Hallux IPJ and Lesser Toe IPJ | Post-Traumatic and Degenerative
ANATOMICAL CLASSIFICATION
Critical Must-Knows
- Post-traumatic arthritis is the most common cause - previous fracture, dislocation, or turf toe injury
- Hallux IPJ arthritis more symptomatic than lesser toes - essential for push-off in gait
- Arthrodesis (fusion) is gold standard - eliminates pain, stable construct, minimal functional loss
- Fusion position critical: hallux IPJ fused in 10-15° plantar flexion to clear ground during gait
- Inflammatory arthritis (RA, psoriatic) can affect multiple IPJs simultaneously
Clinical Pearls
- "Hallux IPJ fusion position: 10-15° plantar flexion, slight valgus (matches contralateral)
- "Lesser toe PIPJ: arthroplasty (resection) acceptable as motion less critical
- "K-wire fixation sufficient for lesser toes, plate/screw preferred for hallux IPJ
- "Nonunion is NOT rare at the hallux IPJ - the largest series (n=227) reports ~25% radiographic nonunion; many are asymptomatic fibrous unions
Clinical Imaging
Imaging Gallery
Critical IPJ Arthritis Concepts
Hallux IPJ vs Lesser Toes
Hallux IPJ arthritis is more significant than lesser toe IPJ arthritis. The hallux IPJ contributes to push-off power in gait. Lesser toe IPJs have minimal functional role. Symptomatic hallux IPJ requires surgical treatment; lesser toe IPJ can often be managed conservatively.
Post-Traumatic Etiology
Post-traumatic arthritis is the primary cause in younger patients. Previous fracture (especially intra-articular), dislocation, or severe turf toe injury damages articular cartilage. Degenerative arthritis predominates in older patients.
Arthrodesis Gold Standard
Fusion (arthrodesis) is the gold standard for symptomatic IPJ arthritis. Eliminates pain reliably, stable construct, minimal functional deficit (IPJs have limited motion normally). Arthroplasty reserved for lesser toes.
Nonunion is Common - and Often Tolerated
Radiographic nonunion at the hallux IPJ is frequent (~25% in the largest single-centre series; up to 40% when combined with a first MTP fusion). Crucially, a painless fibrous (pseudarthrotic) union is an acceptable clinical outcome - radiographic nonunion does not predict patient dissatisfaction. Reserve revision for symptomatic, mobile nonunion.
At a Glance
Interphalangeal joint arthritis of the foot most commonly affects the hallux IPJ, which is functionally more significant than lesser toe IPJs due to its contribution to push-off power during gait. Post-traumatic arthritis (previous fracture, dislocation, turf toe injury) is the primary etiology in younger patients, while degenerative and inflammatory causes predominate in older populations. Arthrodesis (fusion) is the gold standard treatment for symptomatic hallux IPJ arthritis, providing reliable pain relief with minimal functional deficit given the normally limited IPJ motion. Contrary to older teaching, radiographic union is NOT guaranteed: the largest published series reports roughly a 25% nonunion rate, but most nonunions are painless fibrous unions that do not require revision. The critical fusion position is 10-15° plantar flexion with slight valgus matching the contralateral toe—excessive dorsiflexion causes the nail to catch on the ground, while excessive plantar flexion creates dorsal nail pressure in footwear. Lesser toe IPJs can be managed with resection arthroplasty as motion is less critical; K-wire fixation suffices for lesser toes while plate/screw fixation is preferred for the hallux.
