Results of the Matev operation for correction of Boutonnière deformity

Reconstruction of Traumatic Central Slip Injuries: Technique Using a Slip of Flexor Digitorum Superficialis

Multiple reconstruction techniques have been described for correction of boutonniere deformities including direct repair, central slip reconstruction, lateral band reconstruction, transverse retinacular ligament reconstruction, staged reconstruction, and extensor tenotomy. Each technique has been reported to have variable results with complications including capsular contracture, loss of proximal interphalangeal flexion, and residual deformity. We describe a surgical technique for central slip reconstruction using a slip of the flexor digitorum superficialis tendon through a bone tunnel.

Chronic Boutonniere Deformity: Cross-Lateral Band Technique Using Palmaris Longus Autograft

PURPOSE

The purpose of this study was to evaluate the outcomes of treatment of chronic boutonniere deformity with a reconstruction technique using palmaris longus autograft.

MATERIALS AND METHODS

Seven patients with chronic, posttraumatic, flexible boutonniere deformities referred to our clinic between January 2010 and September 2014 were included in the study. In all 7 patients, the lateral bands were deficient or damaged beyond repair. A novel reconstruction technique for chronic boutonniere deformity utilizing palmaris longus autograft was used. The 2 lateral bands were reconstructed by attaching the palmaris longus tendon grafts from the lateral part of the central slip proximally to the volar aspect of the distal phalanx distally using pull-out sutures. The grafts were positioned so that they crossed over one another at the level of the middle phalanx. The patients were followed for a mean of 14 months (range, 12-16 months). The principal outcome measure was the range of motion of the proximal (PIP) and distal (DIP) interphalangeal joints.

RESULTS

Before surgery, the average PIP joint active flexion was 69° (range, 60°-85°). After surgery, the average PIP joint active flexion increased to 92^° (range, 90°-100°). Before surgery, the average PIP joint extension deficit was 54° (range, 40°-60°); after surgery, the average deficit was reduced to 7° (range, 5°-15°). Before surgery, the average DIP posture was 9° of hyperextension (range, 5°-12°); after surgery, DIP hyperextension was reduced to 2° (range, 0°-5°). Before surgery, the average DIP active flexion was 40° (range, 35°-55°); after surgery, this increased to 55° (range, 43°-72°). No patients developed a DIP flexion contracture.

CONCLUSIONS

In the chronic boutonniere deformity, when the lateral bands are deficient or damaged, our cross-lateral band reconstruction technique using palmaris longus autograft is a treatment option with satisfactory results.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Sagittal band, boutonniere, and pulley injuries in the athlete

PURPOSE OF REVIEW

While hand injuries occur frequently in the athletic population, sagittal band ruptures, boutonniere deformities, and pulley ruptures are infrequently encountered. These injuries represent diagnostic challenges and can result in significant impairment. Early recognition with appropriate treatment is necessary to maximize recovery and minimize return to athletic competition. This review will focus on the underlying mechanism, pathophysiology of injury, diagnosis, and treatment of each of these injuries.

RECENT FINDINGS

With respect to sagittal band ruptures, boutonniere deformities, and pulley ruptures, the recent literature has been limited in scope. For sagittal band injuries, current efforts have focused on alternative techniques for sagittal band reconstruction. Little progress has been made in recent years with respect to boutonniere injuries in the athletic population; prevention of fixed deformities remains the backbone of treatment. The exact contribution from individual and combined pulley injuries in the creation of bowstringing remains controversial. Recent anatomical studies have failed to definitively answer the question of what degree of rupture is necessary to create symptomatic bowstringing. Favorable outcomes, with respect to both preventing bowstringing and returning to full athletic participation, have been newly reported following pulley reconstruction in rock climbers. Due to the infrequent nature of sagittal band ruptures, boutonniere deformities, and pulley ruptures, current treatment is mostly guided by historically established methods, limited case series, and case reports. Nonsurgical treatment remains the mainstay for most injuries and, if employed early, often precludes the need for surgery. Further anatomical and clinical research, including outcome studies, is necessary in guiding treatment algorithms.

Extensor tendons injuries

Extensor mechanism injuries are frequently encountered in athletes and can lead to permanent disability or deformity if not promptly and properly treated. This article reviews basic anatomy, and then discusses mallet finger injuries, boutonniere deformity, and sagittal band rupture. Once treatment has begun, return to sport is highly variable because of the varied needs of each athlete and where they fall on the spectrum of disease. As such, each athlete must be carefully evaluated and closely followed to ensure a safe, prompt, and judicious return to athletic pursuits.

