Clean Cut

Minimally invasive procedure heals diabetic foot ulcers.

Ramon Giordano, 88, grew up in an Italian neighborhood in his native North New Jersey before joining the US Air Force, finishing college and relocating to Florida. During his working career, Ramon held several jobs, but he retired as an insurance company executive. In that role, he was responsible for developing new business.

Photo by Nerissa Johnson.

A brief, in-office procedure has finally rid Ramon of his debilitating foot pain.

As Ramon neared retirement, he developed Type 2 diabetes, a condition that led to complications with his feet. One such complication developed on the bottom of his right foot at the joint where his little toe meets the ball of his foot. It was a complication that worsened considerably because Ramon’s Type 2 diabetes limits the feeling he has in his feet.

“The problem I had was my foot was always getting inflamed and sore around my small toe, and there was a wound causing the inflammation,” Ramon shares. “It hurt the most when I tried to walk, but not so much that I stopped walking. I just had to put my foot down so that the right side didn’t touch the floor.”

Despite the adjustments he made to his walking pattern, Ramon’s foot problem didn’t go away. As a result, he eventually turned to the professionals at All About Feet & Legs in St. Augustine for help. That’s where he met Rosana Rodriguez, DPM, CWS and Hany M. Jeffry, DPM, MBBS.

“What we found when Ramon came to the office was an ulcer under the head of the fifth metatarsal bone of his right foot,” Dr. Rodriguez verifies. “Essentially, the head of his metatarsal bone pointed downward, and the pressure from that caused a pre-ulcerative callus. Eventually, the callus broke open into an ulcer, and an infection developed in the area.”

Luckily, Ramon’s wound infection didn’t spread to the bone, and the doctors were able to control the infection before it developed into a limb-threatening diabetic infection.

While treating the infection, the doctors were able to achieve wound closure using an offloading pad that shifts the pressure away from the wound by temporarily lifting the metatarsal bone.

“Following up with Ramon, Dr. Rodriguez and I tried several treatments to prevent the pre-ulcerative callus from recurring under the bone, including various shoe inserts, but those efforts were not successful,” Dr. Jeffry reports. “We finally decided that Ramon’s callus was not going to heal unless we cut the bone, which would eliminate that pressure, so we performed a very minimally invasive procedure for him.”

Moving Upward

The procedure Dr. Jeffry performed on Ramon is called a dorsiflexory osteotomy of the metatarsal head. It is typically performed through a major incision in the skin through which the surgeon cuts the bone with a bone saw. Because of its invasive nature, the patient has to go under general anesthesia, and the incision from this standard version of the procedure requires at least three weeks of healing time.

For Ramon, Dr. Jeffry performed a variation of that procedure in which he created a much smaller incision, one just large enough to accommodate a much smaller bone-cutting tool. The incision is so small – about the size of a pinpoint, Dr. Jeffry relates – that it sometimes doesn’t even require sutures to close it.


“To this day, I have not had a problem with or any pain in my right foot. I have no more inflammation and no more difficulty.” – Ramon

“We use this small tool to slice through the bone from the top, away from the wound,” the doctor explains. “Once the bone is cut, we shift it upward and toward the center of the foot. That is why the procedure is called dorsiflexory. That means going up. Doing this avoids pressure on the area where the callus forms. Then we maintain the bone in its new position with wrapping and a surgical shoe.

“Once we’re done, we simply put a dressing on the wound, and it usually heals in less than two weeks,” Dr. Jeffry adds. “As we did with Ramon, we typically perform this procedure minimally invasive because it is much more tolerable for the patient. It results in less pain and has a quicker recovery time, which allows the patient to return to activities sooner.”

Following the surgery, Ramon was able to walk immediately wearing the surgical shoe. The surgical shoe helps push the bone upward and keep the correction in place.

“Bones generally take about six weeks to heal, so we typically take patients out of the surgical shoes between four to six weeks after the procedure,” Dr. Jeffry reports. “In Ramon’s case, we also performed basic wound care until his ulcer completely healed. Now, he does not even have a callus in the pressure spot, and that is very good news.”

Younger Feet

Dr. Jeffry performed the minimally invasive version of the dorsiflexory osteotomy of the metatarsal on Ramon on January 30. It was an in-office procedure that took less than an hour to complete. As expected, Ramon recovered quickly with little discomfort. And he’s delighted by the final outcome of the procedure.

“The surgery was very minor,” he says. “It was one, two, three and done, and I didn’t have to be put under for it. I was awake the whole time. They just used a local anesthetic on my foot, and I didn’t experience any pain during the surgery. Best of all, I haven’t had any pain since then either.

Before and after images courtesy of All About Feet & Legs.“To this day, I have not had a problem with or any pain in my right foot. I have no more inflammation and no more difficulty. It’s amazing what a little thing can do to you and how a minor correction can prevent the problem.”

Ramon says he’s also extremely pleased with Dr. Jeffry, Dr. Rodriguez and the staff at All About Feet & Legs. He credits them with his now healthy feet.

“Dr. Jeffry is very nice,” he comments. “I think very highly of him, even more so now that my surgery was so successful. The staff is also excellent. Everyone is very highly qualified. I’m happy to be their patient for more than fifteen years.

“The staff schedules me for routine appointments. They trim my toenails and check the bottoms of my feet. They’re always checking on me.

“Let’s face it, at eighty-eight, my feet are not as good as they were when I was nineteen, but with the help of All About Feet and Legs, they’re better now than they used to be!”

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    • All About Feet & Legs

      When you have problems with your feet, you need to turn to a podiatrist who listens and responds ... an experienced doctor who knows the field and can effectively diagnose and treat your needs ... a friendly physician who counsels you on the b... Read More

    • Hany M. Jeffry, DPM, MBBS

      Hany M. Jeffry, DPM, MBBS, is board certified by the American Board of Multiple Specialists in Podiatry for primary care in podiatric medicine. Dr. Jeffry earned a Doctor of Medicine and Surgery degree (MBBS) from King Abdul Aziz Unive... Read More

    • Rosana Rodriguez, DPM, CWSP

      Rosana Rodriguez, DPM, CWSP, is board certified by the American Academy of Wound Management and by the American Podiatric Medical Specialties Board in prevention and treatment of diabetic foot wounds. She earned her undergraduate degree from t... Read More