TRAUMACauses of IPJ Arthritis
| T | Turf toe (hallux IPJ) Severe hyperextension injury damages articular cartilage |
| R | RA and inflammatory arthritis Rheumatoid, psoriatic arthritis affect multiple IPJs |
| A | Age (degenerative) Primary osteoarthritis in older patients |
| U | Undisplaced fractures (missed) Intra-articular fractures cause post-traumatic arthritis |
| M | Mallet/hammer toe Chronic deformity leads to secondary arthritis |
| A | Athletic injuries Repeated microtrauma in athletes (soccer, ballet) |
| T | Turf toe (hallux IPJ) Severe hyperextension injury damages articular cartilage | A | Age (degenerative) Primary osteoarthritis in older patients | M | Mallet/hammer toe Chronic deformity leads to secondary arthritis |
| R | RA and inflammatory arthritis Rheumatoid, psoriatic arthritis affect multiple IPJs | U | Undisplaced fractures (missed) Intra-articular fractures cause post-traumatic arthritis | A | Athletic injuries Repeated microtrauma in athletes (soccer, ballet) |
Hook:TRAUMA is the most common cause of IPJ arthritis in young patients!
PLANTHallux IPJ Fusion Position
| P | Plantar flexion 10-15° Toe angled slightly downward |
| L | Line up with contralateral Match the other great toe position |
| A | Avoid excessive dorsiflexion Nail will catch on ground during gait |
| N | Neutral rotation No internal or external rotation |
| T | Trace of valgus Slight lateral deviation (physiological) |
| P | Plantar flexion 10-15° Toe angled slightly downward | N | Neutral rotation No internal or external rotation |
| L | Line up with contralateral Match the other great toe position | T | Trace of valgus Slight lateral deviation (physiological) |
| A | Avoid excessive dorsiflexion Nail will catch on ground during gait |
Hook:PLANT the hallux IPJ in slight plantar flexion!
PINSSurgical Approach Complications
| P | Pin tract infection K-wire fixation - 5-10% risk |
| I | IPJ stiffness Expected with fusion (goal is ankylosis) |
| N | Nonunion Common at hallux IPJ (~25%); often a painless fibrous union |
| S | Shoe pressure Incorrect fusion angle causes nail or dorsal pressure |
| P | Pin tract infection K-wire fixation - 5-10% risk | N | Nonunion Common at hallux IPJ (~25%); often a painless fibrous union |
| I | IPJ stiffness Expected with fusion (goal is ankylosis) | S | Shoe pressure Incorrect fusion angle causes nail or dorsal pressure |
Hook:Watch for PINS complications after IPJ arthrodesis!
Overview and Epidemiology
Why IPJ Arthritis Matters
Interphalangeal joint arthritis in the foot is less common than MTP arthritis, but when symptomatic (especially hallux IPJ), it significantly impacts gait and footwear. The hallux IPJ is essential for push-off power. Unlike finger IPJs (where motion is critical), toe IPJs have minimal normal motion, making arthrodesis an excellent treatment with minimal functional loss. Post-traumatic arthritis from previous fracture or dislocation is the most common cause in younger patients, while degenerative arthritis predominates in older adults.
Epidemiology
- Prevalence: Less common than MTP arthritis (10-15% of forefoot arthritis)
- Age: Post-traumatic (20-50y), degenerative (over 50y)
- Gender: Male = female (post-traumatic), female predominance (degenerative)
- Location: Hallux IPJ greater than 80%, lesser toe PIPJ less than 20%
- Bilateral: Uncommon (unless inflammatory arthritis)
Risk Factors
Post-Traumatic:
- Previous IPJ fracture (especially intra-articular)
- IPJ dislocation (reduces but cartilage damaged)
- Severe turf toe (hallux IPJ cartilage injury)
- Chronic mallet or hammer toe deformity
Degenerative:
- Age over 60 years
- Obesity (increased forefoot load)
- High-impact activities (running, jumping)
Inflammatory:
- Rheumatoid arthritis, psoriatic arthritis
- Affects multiple IPJs simultaneously
Anatomy and Pathophysiology
IPJ Anatomy
The interphalangeal joints in the foot are hinge joints with minimal normal motion compared to fingers. Hallux IPJ normally has 40-60° dorsiflexion and 0-10° plantar flexion. Lesser toe PIPJ and DIPJ have 30-50° flexion. The collateral ligaments provide medial-lateral stability. The plantar plate (at MTP, not IPJ) does not extend to IPJ level. Because normal IPJ motion is limited, fusion causes minimal functional deficit.
