A first ray amputation involves removing part or all of the first metatarsal bone and sometimes the big toe (hallux). This procedure is most often performed on patients with diabetes-related foot complications, including infection, ulceration, gangrene, or ischemia (poor blood flow). Because the first ray plays a vital role in balance and propulsion during walking, its removal significantly affects foot biomechanics. The primary goal of surgery is to remove the diseased or infected tissue, prevent further infection, and preserve as much foot function as possible.
How Common It Is and Who Gets It? (Epidemiology)
First ray amputation is relatively common among diabetic and vascular-compromised patients. It accounts for a significant portion of partial foot amputations performed for diabetic foot ulcers, osteomyelitis (bone infection), or gangrene. Individuals with poor circulation, peripheral neuropathy (nerve damage), and recurrent ulcers are most at risk. The procedure is more frequent in older adults and those with long-standing, poorly controlled diabetes.
Why It Happens – Causes (Etiology and Pathophysiology)
Diabetic patients are prone to foot infections and tissue death because of:
- Peripheral neuropathy: Loss of sensation allows minor injuries to go unnoticed, leading to infection.
- Peripheral arterial disease: Reduced blood flow impairs healing.
- Repetitive trauma: Ill-fitting shoes or foot deformities create pressure points.
- Osteomyelitis or gangrene: Infection can spread from the skin to bone, requiring partial amputation.
When the first ray becomes severely infected or necrotic, amputation removes the affected tissue to prevent sepsis and preserve limb function.
How the Body Part Normally Works? (Relevant Anatomy)
The first ray consists of the first metatarsal bone and the big toe (hallux). It plays a key role in walking by bearing up to 40% of forefoot pressure during push-off. It helps with:
- Balance: The big toe stabilizes the body during stance.
- Propulsion: Provides the final push needed to move forward when walking.
- Shock absorption: Helps distribute load across the foot.
Removal of the first ray alters these mechanics, requiring compensation by the remaining toes and joints.
What You Might Feel – Symptoms (Clinical Presentation)
Before surgery, patients typically experience:
- Persistent infection or non-healing ulcer on the great toe.
- Foul odor, drainage, or exposed bone (signs of gangrene).
- Pain, swelling, or discoloration in the toe or forefoot.
- Difficulty walking due to deformity or tissue breakdown.
After surgery, pain is usually relieved once infection and necrotic tissue are removed, but changes in balance and walking mechanics may occur.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis is based on clinical evaluation and imaging:
- Physical exam: Assessing tissue viability, circulation, and extent of infection.
- X-rays: Identify bone involvement or osteomyelitis.
- MRI: Defines soft tissue and bone infection.
- Doppler or vascular studies: Evaluate blood flow before surgery.
- Laboratory tests: Elevated white blood cell count or inflammatory markers indicate infection.
Classification
Partial foot amputations are often classified by level:
- Toe amputation: Removal of one or more toes only.
- First ray amputation: Removal of the great toe and all or part of its metatarsal bone.
- Transmetatarsal amputation: Removal of all metatarsal heads.
- Below-knee amputation: Performed if infection or poor circulation extends proximally.
Other Problems That Can Feel Similar (Differential Diagnosis)
- Cellulitis or soft-tissue infection.
- Chronic ulceration without osteomyelitis.
- Charcot foot deformity.
- Peripheral vascular disease without necrosis.
Treatment Options
Non-Surgical Care
In early or less severe cases, conservative management may include:
- Wound care: Regular debridement and dressings.
- Antibiotics: For localized infection.
- Off-loading: Using orthotic devices to relieve pressure on ulcers.
- Vascular intervention: Restoring blood flow via angioplasty or bypass surgery.
If infection or necrosis progresses despite these measures, amputation becomes necessary.
Surgical Care
First Ray Amputation Procedure (CPT 28810):
- Anesthesia: Performed under local, regional, or general anesthesia.
- Incision: A dorsal or plantar incision is made over the first metatarsal and big toe.
- Excision: The infected or necrotic tissue, including the great toe and part or all of the first metatarsal, is removed.
- Wound Management: The wound may be closed primarily or left open for drainage if infection is extensive.
- Dressing and Off-Loading: A sterile dressing and specialized footwear or boot are applied postoperatively.
Goal: To eliminate infection, preserve the rest of the foot, and create a functional weight-bearing surface.
Recovery and What to Expect After Treatment
- Hospital Stay: Usually a few days for infection control and wound care.
- Weight-Bearing: Partial weight-bearing with crutches or walker after 2–3 weeks, progressing to full weight-bearing as healing allows.
- Physical Therapy: Essential to improve balance and gait mechanics.
