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

Discussion

There are limited data on surgical intervention for gouty tophi, with even less focusing on the hand. Previous reports consist of case series generally describing 2 different techniques: open or closed excision. The open technique involves raising skin flaps and directly excising the tophaceous material, including tenosynovectomy if necessary. Closed techniques involve either percutaneous aspiration or shaving of the tophi, depending on consistency. Open techniques are used when the overlying skin is healthy, whereas closed methods are used when there is heavy skin infiltration, ulceration, and/or drainage in an effort to save the subdermal plexus.[8]

Literature review dating to 1960 revealed 9 retrospective case series discussing surgery for tophaceous gout, and only 5 specifically focused on the upper extremity. Straub et al [7] reported a total of 21 patients operated on for excision of tophi of the upper extremity. Metacarpophalangeal joint tophi were excised in 7 patients, and 4 patients had volar pulp tophi excised. The main indication for surgery was functional impairment such as decreased motion or inability to wear clothing. However, postoperative function and follow-up were not specifically reported. No major complications were reported, and the group concluded that, for functional deficits, tophi excision is advantageous.

Similar studies have emphasized the efficacy of surgical treatment for detrimental tophi. Gelberman et al[10] reported on 7 patients with tophi of the proximal interphalangeal joint with flexion contractures. Of those patients, 2 underwent open excision and extensor mechanism reconstruction for contractures that caused difficulty grasping and problems related to incomplete finger extension. Excision was performed via straight dorsal longitudinal incisions, and all tophaceous material was removed that did not compromise tendon continuity. The group noted overall functional improvement documented with goniometry and concluded that open surgery is beneficial for those patients who fail medical therapy.

Mudgal[11] reported successful pain relief with gentle aspiration in a series of 5 elderly patients with acute gouty tophi of the distal interphalangeal joint. If the joint remained painful, the author suggested secondary arthrodesis through healed, stable skin.

Lee et al[12] described 32 patients with tophi of the hands and elbows. The lesions were treated with a soft tissue-shaving technique with emphasis on gentle flap handling and excision prior to skin thinning and ulceration. No major complications were reported.

Tripoli et al[13] reported 19 patients (29 hands) who underwent surgical management of upper extremity tophi with the main indications being loss of function/motion or ulceration. The group describes 3 techniques depending on the quality of the overlying skin: tenosynovectomy, shaving approach, or complex surgical approach for large nodular lesions. Operations for heavy tendon infiltration and loss of motion were performed on 18 patients. These patients underwent tenosynovectomy with resection of external fibers whose bulk limited excursion. The shaving technique similar to the one described by Mudgal was performed on 7 hands with skin ulceration over the tophi, and 4 hands underwent the complex surgical technique involving excision of large tophi. Overall, results were good with high patient satisfaction. The authors advocate the complex open approach for its improved exposure, complete tophus excision, and prolonged disease-free period.

The study presented here further supports open en bloc excision of nodular tophi of the hands and provides one of the largest series specifically examining this technique. The procedure consistently achieves complete excision of the urate deposits, preservation of tendon function, and uncomplicated wound healing. This technique has provided long-term improvement in function and aesthetics while limiting wound complications or recurrence. Postoperative wound healing complications, mostly reported in the lower extremity, emphasize the need to medically optimize patients and the importance of meticulous soft tissue management. These same principles guide the technique described in this study and account for the excellent healing rates achieved in the patient cohort. Specifically, surgical incisions were designed to avoid any tophaceous prominences where the dermal layers may have been thinned or undergone local ischemia due to the impingement of firm tophi against the delicate microcirculation. This helped to ensure that the ultimate coapted skin edges had adequate blood supply to heal effectively. Furthermore, the use of sharp excision techniques minimized the zone of local tissue injury that could be caused by blunt dissection methods. Also, once skin closure was completed, the tourniquet was removed and warm compresses were applied to the flaps with the upper extremity elevated. After a period of approximately 4 to 5 minutes, the wounds were then reassessed to confirm adequate perfusion throughout the entire surgical area. Individual sutures were removed as needed if it was determined that they were applying excessive pressure on the flap. This meticulous attention to perfusion continued in the postoperative period where the flaps were examined in the office multiple times over the span of the first 2 weeks and drained of any underlying hematoma that applied tension to the wound.

With increasing disease prevalence, further study of tophi management as well as their natural development will undoubtedly assume a greater importance.

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