IPJ Anatomy by Location
| Joint | Normal Motion | Functional Role | Arthritis Impact |
|---|---|---|---|
| Hallux IPJ | 40-60° dorsiflexion, 0-10° plantar flexion | Push-off power in gait, significant | High impact - pain with walking, shoe pressure |
| Lesser toe PIPJ | 30-50° flexion | Minimal functional role | Low impact - mostly cosmetic and shoe fitting |
| Lesser toe DIPJ | 20-30° flexion | Negligible functional role | Rarely symptomatic |
Pathophysiological Progression
Post-traumatic: Intra-articular fracture, dislocation, or severe hyperextension injury (turf toe) damages articular cartilage. Even if anatomically reduced, cartilage is permanently injured.
Damaged cartilage undergoes progressive degeneration. Loss of normal proteoglycan and collagen structure. Chondrocytes apoptosis. Subchondral bone exposed in areas.
Complete loss of cartilage. Exposed subchondral bone creates mechanical pain with motion and weight-bearing. Osteophyte formation at joint margins. Joint space narrowing on X-ray.
Joint collapse may occur. Chronic pain leads to altered gait (antalgic). Dorsal osteophytes cause shoe pressure. Surgical intervention required for symptom relief.
Post-Traumatic Arthritis
Mechanism:
- Intra-articular fracture (even if well-reduced)
- IPJ dislocation (cartilage shear injury)
- Severe turf toe (hallux IPJ cartilage contusion)
- Repeated microtrauma (athletics)
Timeline:
- Symptoms develop 6 months to 5 years post-injury
- Earlier onset with more severe initial injury
- X-ray changes may precede symptoms
Clinical Features:
- History of specific injury
- Younger patients (20-50 years)
- Unilateral involvement
- Progressive pain and stiffness
Post-traumatic is most common cause under age 50.
Clinical Presentation and Examination
History
- Pain location: Specific IPJ (hallux or lesser toe)
- Onset: Post-traumatic (months to years after injury), degenerative (insidious)
- Aggravating factors: Walking, push-off (hallux IPJ), shoe pressure
- Stiffness: Morning stiffness (inflammatory), end-of-day stiffness (degenerative)
- Previous treatment: Often tried NSAIDs, shoe modifications
- Functional impact: Difficulty with walking distance, athletic activities
Physical Examination
- Inspection: Swelling, osteophytes (dorsal prominence), malalignment
- Palpation: Tenderness over affected IPJ, warmth if inflamed
- ROM: Reduced ROM, pain at end-range, crepitus with motion
- Deformity: Hallux IPJ hyperextension or flexion contracture, hammer/mallet toe (lesser)
- Gait: Antalgic gait, reduced push-off (hallux IPJ arthritis)
- Footwear: Assess shoe wear pattern, pressure areas
Hallux IPJ Examination
For hallux IPJ arthritis, perform:
- ROM assessment: Compare to contralateral (normally 40-60° dorsiflexion)
- Grind test: Axially load and rotate IPJ - crepitus and pain suggests arthritis
- Dorsal osteophyte: Palpate dorsal joint - prominence indicates advanced disease
- Push-off test: Ask patient to perform single-leg toe raise - weakness/avoidance if painful
These findings confirm symptomatic arthritis requiring treatment.
