Boutonniere Deformity Research Articles

TREATMENT OF THE CHRONIC BOUTONNIERE DEFORMITY BY EXTENSOR TENOTOMY

A patient with a chronic boutonniere deformity often experiences more difficulty because of the hyperextension deformity at the distal joint, rather than the lack of extension at the proximal interphalangeal joint. It is in these cases that restoration of flexion at the terminal joint by tenotomy of the terminal extensor tendon is of most value.

Current recommendations for surgery of the rheumatoid hand and wrist.

Treatment of the hand with rheumatoid arthritis has not changed significantly over the past year. Two studies indicated that methotrexate administration need not be discontinued prior to surgery. Electron microscopy has shown that rheumatoid tendons are morphologically different from normal tendons. Early synovectomy has been reintroduced as a valuable technique, and the need for a team approach in disease management has been emphasized. Several authors emphasized rigid surgical fixation to improve digital and wrist fusions. Three studies reported good long-term results from metacarpophalangeal joint arthroplasty. Derangements of the distal radioulnar joint can benefit from the Sauve-Kapandji procedure. A newer technique to stabilize the distal ulna following the Darrach procedure was introduced, also, the treatment of swan-neck and boutonniere deformities, the results of which were somewhat disappointing, was reviewed.

Surgery for boutonniere deformity

Surgery for boutonniere deformity

Flexible implant resection arthroplasty of the proximal interphalangeal joint in patients with systemic inflammatory arthritis

Forty proximal interphalangeal joint silicone elastomer flexible implant arthroplasties in 19 patients with systemic inflammatory arthritis were reviewed. The follow-up period averaged 94 months. Before surgery, the average arc of motion was 26° for the 20 digits with boutonniere deformities and 23° for the 16 digits with swan-neck deformities. Eight digits had moderate (grade 2) pain, and four digits had severe (grade 3) pain. After surgery, the deformity was completely corrected in six digits. Digits with a preoperative boutonniere deformity (20 digits) achieved the same (26°) arc of motion after surgery, whereas those with a preoperative swanneck deformity (16 digits) actually lost 18°. Six digits had moderate pain and one digit had severe pain at the final follow-up evaluation. Thirteen digits (7 patients) with a boutonniere deformity before surgery and a concurrent or previous silastic metacarpophalangeal arthroplasty had significantly better results than those without. Overall, there were 12 good, 18 fair, and 10 poor results. Based on this study, flexible silicone implant arthroplasty has a limited role in the treatment of proximal interphalangeal joints affected by systemic inflammatory arthritis. When performing the arthroplasty, attention should be directed first toward correction of the deformity at the metacarpophalangeal joint.

Soft tissue reconstruction for rheumatoid swan-neck and boutonniere deformities: Long-term results

Ninety-two fingers with rheumatoid swan-neck deformity were treated with dorsal capsulotomy and lateral band mobilization. An initial increase of 55° of motion into flexion was noted, but this proximal interphalangeal motion deteriorated over time. Of 15 fingers followed at 3 and 12 months, there was a mean loss of 17° of the early postoperative flexion. Nineteen fingers with rheumatoid boutonniere deformity were treated with central slip reconstruction. The results were unpredictable, with only modest improvement in the proximal interphalangeal extension, which deteriorated over time. The authors now recommend arthrodesis for most severe rheumatoid boutonniere deformities.

Surgical treatment of boutonniere deformity

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.

THE BOUTONNIERE DEFORMITY

Understanding the pathophysiology of the boutonniere deformity requires a complete understanding of the anatomy of the dorsal tendon apparatus. This unique tendon mechanism often becomes unbalanced, requiring correction of its components. Splinting is the cornerstone of treatment for the boutonniere deformity. In the acute stage, splinting ensures that the continuity of the central tendon to its insertion into the middle phalanx is maintained, and in the chronic stage, its function is to correct the flexion contracture of the PIP joint and stretch the retinacular ligaments. Splinting is also important postoperatively because it permits healing of the central tendon and lateral bands in their correct anatomic positions. Without proper splinting, the patient with the boutonniere deformity could not be successfully treated. Frequently, surgery is necessary, and the choice of procedure depends on the stage of the condition and the extent of the defect in the extensor tendon mechanism. The procedure also depends on the success of the splinting program and stretching of the tight retinacular structures. If passive joint mobility can be restored and if tendon imbalance and retinacular tightness persist, rebalancing is necessary. This rebalancing can be accomplished by a tenotomy of the terminal extensor tendon, a lysis or release of the retinacular structures, or release of the insertion of the extensor tendon at the base of the proximal phalanx. Reconstituting the defect in the central tendon over the PIP joint is accomplished by using a variety of procedures, including mobilization and advancement of the more proximal portion of the central tendon, shifting the lateral bands, or a tendon graft.

