34: Reconstruction of the Central Slip with the Transverse Retinacular Ligament for Boutonnière Deformity

Procedure 34 Reconstruction of the Central Slip with the Transverse Retinacular Ligament for Boutonnière Deformity



Makoto Motomiya, Akio Minami


imageSee Video 26: Correction of Boutonnière Deformity



Indications




image Boutonnière deformity is classified into three stages by Nalebuff, as follows:


• Stage 1: Mild deformity; 10 to 15 degrees of extension lag at the PIP joint, and PIP joint passively correctable

• Stage 2: Moderate deformity; 30 to 40 degrees of extension lag at PIP joint, and PIP joint passively correctable

• Stage 3: Severe deformity that cannot be corrected passively

image Indication: Boutonnière deformity of the PIP joint with almost full passive extension (stages 1 and 2) is suitable for this reconstructive surgery.


image Contraindication: If articular destruction is evident or if a severe fixed flexion contracture is present (stage 3), arthrodesis or arthroplasty of the PIP joint is recommended.



Examination/Imaging



Clinical Examination




image Boutonnière deformity is seen in a patient with rheumatoid arthritis (Fig. 34-1).


image Passive PIP joint extension should always be evaluated before surgical reconstruction.


image The mobility of the PIP joint is very important for obtaining good results. Therefore, in the case of the boutonnière deformity with severe flexion contracture of the PIP joint, rehabilitation or joint splinting in extension of the PIP joint should be performed before the operation.


image

FIGURE 34-1



Imaging




image Radiographic examination is required to evaluate the status of the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints.


image If the PIP joint is destroyed, arthrodesis or arthroplasty is recommended.


image Magnetic resonance imaging examination may help to identify synovitis of the PIP joint.



Surgical Anatomy




image Disruption of the central slip of the extensor tendon results in palmar migration of the lateral bands with PIP joint flexion. Proximal displacement of the extensor apparatus results in the DIP joint hyperextension deformity (Fig. 34-2A is normal; B shows boutonnière deformity).


image The transverse retinacular ligament is the key component in this procedure. This ligament holds the lateral bands in the palmar direction during flexion. It inserts into the palmar plate of the PIP joint and flexor tendon sheath (Fig. 34-3).


image

FIGURE 34-2


image

FIGURE 34-3



Exposures


Related posts:

28: Pronator Teres Rerouting 35: Silicone Metacarpophalangeal Joint Arthroplasty 85: Wrist Denervation 38: Reconstruction for Congenital Thumb Hypoplasia 65: Arthroscopic Treatment for Septic Arthritis 89: Total Wrist Fusion

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Mar 5, 2016 | Posted by in Hand surgery | Comments Off on 34: Reconstruction of the Central Slip with the Transverse Retinacular Ligament for Boutonnière Deformity

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