Differential Diagnosis
Conditions Mimicking IPJ Arthritis
| Condition | Key Distinguishing Features | Diagnostic Test |
|---|---|---|
| IPJ gout | Acute onset, severe pain, erythema, asymmetric | Serum uric acid, joint aspiration (urate crystals) |
| IPJ infection (septic) | Acute, fever, systemic illness, recent trauma/surgery | Joint aspiration (cell count, culture) |
| Turf toe (acute) | Acute hyperextension injury, plantar plate tear | MRI (plantar plate injury, no chronic arthritis) |
| Nail bed pathology | Pain at nail, paronychia, ingrown nail | Inspection of nail and nail bed |
Investigations
Plain X-ray Assessment
Standard Views:
- AP foot: Shows IPJ alignment and joint space
- Lateral foot: Shows osteophytes, dorsal prominence
- Oblique foot: Additional detail of IPJs
Radiographic Findings:
- Joint space narrowing (bone-on-bone in severe cases)
- Osteophyte formation (especially dorsal)
- Subchondral sclerosis
- Subchondral cysts
- Malalignment (flexion or extension deformity)
Severity Grading:
- Mild: Joint space narrowing, small osteophytes
- Moderate: Significant narrowing, larger osteophytes, sclerosis
- Severe: Bone-on-bone contact, collapse, deformity
X-rays sufficient for diagnosis in most cases.
Management Algorithm
Imaging
Treatment Goal
The goal is pain relief and restoration of function. For symptomatic hallux IPJ arthritis, arthrodesis (fusion) is the gold standard - reliably eliminates pain with minimal functional deficit. Conservative treatment is first-line for mild symptoms. Lesser toe IPJ arthritis can often be managed conservatively or with arthroplasty (resection) if surgery needed.
Non-Operative Management
Indicated for:
- Mild to moderate symptoms
- Patient medically unfit for surgery
- Patient refuses surgery
Interventions:
Footwear Modification:
- Stiff-soled shoes (reduces IPJ motion)
- Rocker-bottom sole (offloads forefoot, reduces push-off stress)
- Extra depth toe box (accommodates dorsal osteophytes)
Orthotics:
- Carbon fiber plate insole (stiffens forefoot)
- Morton extension (limits hallux motion)
Medications:
- NSAIDs for pain and inflammation
- Intra-articular corticosteroid injection (temporary relief 3-6 months)
Activity Modification:
- Avoid high-impact activities
- Low-impact exercise (swimming, cycling)
Outcomes:
- 40-50% achieve acceptable symptom control
- Most eventually progress to surgery
Conservative treatment is palliative, not curative.
Complications
| Complication | Incidence | Risk Factors | Prevention/Management |
|---|---|---|---|
| Nonunion (radiographic) | ~25% (largest HIPJ series); up to 40% if combined with MTP fusion | Diabetes (significant risk factor), inadequate fixation, poor bone quality | Joint preparation to bleeding bone, compression; revise ONLY if symptomatic mobile nonunion (painless fibrous union is acceptable) |
| Malunion | 5-10% | Incorrect positioning during surgery | Careful positioning (10-15° plantar flexion hallux), check alignment intra-op |
| Pin tract infection | 5-10% | K-wire fixation | Pin care, early removal at 3-4 weeks, antibiotics if infected |
| Transfer metatarsalgia | Rare | Altered gait mechanics post-fusion | Proper fusion position, orthotics if symptomatic |
| Nail problems | 5% | Excessive plantar or dorsiflexion fusion | Correct positioning, may need nail removal |
| Neurovascular injury | Under 2% | Iatrogenic during exposure | Careful dissection, protect digital nerves |
Malunion Position Problems
Incorrect fusion position causes functional problems:
- Excessive dorsiflexion: Nail catches on ground during gait, painful
- Excessive plantar flexion: Dorsal toe pressure in shoes, nail driven dorsally
- Varus or valgus: Medial or lateral shoe pressure, unstable gait
Careful positioning and intra-operative verification essential.
