabetic Foot (IWGDF) guidelines¹² in the first stage, followed by the minimally invasive osteotomy in a second stage.

All patients achieved complete ulcer healing. The mean follow-up period was 136.4 (range 31-270) weeks (median 136.5 weeks; range 31-270), and the mean time to complete ulcer healing was 9.8 (range 4-24) weeks (median 9 weeks; range 4-24). The mean time to bone healing was 12 (range 6-24) weeks.

After ulcer healing, all but 1 patient was able to walk with orthopaedic shoes, whereas 1 patient resumed walking with semiorthopaedic shoes. One patient required postoperative antibiotic therapy due to postoperative infection, and 1 patient continued his preoperative antibiotic regimens postoperatively. One patient had a recurrent ulcer at the head of the fifth metatarsal with reinfection 3 years following the unloading surgery requiring debridement and antibiotic therapy (Table 2). Clinically, all but 1 patient remained ulcer-free at final follow up.

Table 2.

Characteristics of the Surgery and Results After the Surgery.^a

Patient	Surgery With K-Wire	One- or 2-Stage Surgery	Postop ATB	Postop Complications	IM Angle Preop/Postop (degrees)	MTP Angle Preop/Postop (degrees)	Time to Bone Consolidation (wk)	Time to Heal Ulcer (wk)	Follow-up (wk)	Coughlin Score
1	No	1 stage	No	Reinfection MT5 3 y postop debridement	11.9/3.7	9.1/7.3	24	24	270	Good
2	No	1 stage	No	None	9/6.1	8.4/4.3	–^b	4	216	Excellent
3	No	1 stage	Yes	Postop infection	5.2/5.2	16.7/12.2	–	7	203	Fair
4	Yes	1 stage	No	None	10.6/2.7	16.2/7.9	11	6	191	Good
5	Yes	1 stage	Yes	None	10/7.1	12.8/1.9	9	9	138	Excellent
	Yes	1 stage	No	None	12/6	11.5/3.9	6	6	135	Excellent
6	Yes	1 stage	No	None	3.2/1.7	5.3/-6.9	10	10	54	Good
7	Yes	2 stages	No	None	13.5/6.2	15.6/4.3	12	10	59	Good
8	No	1 stage	No	Persistent pain	6.9/2	1.4/-8.6	18	18	67	Fair
9	Yes	2 stages	No	None	10.2/8.2	7.4/3.9	6	4	31	Excellent
Mean/median					9.25/4.89	10.44/3.02	12	9.8	136.4/136.5	Good

Abbreviations: ATB, antibiotic therapy; IM, intermetatarsal angle; MTP, metatarsophalangeal.

Note that patient 1 has had a recurrent ulcer with infection at the fifth metatarsal head needing debridement. Patient 7 has had a 2-stage treatment of the foot ulcer because of a foot attack episode needing debridement and antibiotic therapy following International Working Group on the Diabetic Foot guidelines, followed by the minimally invasive osteotomy in a second stage.¹⁴ Also note that patient 3 has only had a condylectomy.

Pseudarthrosis.

Radiographically, we achieved a mean correction of the intermetatarsal (IM) angle of 4.36 degrees and a mean correction of the metatarsophalangeal (MTP) angle of 7.42 degrees. One patient developed a pseudarthrosis, whereas some other patients showed delayed union, although without clinical symptoms. Note that 1 patient showed destructive changes or deformity of the MTP joint on radiographs, likely as a result of postinfectious arthritis or previous osteomyelitis, but no limitation in pain or function was reported.

The overall patient satisfaction using the Coughlin satisfaction score was “good” to “excellent.”⁷

Discussion

MIS techniques have demonstrated safety and efficacy for forefoot deformity correction over the past decade.^{15,16,17,20,21} This study presents outcomes of combined minimally invasive fifth metatarsal osteotomy and bunionette removal for recalcitrant diabetic foot ulcers, including cases with active infection. To our knowledge, this is one of the first case series describing MIS techniques specifically for diabetic foot ulcers in the presence of active infection, although the small sample size and lack of functional outcome measures limit definitive conclusions.

