Surgery is indicated when other treatments have not been effective or are not likely to work, usually in advanced cases. Surgical treatments fall into two groups, joint replacement and joint fusion. Joint replacement surgery is used for the knuckle joints (MCP joints) and the first joint of the finger (PIP joint). The joint replacements that I use are the most modern type, made from a material called pyrocarbon; this is a very hard-wearing material. Joint fusion is a simpler operation where a severely damaged joint is removed and the bones either side fixed together. Joint fusion is a simpler operation than joint replacement. Fusion is effective to relieve pain but has the disadvantage than movement at the joint is lost. Loss of movement is less problematic in the end joints of the fingers and thumb (DIP joints) than the MCP and PIP joints. Arthritis of the small joints of the hand itself may also be treated by fusion.