Hand Injuries in Football Players.

In brief Football players have a fairly high brief risk of injury to the soft tissues of the hand; among the most common problems are thumb sprains and proximal interphalangeal joint dislocations. Stable ligament injuries can be treated with splints and casts, but more severe sprains may require surgical intervention. Closed tendon injuries must be followed carefully to prevent boutonniere deformity or mallet finger. Athletes with these injuries often can return quickly to play with protective splinting, but more recovery time may be necessary for ball handlers and for players who have injuries that require open reduction.

Results of acute zone III extensor tendon injuries treated with dynamic extension splinting

Motivated by the favorable results of dynamic splinting in the treatment of more proximal extensor tendon injuries, we explored the use of dynamic splinting in the treatment of zone III extensor tendon lacerations. Twenty-two tendon repairs in 19 patients were available for review. On the basis of degree of extension lag and pulp-to-palm distance, 14 repairs were rated as excellent, 6 as good, and 2 as fair. Using total active motion at 10 weeks, the proximal interphalangeal and distal interphalangeal joints averaged 170 degrees. There was one mild boutonniere deformity. The results of this prospective study show that carefully monitored dynamic splinting is safe in the treatment of zone III lacerations. When results were compared with the results of our method of static splinting used prior to this prospective study, patients returned to full activities with good-to-excellent results 8 weeks earlier instead of at 16 to 18 weeks.

Nonsurgical management of the boutonniere deformity

AbstractThe present study examined the effectiveness of a 6‐week experimental program of splinting and joint protection education in reducing the progression of the early boutonniere deformity. Nine patients with mild or moderately reducible boutonniere deformities were randomized into experimental and control groups and followed for 1 year. Improvements in active extension of the proximal interphalangial joint for patients in the experimental program suggest that early initiation of a nonsurgical intervention can reduce or reverse progression of the boutonniere deformity in some patients with rheumatoid arthritis. Although the number of patients was small, we conclude that early splinting and joint protection education may limit the anatomical and functional derangements of boutonniere deformity in the rheumatoid hand.

Nonsurgical management of the boutonniere deformity

Nonsurgical management of the boutonniere deformity

Boutonniere rheumatoid thumb deformity

The boutonniere deformity is the most common rheumatoid thumb deformity. It can be classified into early, moderate, and advanced types, depending on whether the deformity is passively correctable. Fifty-three patients with 74 procedures from the basis of these recommendations. The early type treated with metacarpophalangeal joint synovectomy and extensor pollicis longus rerouting have a high recurrence rate of 64%. Metacarpophalangeal joint fusion is the procedure of choice for the moderate type with isolated metacarpophlangeal joint involvement. Metacarpophalangeal joint arthroplasty is best suited for the low-demand, older patients with borderline proximal and distal joints. Interphalangeal joint releases done with metacarpophalangeal joint fusions have a high recurrence rate and are not recommended. In advanced cases metacarpophalangeal joint arthroplasty and interphalangeal joint fusion is our procedure of choice.

Reconstruction of the central slip by the transverse retinacular ligament for boutonnière deformity

A method of repair of boutonniere deformity is described, using the transverse retinacular ligament. Six fingers in five patients were treated by this procedure. The deformity was improved in all fingers; complete or almost complete correction was obtained in four fingers and incomplete correction in two. However, severe limitation of flexion of the D.I.P. joint appeared in two fingers after surgery. This procedure is not indicated for boutonniere deformities with severe contracture of the lateral band; its best indication is in cases in which the central slip is defective and conservative treatment is not effective.

Operative treatment of the post-traumatic boutonniere deformity: A modification of the direct anatomical repair technique

We report 20 cases of post-traumatic boutonniere deformity treated by a modification of the direct anatomical repair technique, particularly indicated in late cases which have complete passive motion. A swallow-tailed flap is excised from the fibrous tissue between the two ends of the central slip. The proximal one is then advanced up to the coaptation with the distal edge of the scarred capsular tissue at the insertion on the middle phalanx to which it is sutured in correct tension. Excellent results have been obtained in 72% of cases and good in 5.5%. The 16% of fair results are probably due to the fact that patients didn't use the splint post-operatively and didn't cooperative with physiotherapy.

