Clinical Example: Excision of Gouty Tophi
| Tophaceous gout presents
three overlapping issues in the hands: pain;
arthropathy; tumor. Medical management is the first line of treatment.
Failing that, surgery may be beneficial. Surgery is unpredictable:
tophi are not encapsulated, and can diffusely permeate tendons and
other soft tissues. Debridement may demonstrate or result segmental
tendon loss, and the surgical plan should include the possible need for
tendon graft. Arthrodesis is preferable to arthroplasty because of the
effect of particulate debris. These cases illustrate surgical excision
of bulky tophaceous gout. |
| Click on each image for a larger picture |
| Case 1. Large tophi have develped
about the right ulnar head and the left ulnar metacarpus, involving the
extensor tendons to the small finger. |
| Surgical exposure. |
| Excision. There was about
50% attrition of the extensor digiti minimi; no reconstruction was
performed. |
| Result at six weeks, with
full range of motion. |
| Case 2. Tophaceous gout
with multiple joint involvement and carpal tunnel syndrome. |
| Left index distal
interphalangeal joint tophus with thin overlying skin and nail
deformity. |
| Despite extensive
remodelling, the joint had 50 degrees of active motion. |
| Exposure through an
eponychial splitting incision. The extensor tendon was intact and the
joint was left relatively undisturbed by surgery. |
| Late result. Lateral tophi
have progressed. |
| The joint has remodelled
further, but there is painless functional motion. |
| Open carpal tunnel release
was performed for carpal tunnel syndrome. An extensile incision was
planned for unexpected findings, but was not used. |
| Flexor tendons were
diffusely infiltrated with tophaceous material, and were left as is.
Debridement would have required segmental tendon graft reconstruction,
which was not indicated. |
| Right hand tophi involved
the extensor mechanism and a painful unstable index PIP joint. |
| Dorsal tophi diffusely
involved extensor mechanism, joint capsule and MCP joints. |
| Debridement and irrigation
removed the bulk of tophaceous material, preserving adequate extensor
tendons. |
| PIP fusion with tension
band technique. |
| Late result. |
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