PIP (Proximal Interphalangeal) Joint Fusion
Edited by Robert Leland, MD
The PIP is the first joint of the small toes. The indication for surgery is when this joint has a fixed curved (Clawtoe or Hammer Toe) deformity and when the deformity is producing enough pain or functional limitations to warrant surgery. The deformity develops gradually and cannot be straightened because it is bent and fixed in this position for a long period of time. The procedure essentially straightens the joint and fuses the proximal and middle phalanx (toe bones) in the straightened position.
There are a variety of ways that a PIP joint fusion can be performed. The joint can be approached either through a longitudinal or transverse incision on the top of the toe. Once the joint is opened up, a small segment of bone is removed from either side of the joint, which creates enough room for the joint to straighten. The joint is then fixed in the straightened position, either with a wire or occasionally with an internal screw. This procedure is usually done in association with other procedures, such as a tendon transfer, to help keep the toe in the newly straightened position (ex. Girdlestone-Taylor procedure, Extensor Tendon Lengthening ). Additional procedures to address underlying mechanical problems such as a gastrocnemius contracture or hypermobile first ray, which may have caused the small toe deformities, may be corrected in addition to the PIP joint fusion.
Recovery from this surgery needs to take into consideration any other operative procedures that were done in conjunction with this surgery. Recovery from a PIP joint fusion typically takes about 6 weeks, although the toe can remain swollen for much longer. During this time, it is usually necessary to keep the joint immobilized in the new position. It’s sometimes possible to have the patient weight bear through the heel during this period. If a wire (pin) is used to maintain the toe in a straightened position, it will be removed between 2 and 6 weeks post-surgery.
- Infection around the wire penetration site. If a wire is used to maintain the position, keeping the tip of the toe clean is very important until the pin is removed. This normally needs to stay clean, dry, and protected from possible trauma.
- Stiffness and rigidity of the toe. This comes not just from the toe being fuse, but also from the increased blood flow to the area, which can cause increased tissue swelling. Generally, a straight stiff toe is more functional than a bent stiff toe which is present prior to surgery.
- Swelling of the toe. The toe can remain swollen for many months.
- Malposition. It is not uncommon for the joint to be fused in a slightly off-centered position, which in some instances can be problematic.
- Blood Vessel (Vascular) Injury. There are two small blood vessels that run on either side of the toe. If these are injured, the blood flow to the tip of the toe may be lost. This can result in necrosis of the tip of the toe. Although rare, this may lead to a partial amputation of the toe.
- Residual pain: As the toe is a relatively confined space, it’s not uncommon to have swelling and residual pain for an extended period of time.
- Toe Shortening: By removing a small piece of bone prior to fusion, the toe will be slightly shortened.
- Wound healing problems
- Nerve injuries
- Blood clots
- Pulmonary embolism (PE): Although much less likely for toe surgery, blood clots and PE’s can still occur.
Edited on December 20, 2015
(Previously edited by Hossein Pakzad, MD)