Arthritis, an old injury or a bent toe can leave a small joint that hurts with every pinch or every step. When splints, injections and shoe changes stop working, surgery offers two answers, replacing the joint or fusing it.
Fusion lasts.
Which small joints are fused and why
Six small joints account for nearly all fusions, three in the hand and three in the foot.
Why give up movement to lose pain
A fingertip joint moves only a little in daily life, and a stable, painless fingertip pinches harder than a loose, painful one. A big toe that no longer bends still lets you walk, climb stairs and run, because the foot rolls over the fused joint in a normal shoe. For these joints, patients rarely miss the movement once the pain has gone.
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Small joints commonly fused
| Joint |
Common reason |
What you notice after |
| Fingertip joint, DIP |
Arthritis with bony nodes, a bent fingertip |
Firm painless pinch, no bend at the tip |
| Middle finger joint, PIP of the index |
Arthritis or an old injury |
Stable pinch against the thumb |
| Thumb knuckle, MCP |
Instability or arthritis |
Strong key pinch |
| Thumb base, CMC |
Arthritis in young manual workers |
Strong grip, the thumb cannot lie flat |
| Big toe joint, first MTP |
Hallux rigidus, severe bunion |
Pain-free push-off, limited heel height |
| Lesser toe joint, PIP |
Hammer toe |
A straight toe that fits a shoe |
Fusion or a joint replacement in the hand
Silicone or surface replacements keep movement in the middle finger joints of the middle, ring and little fingers, where grip needs bend. The index finger pinches against the thumb with great force, so a fusion suits it better, and at the fingertip joint fusion remains the standard because replacements there loosen.
Finger and thumb fusion
How the operation runs
1
Anesthesia
A nerve block numbs the hand, and you stay awake or sleep lightly.
2
Preparing the joint
Through a small incision over the back of the joint, the surgeon removes the cartilage and shapes the bone ends to fit together.
3
Setting the angle and fixing
A headless screw buried inside the bone for a fingertip, crossed wires or a small plate for the middle joints and the thumb.
4
Splint
A light splint for two to six weeks, then free use.
The angle for each finger
The fingertip joint fuses almost straight, at zero to ten degrees. The middle joints fuse more bent the further you go from the thumb, from around 25 degrees at the index to around 40 at the little finger, so the fingers still close into a fist. The thumb knuckle sets slightly bent for pinch.
Back to using the hand
Desk work in days and light housework in two weeks. Heavy gripping waits until the X-ray shows the bones have joined, six to eight weeks for a fingertip and up to twelve for the thumb base.
The thumb base, fusion or trapeziectomy
Two operations for one joint
Arthritis at the base of the thumb treats well with trapeziectomy, removing the small trapezium bone and filling the space with a rolled tendon, or with fusion, joining the thumb metacarpal to the trapezium. Trapeziectomy keeps a mobile thumb. Fusion gives a stiff, strong one.
A trial stopped early
Vermeulen and colleagues randomized women over forty with thumb base arthritis to fusion with a plate or to trapeziectomy with tendon interposition. Moderate and severe complications reached 71 percent after fusion and 29 percent after trapeziectomy, and the trial ended before its planned size. Function scores at one year matched, and 86 percent after trapeziectomy against 53 percent after fusion would choose the same operation again.
Who still suits a thumb base fusion
Younger patients in heavy manual work who need a strong, stable pinch, and patients whose thumb base has collapsed after an injury. For a woman over forty with typical arthritis there, we recommend trapeziectomy.
Big toe fusion for hallux rigidus
What hallux rigidus feels like
Pain and a bony lump on top of the big toe joint, worse when the toe bends up as you push off, climb stairs or wear a heel. Early on, removing the bony lump, a cheilectomy, restores movement. Once the cartilage has gone across the joint, fusion becomes the reliable answer.
Seven UK studies included 277 feet and a 95.7% overall union rate at a mean union time of 83.5 days.
Systematic review of first toe joint fusion, Journal of Foot and Ankle Research, 2022
Walking, running and shoes after a big toe fusion
The toe fuses angled slightly upward, so the foot rolls off it in a flat shoe. Walking, hiking, cycling and running return. Heels above three to four centimeters become hard, and some people notice a stiff push-off when sprinting.
The synthetic implant was an excellent alternative to arthrodesis in patients who wished to maintain first MTP motion.
Randomized trial of 202 patients, Foot and Ankle International, 2016
1
Day of surgery
Home the same day or the next, walking on the heel in a stiff-soled surgical shoe.
3
Six weeks
X-ray, and a wide normal shoe if the bones are joining.
4
Three months
Most shoes and sport, once the X-ray shows the fusion solid.
Walking early and the implant alternative
Across 898 big toe fusions where patients put weight on the foot within two weeks, 6.4 percent failed to join, close to rates with longer protection. In a trial of a small hydrogel implant against fusion, pain relief and function matched at two years, the implant kept six degrees more movement, and 9.2 percent of implants were removed and converted to fusion.
Of these, 57 (6.35%) were described as developing a non-union.
Systematic review of 898 big toe fusions with early weight bearing, Journal of Foot and Ankle Surgery, 2018
Hammer toe fusion, risks and recovery
A hammer toe bends at the middle joint and rubs on the shoe. Corns follow. While the toe still straightens by hand, a tendon release alone straightens it. When the bend has become fixed, the surgeon removes the joint surfaces, straightens the toe and holds it with a wire through the tip of the toe for four to six weeks, or with a small implant buried inside the bone.
