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En Masse Excision and Curettage for Gouty Tophi of the Hands

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En Masse Excision and Curettage for Gouty Tophi of the Hands


Abstract and Introduction

Abstract

Background: Despite increasing disease prevalence, there remains a paucity of data examining surgical treatments for gouty tophi. This article assesses en masse excision and curettage of articular tophi involving the hands and shows that carefully planned and precisely executed surgery can consistently alleviate pain, preserve function, and enhance the aesthetics of afflicted hands.

Methods: A retrospective review was conducted of all consecutive patients who underwent surgical excision of tophaceous deposits from the upper extremity. All patients had an established diagnosis of gout and had been treated with urate-lowering medication. All tophi were substantive in size and were causing significant digital joint dysfunction and disfigurement with variable skin ulcerations.

Results: The study group included 12 patients with 24 tophaceous deposits excised from the metacarpal and interphalangeal joints; 2 deposits were also concomitantly excised from the wrist and 2 from the elbow. The study group included 8 men and 4 women, with an average age of 67 years. Follow-up evaluation ranged from 2 to 15 years. All patients underwent successful tophus excision with restoration of tendon excursion and joint mobility without wound complications. All regained high levels of function, and all reported satisfaction with their outcome. On follow-up for as long as 15 years, recurrence has not been observed and secondary surgery has not proved necessary.

Conclusions: This study indicates that surgical excision of articular tophi of the hands can provide long-term improvement in function and aesthetics with minimal risk of wound complications or recurrence.

Introduction

Gouty tophi are the result of chronically elevated serum urate levels causing the formation and tissue deposition of monosodium urate crystals (Figure 1). Such deposits occur in up to 12 to 35% of patients with the disease.[1] This is a significant number given that gout is the most common inflammatory arthritis in North America and Western Europe (prevalence of 1 to 4%) with an increasing incidence over the last several decades.[2] The anatomic location of the tophus can cause a significant decrease in quality of life as the destructive lesions can lead to arthritis, tendon disruption or rupture, decreased range of motion, nerve entrapment, and skin ulceration.[3]

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Figure 1.

Multiple large periarticular tophi causing loss of digital function and considerable disfigurement. All deposits were excised simultaneously from this patient with preservation of tendon and joint function.

Medical intervention, principally urate-lowering therapy, is accepted as the first step in treatment of tophaceous gout.[4] Timely use of such drugs can increase joint function and decrease overall tophi size.[5,6] Despite this, a significant number of patients prove refractory to medical treatment owing to complicating comorbidities, poor patient compliance, and the prolonged duration of therapy required to facilitate tophus response. This extended period allows for the increased chance of tophi-related tissue injury that necessitates surgery.

Whereas surgical intervention of tophaceous gout dates back centuries, modern indications were not outlined until the mid-20th century. Straub et al[7] described indications that include tophi hindering normal tendon or joint function, skin breakdown/infection, nerve compression, and functional cosmesis (ie, wearing clothes/gloves).A secondary indication for purely cosmetic surgical intervention should be approached cautiously.[1] Excision to lessen the overall metabolic burden of urate as described by some studies remains controversial.

Despite increasing disease prevalence and established indications, there remains a paucity of data examining surgical treatments for gouty tophi. Moreover, there are no guidelines for technique or timing. A recent review identified only 7 published studies on surgery for tophaceous gout over the last 65 years.[1] All of the studies are case series with only limited information regarding patient outcomes. Additionally, complications, principally related to difficulty with wound healing, have been reported and have undoubtedly dissuaded surgeons from undertaking the procedure.[8,9] The purpose of this article is to review a technique with en masse surgical excision, tenolysis, and curettage of periarticular gouty tophi of the hands and to support the efficacy of timely surgery.