Outcomes and Prognosis
Favorable Factors
- Rigid fixation (plate preferred over K-wires)
- Good bone quality
- Non-smoker
- Normal body weight
- Compliant with post-op protocol
- Correct fusion position
Unfavorable Factors
- Smoking (impairs bone healing)
- Poor bone quality (osteoporosis, RA)
- Inadequate fixation
- Infection
- Non-compliance with weight-bearing restrictions
- Inflammatory arthritis (higher nonunion risk)
Functional Outcomes
Hallux IPJ Fusion:
- Pain relief and patient satisfaction generally high despite imperfect radiographic union
- Radiographic nonunion ~25% in the largest series; ~21% reoperation rate (Braswell 2023) - but radiographic nonunion did NOT predict dissatisfaction
- Painless fibrous (fibrous ankylosis) union is an accepted clinical endpoint
- Return to shoes: most patients by 3-4 months
- Minimal functional deficit: IPJ has limited normal motion
Lesser Toe IPJ Surgery:
- Fusion and arthroplasty (resection) both used; resection less predictable but acceptable as motion is non-critical
- Cosmetic and footwear improvement with correction of hammer/mallet toe
Key honesty point for the viva: older texts quote "over 90% union" for IPJ fusion; the best contemporary data (institutional series, n=227) shows ~25% radiographic nonunion. The reconciling concept is that a stable, painless fibrous union behaves clinically like a solid fusion.
Evidence Base and Key Studies
The single most important paper on this topic
The Braswell (2023) series below is the landmark contemporary dataset and directly overturns the "over 90% union" figure repeated in older textbooks. Know the ~25% radiographic nonunion / ~21% reoperation numbers AND the reconciling concept (painless fibrous union behaves like a solid fusion) for the viva.
Outcomes After Hallux Interphalangeal Joint Arthrodesis (largest series to date)
- 227 primary hallux IPJ arthrodeses - largest single-centre series published
- Radiographic nonunion rate 25.5% (58/227); reoperation rate 21.1% (48/227)
- Diabetes was a significant risk factor for nonunion (p=0.014)
- No significant difference by smoking status, inflammatory arthritis, or implant type (single screw vs multiple screws vs screw+other vs non-screw)
- Prior first MTP arthrodesis did NOT significantly raise IPJ nonunion rate in this cohort
Ipsilateral Hallux MTP + IP Joint Arthrodesis
- 20 feet (14 rheumatoid arthritis, 5 failed hallux valgus surgery, 1 hallux rigidus)
- All MTP arthrodeses healed, but 8/20 (40%) failed to heal at the IP joint
- IP nonunion lowest when IP fused first (17%) vs MTP first (50%) vs simultaneous (50%)
- IP nonunion did NOT predict AOFAS score or satisfaction; 18/20 patients satisfied
- Median hallux AOFAS rose from 25 to 68; fibrous ankylosis was an acceptable clinical outcome
Fixation Technique and Implant Survival in First MTP/IP Arthrodesis
- 83 patients / 89 fusions comparing two crossed screws vs dorsal plate vs dorsal plate + lag screw
- Overall implant survival 96.5% at 1 year and 94.0% at 10 years - no significant difference between constructs
- Highest union rate with dorsal plate plus lag screw (93.1%)
- Hardware removal higher with plate constructs (10.3%) than two-screw (3.1%)
- Mean AOFAS 83 with no significant difference between fixation groups
Immediate Weightbearing After First-Ray Fusion (HIPJ arthralgia signal)
- 25 first MTP arthrodeses with interfragmentary screw plus dorsal locking plate, immediate full weightbearing
- Overall union 96%; clinical healing ~5.9 weeks, radiographic fusion ~6.8 weeks
- Mean VAS pain fell from 6.6 to 0.6
- 2 patients developed symptomatic hallux IPJ arthralgia after MTP fusion (adjacent-joint load transfer)
First MTP Joint Pain and Turf Toe in Athletes (etiology review)
- Reviews turf toe, sand toe, sesamoiditis, FHL/EHL tendinopathy, gout and hallux rigidus as causes of first-ray pain in athletes
- Turf toe is a hyperextension plantar-plate injury of the first MTP - a recognised precursor to post-traumatic forefoot arthritis
- Weightbearing radiographs and point-of-care ultrasound aid diagnosis
- First-line management is non-surgical: footwear/activity modification, physical therapy, selective injection
Arthrodesis for Hallux Rigidus (contemporary review)
- First MTP arthrodesis remains the cornerstone for advanced first-ray degeneration with favourable long-term outcomes and low revision when fusion succeeds
- Interphalangeal arthritis is an explicitly recognised complication of MTP fusion
- Nonunion and malunion are the principal failure modes requiring revision
- Careful patient selection is emphasised
Exam Viva Scenarios
Use these scenarios to practise clinical reasoning and management decisions
Scenario 1: Post-Traumatic Hallux IPJ Arthritis
"A 35-year-old footballer presents with 2 years of progressive hallux IPJ pain. He sustained a severe turf toe injury 3 years ago. Examination shows reduced hallux IPJ ROM (20° vs normal 60°), crepitus with motion, and tenderness. X-rays demonstrate joint space narrowing, osteophytes, and subchondral sclerosis. What is your diagnosis and management?"
