Surgical Reconstruction of Severe Tophaceous Gout in the Hand

A Customized Approach

Mariarosaria Galeano, MD, PhD; Michele R. Colonna, MD, FEBOPRAS; Sandra Pfanner, MD; Massimo Ceruso, MD


Plast Reconstr Surg Glob Open. 2021;9(11):e3912 

In This Article

Case Report

A 62-year-old woman presented with a long history of chronic tophaceous gout, allopurinol intolerance, renal failure, and rasburicase treatment. Multilobular nodules in both hands caused significant pain and disability, and x-ray showed osteolysis of the right index finger across MP and of the left index, middle, and small fingers across the PIP joints, destroying the metaphysis and shaft of the first phalanx in the index fingers and involving the second phalanx of the middle and small finger (Figures 1, 2).

Figure 1.

Clinical appearance of multiple tophaceous deposits on the right hand.

Figure 2.

Clinical appearance of multiple tophaceous deposits on the left hand.

Preoperation range of motion was 0 degrees (all involved fingers), pinch strength 0 kg (both hands), visual analogue scale (0–10) 9, and disabilities of the arm, shoulder, and hand score, 85.

The patient refused the amputations proposed for the right index and the left middle and small finger. She asked us to perform reconstructions adapting to her low-demand function.

In both hands, tophi were resected using a dorsal approach, showing prevalent dorsal compartment invasion, sparing the flexor tendons and neurovascular bundles.

A 5-cm corticocancellous bone autograft (harvested from the iliac crest, and fixated with a plate) was used to reconstruct and stabilize the right index MP joint (Figure 3). It was protected with a postoperation volar plaster slab and later with a custom-made static splint, for 3 months.

Figure 3.

Right hand index finger: reconstruction with long cortico-cancellous iliac crest autograft after excision of tophi.

On the left hand, the index and small fingers were chosen for stabilization, and the middle finger for functional reconstruction; autologous grafts were excluded to avoid further donor site morbidity.

A customized cadaveric allograft from the bone bank of the Careggi University Hospital, Florence was acquired, including the PIP joint and extensor apparatus.

The left middle finger PIP joint was modeled and fixed proximally with a double bar miniplate, and distally with an Acutrak screw inserted from the fingertip through the DIP joint. The extensor tendon was reconstructed with the extensor tendon of the allograft (Figure 4).

Figure 4.

Left hand middle finger; after excision of tophi, showing an osteoarticular allograft, including extensor apparatus for middle finger reconstruction and a tenorrhaphy of allograft extensor tendon to residual tendon stumps.

The index and small finger PIP joints were stabilized with antibiotic-impregnated cement spacers fixed proximally with plates and distally with intramedullary nailing.

At 1 year, follow-up radiographs showed successful arthrodesis and remodeling of the bone graft in the right hand, and fusion and integration of the allograft, as well as stability of the cement spacers in the left hand; functional recovery of both hands was good with high patient satisfaction; no pain or discomfort was reported. (See figure, Supplemental Digital Content 1, which displays the clinical result at 1 year.

At 3-year follow up, no recurrence was registered, and postoperation range of motion was 0 degrees for the right index finger, left index, and small fingers; the middle left finger registered 10 degrees; pinch strength 1 kg (both hands), visual analogue scale (0–10) 2, and disabilities of the arm, shoulder, and hand score, 22.

In the following years, the patient underwent a liver transplantation and was no longer able to attend follow-ups. The last follow-up was performed by phone call and radiographs 13 years after, showing that cement and intramedullary nail had been extruded from the small finger DIP joint 6 years after surgery, while range of motion, visual analogue scale, and disabilities of the arm, shoulder, and hand score were unmodified, as reported by the patient.

The radiographs showed allograft function and stability; cement and DIP fixation were no longer present on the left small finger (See figure 2, Supplemental Digital Content 2, which displays lateral view of the left hand 13 years after surgery, showing good integration and function of the middle finger, reconstructed with a composite allograft. Despite bone resorption, the index finger maintains stability; cement stabilizing the small finger had been previously extruded.; and significant resorption of the long autologous graft was documented in the right index finger.