An anatomic. deformity. onic boutonniere :onstruction. "he Journal. ne Joint. urgery in :o. p 115, evolution~ alis muscle [:396-7, earra flex~

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1 "he Journal 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. to an imbalance of forces between the flexor and i!"~xlensor mechanisms. If the condition is recognized s!]exor dig i~d appropriate treatment instituted, the results of Ciin Or~h~- ~n:atment are excellent. Frequently, however, the seriousness of the acute injury is not recognized, and the t~aractcristic flexed proximal interphalangeal (PIP) ~int ~" hyperextension of the distal joint develops. ~scle with econstr if his dciormity has proven to be one of the most e ttexor d~g, syndrome, de Groo, t i~s muscle clinical 41:626-32, onic boutonniere :onstruction deformity An anatomic of motion and appearance of the chronic boutonniere deformio is often accomplished by If 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 had reconstruction over a lo-year period, with satisfactoo, improvement in all but one. This involves release of the transverse retinacular ligaments and reconstruction of the damaged slip 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 idifficult reconstructive problems in hand surgery. : The anatomy of the extensor appardtus has been well described by various authors,~-:3 and the pathomechanks of the boutonniere lesion have also been investigated ~xlensively. 4. ~ Numerous procedures have been designed to overcome the chronic boutonniere deformity. ; Reconstruction of the middle slip by direct repair, < r ~umring together of the lateral bands ș repair using ten- ~n gral ;.~" 10 and fascial slips, ~ and advancement of the central,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.utilizing the 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 lateral bands dorsally. Littler and Eaton 4 reported success in,~gmm the Division of Orthopedic Surgery, Duke University Medical Center. Durham, N.C., and Department of Orthopaedic Surgery, Royal Adelaide Hospital, Adelaide, Australia. ~ epted for publication Aug. 2I, 1980; revised Jan. 23, Ik"print requests: James R. Urbaniak, M.D., Division of Orthopaedic Surgery, P.O. Box 2912, Duke University Medical Center, Durham, NC restoring full extension of the PIP joint by separating the extrinsic and interosseous tendon from the lumbrical and oblique retinacular ligaments and centralizing the lateral bands. Tenotomy of the extensor tendon distal to the,. triangular ligamen0 6 has also proven useful in chronic deformities, especially those caused by rheumatoid arthritis. ~ Z Prerequisites for surgery There are several basic factors required for successful restoration of function. The most important is that there must be afidl range of passive motion at the PIP joint. Any compromise of this prerequisite will lead to a disappointing result. Most of the reported surgical procedures are somewhat complex, requiring the transfer of additional tissue into an area that does not ~readily accommodate more tendinous or ligamentous material. If the dorsal skin about the PIP joint is abnormal, or if there is considerable subcutaneous ddema or induration, operating at the PIP joint is not recommended; a tenotomy of the extensor tendon, distal to the triangular ligament but proximal to the distal interphalangeal (DIP) joint, preferable. ~o, ~8 The method is simple, uses only local tissue, and restores normal balance. The operation should be performed only after a 1- to 3-month period of splinting has failed to improve the clinical state significantly and a fldl range of passives.movement has been restored at the PIP joint.. Surgical technique Through a curvilinear, dorsal incision centered over the PIP joint, the extensor apparatus is exposed and the transverse retinacular ligaments are identified and ~3-5023, 81/ / American Society for Surgery of the Hand THE JOURNAL OF HAND SURGERY 379

2 380 Urbaniak and Hayes The Journal HAND SUR~ Fig. 1. Extensor apparatus at PIP joint ~s exposed by dorsal incision. Probe is placed beneath right transverse retinacular ligament, which is to be separated from lateral band. Triangular flap in extensor tendon is based proximally. sharply separated from their insertion on the lateral bands (Fig. 1). A proximally based triangular flap is elevated between the lateral bands of the extensor mechanism. This flap is carefully separated from the underlying joint capsule and synovium and reflected proximally. A further capsular flap, attached to the base of the middle phalanx, is then fashioned and passed through a split in the proximally based flap of the extensor tendon (Figs. 2 and 3). The lateral bands are then opposed using two or three 4-0 polyester sutures. This approximation is adjusted so that full passive flexion of the DIP joint is possible (Fig. X 4). The, i:tistally based capsular flap is then sewn into place on the extensor tendon, and the large proximally based triangular flap is sutured to the extensor apparatus so that it overlaps the dorsally placed extensor slips (Fig. 5). A small Kirschner wire is passed across the joint, which is held in full extension. After hemostasis has been achieved, the wound is carefully closed and the forearm immobilized in a compression dressing with the metacarpophalangeal joint flexed and the DIP joint free to allow active flexion. Four weeks postoperatively, the Kirschner wire is removed; for a further 3 to 4 weeks, a splint is worn. 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 allowing flexion of the DIP joint. Materials and Results Over an 8-year period, 13 patients, ranging 21 to 66 years of age, were operated using technique. The delay from injury to operation was 2 6 months, with the exception of one patient who operated at 2 years. All but one patient had at lea a! month of splinting (Table I). Of the 13 patients which this procedure was done, there were eight g results, with less than 15 of extensor lag at the joint and at least 30 oof flexion at the DIP.1 omt (Fi~ Table II). Four patients improved. They had between 30 of lag at the PIP joint, with at least 20 of the DIP join~ ~-All 12 of the patients in the good.~ improved groups obtained at least 90 of active at 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