Call the team the same day
A wound that reddens, leaks or opens, a temperature of 38 degrees or more, a toe or finger that turns white or blue, or a calf that swells and aches after foot surgery.
Wire or implant for a hammer toe
A review of 3,878 toe fusions found union in 73 percent with a wire through the toe and up to 87 percent with one buried implant, though that implant also broke in up to 20.7 percent of cases. Wires came out in clinic without anesthetic, cost a fraction of an implant and gave comparable comfort. A toe that has not fused solidly on X-ray often stays straight and painless all the same, held by firm scar.
Risks of small joint fusion
Fusion carries a short list of risks, and the commonest one rarely needs another operation.
- The bones not joining, nonunion, which may need a second fixation with bone graft.
- A screw, wire or plate that irritates and comes out once the fusion has healed.
- Wound infection.
- Strain and later arthritis in the neighboring joint, which now moves more.
- Numbness along the side of the finger or toe.
Smoking raises the risk of nonunion more than anything else we can change.
Stop four weeks before surgery and stay off cigarettes until the X-ray shows the bones joined, because nicotine narrows the small vessels that feed a healing fusion, and in the toes and fingertips those vessels are already few. Diabetes, steroid tablets and rheumatoid arthritis slow healing too, so we check each one and plan the fixation and the follow-up around them.
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Fixation for hammer toe fusion, review of 3,878 toes
| Fixation |
Union on X-ray |
Hardware failure |
| Wire through the tip of the toe |
73 percent |
0.1 to 4.3 percent |
| Buried wire |
72 percent |
None reported |
| ToeGrip implant |
83 percent |
None reported |
| SmartToe implant |
87.2 percent |
Up to 20.7 percent |
The SmartToe implant demonstrated the highest mean osseous union rate 87.2%, 83% in ToeGrip studies, similar results between the buried k-wire and percutaneous k-wire studies 72% and 73% respectively.
Review of 3,878 toe fusions, The Foot, 2020
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Thumb base fusion against trapeziectomy, randomized trial
| Outcome |
Fusion |
Trapeziectomy |
| Moderate or severe complications |
71 percent |
29 percent |
| Would have the same surgery again |
53 percent |
86 percent |
| Function scores at one year |
Similar |
Similar |
We do not recommend routine use of arthrodesis with plate and screws in the treatment of women who are forty years or older with stage-II or III trapeziometacarpal osteoarthritis.
Randomized trial, Journal of Bone and Joint Surgery, 2014
Recovery and the stay in Istanbul
Small joint fusions run as day cases under a nerve block or a light anesthetic. We suggest five to seven days in Istanbul, for the first dressing change and to make sure the wound has settled before the flight, and for a big toe fusion a seat with room to keep the foot raised.
Pack a wide sandal for the other foot.
Your stay, the person with you and the follow-up
A relative or friend can stay with you, in the room on a companion bed if you spend a night in hospital and in the hotel next door afterward. Our coordinators speak English, Arabic, French, Russian, Serbian, Romanian and Spanish, meet you at the airport and book interpreters for other languages. Follow-up after you return home runs through the same coordinator, and an X-ray taken at six weeks near your home, sent by WhatsApp, lets the surgeon confirm the fusion. The cost depends on the joint, the fixation and the nights, and the estimate after the free review lists each item.
Small joint fusion FAQ
Will I miss the movement in a fused joint?
At the fingertip and the big toe, few patients do once the pain has gone. At the thumb base and the middle finger joints, the loss shows more, and other operations may suit better.
How long until the bones join?
Six to twelve weeks, depending on the joint, with fingertips at the quick end and the thumb base and big toe at the slow end. The surgeon confirms it on an X-ray before heavy use.
Can I walk after a big toe fusion?
Yes, on the heel in a surgical shoe from the day of surgery, and in a wide normal shoe from around six weeks.
Does the screw or wire stay in?
Buried screws and plates usually stay. Wires through the toe come out in clinic at four to six weeks.
Can my family member come with me?
Yes. One companion stays with you through the admission and the hotel days, and the coordinator arranges both rooms together.
References
- Kang YS, Bridgen A. First metatarsophalangeal joint arthrodesis/fusion: a systematic review of modern fixation techniques. Journal of Foot and Ankle Research. 2022;15(1):30.
- Crowell A, Van JC, Meyr AJ. Early weight-bearing after arthrodesis of the first metatarsal-phalangeal joint: a systematic review of the incidence of non-union. Journal of Foot and Ankle Surgery. 2018;57(6):1200-1203.
- Baumhauer JF, Singh D, Glazebrook M, et al. Prospective, randomized, multi-centered clinical trial assessing safety and efficacy of a synthetic cartilage implant versus first metatarsophalangeal arthrodesis in advanced hallux rigidus. Foot and Ankle International. 2016;37(5):457-469.
- Vermeulen GM, Brink SM, Slijper H, et al. Trapeziometacarpal arthrodesis or trapeziectomy with ligament reconstruction in primary trapeziometacarpal osteoarthritis: a randomized controlled trial. Journal of Bone and Joint Surgery (American Volume). 2014;96(9):726-733.
- Hendrick SE, Kannegieter E. SmartToe, ToeGrip and buried k-wire versus percutaneous k-wire fixation for 2nd PIPJ arthrodesis: a comprehensive review of outcomes. The Foot. 2020;45:101692.
