Essential thrombocythemia is a chronic myeloproliferative syndrome characterised by excessive proliferation of platelets and megakaryocytes, with a relatively favourable course. We present a case of extreme thrombocytosis resulting from minimally invasive foot surgery with forefoot necrosis. A 72-year-old female patient presented with hallux valgus and metatarsalgia. A platelet count of 560,000/µL was detected as an unexpected finding. Minimally invasive surgery was performed, and in the first post-surgical week, skin lesions appeared on the forefoot. Three weeks later, the patient presented complete necrosis of the first toe and phlegmonosis of the forefoot. On admission, a platelet count of > 1,000,000/µl was observed. Multidisciplinary treatments were conducted. Initially, ASA 100 mg/24 h and hydroxyurea 500 mg/24 h were administrated, and clinical and analytical improvements were achieved. Two weeks later, transmetatarsal amputation and cutaneous advance flap were operated as definitive treatment. Six months later the treatment with hydroxyurea was maintained with a platelet count of 290,000/µl. In conclusion, mild thrombocythemia is considered as an unexpected finding of uncertain significance and does not contraindicate surgical treatment. Patients with mild thrombocytosis in the preoperative stage could benefit from prophylactic ASA 100 mg/24 h until the surgical treatment is completed, given the risk/benefit balance.