Surgical treatment of boutonniere deformity

Abstract

The boutonniere deformity is characterized by proximal interphalangeal (PIP) joint flexion and distal interphalangeal (DIP) joint hyperextension. There are a multitude of causes, and all cause attenuation, attrition, or discontinuity of the extensor mechanism over the PIP joint. Loss of the central slip alters the balance between flexion and extension forces and the PIP joint assumes a flexed posture. Initial disruption or gradual attenuation of the triangular ligament allows migration of the lateral bands volar to the PIP joint axis and propagates PIP joint flexion. Reciprocal DIP joint hyperextension occurs as the retracted central slip increases the lateral band pull via interconnections. Treatment of the acute closed boutonniere deformity involves early recognition and PIP extension splinting. Open injuries require meticulous surgical repair using loupe magnification and tourniquet hemostasis. Appropriate management of acute central slip injuries will lead to good results. Treatment of the chronic boutonniere deformity is more problematic as secondary soft tissue contracture makes correction more difficult. Restoration of full motion is often an unrealistic goal. Management must be individualized to the patient. Prolonged therapy is often necessary to obtain optimum result. Restoration of passive mobility is a prerequisite to central slip repair or reconstruction. After obtaining supple PIP and DIP joints, surgical correction of the extensor mechanism can be performed. We favor an anatomic repair technique with restoration of tendon excursion, balance, and central slip insertion.