Boutonnière and pulley rupture in elite athletes

This article discusses injuries to the central slip (boutonnière) and to the annular pulleys in the digit, with an emphasis on the elite athlete. Pertinent anatomy, mechanism of injury, diagnosis, treatment, and a discussion emphasizing the elite athlete and return to play form the basis of the article.

SURGICAL MANAGEMENT OF CHRONIC BOUTONNIERE DEFORMITY

Purpose: Boutonniere deformity is caused by damage to the central slip of the extensor tendon hood with secondary palmer migration of the lateral bands. Accordingly, patients complain of disfigurement and impairment of function due to hyperextension of their DIP. The aim of this study is to evaluate the results of surgical treatment of chronic boutonniere deformity by using a modified technique.

Patients and methods: Twelve patients with posttraumatic boutonniere deformity were available for follow up as a retrospective study. They were treated by release of the extensor expansion proximal to the distal insertion of the oblique retinacular ligaments with proximal recession of the extensor tendon and lifting the lateral bands dorsally onto the PIP joint after separation of the transverse retinacular ligaments from their insertion volarly. All patients had closed injury. The mean age was 32 years (range: 16–48 years). The average follow-up period was 33 months (range: 26–38 months). We included only cases with deformities that were totally correctable passively with or without joint osteoarthritic changes.

Results: Preoperatively the average PIP joint extension deficit was 60° and postoperatively the average is reduced to 7°, preoperative the average DIP motion was 10° of hyperextension, post-surgery the average DIP active flexion was 75°. The final outcomes were 58.3% excellent, 33.3% good, and 8.3% poor.

Discussion: This modified technique gave (91.6%) excellent and good results. The extensor tendon acted mainly on the PIP joint and allowing the DIP joint to flex freely. The procedure is simple and provides long-term good results.

Level of evidence: Therapeutic case series, level 1V.

[Swan-neck and buttonhole deformities on rheumatic long fingers]

Patients suffering from rheumatoid arthritis in many cases develop typical swan-neck and buttonhole deformities. In the further course of the disease we observe several stages. In the beginning active and later passive correction are still possible, while ultimately a fixed contracture is present. The activities of daily life may be severely reduced. The pathology of the swan-neck deformity is initiated at the level of the metacarpophalangeal joint, while at the origin of the buttonhole deformity the synovitis of the proximal interphalangeal joint is obvious. In the early stages, synovectomy and balancing of the soft tissues are surgically indicated. In advanced stages, complicated soft tissue reconstruction in combination with alloarthroplasty or arthrodeses may become necessary to allow for sufficient finger function.

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 degrees 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 degrees 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.

Biomechanical evaluation of chronic boutonnière reconstructions

The magnitudes of the extensor forces generated across the proximal interphalangeal joint by the Littler-Eaton, Matev, Hellmann, and Fowler reconstructive procedures for posttraumatic chronic boutonnière deformity were measured in a laboratory study. The purpose of the experiment was to determine whether the mechanical design of a procedure had a significant impact on biomechanical performance. Results showed that each method produced adequate extensor forces and restored full proximal interphalangeal joint extension. There were few statistically significant differences among the procedures for the different joint angles and load conditions tested. The data suggest that the mechanical designs of these reconstructions are satisfactory for correction of the extensor deficit of the deformity. The preoperative condition of the finger is probably responsible for the variations seen in clinical results.

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

Twenty consecutive patients with severe chronic nonrheumatoid deformities were treated with a modification of the Matev procedure. Fourteen of the 20 had normal passive range of motion preoperatively, with the proximal interphalangeal joints lacking 59 degrees of active extension and the distal interphalangeal joints hyperextended 17 degrees. In the other six patients with PIP contracture at the time of reconstruction, PIP joints lacked 68 degrees of active extension and the DIP joints were hyperextended 13 degrees. Follow-up averaged 8 months, and at that time the patients with no contracture had an average of 14 degrees/96 degrees of active motion at the PIP joint and 9 degrees/59 degrees of motion at the DIP joint. The group with contracture had an average of 21 degrees/80 degrees of active motion at the PIP and 13 degrees/41 degrees of motion at the DIP joint. There were 85% good or satisfactory outcomes in the group without contracture and 67% good or satisfactory outcomes in the group with contracture.