Metacarpal-phalangeal joint arthroplasty of the rheumatoid thumb

Fifty patients with rheumatoid arthritis had 59 Swanson implants of the metacarpal-phalangeal joint of the thumb. Eleven patients (15 implants) have since died and only 1 patient (1 implant) has been lost to follow-up leaving 43 implants available for study. The most common preoperative deformity was a boutonniere deformity with a flexible interphalangeal joint. All thumbs had less pain after operation. The average range of active motion is 25 degrees, with a flexion arc from 15 to 40 degrees. There is an average key pinch strength of 4 pounds (range, 0.5 to 10). Improvement in activities of daily living were noted in 40 hands. One thumb required reoperation for instability; the implant was removed and a metacarpal-phalangeal arthrodesis was done. Radiographic progression of disease was noted in only one thumb at the interphalangeal joint and in two other thumbs at the carpometacarpal joint. None of these have required further operations. The maintenance of motion appears to help in activities of daily living as stability and pinch strength are often adequate.

外傷性ボタン孔変形の治療経験

Posttraumatic boutonnière deformity, 13 cases in number, were experienced. Eight cases were subjected to conservative treatment and five cases to operative treatment. For cases within four weeks subsequent to injury sustained good results were obtained through conservative treatment, while for cases with longer period subsequent to injury sustained results were recorded to be inferior to those of operative treatment. A case with three months elapsed subsequent to injury sustained was sttached with a coil splint and a good result was obtained. Accordingly, it is considered that, in case cooperation will be available for conservative treatment of a long period of time, conservative treatment ought to be attempted as much as possible.

Surgical Treatment of the Boutonniere Rheumatoid Thumb Deformity

The boutonniere deformity is the most common rheumatoid thumb deformity. Its treatment is based on the type or stage of the deformity. We have reviewed our recent cases which are the basis for our current recommendations. MP joint synovectomy and EPL rerouting have a high recurrence rate of 64 per cent. MP joint fusion is the procedure of choice for the moderate type with isolated MP joint involvement. There is a low incidence of later IP joint collapse. MP joint arthroplasty is best suited for the low-demand, older patient with borderline proximal and distal joints. IP joint releases have a high degree of recurrence and are not recommended. In a low-demand patient with an advanced thumb, MP joint arthroplasty and IP joint fusion are the procedures of choice.

Boutonniere Deformities in Rheumatoid Arthritis

The emphasis in rheumatoid hand surgery has been on the MP joints, but the PIP joints are often involved with the boutonniere deformity being one common pattern. The pathology of the boutonniere begins with a synovitis of the joint, followed by elongation al the central slip, subluxation of the later bands, and contracture of the retinacular ligaments. Treatment in the early stages can include synovectomy and tendon reconstruction. In the later stages, when the joint is fixed or there is articular surface damage, a joint replacement or arthrodesis is necessary.

Extensor tenotomy: A technique for correction of posttraumatic distal interphalangeal joint hyperextension deformity

Tenotomy of the dorsal apparatus over the middle phalanx was done in 13 digits for treatment of posttraumatic hyperextension of the distal interphalangeal joint associated with a boutonniere deformity. All but one patient was improved with distal interphalangeal joint flexion averaging 45 degrees at follow-up. Four digits had a 5 degree to 10 degree extensor lag. This procedure is simple and reliable and should be considered when increased distal interphalangeal joint flexion is desired.

Duchenne muscular dystrophy: a study of wrist and hand function.

The wrist and hands of 18 Duchenne muscular dystrophy (DMD) patients were assessed for abnormalities. The subjects were divided into three groups by age. Flexion and ulnar deviation contractures of the wrist began in the youngest age group, 8-14 years. Other abnormalities, present in all age groups, included extrinsic and intrinsic digital muscle shortness, boutonniere and swan neck deformities, and hyperextension of the digital interphalangeal joints. Pain found with passive proximal interphalangeal joint flexion has not been reported previously. This study supports the importance of early assessment of the wrist and hand in DMD and suggests intervention techniques to possibly retard the deforming process.