What is the treatment for Boutonniere deformity?

Treatment of Boutonniere Deformity

For acute boutonniere deformity (within 6 weeks), splinting the PIP joint in extension for 4-6 weeks is the treatment of choice, while for chronic flexible deformities, surgical reconstruction of the extensor apparatus with lateral band repositioning provides excellent outcomes in over 90% of cases.

Initial Assessment and Classification

The treatment approach depends critically on three factors:

• Timing: Acute (< 6 weeks) versus chronic (> 6 weeks) 1, 2
• Flexibility: Whether the deformity is passively correctable (flexible) versus fixed (stiff) 3, 4
• Joint integrity: Presence or absence of PIP joint osteoarthritis 3, 4

Treatment Algorithm

Acute Boutonniere Deformity (< 6 weeks)

Conservative management is highly effective and should always be attempted first 1, 2:

• Dynamic extension splinting applied from the dorsal hand to the PIP joint, leaving the DIP joint free to flex actively 1
• Duration: Minimum 6 weeks of continuous splinting 1, 2
• Expected outcomes: Mean extension loss of only 23 degrees with preserved DIP flexion 1
• Success rate: 86% excellent/good results when initiated early 1

Critical pitfall: Delayed recognition leads to chronic deformity requiring surgery with inferior outcomes 2. In pediatric patients, early splinting at 4 weeks can yield favorable results 2.

Chronic Flexible Boutonniere Deformity

For deformities that are passively correctable after physical therapy 3, 4:

Surgical reconstruction is the definitive treatment 3, 4:

• Procedure: Resection-suture of the central slip with dorsal repositioning of the lateral bands 3, 4
• Modified technique: Release of extensor expansion proximal to oblique retinacular ligament insertion, with separation of transverse retinacular ligaments and dorsal lifting of lateral bands 4
• Success rate: 90-91.6% excellent/good results 3, 4
• Outcomes: Average PIP extension deficit improves from 60° preoperatively to 7° postoperatively, with DIP active flexion restored to 75° 4

Essential caveat: Poor results occur when patients fail to complete postoperative physical therapy (2 of 4 failures in one series) 3. Compliance with hand therapy is mandatory.

Chronic Stiff Boutonniere Deformity

For deformities that remain fixed despite physical therapy 3:

Treatment depends on joint condition:

• Normal PIP joint with moderate deformity: Two-stage approach—initial tenoarthrolysis with hand therapy, followed by secondary extensor apparatus reconstruction 3
• PIP joint osteoarthritis: Silicone spacer arthroplasty provides satisfactory results (30-70° range of motion) 3
• Isolated DIP hyperextension with moderate PIP flexion: Distal extensor tenotomy alone can provide useful results (20-70° range) 3

Major pitfall: Attempting extensor reconstruction on arthritic PIP joints yields poor results; these cases require arthroplasty first 3.

Rheumatoid Boutonniere Thumb Deformity

Treatment is stage-dependent 5:

• Early stage with isolated MP involvement: MP joint fusion is the procedure of choice with low recurrence 5
• Advanced deformity: Combined MP arthroplasty and IP joint fusion for low-demand patients 5
• Avoid: MP synovectomy with EPL rerouting has 64% recurrence rate 5; IP joint releases have high recurrence and are not recommended 5

Key Surgical Principles

For optimal outcomes 3, 4:

• Surgery should only be performed on flexible deformities or after achieving flexibility through staged procedures 3
• The reconstructed extensor tendon must act primarily on the PIP joint while allowing DIP flexion 4
• Postoperative hand therapy is non-negotiable for success 3