The initial approach to treating forefoot ulcers over the fifth metatarsal head typically involves conservative management, which includes offloading techniques such as total contact casts, stiff-soled wound shoes (with a bandage using a thick cotton layer or felt), or diabetic walkers. However, when conservative measures fail, surgical intervention may be considered. The failure of conservative treatment could be due to several factors, including poor patient compliance, inappropriate offloading devices, severe deformities with rigid characteristics, or active osteomyelitis. Preventing recurrence after conservative treatment remains a major challenge for clinicians managing diabetic foot ulcers, as structural deformities often persist after offloading devices are removed.

Various surgical techniques have been proposed for offloading, including Achilles tendon lengthening, osteotomies, metatarsal head resection, and limited amputations. Tamir¹⁹ suggested that ulcers penetrating deep structures with infection, classified as Wagner type 2 and 3 lesions, were contraindications for surgery. Fleischli et al reported on 20 diabetic patients who underwent 22 open dorsiflexion metatarsal base osteotomies with internal fixation for chronic, persistent, or recurrent neuropathic forefoot ulcers. Complete ulcer healing was achieved in 21 cases (95%); however, complications occurred in 15 cases (68%), including acute Charcot disease (32%), deep wound infections (14%), and transfer lesions (9%). No cases of ulcer recurrence were reported.⁹ Although the open procedure was effective, it was associated with a high complication rate because of the required soft tissue dissection, osteotomy, joint realignment, and internal fixation. In patients with ulcers, osteomyelitis, and osteoporotic bone, such invasive procedures may increase the risk of complications, including wound infections, necrosis, hematoma, nonunion, and osteosynthesis failure.

On the other hand, MIS techniques offer potential advantages, such as minimal skin and soft tissue dissection, the bio-friendly nature of bone debris acting as an osteoconductive scaffold, the versatility and multiaxial character of the osteotomy, and the nonmandatory use of hardware. These factors contribute to a potentially lower complication rate.

Tamir et al²¹ demonstrated that minimally invasive floating metatarsal osteotomy can be effective in the treatment of diabetic plantar pressure lesions. However, their heterogeneous patient group included only 16% with isolated ulcers beneath the head of the fifth metatarsal. Notably, in that study, 50% of patients who underwent an isolated fifth metatarsal floating osteotomy developed a postoperative transfer ulcer. In contrast, none of the patients in our cohort developed transfer lesions, which may be attributed to a more controlled surgical technique and the stabilization of the osteotomy using a compressive bandage and/or K-wire fixation.

In our technique, uncontrolled dorsal displacement of the fifth metatarsal head is specifically avoided, as we believe this may lead to secondary overloading of the adjacent fourth MTP joint and potentially cause a transfer ulcer beneath the fourth MTP joint. This complication has been described in association with floating osteotomies and metatarsal head resections. Our oblique osteotomy orientation was therefore chosen to allow slight shortening and medial shift for offloading, while preserving stable plantar support and minimizing the risk of transfer lesions.

Given that the patency of endovascular interventions tends to decline over time, especially in small-caliber distal arteries such as those supplying the foot, we aimed to perform surgical offloading as soon as possible after vascular treatment to maximize tissue perfusion and optimize healing conditions. We however consider that after a successful endovascular procedure, transient edema often occurs, probably because the venous circuit needs some time to adjust to the sudden increase in inflow. If possible, we waited with the procedure until this edema had sufficiently subsided.

This study differs from previous research in several aspects, which may be considered controversial. Unlike many other cohorts, this study population included patients with active pressure ulcers, some of whom presented with ongoing soft tissue infection or osteomyelitis. Additionally, in certain cases, K-wires were used to stabilize the correction, even within the infected region.

In this study, all ulcers (100%) healed completely after surgical offloading, even in cases with Wagner grade 3 lesions and superinfection at the ulcer site (Figure 6). This demonstrates that minimally invasive offloading can be an effective technique for treating complex cases with deep ulcerations and superinfection. Postoperatively, all patients returned to ambulatory status with orthopaedic shoes, and in 1 case, the surgery significantly improved mobility as the patient had been unable to walk preoperatively because of the ulcer.

Radiographic follow-up showed that adequate correction of the IM angle and MTP angle was achieved using MIS. All patients who developed a pseudarthrosis or delayed union were clinically asymptomatic. This was likely due to neuropathy. These findings align with previous studies reporting delayed union after percutaneous surgery on the lateral metatarsals.^5,15,16 At final follow-up, 1 patient showed destructive changes or deformity of the MTP joint on radiographs, likely as a result of postinfectious arthritis or previous osteomyelitis (Figure 9). This had been addressed during earlier treatment stages. Notably, because of diabetic neuropathy, this patient reported no pain or functional limitation.

