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.
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Case 1. Large tophi have develped about the right ulnar head and the left ulnar metacarpus, involving the extensor tendons to the small finger.
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Surgical exposure.
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Excision. There was about 50% attrition of the extensor digiti minimi; no reconstruction was performed.
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Result at six weeks, with full range of motion.
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Case 2. Tophaceous gout with multiple joint involvement and carpal tunnel syndrome.
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Left index distal interphalangeal  joint tophus with thin overlying skin and nail deformity.
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Despite extensive remodelling, the joint had 50 degrees of active motion.
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Exposure through an eponychial splitting incision. The extensor tendon was intact and the joint was left relatively undisturbed by surgery.
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Late result. Lateral tophi have progressed.
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The joint has remodelled further, but there is painless functional motion.
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Open carpal tunnel release was performed for carpal tunnel syndrome. An extensile incision was planned for unexpected findings, but was not used.
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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.
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Right hand tophi involved the extensor mechanism and a painful unstable index PIP joint.
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Dorsal tophi diffusely involved extensor mechanism, joint capsule and MCP joints.
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Debridement and irrigation removed the bulk of tophaceous material, preserving adequate extensor tendons.
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PIP fusion with tension band technique.
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Late result.
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