- Full Recovery: Typically 6–12 weeks, though healing may take longer in diabetic patients with poor circulation.
Possible Risks or Side Effects (Complications)
- Delayed wound healing or infection recurrence.
- Ulceration or pressure sores on remaining toes.
- Balance issues and gait alteration.
- Pain or neuropathic discomfort.
- Progressive infection requiring higher-level amputation.
- Re-amputation: Nearly half of diabetic patients may eventually require a more proximal amputation if underlying disease progresses.
Long-Term Outlook (Prognosis)
First ray amputation can successfully control infection and prevent limb loss when performed promptly. However, it profoundly affects gait:
- Patients walk with a shorter stride and slower speed.
- Weight shifts to the outer foot and smaller toes, increasing stress on these areas.
- Use of custom orthotics, rocker-bottom shoes, or toe fillers helps redistribute pressure and improve walking efficiency.
Despite these challenges, most patients regain mobility with rehabilitation and appropriate footwear.
Out-of-Pocket Cost
Medicare
CPT Code 28810 – First Ray Amputation (Removal of the Great Toe and Associated Metatarsal): $97.73
Medicare Part B typically covers 80% of the approved cost for this procedure after your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield usually cover that remaining 20%, minimizing or eliminating out-of-pocket expenses for Medicare-approved procedures. These supplemental plans coordinate with Medicare to close the coverage gap and help reduce total patient costs.
If you have Secondary Insurance such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it acts as a secondary payer. These plans generally cover any remaining coinsurance or small deductibles, which typically range between $100 and $300, depending on your plan and provider network.
Workers’ Compensation
If your First Ray Amputation is required due to a work-related injury, Workers’ Compensation will cover all related medical expenses, including surgery, wound care, and rehabilitation. You will not have any out-of-pocket expenses, as the employer’s insurance carrier pays directly for all approved services.
No-Fault Insurance
If your First Ray Amputation is needed because of an automobile accident, No-Fault Insurance will generally cover the total cost of treatment, including the procedure, hospitalization, and postoperative care. The only possible out-of-pocket expense may be a small deductible or co-payment depending on your policy.
Example
Robert Hayes sustained a traumatic foot injury that required a First Ray Amputation (CPT 28810). His estimated Medicare out-of-pocket cost was $97.73. Because Robert had supplemental coverage through AARP Medigap, his remaining balance was fully covered, leaving him with no out-of-pocket expenses for the surgery.
Frequently Asked Questions (FAQ)
Q. What is a First Ray Amputation?
A. A first ray amputation involves removing part of the first metatarsal bone and, in some cases, the big toe (hallux). It is commonly performed in diabetic patients with severe foot complications like infections or gangrene to prevent further damage.
Q. Why is the First Ray Amputation important for diabetic patients?
A. Diabetic foot problems often lead to damage in the first ray, and this procedure helps prevent further infection or complications, preserving the rest of the foot and improving overall foot function.
Q. What are the impacts of First Ray Amputation on gait and quality of life?
A. The loss of the first ray can cause slower walking speeds, shorter steps, and a wider stance due to the lack of push-off from the big toe. These changes can lead to increased pain, difficulty walking, and a higher risk of falling.
Q. How does the First Ray Amputation affect joint movement and mobility?
A. Following the amputation, there may be reduced ankle joint flexibility, especially when trying to push off the ground, leading to more strain on the body and quicker fatigue.
Q. How can the First Ray Amputation lead to further complications?
A. Many patients develop additional complications, such as ulcers and infections, after the procedure, which may require more extensive surgeries like transmetatarsal amputation.
Q. How is the First Ray Amputation performed?
A. The procedure involves removing part of the first metatarsal and sometimes the big toe, often under local or general anesthesia. It may be followed by a thorough wound care plan to prevent infection.
Q. What is the recovery time for First Ray Amputation?
A. Recovery typically takes several weeks to months, depending on healing progress and the type of post-surgical rehabilitation provided. Mobility aids, such as crutches or a boot, are often necessary during this time.
Q. How does First Ray Amputation affect the appearance of the foot?
A. The foot will appear altered, with the loss of the first metatarsal and possibly the big toe. However, the primary goal is to alleviate pain and improve the ability to walk, and cosmetic concerns are secondary.
Q. What are the risks of First Ray Amputation?
A. Risks include infection, delayed wound healing, recurrence of ulcers, joint stiffness, nerve damage, and changes in foot biomechanics that could lead to further complications or amputations.
Q. Will I need physical therapy after First Ray Amputation?
A. Yes, physical therapy is often recommended to help improve strength, balance, and mobility after surgery. It focuses on helping patients adjust to walking without the first ray and preventing complications like falls.
