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

Disclosures

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

In This Article

Discussion

Tophaceous gout osteoarthritis, unresponsive to medical therapy, may progress to clinical manifestations requiring surgery. Treatment includes tophi excision, curettage, shaving, arthrodesis, and ray amputation,[3–7] and is tailored according to functional recovery and patient's request.

We believe that when patients refuse amputations and ask for reconstruction, two options can be proposed: either stabilization with long bone grafts, plates, and screws, together with distal joint arthrodeses, or functional reconstruction with composite functioning osteoarticular transfers.

Indeed, even in functional low-demand patients, bone resorption together with recurrence should be taken into consideration, especially when a medium/long life expectancy is present. Our experience clearly shows that these long-term complications are present, especially in stabilization and arthrodesis. It may be that the effect of time is tempered in the case of functional reconstruction, as in our allograft.

In our patient, the refusal of multiple digit amputations and a low functional demand led to a customized reconstruction. Both index fingers and the left small finger were stabilized: on the right index finger, a long cortico-cancellous iliac graft was used, obtaining MP joint fusion while restoring metaphyseal lengths. No further autograft was taken, so as to reduce donor site morbidity. On the left index and small fingers, antibiotic-impregnated cement implants fixed with plates proximally, and intramedullary wires distally, were chosen.

Finally, an osteoarticular functional reconstruction for the left middle finger (fundamental for left hand pich) was achieved with a composite allograft, including extensor tendon, producing a certain degree of functional joint mobility. As a result, the patient achieved a painless pinch between the thumb and the third fingers in both hands. (See Supplemental Digital Content 1, http://links.lww.com/PRSGO/B830. See figure 2, Supplemental Digital Content 2,http://links.lww.com/PRSGO/B831.)

In reconstructive surgery after a wide excision of tophaceous gout, we believe that each reconstruction has a specific indication. Autogenous cortico-cancellous bone graft has the qualities for new bone growth, namely osteoconductivity, osteogenicity, and osteoinductivity.[8] However, the iliac crest bone autograft does not include joints and may raise concerns about donor site morbidity[9] (as in this case) and graft availability. Furthermore, an autograft can be resorbed due to tophaceous disease progression. Our long-term follow-up shows significant autograft resorption.

The antibiotic-impregnated cement spacer is a simpler reconstructive tool and, associated to rigid fixation, may obtain a medium-term result for low-demand cooperative patients, particularly with a stable fixation in moderate stress segments and in low-demand patients, as in our case. However, as previously pointed out, long-term follow-up may show bone resorption and loss of both cement and fusion screws, even if extrusion of the cement spacer and distal fixation from the left small finger, documented in the last follow-up, did not condition functional results in the left hand. Progressive osteolysis indeed, as a combined effect of ageing demineralization and possibly also gout local recurrence, should always be taken into account when performing stabilization procedures together with osteoarticular reconstructions in these patients. Small joints, such as DIP, may be more affected by this complication.

A composite allograft allows segmental bone, tendon, and joint reconstruction of complex skeletal gaps.

Literature highlights the incidence of resorption, delayed nonunion, stress fracture, and cartilage erosion of osteoarticular allografts over time.[10] This is, to our knowledge, the first report of a composite allograft for reconstruction in invasive tophaceous gout[11] and shows satisfactory results at medium and long term with regard to maintenance and integration of the reconstruction.

The last follow-up showed that the best reconstructed ray is the middle in the left hand, possibly due to the maintenance of use and function: the allograft indeed appears to be the most stable and the least reabsorbed.

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