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

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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

image Extensor apparatus is approached through a dorsal curved incision over the PIP joint. The dissection is carried down to the extensor hood, preserving the dorsal venous system (Fig. 34-4).

image

FIGURE 34-4

Pearls

The surgery is done under wrist block/digital block to confirm the proper tension for the active finger motion during operation.

Pitfalls

The surgeon should be careful to protect any dorsal sensory subcutaneous veins and nerves encountered.

Procedure

Step 1

image Both lateral bands and transverse retinacular ligaments are identified first. The central slip is usually attenuated or ruptured, and the capsule of the PIP joint appears directly under the fat tissue. In Figure 34-5, the black arrow shows the transverse retinacular ligament.

image The radial and ulnar transverse retinacular ligaments are cleanly separated from their insertions at the palmar plate.

image

FIGURE 34-5

Step 1 Pearls

If there is a contracture of the PIP joint, the surgeon should cut the accessory collateral ligament and release the volar plate at the proximal portion to obtain full passive extension of the PIP joints.

Removing adhesion of the lateral band and cutting the oblique retinacular ligament may be necessary to obtain flexion of the DIP joint.

Synovectomy of the PIP joint should be performed for patients with active rheumatoid arthritis.

Step 1 Pitfalls

Collateral ligaments of the PIP joint should be preserved to prevent instability of the joint.

Step 2

image The transverse retinacular ligaments are turned over onto the dorsal aspect on the PIP joint to lift the lateral band dorsally and are then sutured to one another (Fig. 34-6).

image Tension of the suture is determined by noting the nearly full active extension of the PIP joint (Fig. 34-7).

image The schema of this operation is shown in Figure 34-8.

image

FIGURE 34-6

image

FIGURE 34-7

image

FIGURE 34-8

Step 2 Pearls

Determining the tension of the suture is very important to obtain good flexion and extension of the PIP and DIP joints.

Step 2 Pitfalls

If the suture is too tight, it is likely to result in extension contracture of the PIP and DIP joints.

Step 3

image Check active flexion of the DIP joint because the tension of the lateral band is tighter after suturing of the transverse retinacular ligaments (Fig. 34-9).

image If DIP joint flexion is limited, releasing the lateral band between the PIP and DIP joints is recommended.

image Make small transverse cuts in the lateral band until the DIP joint can be actively flexed at 30 degrees (Fig. 34-10).

image After the operation, the PIP joint is immobilized in full extension with a Kirschner wire or volar splint for about 14 days.

image

FIGURE 34-9

image

FIGURE 34-10

Step 3 Pearls

The release of the lateral band should be done at the level of the distal half of the middle phalanx.

Step 3 Pitfalls

Releasing the lateral bands too far is likely to result in the extension lag of the DIP joint.

Postoperative Care and Expected Outcomes

image Active flexion exercises of the DIP joint are started within 3 days while the PIP joint remains immobilized.

image About 14 days after surgery, active flexion exercises of the PIP joint are gently started, but active extension exercises of the PIP joint should be avoided at the early stages.

image The PIP joint is held in full extension in the daytime by a dynamic splint and at night by a static splint for several weeks.

image After removing the splint, active finger exercises are started gradually.

Pitfalls

Rehabilitation should be performed under the supervision of a hand therapist.

Evidence

Kato H, Uchiyama S, Yamazaki H, et al. Treatment for boutonnière deformity in rheumatoid arthritis [Japanese]. Kansetsugeka. 2008;27:58-63.

A clinical experience report of a modified Ohshio method of repair of boutonnière deformity using the transverse retinacular ligament. This modification involves releasing the lateral bands between PIP and DIP joints to obtain active flexion of the DIP joint. There was a significant improvement in all seven fingers of six patients, and the DIP joint could be actively flexed by releasing the tight lateral bands. (Level IV evidence)

Nalebuff EA, Millender LH. Surgical treatment of the boutonnière deformity in rheumatoid arthritis. Orthop Clinic North Am. 1975;6:753-763.

In this paper, boutonnière deformity in patients with rheumatoid arthritis can be classified into three stages, which serve as a guide to the appropriate management. (Level V evidence)

Ohshio I, Ogino T, Minami A, et al. Reconstruction of the central slip by the transverse retinacular ligament for boutonnière deformity. J Hand Surg [Br]. 1990;15:407-409.

A clinical experience report of a new method of repairing boutonnière deformity using the transverse retinacular ligament. There was a significant improvement in all six fingers of five patients, but moderate limitation of flexion of the DIP joint remained in cases with severe contracture of the lateral bands. (Level IV evidence)

Salvi V. Technique for the buttonhole deformity. Hand. 1969;1:96-97.

A surgical technique for boutonnière deformity is described using the dorsally based flaps of the PIP joint capsule to reposition the lateral band dorsally. The Ohshio method was modified from this Salvi procedure. (Level V evidence)

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