"he JournalD

ne Joint

urgery in:o. p 115,’ evolution~alis muscle[:396-7,’earra flex~

earm flexon:it 70:281.9L

Philadelphia,

tot dieitoru~lie. Br J Pla~

.or d io~ito~-a~Dis 36:524.

s !]exor digCiin Or~h~-

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e ttexor d~g,syndrome,

de Groo, ti~s muscle

clinical41:626-32,

onic boutonniere

:onstruction

deformity An anatomic

of motion and appearance of the chronic boutonniere deformio’ is often accomplished byIf the deformity persists following appropriate splinting, and if a full passive range of nlotion of

interphalangeal joint is present, surgery may be recommended. Thirteen patients hadreconstruction over a lO-year period, with satisfactoo, improvement in all but one. This

involves release of the transverse retinacular ligaments and reconstruction of the damagedslip by using the local joint capsule and synovium attached to the base of the proximal phalanx.

R. Urbaniak, M.D., and Michael G. Hayes, F.R.A.C.S.,N.C., and Adelaide, Australia

to an imbalance of forces between the flexor andi!"~xlensor mechanisms. If the condition is recognized

i~d appropriate treatment instituted, the results of~n:atment are excellent. Frequently, however, the seri-

ousness of the acute injury is not recognized, and the¢t~aractcristic flexed proximal interphalangeal (PIP)~int ~" hyperextension of the distal joint develops.

if’his dciormity has proven to be one of the mostidifficult reconstructive problems in hand surgery.: The anatomy of the extensor appardtus has been well¯ described by various authors,~-:3 and the pathomechan-

ks of the boutonniere lesion have also been investigated

¯ ~xlensively.4. ~ Numerous procedures have been de-signed to overcome the chronic boutonniere deformity.

; Reconstruction of the middle slip by direct repair,< r~umring together of the lateral bands,s repair using ten-~n gral ;.~"’ 10 and fascial slips,~ and advancement of thecentral ,qip~ have all provided variable results.

Stack~a has used the superficial flexor tendon to rebal,a~ce the forces across the joint and also to reconstruct

, ~e middle slip. Matev~4 described a proced_ui’e.utilizingthe lateral bands vda’~reby the lateral band on one side is~ed to reconsffuct the middle slip, and on the other~ide it is elongated to restore a single lateral band.~alvi~’’ described a technique to reposition the lateralbands dorsally. Littler and Eaton4 reported success in

,~gmm the Division of Orthopedic Surgery, Duke University MedicalCenter. Durham, N.C., and Department of Orthopaedic Surgery,Royal Adelaide Hospital, Adelaide, Australia.

~’¢epted for publication Aug. 2I, 1980; revised Jan. 23, 1981.Ik"print requests: James R. Urbaniak, M.D., Division of Orthopaedic

Surgery, P.O. Box 2912, Duke University Medical Center,Durham, NC 27710.

restoring full extension of the PIP joint by separatingthe extrinsic and interosseous tendon from the lumbri-cal and oblique retinacular ligaments and centralizingthe lateral bands. Tenotomy of the extensor tendon dis-tal to the,. triangular ligamen06 has also proven useful inchronic deformities, especially those caused by rheu-matoid arthritis. ~ Z

Prerequisites for surgery

There are several basic factors required for success-ful restoration of function. The most important is thatthere must be afidl range of passive motion at the PIPjoint. Any compromise of this prerequisite will lead toa disappointing result.

Most of the reported surgical procedures are some-what complex, requiring the transfer of additional tis-sue into an area that does not ~readily accommodatemore tendinous or ligamentous material. If the dorsalskin about the PIP joint is abnormal, or if there isconsiderable subcutaneous ddema or induration, operat-ing at the PIP joint is not recommended; a tenotomy ofthe extensor tendon, distal to the triangular ligamentbut proximal to the distal interphalangeal (DIP) joint, preferable. ~o, ~8

The method is simple, uses only local tissue, andrestores normal balance. The operation should be per-formed only after a 1- to 3-month period of splintinghas failed to improve the clinical state significantly anda fldl range of passives.movement has been restored atthe PIP joint. .

Surgical technique

Through a curvilinear, dorsal incision centered overthe PIP joint, the extensor apparatus is exposed and thetransverse retinacular ligaments are identified and

’~3-5023,’81/040379+05500.50/0 © 1981 American Society for Surgery of the Hand THE JOURNAL OF HAND SURGERY 379

380 Urbaniak and Hayes

Fig. 1. Extensor apparatus at PIP joint ~s exposed by dorsalincision. Probe is placed beneath right transverse retinacularligament, which is to be separated from lateral band. Triangu-lar flap in extensor tendon is based proximally.

sharply separated from their insertion on the lateralbands (Fig. 1).

A proximally based triangular flap is elevated be-tween the lateral bands of the extensor mechanism.This flap is carefully separated from the underlyingjoint capsule and synovium and reflected proximally. Afurther capsular flap, attached to the base of the middlephalanx, is then fashioned and passed through a split inthe proximally based flap of the extensor tendon (Figs.2 and 3).

The lateral bands are then opposed using two or three4-0 polyester sutures. This approximation is adjusted sothat full passive flexion of the DIP joint is possible(Fig. 4).X

The, i:tistally based capsular flap is then sewn intoplace on the extensor tendon, and the large proximallybased triangular flap is sutured to the extensor appara-tus so that it overlaps the dorsally placed extensor slips(Fig. 5). A small Kirschner wire is passed across thejoint, which is held in full extension.

