En Masse Excision and Curettage for Periarticular Gouty Tophi of the Hands

Matthew Doscher, MD, FACS; Bryan G Beutel, MD; Andrew Lovy, MD; Brandon Alba, MD, MPH; Charles Melone, MD, FACS, FAOA

Disclosures

ePlasty. 2022;22(e25) 

In This Article

Results

The study group included 12 patients with 24 tophaceous deposits excised from the metacarpal and interphalangeal joints; 2 deposits were also concomitantly excised from the wrist and 2 from the elbow. The study group included 8 men and 4 women, with a mean age of 67 years (range, 28–85 years). Follow-up evaluation ranged from 2 to 15 years (average, 4.75 years) and included pain, mobility, function, and patient satisfaction. All patients underwent successful tophus excision with restoration of tendon excursion and joint mobility without wound complications. Additionally, all patients regained high levels of function with the ability to perform all activities of daily living, experienced decreased pain, and reported a high level of satisfaction with the outcome. On follow-up for as long as 15 years, recurrence has not been observed and, thus, secondary surgery has not proved necessary.

Patient Example

A 28-year-old right-hand-dominant man suffered from chronic tophaceous gout for 8 years. He presented with a functional restriction and pain unresponsive to analgesics in both hands. His treatment at presentation consisted of colchicine, which provided little relief.

Physical examination of the right hand revealed tophi over the right index and long finger metacarpophalangeal joints. Examination of the left hand showed a tophus over the left ring finger metacarpophalangeal joint as well as pain and swelling over the wrist.

Due to the bilateral involvement of tophi, a staged surgical intervention was planned for the patient (first the right hand, and then the left). Incisions were carefully planned over the metacarpophalangeal joints avoiding the metacarpal heads and the tophaceous prominences. After skin flaps were carefully elevated and neurovascular bundles protected, the long finger tophus was sharply delineated and excised (3 x 3-cm tophus). After thorough irrigation, the tendon was then debrided, centralized, and repaired using absorbable sutures. A similar procedure was carried out for the index finger (2 x 2-cm tophus). A similar procedure was performed on the left ring finger 2 months later (Figure 2).

Figure 2.

a) Preoperative and b) intraoperative views of left ring finger metacarpophalangeal joint tophi treated with en masse excision, c) tenosynovectomy, and d) extensor tendon repair.

The patient had a highly favorable recovery with no recurrence of tophi over a 14-year follow-up. He then presented again with a new tophus overlying the left small finger metacarpophalangeal joint with a resultant extensor lag as well as left wrist swelling. A similar procedure was used to excise the tophus (3 x 3.5-cm) while meticulously maintaining the substance of the extensor tendon. At 2-year follow-up, the patient demonstrated full range of motion with no recurrence and expressed a high level of satisfaction (Figure 3 and Figure 4).

Figure 3.

Intraoperative views of the same patient as Figure 2, now with new left small finger metacarpophalangeal joint tophi and dorsal wrist tophi 14 years after first surgery. a) The angled skin flaps employed for tophi excision. b-d) Intraoperative views demonstrating en masse excision.

Figure 4.

Postoperative photos 2 months after second surgery and 14 years from initial procedure. Illustrates restoration of full digital motion with no evidence of tophi recurrence and uncomplicated wound healing.

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