Successful preservation of the first ray was achieved in a diabetic patient with a penetrating ulcer with underlying osteomyelitis of the first metacarpophalangeal joint and arterial insufficiency. Resection of the joint followed by stabilisation using an external fixator for four weeks resulted in permanent control of infection and preservation of the toe without recurrence of osteomyelitis or ulceration. Since preservation and correct alignment of the first ray is essential for foot stability, this technique may be beneficial in young and active diabetic patients suffering from this difficult complication of their disease.