3 NO. 4 Chronic boutonniere deformity 381 Fig. 3. Lateral view of triangular flaps at PiP joint. Flap on left is distally based dorsal capsule from base of middle phalanx. Large more superficial flap on right is proximally based in extensor apparatus. ba,cd allowing ra:-~ ;ing :d ~ising ation lent had at.3 patient~ :re eight a,.z, at the ~j, :,s.. n )o active ml ~ of cular 4. Lateral bands are carefully approximated with two or interrupted sutures after tongue of capsule is pulled proximally based flap of extensor tendon. Fig. 5. Final posiuon of two triangular flaps. Proximally based flap is sutured over two distally approximated lateral bands.

4 382 Urbaniak. and Hayes The 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 full flexion and good extension of ring finger. Table I. Surgical reconstruction of chronic boutonniere deformity Date of surgery A ge/sex Injury to surgery (months) Splinting (months) Active PIF motion Active DIP motion Preop ~ Postop Preop L Postop Rating June 73 (TN) 34M /90 45/90-20/-20-10/-10 Jan. 74 (GC) 27 F /85 0/90-40/-30-20/75 Jan. 74 (KE) 47 F 5 Unknown 60/90 20/95 -t0/-10-10/15 May 75 (AR) 38M 2 (years) 2 70/95 10/95-5/15! 5/60 June 75 (MY) 21M /130 0/130-30/45 0/90 Sept. 75 (NS) 37M /90 8/110-10/20 0/40 Jan. 77 (MH) 24M /90 20/90-20/30 10/30 May 77 (FS) 49 F /95 10/120 0/20 0/84 May 78 (UW) 56 M /90 0/95-10/0 0/70 Jan. 79 (SR) 66M 2 ~, 1 90/95 15/95-30/-30-15/45 Feb. 79 (CC)./ 32 F /90. 0/90-5/45 20/60 May 79 (EMy 27 F /110 27/105-30/0 5/70 April 80 (SD) 37M /90 5/100 10/10 0/70 Failed Good Impr,,.ed Good Improved Go~ Improv~ Impro~ Go(~ Table II. Summary of results of reconstruction of chronic boutonniere deformity in 13 patients patients lag PIP joint DIP joint Rating 8 15 or less 30 or more Good 4 15 to or more Improved 1 30 or more None Failed and it was not possible to restore a full range,~r motion at the PIP joint preoperatively. Summary ~ A method for overcoming the loss of motion deformity in the chronic boutonniere deformity been described. The operation consists of (1) retort structing the damaged central slip using the joint

5 The ~0. 4 Chronic boutonniere defortnity 383 synovium and (2) a careful dorsal repositionlateral bands. :ERENCES EB: Injuries and treatment of the extensor apparai of tl:e hand and digits. Clin Orthop 13:24-30, t959 JW: The finger extensor mechanism. Surg Clin Am 47:415-32, 1967 R, Valentin P: Anatomy of the extensor appara- ~ofthe lingers. Surg Clin North Am 44: , 1964 :tier JW, Eaton RG: Redistribution of forces in the ion of boutonniere deformity. J Bone Joint Surg 49: , 1967 ~ter WA: The problem of boutonniere deformity. Clin 104:116-33, 1974 ttc~" ".. \: The boutonniere deformity. J Bone Joint [l.q] 49:710-21, 1967 Iliot RA: Injuries to the extensor mechanism of the I ~and. Ortho Clin North Am t:335-54, 1970 ham DLC, Jack EA: "Buttonholed" extensor extra. Br Med J 2:701-2, 1937 Nichols HM: Repair of extensor tendon insertions in the fingers. J Bone Joint Surg [Am] 33:836-41, Weeks PM: The chronic boutonniere deformity: A method of repair. Plast Reconst Surg 40:248-51, Suzuki K: Reconstruction of posttraumatic boutonniere deformity. Hand 5:145-8, Kilgore ES, Graham WP: Operative treatment of boutonniere deformity. Surg 64: , Stack HG: "Buttonhole deformity". Hand 3:152-4, Matev I: Transposition of the lateral slips of the aponeurosis in treatment of longstanding "boutonniere deformity" of the fingers. Br J Plast Surg 17:281-6, 1964 " 15. Salvi V: Technique for the "Buttonhole" deformity. Hand 3:96-7, Dolphin JA: Extensor tenotomy for chronic boutonniere deformity of the finger. J Bone Joint Surg [Am] 47:161-4, Blue AI, Spiram B, Hardy S: Repair of extensor tendon injuries of the hand. Am J Surg 132:128-32, Goldner JL: Deformities of the hand incidental to pathological changes of the extensor and intrinsic muscle mechanisms. J Bone Joint Surg [Am] 35:115-31, 1953 Rating ange, of motion deformity s of (!./ g the joint