Surgical Reconstruction of Tophaceous Gout in the Hand

Abstract and Introduction

Abstract

Tophaceous gout can represent a major problem for hand surgeons when it turns into aggressive nodules, spreading and destroying soft tissue and bone. The combination of ablative and reconstructive surgery may also be complex when the patient refuses amputations and multiple segments are involved. We present a difficult case, where a customized approach, chosen according to the different features of the osteoarticular and tendon involvement of fingers, adopted different solutions for the four affected rays. A patient suffering from severe gout arthritis with osteoarticular destruction in both hands refused amputations and was treated with several reconstructive procedures. After excision of the tophaceous deposits, a long bone autograft, two segmental cement spacers together with distal arthrodeses, and an osteoarticular allograft were used. Functional pinches were maintained in both hands, even at a 13-year follow up, with the allograft preserved and working. On the other hand, significant osteolysis and bone resorption in all the segments that had undergone stabilization was documented, producing extrusion of both cement and distal interphalangeal joint fusion screws. Pre- and postoperation range of motion, visual analogue scale, disabilities of the arm, shoulder, and hand score, and pinch strength tests showed reduced pain and improved function. A review of literature is presented in particular regarding different reconstructive approaches. Combining different techniques in the same hand can lead to successful osteoarticular reconstruction after tophi resection, above all to avoid amputation. However, long-term follow up shows that functional osteoarticular reconstructions seem to be more stable, whereas osteolysis may damage bone grafts used for arthrodesis and produce screw extrusion.

Introduction

Chronic tophaceous gout^[1,2] may present with aggressive tophi invading the soft tissue, joints, and bones. Tophi are usually treated by simple shaving, removal, or segment resections, followed by amputation or complex reconstructions. We present a case of a 62-year-old woman with severe progressing arthritis in both hands who had no benefits from medical therapy and refused amputations.

The different reconstructive approaches may include arthrodesis or functional arthroplasties, especially for metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints. Distal interphalangeal (DIP) joints when involved should be considered for arthrodesis.

In this case, on the right hand, gout had caused the destruction of the MP of the index finger and, on the left hand, of the PIP of the index, middle, and small finger. Functional pinch in the right hand was conserved, even if weak, and we chose a functional reconstructive approach for the middle finger of the left hand, and stable reconstructions for the remaining fingers.