A patient with diabetes presented with ischemic gangrene of the great toe. Following vascular assessment, the necrotic hallux was deemed non-salvageable, while the first metatarsal head remained viable and free of infection. The primary goal was complete removal of the ischemic tissue while preserving the structural integrity of the forefoot.

An open hallux amputation was performed, preserving the first metatarsal head. The wound was intentionally left open because of tissue ischemia and allowed to heal by secondary intention, with regular wound care, off-loading, and close follow-up until complete epithelialization.

The wound gradually filled with healthy granulation tissue and healed completely by secondary intention without further bone resection. Preservation of the first metatarsal head maintained the first ray and helped preserve forefoot biomechanics, reducing gait disturbance while achieving definitive control of the ischemic lesion.