The PIPJ arthroplasty is one of the most common surgical foot procedures performed today. The evolution and refinement of surgical PIPJ procedures have made the “non-fixated” arthroplasty much less common. It however still has its place and will be discussed with a recent case involving an elderly diabetic patient. Multiple factors played into the decision-making, which include the patient age (77), activity level (moderate/low), and mild cellulitis within the digit, and the most significant was an open pressure lesion on the distal third toe. A PIPJ arthroplasty with transverse elliptical incision was used. Additionally after appropriate bone resection off the head of the proximal phalanx, an extensor tendon shortening was used to assist a skin wedge removal to obtain the needed correction to remove the pressure on the distal toe.