Q. How soon can I return to normal activities after First Ray Amputation?
A. Most patients can resume light activities within a few weeks, but full recovery, including returning to high-impact activities, may take several months depending on healing progress.
Q. Can the first ray be replaced with prosthetics?
A. While prosthetics are available to help with foot function after amputation, they are usually not used to replace the first ray directly. The main focus is on preserving the remaining structure and providing support through custom orthotics.
Q. How will First Ray Amputation affect my ability to wear shoes?
A. After surgery, patients may need to wear specialized shoes or orthotics to accommodate the changes in foot structure and provide adequate support and comfort.
Q. Can the procedure be done on both feet?
A. Yes, the procedure can be performed on both feet if necessary, but typically, it is done one foot at a time to allow for proper healing and avoid complications that might arise from performing the surgery on both feet simultaneously.
Q. Is there a possibility of recurrence of foot problems after First Ray Amputation?
A. While the procedure helps alleviate immediate concerns, patients must follow a comprehensive foot care regimen to prevent complications such as infections, ulcers, or further amputations. Regular follow-up care is essential to monitor the foot’s health.
Q. What is a first ray amputation?
A. It’s the surgical removal of the great toe and part or all of its metatarsal bone, usually to control infection or gangrene.
Q. Why is this procedure necessary for diabetic patients?
A. It removes infected tissue, prevents sepsis, and preserves as much of the foot as possible while allowing better chances for healing.
Q. How does it affect walking?
A. The loss of the great toe reduces push-off power, leading to slower walking and balance changes. Orthotics and therapy help restore gait.
Q. Can more amputations occur later?
A. Yes. Diabetic patients remain at risk for new ulcers or infections, which can require additional surgery if not managed carefully.
Q. Is physical therapy important?
A. Absolutely. It retrains gait, strengthens the leg, and teaches balance techniques to reduce fall risk.
Q. Can I wear normal shoes after surgery?
A. Special diabetic or custom orthotic shoes are usually needed to protect the foot and prevent pressure ulcers.
Summary and Takeaway
A first ray amputation is a limb-saving procedure often required for diabetic patients with severe infection or gangrene. Although it alters foot biomechanics and walking patterns, it prevents the spread of infection and allows most patients to remain ambulatory. With proper rehabilitation, footwear, and blood sugar control, patients can maintain mobility and a good quality of life.
Clinical Insight & Recent Findings
Studies show that diabetic patients who undergo first ray amputation walk with shorter steps, slower speed, and a wider base, reflecting compensation for lost push-off function. Nearly 50% of patients may require further surgery, often due to recurrent ulceration or imbalance. Early intervention with custom orthotics, pressure off-loading, and physical therapy significantly improves long-term gait and reduces re-amputation risk.
Who Performs This Treatment? (Specialists and Team Involved)
The procedure is performed by a vascular surgeon, orthopedic foot and ankle surgeon, or podiatric surgeon experienced in diabetic limb salvage. The multidisciplinary team includes endocrinologists, wound care specialists, and rehabilitation therapists.
When to See a Specialist?
Patients with non-healing ulcers, toe gangrene, or chronic infection despite antibiotics should see a specialist immediately. Early evaluation improves outcomes and may prevent higher-level amputation.
When to Go to the Emergency Room?
Seek emergency care if you experience spreading redness, foul-smelling drainage, blackened tissue, fever, or severe foot pain — all signs of infection or gangrene.
What Recovery Really Looks Like?
The first few weeks focus on wound healing and infection control. As recovery progresses, patients work with therapists to regain balance and walking ability. Orthotic shoes or custom inserts help distribute pressure and restore function.
What Happens If You Ignore It?
Untreated infection or gangrene can spread rapidly, leading to sepsis or requiring below-knee amputation. Early surgical intervention prevents life-threatening complications.
How to Prevent It?
- Maintain tight blood sugar control.
- Perform daily foot checks for cuts, redness, or ulcers.
- Wear protective diabetic footwear.
- Manage peripheral vascular disease with medical therapy or revascularization when indicated.
Nutrition and Bone or Joint Health
A high-protein diet with adequate vitamins (especially vitamin C, zinc, and B-complex) supports wound healing. Diabetic patients should limit sugars and maintain optimal glucose levels to enhance recovery.
Activity and Lifestyle Modifications
After recovery, most patients can walk independently with proper footwear and gait training. Avoid barefoot walking, check feet daily for irritation, and continue regular follow-up with a podiatrist or wound specialist to prevent recurrence.
Dr. Mo Athar
