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

Gouty tophi are the result of chronically elevated serum urate levels causing the formation and tissue deposition of monosodium urate crystals (Figure 1). Such deposits occur in up to 12 to 35% of patients with the disease.¹ This is a significant number given that gout is the most common inflammatory arthritis in North America and Western Europe (prevalence of 1 to 4%) with an increasing incidence over the last several decades.² The anatomic location of the tophus can cause a significant decrease in quality of life as the destructive lesions can lead to arthritis, tendon disruption or rupture, decreased range of motion, nerve entrapment, and skin ulceration.³

Medical intervention, principally urate-lowering therapy, is accepted as the first step in treatment of tophaceous gout.⁴ Timely use of such drugs can increase joint function and decrease overall tophi size.^5,6 Despite this, a significant number of patients prove refractory to medical treatment owing to complicating comorbidities, poor patient compliance, and the prolonged duration of therapy required to facilitate tophus response. This extended period allows for the increased chance of tophi-related tissue injury that necessitates surgery.

Whereas surgical intervention of tophaceous gout dates back centuries, modern indications were not outlined until the mid-20th century. Straub et al ⁷ described indications that include tophi hindering normal tendon or joint function, skin breakdown/infection, nerve compression, and functional cosmesis (ie, wearing clothes/gloves).A secondary indication for purely cosmetic surgical intervention should be approached cautiously.¹ Excision to lessen the overall metabolic burden of urate as described by some studies remains controversial.

Despite increasing disease prevalence and established indications, there remains a paucity of data examining surgical treatments for gouty tophi. Moreover, there are no guidelines for technique or timing. A recent review identified only 7 published studies on surgery for tophaceous gout over the last 65 years.¹ All of the studies are case series with only limited information regarding patient outcomes. Additionally, complications, principally related to difficulty with wound healing, have been reported and have undoubtedly dissuaded surgeons from undertaking the procedure.^8,9 The purpose of this article is to review a technique with en masse surgical excision, tenolysis, and curettage of periarticular gouty tophi of the hands and to support the efficacy of timely surgery.

A retrospective review was conducted of all consecutive patients who underwent surgical excision of tophaceous deposits from the upper extremity. All patients had an established diagnosis of gout and had been treated with urate-lowering medication. All tophi were substantive in size and were causing notable digital joint dysfunction with variable skin ulcerations. The tophi were also a source of considerable disfigurement. In all cases, tophi were excised en masse and underlying tendons and joint capsules were curetted and repaired when necessary. Similarly, residual deposits in the overlying skin were either curetted or excised. Primary wound closure with local flap advancement was achieved in all cases. Postoperatively, the patients were typically evaluated in the office approximately 4 times within the first 2 weeks, during which time the surgical wounds were carefully assessed and cleaned with hydrogen peroxide, and the flaps were spread and drained of underlying hematoma (as needed) in order to maximize perfusion to facilitate healing.

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).

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 (Figures 3 and 4).

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 al¹⁰ 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.

Mudgal¹¹ 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 al¹² 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 al¹³ 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.

Affiliations: ¹The Hand Surgery Center, Mount Sinai Icahn School of Medicine, New York, NY; ²Plastic and Reconstructive Surgery, John H. Stroger Hospital of Cook County, Chicago, IL; ³Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL

Correspondence: Matthew Doscher, MD; matthew.doscher@gmail.com

Disclosures: The authors have no relevant financial or nonfinancial interests to disclose.