After hemostasis has been achieved, the wound iscarefully closed and the forearm immobilized in acompression dressing with the metacarpophalangealjoint flexed and the DIP joint free to allow active flex-ion. Four weeks postoperatively, the Kirschner wire isremoved; for a further 3 to 4 weeks, a splint is worn.

The JournalHAND SUR~

Fig. 2. Dorsal view at PIP joint shows distally based capsul~flap being pulled through transverse slit in proximally ba~flap to reconstruct central slip.

holding the PIP joint in extension but allowingflexion of the DIP joint.

Materials and Results

Over an 8-year period, 13 patients, ranging21 to 66 years of age, were operated usingtechnique. The delay from injury to operation was 26 months, with the exception of one patient whooperated at 2 years. All but one patient had at lea’a!month of splinting (Table I). Of the 13 patientswhich this procedure was done, there were eight gresults, with less than 15° of extensor lag at the

o omt (Fi~joint and at least 30 of flexion at the DIP.1 ’Table II).

Four patients improved. They had between30° of lag at the PIP joint, with at least 20° ofthe DIP join~’~-All 12 of the patients in the good.~improved groups obtained at least 90° of activeat the PIP joint.

There was one poor result with residual contract~

of the PIP joint of 30° and an active range of move~of only 15°. This patient had an intraarticular

NO. 4 Chronic boutonniere deformity 381

Fig. 3. Lateral view of triangular flaps at PiP joint. Flap on left is distally based dorsal capsule frombase of middle phalanx. Large more superficial flap on right is proximally based in extensorapparatus.

ba,cd

allowing

ra:-~ ;ing

:d ~isingationlenthad at

.3 patient~:re eighta,.z, at the~j,

:,s.. n)o

’active

ml~ ofcular

4. Lateral bands are carefully approximated with two orinterrupted sutures after tongue of capsule is pulled

proximally based flap of extensor tendon.

Fig. 5. Final posiuon of two triangular flaps. Proximallybased flap is sutured over two distally approximated lateralbands.

382 Urbaniak. and HayesThe Journal i

¯ HAND SURGEI~

Fig. 6. A, Preoperative hand of 21-year-old male with chronic boutonniere deformity of ring finger(MY in Table I). Full passive range of motion is present. B and C. Postoperative hand with fullflexion and good extension of ring finger.

Table I. Surgical reconstruction of chronic boutonniere deformity

Date ofsurgery A ge/sex

Injury tosurgery Splinting(months) (months)

Active PIF motion

Preop

Active DIP motion

~ Postop Preop L Postop

June 73 (TN) 34M 6 1 45/90 45/90 -20/-20 -10/-10Jan. 74 (GC) 27 F 6 4 60/85 0/90 -40/-30 -20/75Jan. 74 (KE) 47 F 5 Unknown 60/90 20/95 -t0/-10 -10/15May 75 (AR) 38M 2 (years) 2 70/95 10/95 -5/15 ! 5/60June 75 (MY) 21M 2 1 37/130 0/130 -30/45 0/90Sept. 75 (NS) 37M 3 2 45/90 8/110 -10/20 0/40Jan. 77 (MH) 24M 6 2 -- 70/90 20/90 -20/30 10/30May 77 (FS) 49 F 4 3 45/95 10/120 0/20 0/84May 78 (UW) 56 M 3 2 65/90 0/95 -10/0 0/70Jan. 79 (SR) 66M 2 ~, 1 90/95 15/95 -30/-30 -15/45Feb. 79 (CC) ./ 32 F 4 2 45/90 . 0/90 -5/45 20/60May 79 (EMy 27 F 4 3 60/110 27/105 -30/0 5/70April 80 (SD) 37M 4 2 40/90 5/100 10/10 0/70

Rating

FailedGoodImpr,,’.ed

GoodImproved

Go~Improv~

Impro~Go(~

Table II. Summary of results of reconstruction ofchronic boutonniere deformity in 13 patients

patients lag PIP joint DIP joint Rating

8 15° or less 30° or more Good4 15° to 30° 20° or more Improved1 30° or more None Failed

and it was not possible to restore a full range ,~rmotion at the PIP joint preoperatively.

Summary ~

A method for overcoming the loss of motiondeformity in the chronic boutonniere deformitybeen described. The operation consists of (1) retort’structing the damaged central slip using the joint

The

Rating

’ange ,

of motiondeformity

s of (!./g the joint

~0. 4

synovium and (2) a careful dorsal reposition-lateral bands.

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JW: The finger extensor mechanism. Surg ClinAm 47:415-32, 1967

R, Valentin P: Anatomy of the extensor appara-~ofthe lingers. Surg Clin North Am 44:897-906, 1964

:tier JW, Eaton RG: Redistribution of forces in theion of boutonniere deformity. J Bone Joint Surg

49:1267-74, 1967~ter WA: The problem of boutonniere deformity. Clin

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Chronic boutonniere defortnity 383

10. Weeks PM: The chronic boutonniere deformity: Amethod of repair. Plast Reconst Surg 40:248-51, 1967

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15. Salvi V: Technique for the "Buttonhole" deformity.Hand 3:96-7, 1971

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