Further, ASA classification and HbA_1c levels were recorded as indicators of overall health and glycemic control. Given the small sample size and limited statistical power, no analysis of their association with healing time was performed. This limitation highlights the need for future prospective studies to examine these factors systematically.

Smoking is also a well-established factor to impair wound healing through multifactorial mechanisms, most notably via compromised microcirculation. Obesity may also contribute to delayed healing by increasing mechanical load on pressure areas and by impairing venous return secondary to elevated intra-abdominal pressure. We concur that these comorbidities are likely to influence healing outcomes; however, in the present study the sample size was insufficient to demonstrate a statistically significant association.

In patients with recurrent ulceration at the plantar or lateral aspect of the fifth metatarsal head, particularly those with rigid deformities unresponsive to conservative treatment, prophylactic minimally invasive offloading may be a valuable strategy. Our cohort showed high healing rates following MIS in such cases, supporting a potential role for earlier surgical intervention in high-risk diabetic patients, even before ulceration occurs. Other MIS procedures, that have shown potential for prevention are digital flexor tendon tenotomy and Achilles tendon lengthening.³

Future studies are needed to assess the preventive value of MIS fifth metatarsal osteotomy and bunionette removal and its effect on reducing ulcer recurrence, infection, osteomyelitis, or minor amputation. These studies should include larger sample sizes and consider both general risk factors (vascular status, glycemic control, BMI, smoking) and biomechanical variables (posterior chain function, hindfoot alignment, tarsometatarsal joint mobility, and sagittal position of the metatarsal head) to identify patients who would benefit most.

This study has several important limitations that must be acknowledged. First, the small sample size of 10 patients limits statistical power and generalizability of findings. Second, the retrospective design and lack of standardized treatment protocols introduce potential selection bias. Third, we did not assess functional outcomes, pain scores, or quality of life measures, which are crucial for determining clinical success. Fourth, the lack of a control group prevents comparison with alternative treatments or natural history. Fifth, the follow-up period varied significantly between patients (31-270 weeks), potentially affecting outcome assessment. Finally, although we describe this as one of the first series using MIS in infected diabetic ulcers, the controversial nature of operating in infected tissue requires validation in larger studies. Future prospective studies with larger cohorts, standardized protocols, and comprehensive outcome measures are essential before recommending widespread adoption of this technique.

Conclusion

This relatively small case series suggests that minimally invasive fifth metatarsal osteotomy with bunionette removal may be a viable treatment option for refractory diabetic foot ulcers, even in the presence of infection. All ulcers healed with acceptable complication rates, although radiographic delayed union was common but asymptomatic. However, the significant limitations of this study—including small sample size, lack of functional outcome measures, and absence of a control group—preclude definitive recommendations. Well-designed prospective studies with comprehensive outcome assessments are essential to establish the role of this technique in diabetic foot care.

Supplemental Material

sj-pdf-1-fao-10.1177_24730114251375029 – Supplemental material for Minimally Invasive Fifth Metatarsal Osteotomy and Bunionette Removal for Recurrent Diabetic Foot Ulcers: A Case Series

Supplemental material, sj-pdf-1-fao-10.1177_24730114251375029 for Minimally Invasive Fifth Metatarsal Osteotomy and Bunionette Removal for Recurrent Diabetic Foot Ulcers: A Case Series by Baïdir Haloui, Frank Nobels and Wahid Rezaie in Foot & Ankle Orthopaedics

Footnotes

ORCID iD

Baïdir Haloui, MD,

Ethical Considerations

Ethical approval to report this case series was obtained from the Azorg ethics committee (approval number: 2025/097).

Consent to Participate

Informed consent was obtained verbally before participation.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Wahid Rezaie, MD, reports disclosures related to manuscript of course instructor for a minimally invasive surgery (MIS) course organized and supported by Arthrex, for which he receives a consultant fee. Disclosure forms for all authors are available online.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, H.B., upon reasonable request.

Consent to Publish

Informed consent was obtained verbally before manuscript submission.

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