Scenario 2: Inflammatory Arthritis Multiple IPJs
"A 48-year-old female with known rheumatoid arthritis presents with bilateral painful hallux and second toe IPJ swelling and stiffness. She has tried DMARDs and biologics with partial control. X-rays show erosive changes at multiple IPJs bilaterally. She requests surgical treatment for pain relief. How do you approach this?"
Scenario 3: Malunion After Hallux IPJ Fusion
"A 52-year-old male presents 6 months after hallux IPJ fusion performed elsewhere. The fusion has healed (solid union on X-ray) but he complains that his great toe nail catches on the ground when walking and is painful. X-rays show the IPJ fused in 30° dorsiflexion. What is the problem and how do you manage it?"
MCQ Practice Points
Most Common Cause
Q: What is the most common cause of hallux IPJ arthritis in patients under 50 years? A: Post-traumatic arthritis - previous intra-articular fracture, IPJ dislocation, or severe turf toe injury causing articular cartilage damage.
Gold Standard Treatment
Q: What is the gold standard surgical treatment for symptomatic hallux IPJ arthritis? A: Arthrodesis (fusion) - reliably relieves pain with minimal functional deficit (IPJ has limited normal motion). Note: radiographic union is NOT guaranteed (~25% nonunion in the largest series), but a painless fibrous union behaves clinically like a solid fusion.
Fusion Position
Q: What is the correct position for hallux IPJ arthrodesis? A: 10-15° plantar flexion, slight valgus to match contralateral great toe, neutral rotation. Excessive dorsiflexion causes nail ground strike; excessive plantar flexion causes shoe pressure.
Fixation Method
Q: What fixation method is preferred for hallux IPJ arthrodesis? A: Plate and screw or lag screw - provides rigid fixation with highest union rate. K-wires acceptable for lesser toe IPJs but plate preferred for hallux.
Controversies and Areas of Uncertainty
Does radiographic union actually matter?
The dominant controversy. Dedicated series report ~25% radiographic nonunion (Braswell 2023) and up to 40% when combined with MTP fusion (Brodsky 2021) - yet radiographic nonunion does NOT predict pain or satisfaction. A painless fibrous union is widely accepted as a successful clinical endpoint, so routine revision for asymptomatic radiographic nonunion is not justified.
Optimal fixation construct
No construct has been shown to reliably reduce IPJ nonunion (single screw vs multiple screws vs screw+plate vs non-screw all comparable). At the first ray more broadly, implant survival is similar across two-screw, plate, and plate+lag-screw constructs; plates carry a higher hardware-removal rate. Joint preparation likely matters more than implant choice.
Fusion vs arthroplasty/preservation
Arthrodesis is gold standard for the hallux IPJ; resection arthroplasty is reserved for lesser toes where motion is non-critical. There is no robust evidence base for IPJ implant arthroplasty or cheilectomy at the toe IPJ, unlike the better-studied first MTP.
Sequence in combined MTP + IPJ fusion
When both joints need fusing, IP nonunion was lowest when the IPJ was fused FIRST (17%) versus MTP-first or simultaneous (both 50%) - a small-series signal, not a guideline, but a plausible mechanical argument (immobilising the MTP loads the IPJ).
