Disruption or
laceration of the central slip of the extensor tendon at the proximal interphalangeal (PIP) joint with volar displacement of the lateral bands can result in the so-called boutonniere
deformity which includes loss of extension at the PIP joint and compensatory hyperextension of the distal interphalangeal (DIP) joint. Many procedures has been described in the literature and no standard treatment can be recommended. The authors reports a series of 47 cases of posttraumatic boutonniere
deformity. The mean follow-up was five years. Majority of patients were males (38 males). The mean age was 41 years-old (17-82 y.o.). The etiology was in 23 cases a missed subcutaneous disruption of the central slip of the extensor tendon and in 24 cases an inappropriate treatment of
laceration of the extensor apparatus at the dorsal aspect of the PIP joint. The involved digit was in seven cases the index finger, in 14 cases the long finger, in 14 cases the ring finger and in 12 cases the little finger. It is essential to distinguish the supple boutonniere
deformity without or after
physical therapy (34 cases) and the stiff boutonniere
deformity even after a hand
physical therapy program (13 cases). Results were assessed on
pain and active range of motion of the PIP joint as well as the range of motion of the DIP joint. Supple boutonniere
deformities, except one treated by an isolated distal
tenotomy of the extensor tendon (1/34), was treated by a procedure of reconstruction of the extensor apparatus including resection-
suture of the central slip and redorsalisation of the lateral bands when there was a DIP hyperextension with a moderate flexion
deformity of the PIP joint, and (33/34) with 90% of excellent and good results. Poor results (4/33) were due in two cases to the absence of
physical therapy, in one case to septic
osteoarthritis and in one to secondary
rupture of the
suture. For the 13 stiff boutonniere
deformities, when the PIP flexion
deformity was moderate, a distal
tenotomy performed to correct the DIP hyperextension was satisfactory in three cases with a useful result (20 degrees-70 degrees). For destroyed PIP joint (
osteoarthritis), two
silicone spacers were implanted with also a satisfactory result (30 degrees-70 degrees). In the eight remaining cases, a teno-arthrolysis was performed combined with a reconstruction of the extensor apparatus as described. Six poor results were obtained with arthritic PIP joints (which should have required initially
silicone implants), and two fair results (30 degrees-60 degrees) with non-destroyed PIP joints. Supple boutonniere
deformity must always be treated by initial
physical therapy.
Surgical procedure with reconstruction of the extensor apparatus is satisfactory if the PIP joint is normal. When there is PIP
osteoarthritis, it may be beneficial to perform a two-stage technique with tenoarthrolysis followed hand
therapy and a secondary reconstruction of the extensor apparatus as these last procedure give satisfactory results on a supple boutonniere
deformity.