The management of gouty tophi has generally shifted from surgical excision to conservative therapy due to surgery’s traditional association with high wound complication rate. Yet there are still patients who are indicated for surgical excision of gouty tophi, including for functional or cosmetic reasons. We describe our surgical technique and clinical outcomes in patients who underwent gouty tophi excision. This technique includes near complete excision of non-infected gouty tophi with preservation of important soft tissue structures. We have performed 44 elective tophi excision surgery in ten patients with an average follow-up of 29 months. The overall patients’ satisfaction rate was 90%. Only one post-operative infection was noted. No recurrence was observed. Our results suggested that this technique is a safe and effective option for a selected group of patients suffering from tophaceous gout.
Surgical management of gouty tophi was first described by Lindsay in 1913, with the earliest case series reported in 1943 [
Pre-emptive surgery of tophi excision is indicated for the following conditions:
1) Frequent exacerbations of gouty attacks were noted at a focal region causing pain and functional impairment;
2) Progressive deformity was noted at a focal region secondary to continuous destruction by tophaceous material;
3) Unacceptable cosmesis.
Gouty tophi in the extremities where skin breakthrough or superimposed infection were actively present were contra-indicated to pre-emptive surgical excision.
Our preferred approach is a complete or near-complete excision of the gouty tophi. The rationale is based on our experience; we observed that delayed wound healing and wound complications often occur if we only remove a portion of the tophaceous material instead of the entire tophi in a region. We postulate this to be due to disturbance of previously inert portions of tophi during surgery. Figures 1(a)-(f) illustrated a case where surgical excision of gouty tophi was performed with our surgical approach (Figures 1(a)-(f)), described below.
No routine perioperative colchicine was given for prophylactic purpose. The anaesthesia employed included regional, spinal and general anaesthesia. We used a tourniquet for all patients to create a bloodless surgical field for both upper and lower limbs. While the use of tourniquet in the lower limbs in the presence of arteriosclerotic vascular disease [
We prefer the surgical incision to be longitudinal and made over the most affected area. Because of the mass effects or the infiltration of the tophi, the skin could be stretched out and become extremely thin. Thus, gentle and meticulous handling of soft tissue was essential for all cases and excessive undermining should be avoided as this would further impair the viability of the skin flap.
For areas where a fibrous capsule had been formed between tophaceous material and healthy tissue, the tophi could usually be excised completely by sharp dissection. Where the tophaceous material had infiltrated the adjacent skin, soft tissue or bone, a sharp scalpel was used to excise most of the tophi leaving behind a small cuff of tophaceous material that remained tightly adherent to adjacent
tissues. We then utilized small curettes to curettage the remaining, infiltrative tophaceous material from the normal tissue while irrigating the area with a continuous flow of sterilized water. This was because we had observed that tophaceous material dissolved in water, making the removal of the remaining material easier. In some instances, it might be difficult to excise all the tophaceous material especially if they had infiltrated into the entire segment of the tendon or were tightly adherent to the neurovascular bundles. In such circumstances, we first identified the tendon or the neurovascular bundles in an unaffected area and traced them into the affected zone. Then, we removed the tophaceous material preserving as much as possible the now clearly identified tendon and the neurovascular bundles. For areas where the joint was involved, the joint capsule and collateral ligaments were usually damaged by the infiltrating tophaceous material. This could be addressed after the debridement by making use of the remaining soft tissue to create a pseudo-joint capsule in order to place the joint in an acceptable alignment. Kirchner wire pinning might then be used to further stabilize the joint.
We preferred not to excise skin until the very end of surgical excision. We observed that after excision of abundant tophaceous material we usually had excessive skin left behind as a result of the chronic stretching of skin by the tophi. Hence, our approach was to take down the tourniquet and then observe the circulation of the skin flap. We could then excise the areas of skin where the circulation was unsatisfactory or marginal without the problems of inadequate wound coverage. In some instances, additional skin graft might still be required to achieve satisfactory wound coverage.
Postoperatively, a plaster was given for 2 to 3 weeks in order to immobilize the affected joints temporarily after excision of tophi. Stitches were taken off at 3 weeks post-operatively to avoid early wound breakdown. For lower limb surgery, we advised patients to avoid excessive walking in order to avoid excessive tension to the wound. Again, we did not routinely prescribe colchicine in the perioperative period for prophylactic purpose.
This study was approved by Institutional Review Board for ethical clearance. Ten patients with a mean age of 61 years old (range, 49 - 81 years old) were studied between 2007 and 2013 based on the above mentioned surgical indications. Of the ten patients, eight were male and two were female. 44 surgical sites including both upper limbs and lower limbs involvement were operated (
All the surgical sites could be closed primarily without tension. No skin graft or flap was needed. No Kirchner wire was needed to stabilize the joint.
| Severity grading | Condition |
|---|---|
| I | Infiltration of tendon and ligaments |
| II | Infiltration of joints |
| III | Erosion of bones |
| IV | Adhesion to skin surface |
described in the previous section “Operative Technique” (
One patient developed wound infection over his left 1st metatarsal-phalangeal joint 2 weeks post-excision of bilateral 1st meta-tarsal phalangeal joint tophi. Poor hygiene was noted at the foot dressing together with early excessive mobilization. Wound debridement was subsequently performed and healed with no further complication.
Tips and tricks:
Meticulous handling of skin and soft tissue is essential during the surgery. It is important to identify and preserve vital structures, to manage bone and joint erosion and to have continuous irrigation during the excision of tophi. We use tourniquets in both upper and lower limbs, setting the maximum limit to 180 min, without any observed complication. However, we emphasize the need of tourniquet release before the closure of skin and subcutaneous tissue to assess the viability of the tissue. With meticulous handling of skin and soft tissue, we did not find the need for skin grafting in any of our cases.
After the incident of the wound infection, which was likely to be related to early mobilization, we recommend a relatively long period of immobilization of the surgical sites, especially for surgeries in the foot region.
If needed, the excision of multiple gouty tophi in one operation can be done, especially if they were present in the same limb, in order to minimize the rehabilitation period.
The prevalence of gout has increased in recent years in developed countries in association with the change in diet and the advances in medicine [
While the current main stay of treatment encompasses medication and dietary control, there is a role for surgical intervention for the management of gouty tophi.
Surgical indications for the excision of gouty tophi advocated by Larmon [
1) to reduce pain;
2) to control drainage and infection;
3) to decompress nerves compressed by tophaceous material;
4) to decrease total body urate load;
5) to improve function including facilitating wearing of clothes and gloves;
6) to improve cosmesis.
Many different techniques have been described for the excision of gouty tophi in the literature [
Our proposed technique was similar to Larmon’s technique [
We had a relatively low complication rate at 3% as compared with other studies [
Our technique has several limitations. Firstly, our approach requires meticulous soft-tissue-handling; otherwise, the circulation of the skin flap may be compromised. Secondly, this technique is applicable only to gouty tophi that are not infected. Infected soft tissue behaves differently and poor healing may result from use of our technique. Finally, our technique demands radical excision of gouty tophi in order to minimize the wound healing complication. In cases where the neuromuscular bundle is embedded within the gouty tophi, it is technically difficult to excise all tophi. There is thus a relatively higher risk of developing wound healing problem.
A retrospective study by Kumar et al. [
So, L.W.N., Fok, M.W.M., Kwan, K.Y.H. and Fung, K.K.B. (2017) Revisiting an Old Surgical Approach to the Management of Tophaceous Gout. Surgical Science, 8, 436-443. https://doi.org/10.4236/ss.2017.810048