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Boutonniere Injuries: Soft Tissue Reconstructive Procedures

- Discussion:
    - soft tissue procedures will work only passive ROM is re-established;

- Staged Method of Treatment: (from Raymond et al 1982)
    - use a metacarpal block for anesthesia (for intial three stages);
    - stage I and II:
           - lazy "S" incision over the PIP joint;
           - lateral bands are freed from their attachments to transverse retinacular ligament;
           - extensor tenolysis is performed over the proximal phalanx and over the PIP (freeing the tendon from the capsule);
           - at this point re-assess ability to extend the PIP joint;
    - stage III:
           - modified lateral band tenotomy (see below);

- Extensor Tenotomy:
    - may be indicated for both rheumatoid and traumatic hyperextension DIP deformities;
    - is especially indicated when the skin over the PIP is abnormal or scarred;
    - is simple and is carried out to allow flexion of the DIP joint;
    - this takes the tension off the proximal joint to some extent and can be effective in correcting the deformity of the PIP Joint as well as the deformity at the DIP joint;
    - tenotomy of the extensor tendon is performed distal to the triangular ligament but proximal to the DIP joint (and proximal to the ORL insertion, in order to allow the ORL to maitain some DIP extension);
    - alternative is to step cut the lateral bands over the middle phalanx and to then suture the proximal and distal portions of the lengthened tendons;
            - this method re-establishes the balance with the lengthened central slip, while avoiding the complication of a mallet deformity;
    - the DIP is then manipulated into hyperflexion to break up adhesions;
    - postoperative dynamic splinting is directed at bringing the PIP joint into extension;
    - mallet deformity should not develop as long as the oblique retinacular ligaments;
            - if postoperative mallet deformity is noted, then postoperative splinting should correct the problem;
    - refs:
            - Redistribution of forces in the correction of the Boutonniere deformity.
            - Extensor Tenotomy for Chronic Boutonniere Deformity of the Finger.
            - Extensor tenotomy: a technique for correction of posttraumatic distal interphalangeal joint hyperextension deformity.

- Lateral Bands:
    - release or reconstruction lateral bands;
    - triangular ligament and transverse retinacular ligaments are excised, which allows the lateral bands to be repositioned dorsally;
           - the bands are then sutured distal to the PIP joint;
           - disadvantages: this procedure does not permit optimal tension and excursion of the tendon to be extablished;
    - Salvi Technique:
           - requires good passive ROM;
           - transverse retinacular ligaments are freed from palmar plate & then transferred dorsally and are sutured together over the PIP joint;
           - this technique helps to lift the lateral bands out of their volar position but not rigidly fix them in a dorsal position;
    - oblique or step cut tenotomy of lateral bands distal to central slip insertion over proximal metaphysis of middle phalanx (Dolphin, Fowler, or Nalebuff);
    - dorsal transposition and suture of lateral bands (Littler);
    - transposition of lateral bands to central slip (Matev & Littler);
           - lateral bands are divided at different levels;
           - the shorter proximal stump is sutured to the central slip;
           - the longer proximal stump is sutured to the contralateral long distal stump;

- Method of Urbaniak and Hayes:
    - curvilinear incision is made over the PIP;
    - lateral bands are freed from transverse retinacular ligaments;
    - a proximally based triangular flap is created between the lateral bands;
    - the flap is elevated off the joint capsule, and is reflected proximally;
    - a second distally based flap is made off the capsule of the PIP joint;
    - the second flap is passed proximally through a rent made in the first flap;
    - the lateral bands are opposed over the middle phalanx;
          - they may be sutured more proximal as long as full passive flexion of the DIP joint is maintained;
    - the distally based flap is sutured to the central slip;
    - the proximally based flap is sutured over the dorsally positioned lateral bands;
    - a K wire holds the joint in full extension 

Chronic boutonniere deformity--an anatomic reconstruction.

The management of chronic posttraumatic boutonniere deformity.

Surgical repair of the boutonniere deformity of the fingers.

Correction of the severe nonrheumatoid chronic boutonniere deformity with a modified Matev procedure.

Biomechanical evaluation of chronic boutonniere reconstructions.

Tendon reconstruction for postburn boutonniere deformity.

Operative treatment of the post-traumatic boutonnière deformity. A modification of the direct anatomical repair technique.

A Staged Technique for the Repair of the Traumatic Boutonniere Deformity.