This single-center retrospective case series included consecutive patients who underwent hallux interphalangeal joint (IPJ) arthrodesis with the documented intent of healing a chronic plantar hallux IPJ ulcer at one academic medical center between January 2019 and April 2026. The institutional review board approved the study and waived individual informed consent for use of de-identified retrospective data.

All cases performed by a single surgeon were identified by the Current Procedural Terminology code for hallux IPJ arthrodesis (28,755). Of 18 consecutive cases screened, inclusion required age 18 years or older, arthrodesis performed specifically to heal an active chronic plantar hallux IPJ ulcer (documented in both the preoperative note and operative report), and ulcer duration of at least 4 weeks. Cases performed for other indications, those with concurrent toe amputation precluding hallux preservation, and those with insufficient documentation of the primary outcome were excluded. Five patients accounting for 6 feet (including 1 staged bilateral arthrodesis) constituted the final cohort.

All procedures were performed under monitored or general anesthesia in the supine position without tourniquet. Through a dorsal “T-shaped” incision, commencing just distal to the hallux IPJ and extending to the midshaft of the proximal phalanx, the joint was exposed, residual cartilage removed with rongeurs and curettes, and the subchondral plate perforated to viable bleeding bone. The joint was reduced into neutral sagittal alignment with slight plantarflexion to recreate a stable propulsive lever and fixed with a single intramedullary cannulated compression screw. The plantar ulcer was sharply debrided to a clean granular bed, an acellular skin substitute applied, and a non-adherent compressive dressing placed. Concurrent procedures—gastrocnemius recession, sesamoidectomy, Akin osteotomy, chevron bunionectomy, distal plantar fasciotomy, and lesser-digit corrections—were performed at the surgeon’s discretion to address contributing deformity and offloading needs.

5 of the 6 patients were placed in a postoperative surgical shoe with heel weight-bearing; 1 was placed in a controlled ankle motion boot. Sutures were removed at 2 to 3 weeks, and patients transitioned to protective footwear as the site epithelialized. Serial weight-bearing radiographs were obtained at standard intervals.

The primary outcome was complete healing of the index ulcer, defined as full re-epithelialization without dressings sustained at 2 consecutive visits at least 2 weeks apart. Secondary outcomes were time to healing; radiographic union, defined as bridging trabeculation across at least 3 of 4 cortices on weight-bearing radiographs; and complications. Because 1 foot required revision for nonunion, two union endpoints were pre-specified: union by 6 months after the index procedure (primary union at index) and union at any time including after revision (ultimate union). Delayed union was union after 12 weeks but within 6 months at the index procedure; nonunion was failure of union by 6 months at the index procedure. Recorded complications included wound dehiscence, surgical site infection, hardware removal, revision arthrodesis, index-site ulcer recurrence, transfer lesion (defined a priori as new ulceration at a different forefoot location attributed to altered mechanics), new ulcer at another location, minor amputation (toe or ray), major amputation (transmetatarsal or more proximal), and mortality.

Demographic, clinical, ulcer, biomechanical, operative, and postoperative variables were abstracted from the medical record by a single reviewer onto a standardized form; the hallux abductus interphalangeus angle was measured on weight-bearing anteroposterior radiographs. Given the cohort size, no inferential testing or multivariable modeling was performed, and the predictor analyses pre-specified in the original protocol were not pursued because outcome events were insufficient under the conventional 10-events-per-variable rule. Continuous variables are reported as median (range) and categorical variables as counts (percentages). Site-level outcomes used foot-level denominators (n = 6) and patient-level events (major amputation, mortality) used patient-level denominators (n = 5); the staged bilateral patient contributed 2 foot-level and 1 patient-level observations. Missing data were not imputed and are noted in the tables.

Of 18 screened arthrodeses, 5 patients (6 feet) met inclusion criteria; 1 underwent staged bilateral arthrodesis ( Table 1 ). Median age was 55 years (range 40–78), 2 of 5 (40%) were women, and 4 of 5 (80%) were White. Median body mass index, available in 4 of 5, was 32.6 kg/m² (range 24.9–43.7). All 5 had diabetes (1 type 1, 4 type 2), with median duration 9 years (range 3–25) and median preoperative hemoglobin A1c 7.6% (range 4.7–9.5). All had documented peripheral neuropathy; none had peripheral arterial disease, Charcot neuroarthropathy, or prior lower-extremity amputation. No patient smoked. Three of 5 (60%) had a contralateral hallux ulcer history and 2 of 5 (40%) had prior ipsilateral foot surgery.

All 6 ulcers were plantar to the hallux IPJ. Median preoperative duration was 50 weeks (range 20–57), with median dimensions of 1.25 cm length (0.5–1.5), 0.9 cm width (0.3–2.0), and 0.2 cm depth (0.1–0.2). No ulcer was probe-to-bone positive and none had osteomyelitis. Median hallux abductus interphalangeus angle was 23.4° (range 4.5°–35.5°). Hammered hallux was present in 2 of 6 feet (33%), equinus in 1 of 6 (17%), and hallux valgus in 1 of 6 (17%); none had hallux rigidus or limitus.

All 6 feet underwent arthrodesis with a single intramedullary cannulated compression screw after curettage preparation, with split-thickness skin graft coverage of the plantar bed. Concurrent procedures included gastrocnemius recession in 1 of 6 (17%) and sesamoidectomy in 2 of 6 (33%). Median operative time was 65 min (range 53–105). Offloading was a postoperative surgical shoe in 5 of 6 feet (83%) and a controlled ankle motion boot in 1 of 6 (17%).