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

Abstract

Background: Despite increasing disease prevalence, there remains a paucity of data examining surgical treatments for gouty tophi. This article assesses en masse excision and curettage of articular tophi involving the hands and shows that carefully planned and precisely executed surgery can consistently alleviate pain, preserve function, and enhance the aesthetics of afflicted hands.

Methods: 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 significant digital joint dysfunction and disfigurement with variable skin ulcerations.

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 an average age of 67 years. Follow-up evaluation ranged from 2 to 15 years. All patients underwent successful tophus excision with restoration of tendon excursion and joint mobility without wound complications. All regained high levels of function, and all reported satisfaction with their outcome. On follow-up for as long as 15 years, recurrence has not been observed and secondary surgery has not proved necessary.

Conclusions: This study indicates that surgical excision of articular tophi of the hands can provide long-term improvement in function and aesthetics with minimal risk of wound complications or recurrence.

Keywords: gout; hand; tophi.

FIGURE 1

Multiple large periarticular tophi causing loss of digital function and considerable disfigurement. All deposits were excised simultaneously from this patient with preservation of tendon and joint function.

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.

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.