A Novel Classification for Diabetic Foot Ulcers of the First Ray

Background:
Diabetic foot ulcers of the first ray are difficult to treat and prevent recurrence by conservative offloading. They result from several distinct biomechanical mechanisms related to anatomical deformities, which must be addressed, if surgical offloading is contemplated. The aim of this study is to create a classification of the anatomical deformities of first ray ulcers that could lead to better standardization of treatment and reporting.

Methods:
We reviewed files of patients with diabetic neuropathy diagnosed with first ray ulcers over a period of 3 years in an outpatient setting. Anatomical deformities were diagnosed clinically and reported with ulcer location. The primary classification was: metatarso-phalangeal joint, the inter-phalangeal joint and the distal phalanx. Chi square and Fisher’s exact test were used to prove the validity of the relationship we found between ulcer location and foot deformity.

Results:
We found records for 59 patients (mean age 62) with University of Texas A1 & A2 ulcers. The ulcer`s mean age was 2 months. The more common deformities were hallux valgus (41%) hallux valgus inter-phalangeus (14%) and hallux malleus (20%) and these were primarily associated with metatarso-phalangeal, inter-phalangeal joint and tip of toe deformities, respectively (P < 0.0001).

Conclusions:
Specific ulcer locations are related to specific anatomical deformities, and these can indicate the relevant corrective surgery. While some prophylactic procedures have been reported to be safe and effective, prophylactic hallux valgus correction in the diabetic foot still needs to be studied.