Preserving the first ray or first two rays in forefoot amputation for diabetic foot ulcers

Approximately 20% of diabetic foot ulcers (DFUs) patients require lower extremity amputation, and postoperative reulceration and reamputation remains common. To clarify the biomechanical consequences and reulceration risk of different ray amputations (RAs), we built finite-element models and simulated various RAs. During the simulated gait cycle, amputation of the first ray or first two rays (1 RA and 1-2 RA) exhibited higher von Mises stress and strain values. These two RAs also generated larger plantar "danger areas" for reulceration, suggesting that 1 RA and 1-2 RA may substantially increase reulceration risk. Conversely, preserving the first ray or first two rays mitigates reulceration risk. Two clinical case examples aligned with the modelling results. This study concludes that, when feasible, preserving the first ray or first two rays helps maintain foot biomechanics and reduces reulceration risk; if 1 RA or 1-2 RA is unavoidable, transmetatarsal amputation might be more suitable.