Guidelines, Registries & Global Practice
Global epidemiology. IPJ arthritis of the foot is uncommon relative to first MTP (hallux rigidus) and lesser-toe MTP disease. The hallux IPJ accounts for the large majority of symptomatic cases; isolated lesser-toe IPJ arthritis is usually incidental. Post-traumatic disease (turf toe / hyperextension injury, intra-articular fracture, dislocation) predominates in younger and athletic populations worldwide, while primary degenerative and inflammatory (rheumatoid, psoriatic) disease predominate with age.
Society guidance (side by side). No orthopaedic society publishes an IPJ-arthritis-specific guideline; recommendations are extrapolated from first-ray degenerative-disease and inflammatory-arthritis pathways. Practice converges on a non-operative-first approach with arthrodesis for refractory disease.
How major bodies frame the relevant principles
| Body / Region | Relevant position | Practical implication |
|---|---|---|
| AAOS (US) | Stepwise non-operative care for forefoot OA before surgery; arthrodesis for advanced first-ray degeneration | Document failed conservative trial before fusion |
| BOA / BOFAS (UK) | Foot & ankle arthrodesis for end-stage forefoot arthritis; honest consent on nonunion | Quote realistic, series-based nonunion figures at consent |
| EULAR / ACR (rheumatology) | Optimise DMARD/biologic therapy before elective forefoot surgery in inflammatory arthritis | Co-manage with rheumatology; time surgery to disease control |
| AO Foundation | Stable internal fixation with adequate joint-surface preparation and compression | Preparation to bleeding bone emphasised over specific implant |
Registry note. Toe IPJ arthrodesis is not separately tracked by national joint registries (NJR, AOANJRR, AJRR, SHAR), which capture replacement arthroplasty rather than small-joint fusion - so the best evidence remains institutional case series rather than registry data. This is itself an exam-worthy point about the limits of the evidence base.
High- vs limited-resource practice variation. In well-resourced settings, weightbearing radiographs, occasional MRI/ultrasound, plate or screw fixation, and formal gait/footwear rehabilitation are standard. In limited-resource settings, plain radiographs and K-wire fixation (inexpensive, effective) predominate, and accommodative footwear plus simple analgesia carry much of the non-operative burden. Outcomes hinge on joint preparation and patient selection rather than implant cost.
INTERPHALANGEAL ARTHRITIS (FOOT)
Clinical summary
DEFINITION
- •IPJ arthritis: hallux IPJ, lesser toe PIPJ/DIPJ
- •Hallux IPJ most symptomatic (essential for push-off)
- •Post-traumatic (under 50y) vs degenerative (over 60y)
- •Inflammatory arthritis: bilateral, multiple IPJs
- •Limited normal IPJ motion = fusion causes minimal deficit
CAUSES
- •Post-traumatic: fracture, dislocation, turf toe
- •Degenerative: age-related (over 60y)
- •Inflammatory: RA, psoriatic (bilateral)
- •Timeline: symptoms 6mo-5y post-injury
CLINICAL FEATURES
- •Pain at specific IPJ with walking
- •Reduced ROM, crepitus with motion
- •Dorsal osteophytes (palpable prominence)
- •X-ray: joint space narrowing, osteophytes, sclerosis
CONSERVATIVE TREATMENT
- •Stiff-soled shoes or rocker-bottom
- •Carbon fiber plate insole
- •NSAIDs, intra-articular steroid
- •40-50% achieve symptom control
HALLUX IPJ FUSION
- •Gold standard for failed conservative
- •Position: 10-15° plantar flexion, slight valgus
- •Fixation: plate/screw or lag screw (no construct eliminates nonunion)
- •Radiographic nonunion ~25% (largest series); painless fibrous union is acceptable
- •Time to union: typically 8-12 weeks
KEY POINTS
- •Hallux IPJ more significant than lesser toes
- •Fusion eliminates pain, minimal functional loss
- •Correct position critical (10-15° plantar flexion)
- •Nonunion ~25% radiographically; diabetes is the key risk factor
- •Malunion causes nail or shoe pressure problems